Concomitant Mitral Regurgitation in Severe Aortic Stenosis　- Insights From the CURRENT AS Registry-2.

BACKGROUND: Data on concomitant mitral regurgitation (MR) in patients with severe aortic stenosis (AS) are scarce.Methods and Results: We investigated the risk of concomitant MR in patients with severe AS in the CURRENT AS Registry-2 according to initial treatment strategy (transcatheter aortic valve implantation [TAVI], surgical aortic valve replacement [SAVR], or conservative). Among 3,365 patients with severe AS, 384 (11.4%) had moderate/severe MR (TAVI: n=126/1,148; SAVR: n=68/591; conservative: n=190/1,626). The cumulative 3-year incidence for death or heart failure (HF) hospitalization was significantly higher in the moderate/severe than no/mild MR group in the entire population (54.6% vs. 34.3%, respectively; P<0.001) and for each treatment strategy (TAVI: 45.0% vs. 31.8% [P=0.006]; SAVR: 31.9% vs. 18.7% [P<0.001]; conservative: 67.8% vs. 41.6% [P<0.001]). The higher adjusted risk of moderate/severe MR relative to no/mild MR for death or HF hospitalization was not significant in the entire population (hazard ratio [HR] 1.15; 95% confidence interval [CI] 0.95-1.39; P=0.15); however, the risk was significant in the SAVR (HR 1.92; 95% CI 1.04-3.56; P=0.04) and conservative (HR 1.30; 95% CI 1.02-1.67; P=0.04) groups, but not in the TAVI group (HR 1.03; 95% CI 0.70-1.52; P=0.86), despite no significant interaction (Pinteraction=0.37). CONCLUSIONS: Moderate/severe MR was associated with a higher risk for death or HF hospitalization in the initial SAVR and conservative strategies, while the association was less pronounced in the initial TAVI strategy.

[Outcomes of Infectious Endocarditis Requiring Surgical Intervention for an Aortic Root Abscess].

OBJECTIVE: We report the results of infectious endocarditis requiring surgical intervention for aortic root abscess. METHODS: We performed 63 surgeries for infectious endocarditis from April 2013 to August 2022. Of those series, we further investigated 10 cases (15.9%, eight males, mean age 67 years, range 46~77 years) requiring surgical intervention for aortic root abscess. RESULT: Five cases were prosthetic valve endocarditis. Aortic valve replacement was performed in all 10 cases. To repair root abscess, we performed one direct closure, seven patch repairs with autologous pericardium, and two Bentall procedures with stented bioprosthetic valve and synthetic graft, following radical and complete debridement. All patients were discharged alive (mean number of postoperative days 44, range 29~70 days), and no recurrence of infection or late death was observed during the follow-up period (mean 51 months, range 5~103 months). CONCLUSION: Although aortic root abscess is a gravely dangerous condition and has a high risk of death, we presented excellent surgical outcomes of this life-threatening disease.

Rationale, Design, and Baseline Characteristics of the CURRENT AS Registry-2.

BACKGROUND: There is scarce data evaluating the current practice pattern and clinical outcomes for patients with severe aortic stenosis (AS), including both those who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) and those who were managed conservatively in the TAVI era.Methods and Results: The Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis (CURRENT AS) Registry-2 is a prospective, physician-initiated, multicenter registry enrolling consecutive patients who were diagnosed with severe AS between April 2018 and December 2020 among 21 centers in Japan. The rationale for the prospective enrollment was to standardize the assessment of symptomatic status, echocardiographic evaluation, and other recommended diagnostic examinations such as computed tomography and measurement of B-type natriuretic peptide. Moreover, the schedule of clinical and echocardiographic follow up was prospectively defined and strongly recommended for patients who were managed conservatively. The entire study population consisted of 3,394 patients (mean age: 81.6 years and women: 60%). Etiology of AS was degenerative in 90% of patients. AS-related symptoms were present in 60% of patients; these were most often heart failure symptoms. The prevalence of high- and low-gradient AS was 58% and 42%, respectively, with classical and paradoxical low-flow low-gradient AS in 4.6% and 6.7%, respectively. CONCLUSIONS: The CURRENT AS Registry-2 might be large and meticulous enough to determine the appropriate timing of intervention for patients with severe AS in contemporary clinical practice.

[Early Experience of Robot-assisted Mitral Valve Surgeries in Our Local Hospital].

We report the early experience of robot-assisted mitral valve repair in our local hospital. It took about two years from the application for the robot-assisted cardiac surgery until the first case of robot-assisted mitral repair. Since July 2020 to June 2022, we have performed 23 cases of robot-assisted mitral valve repair with da Vinci Xi system. There was no hospital death. The mean cross-clamp and total operation time were 118±22 and 295±41 min, respectively. Pre-discharge echocardiograms showed none-to-mild residual mitral regurgitation (MR) in all patients. The mean post-operative hospital stay was 7.6±5 days. Robot-assisted mitral valve repair could safely be started in our hospital. Early results were acceptable. Further experiences will be needed to confirm the efficacy of robotic mitral valve repair.

[Joint Cardiovascular Surgeries of Two Hospitals in Shizuoka for Adult Congenital Heart Disease (ACHD) Patients].

BACKGROUND: As for the medical management including surgery for the patients with adult congenital heart disease(ACHD), it may be difficult for most hospitals other than that have both adult/congenital cardiologists/cardiovascular surgeons. Between Shizuoka Prefectural General Hospital and Mt. Fuji Shizuoka Children's Hospital, medical stuff and information have been shared for these 4 years. And joint cardiovascular surgeries have started since 2015 autumn at Shizuoka Prefectural General Hospital. PURPOSE: The contents and the results of these joint operations were evaluated. PATIENTS AND METHODS: Thirteen joint operations were performed and median age at operation was 55 years old( male 3, female 10). The original diagnosis was tetralogy of Fallot/pulmonary atresia with ventricular septal defect 6, ventricular septal defect( VSD)±pulmonary stenosis 4, atrioventicular septal defect/two chamber right ventricle/Ebstein's anomaly 1 ( each). The procedures were pulmonary valve replacement/right ventricle out flow tract reconstruction 7, mitral valve plasty/tricuspid annuloplasty 4, Bentall 2, VSD closure 2 etc.(included multiple choices). RESULTS: There was no early mortality. One late mortality was occurred 17 months after the surgery due to acute myeloid leukemia. General conditions in other patients have been feasible and most of them were followed in Shizuoka Prefectural General Hospital. CONCLUSIONS: The results of the joint operations were feasible in the present study. Our joint project may become more important in the future.

Early Surgery vs. Surgery After Watchful Waiting for Asymptomatic Severe Aortic Stenosis.

BACKGROUND: There is no large-scale study comparing postoperative mortality after aortic valve replacement (AVR) for asymptomatic severe aortic stenosis (AS) between initial treatment with AVR vs. eventual AVR after conservative management. Methods and Results: We analyzed data from a multicenter registry enrolling 3,815 consecutive patients with severe AS. Of 1,808 asymptomatic patients, 286 patients initially underwent AVR (initial AVR group), and 377 patients were initially managed conservatively and eventually underwent AVR (AVR after watchful waiting group). Mortality after AVR was compared between the 2 groups. Subgroup analysis according to peak aortic jet velocity (Vmax) at diagnosis was also conducted. There was no significant difference between the 2 groups in 5-year overall survival (OS; 86.0% vs. 84.1%, P=0.34) or cardiovascular death-free survival (DFS; 91.3% vs. 91.1%, P=0.61), but on subgroup analysis of patients with Vmax ≥4.5 m/s at diagnosis, the initial AVR group was superior to the AVR after watchful waiting group in both 5-year OS (88.4% vs. 70.6%, P=0.003) and cardiovascular DFS (91.9% vs. 81.7%, P=0.023). CONCLUSIONS: Asymptomatic severe AS patients who underwent AVR after watchful waiting had a postoperative survival rate similar to those who initially underwent AVR. In a subgroup of patients with Vmax ≥4.5 m/s at diagnosis, however, the AVR after watchful waiting group had worse postoperative survival rate than the initial AVR group.

[Valve Replacement for Infective Endocarditis of Pulmonary Valve;Report of a Case].

Generally, infective endocarditis is found at the left side of the heart. The right side infective endocaritis accounts for only 5~10% of all cases of infective endocarditis. The right side infective endocarditis occurs especially among drug users employing intravenous injection. A typical site of infection is the tricupid valve, and isolated pulmonary valve involvement is rare. It is assumed that its rarity is due to the low pressure gradients within the right heart, the low prevalence of valve disease, and the lower oxygen content of the venous blood. We describe a case of isolated pulmonary valve endocarditis requiring valve replacement. Antibiotic therapy was conducted for 4 weeks before surgery and 2 weeks after surgery. Clinical course was favorable and the patent was discharged home 18 days after surgery.

Physician Modification to Shorten a TAG Thoracic Endoprosthesis for Treatment of a Pseudoaneurysm in the Ascending Aorta.

PURPOSE: To report initial use of a physician-modified Gore TAG Thoracic Endoprosthesis for the treatment of pseudoaneurysm in the ascending aorta. TECHNIQUE: This technique is demonstrated in a 42-year-old man with a pseudoaneurysm of the ascending aorta after a Bentall operation. The treatable length extending from the sinotubular junction to the anastomotic aneurysm edge was only 5 cm. A 45×100-mm TAG endograft for the pseudoaneurysm was modified on a back table to shorten its length. The delivery shaft was incised, and the 2 threads that fasten the top and bottom portions of the stent-graft to the sleeve were pulled out. The unfolded half of the stent-graft was cut back after pulling out the strand for the back half. Next, this custom-made graft was deployed via a transcarotid approach with cardiopulmonary bypass; no endoleak was observed. Postoperative computed tomography showed a minute type Ib endoleak. The patient was doing well at postoperative month 6. CONCLUSION: Physician modification of a TAG endograft facilitated effective management of this ascending aortic lesion by shortening the length of aortic coverage.

Accuracy of Aortic Annulus Diameter Measurement: Comparison of Multi-Detector CT, Two- and Three-Dimensional Echocardiography.

OBJECTIVE: Accurate preprocedural quantification of the aortic annulus diameter is crucial for the operative success of the aortic valve surgery and especially transcatheter aortic valve replacement (TAVR). We conducted a prospective study to compare the accuracy of preoperative aortic annulus measurements using different imaging methods and direct measurements for aortic valve surgery. METHODS: We enrolled 52 patients who underwent open aortic valve surgery between March 2012 and March 2014. Aortic annulus diameter was prospectively measured by transthoracic two-dimensional echocardiography (2D-TTE), transesophageal three-dimensional echocardiography (3D-TEE), and multi-detector computed tomography (MDCT). Imaging measurements were performed blindly by lab technicians. At surgery, the aortic annulus diameter was directly measured. RESULTS: Of the three methods, MDCT provided the smallest error in determining aortic annulus size as compared with the measurements at surgery. The limit of agreement of the aortic diameter by MDCT was smallest in the present study. CONCLUSIONS: The MDCT provided the most accurate measurement of aortic annulus diameter compared with 2D-TTE and 3D-TEE.

[Quadricuspid Aortic Valve Repair].

A 58-year-old man presented with severe aortic regurgitation(AR) with quadricuspid valve. Intraoperatively, the small accessory cusp was separated from non-coronary cusp( NCC). The NCC and small accessory cusp were sutured to obtain 1 competent cusp, aiming at an effective height of 8 mm. His AR was trivial at the postoperative 7th day.

A Case of Thrombectomy for Loeffler's Endocarditis.

Loeffler's endocarditis, characterized by eosinophilic infiltration leading to thrombus formation and fibrosis in the ventricle, is associated with severe complications, such as embolism and heart failure. While anticoagulation and steroids are standard treatments, surgical thrombectomy is rarely reported. This is a case report of a 74-year-old man presented with an abnormal electrocardiogram. Echocardiography revealed a 38 × 29 mm mass in the left ventricular apex, and blood studies revealed hypereosinophilia, leading to a diagnosis of Loeffler's endocarditis. Despite warfarin treatment, the thrombus persisted. The left ventricular intracardiac thrombus exhibited significant mobility, and we decided to perform a thrombectomy via a trans-left ventricular approach. After the surgery, steroid therapy was initiated. The patient recovered without recurrence of the thrombus or deterioration in cardiac function. Left ventricular thrombectomy for Loeffler's endocarditis is considered a beneficial option to prevent thrombosis.

Effects of peripheral artery disease on long-term outcomes after percutaneous coronary intervention versus coronary artery bypass grafting in patients with severe coronary artery disease.

BACKGROUND: There is a scarcity of data evaluating the effect of peripheral artery disease (PAD) on long-term mortality after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG) in patients with severe coronary artery disease in real-world practice. METHODS: Among 14,867 consecutive patients who underwent their first coronary revascularization with PCI or isolated CABG between 2011 and 2013 in the CREDO-Kyoto PCI/CABG registry Cohort-3, the current study population consisted of 3380 patients with three-vessel coronary artery disease or left main coronary artery disease. Long-term clinical outcomes were compared between PCI and CABG stratified by the presence or absence of PAD. Median clinical follow-up was 5.9 (IQR: 5.1-6.8) years. RESULTS: There were 461 patients with PAD (PCI: N = 307, CABG: N = 154), and 2919 patients without PAD (PCI: N = 1823, CABG: N = 1096). The cumulative 5-year mortality after coronary revascularization was 31.2 % in patients with PAD and 16.2 % in those without PAD (p < 0.0001). There was a higher risk of PCI relative to CABG for all-cause death in patients with and without PAD (adjusted HR, 1.59; 95%CI, 0.99-2.53; p = 0.054, and HR, 1.25; 95%CI, 1.01-1.56; p = 0.04) without interaction (p interaction p = 0.48); Nevertheless, there was no excess risk of PCI relative to CABG for cardiovascular death regardless of PAD. CONCLUSIONS: The long-term mortality after coronary revascularization was significantly higher in severe CAD patients with PAD than those without PAD. There was a higher mortality risk of PCI relative to CABG in patients with and without PAD without interaction, which was mainly driven by excess non-cardiovascular deaths.

In-hospital outcomes after SAVR or TAVI in patients with severe aortic stenosis.

There were no data comparing the in-hospital outcomes after transcatheter aortic valve implantation (TAVI) with those after surgical aortic valve replacement (SAVR) in Japan. Among consecutive patients with severe AS between April 2018 and December 2020 in the CURRENT AS Registry-2, we identified 1714 patients who underwent aortic valve replacement (TAVI group: 1134 patients, and SAVR group: 580 patients). Patients in the TAVI group were much older (84.4 versus 73.6 years, P < 0.001) and more often had comorbidities than those in the SAVR group. In-hospital death rate was numerically lower in the TAVI group than in the SAVR group (0.6% versus 2.2%). After excluding patients with dialysis, in-hospital death rate was very low and comparable in the TAVI and SAVR groups (0.6% versus 0.8%). The rates of major bleeding and new-onset atrial fibrillation during index hospitalization were higher after SAVR than after TAVI (72% versus 20%, and 26% versus 4.6%, respectively), while the rate of pacemaker implantation was higher after TAVI than after SAVR (8.1% versus 2.4%). Regarding the echocardiographic data at discharge, the prevalence of patient-prosthesis mismatch was lower in the TAVI group than in the SAVR group (moderate: 9.0% versus 26%, and severe: 2.6% versus 4.8%). In this real-world data in Japan, TAVI compared with SAVR was chosen in much older patients with more comorbidities with severe AS. In-hospital death rate was numerically lower in the TAVI group than in the SAVR group.

Prognostic significance of baseline low-density lipoprotein cholesterol in patients undergoing coronary revascularization; a report from the CREDO-Kyoto registry.

BACKGROUND: The impact of very low baseline levels of low-density lipoprotein cholesterol (LDL-C) on patients with coronary artery disease remains unclear. METHOD: We enrolled 39,439 patients of the pooled population from the CREDO-Kyoto registries Cohorts 1, 2, and 3. The study population consisted of 33,133 patients who had undergone their first coronary revascularization. We assessed the risk for mortality and cardiovascular events according to quintiles of the baseline LDL-C levels. RESULTS: Patients in the very low LDL-C quintile (<85 mg/dL) had more comorbidities than those in the other quintiles. Lower LDL-C levels were strongly associated with anemia, thrombocytopenia, and end-stage renal disease. The cumulative 4-year incidence of all-cause death increased as LDL-C levels decreased (very low: 19.4 %, low: 14.5 %, intermediate: 11.1 %, high: 10.0 %, and very high: 9.2 %; p < 0.001), which was driven by both the early and late events. After adjusting for baseline characteristics, the adjusted risks of the very low and low LDL-C quintiles relative to the intermediate LDL-C quintile remained significant for all-cause death (very low: HR 1.29, 95 % CI 1.16-1.44, p < 0.001; low: HR 1.15, 95 % CI 1.03-1.29, p = 0.01). The excess adjusted risks of the lowest LDL-C quintile relative to the intermediate LDL-C quintile were significant for clinical outcomes such as cardiovascular death (HR 1.17, 95 % CI 1.01-1.35), non-cardiovascular death (HR 1.35, 95 % CI 1.15-1.60), sudden death (HR 1.44, 95 % CI 1.01-2.06), and heart failure admission (HR 1.11 95 % CI 1.01-1.22), while there was no excess risk for the lowest LDL-C quintile relative to the intermediate LDL-C quintile for myocardial infarction and stroke. CONCLUSIONS: Lower baseline LDL-C levels were associated with more comorbidities and a significantly higher risk of death, regardless of cardiovascular or non-cardiovascular causes, in patients who underwent coronary revascularization.

Cut-off values for transit time flowmetry: are the revision criteria appropriate?

BACKGROUND: Graft Imaging to Improve Patency (GRIIP), a single-center, randomized blinded clinical trial, reported that intraoperative graft assessment with graft revision according to a priori criteria of transit time flowmetry (TTF) and intraoperative fluorescent angiography did not improve graft patency at one year after coronary artery bypass grafting (CABG) when compared with standard intraoperative management. The objective of this study is to investigate whether other TTF values are more predictive of the saphenous vein graft (SVG) failure and/or clinical outcomes. METHODS: This is a case control retrospective study of 65 SVGs from 44 patients from GRIIP. Study outcomes were graft patency at 12 months and major adverse cardiac events (MACE; death, myocardial infarction, repeat revascularization). RESULTS: Twenty-two SVGs were occluded. In receiver operating characteristic curve analysis, TTF mean flow was significantly predictive of one-year SVG failure (area under the curve = 0.698, p < 0.01), and 31 mL/min was the best cut-off value (p = 0.017, sensitivity 63.6%, specificity 67.4%). The risk of graft occlusion was 14/28, 50% for grafts with mean flow <31 mL/min and 8/37, 21.6% for grafts with mean flow ≥ 31 mL/min. In logistic regression models, mean flow was a significant predictor of early SVG failure (Odds Ratio 0.95 [0.91-0.99] per mL/min, p = 0.014) whereas other TTF values, patient comorbidities, and/or medication at discharge were not. However, TTF values were not predictive of MACE. CONCLUSIONS: TTF can identify non-functional grafts during CABG, but is of questionable value to improve one-year graft patency.

Observation of Atrial Fibrillation Dependent on an Intra-atrial Re-entrant Tachycardia Within the Right Atrium in a Repaired Tetralogy of Fallot.

Atrial fibrillation (AF) can occur predominantly associated with right atrial (RA) lesions in congenital heart disease, particularly when the RA cavity is dilated. RA electrical potentials occasionally appear organized during AF. We clearly mapped such areas circumscribed by an intra-atrial re-entrant circuit during an isoproterenol infusion, in a patient with a repaired tetralogy of Fallot, using an ultrahigh-density mapping system and its beat acceptance criteria function. Ablation of areas inside the re-entrant circuit successfully eliminated the AF. Our experience indicated that a macro-re-entrant tachycardia was a driver as well as a trigger of AF of this right-sided origin.

Chez les patients atteints d'une cardiopathie congénitale, la fibrillation auriculaire (FA) peut souvent survenir en association avec des lésions auriculaires droites (AD), en particulier lorsque la cavité AD est dilatée. Lors d'une FA, il peut arriver que les potentiels électriques AD semblent normaux. Chez un patient ayant une tétralogie de Fallot réparée, nous avons clairement cartographié des zones délimitées par un circuit de réentrée intra-auriculaire lors d'une perfusion d'isoprotérénol, et ce, à l'aide d'un système de cartographie à très haute densité et de ses critères d'acceptation liés aux battements cardiaques. L'ablation des régions se trouvant dans le circuit de réentrée a permis d'éliminer la FA avec succès. Notre expérience a démontré qu'une tachycardie macroréentrante avait été un facteur déterminant et même un déclencheur de la FA, laquelle est apparue à droite.

A snare maneuver to reposition self-expandable aortic valve after transcatheter replacement of surgically implanted valve.

In this case, we successfully repositioned the transcatheter heart valve (THV) by pulling it with a snare inserted via the right brachial artery. Attempting to pull the THV via the femoral approach was not successful, due to the vector of the pulling force not being coaxial. Changing the direction of the force by switching to an approach from the right brachial artery successfully prevented perivalvular leakage. While there are previous case reports of repositioning an implanted transcatheter valve in a native valve using a gooseneck snare, to our knowledge, this is the first case of successfully repositioning an implanted transcatheter valve in a valve-in-valve procedure using the precise assessment that can be achieved with intra-procedural transesophageal echocardiography. Learning objective: Perivalvular leakage (PVL) is a major problem after transcatheter aortic valve replacement. In this case, we experienced PVL after implantation of self-expandable transcatheter heart valve (THV) inside the previously inserted Mosaic bioprosthetic valve. Depth of the implanted valve was too low into left ventricle accessed with transesophageal echocardiogram. It is barely known whether THV in surgical implanted aortic valve could be repositioned using snare maneuver, but we successfully pulled the valve via brachial artery and PVL was controlled.

Life Expectancy of Patients With Severe Aortic Stenosis in Relation to Age and Surgical Risk Score.

BACKGROUND: There is a paucity of data regarding shorter life expectancy after aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). METHODS: Among 3815 patients with severe AS enrolled in the CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) registry, there were 1469 patients (initial AVR: n = 647; conservative strategy: n = 822) with low surgical risk, 1642 patients (initial AVR: n = 433; conservative strategy: n = 1209) with intermediate surgical risk, and 704 patients (initial AVR: n = 117; conservative strategy: n = 587) with high surgical risk. Among 1163 patients who actually underwent surgical AVR as the initial strategy, patients were divided into 4 groups according to age <65 years (n = 185), 65 to 74 (n = 394), 75 to 80 (n = 345), and >80 (n = 239). The expected survival of the general Japanese population was obtained from the Statistics Bureau of Japan. The surgical risk was estimated using The Society of Thoracic Surgery (STS) score. RESULTS: The median follow-up was 3.7 years. The cumulative incidences of all-cause death were significantly lower in the initial AVR strategy than in the initial conservative strategy across the 3 STS groups. Shorter life expectancy after surgical AVR was seen especially in younger patients. The observed mortality in low-risk patients was comparable to the expected mortality across all the age-groups, while intermediate-risk patients aged <75 years, and high-risk patients across all age-groups had higher mortality compared with the expected mortality. CONCLUSIONS: The risk stratification according to age and STS score might be useful to estimate shorter life expectancy after AVR, and these findings have implications for decision making in the choice of surgical or transcatheter AVR.