Impact of diabetes mellitus on long-term clinical and graft outcomes after off-pump coronary artery bypass grafting with pure bilateral skeletonized internal thoracic artery grafts.

BACKGROUND: The effect of diabetes mellitus (DM) on the long-term outcomes of coronary artery bypass graft (CABG) remained debatable and various strategies exist for CABG; hence, clarifying the effects of DM on CABG outcomes is difficult. The current study aimed to evaluate the effect of DM on clinical and graft-related outcomes after CABG with bilateral internal thoracic artery (BITA) grafts. METHODS: From January 2001 to December 2017, 3395 patients who underwent off-pump CABG (OPCAB) with BITA grafts were enrolled. The study population was stratified according to preoperative DM. The primary endpoint was cardiac death and the secondary endpoints were myocardial infarction (MI), revascularization, graft failure, stroke, postoperative wound infection, and a composite endpoint of cardiac death, MI, and revascularization. Multiple sensitivity analyses, including Cox proportional hazard regression and propensity-score matching analyses, were performed to adjust baseline differences. RESULTS: After CABG, the DM group showed similar rates of cardiac death, MI, or revascularization and lower rates of graft failure at 10 years (DM vs. non-DM, 19.0% vs. 24.3%, hazard ratio [HR] 0.711, 95% confidence interval [CI] 0.549-0.925; P = 0.009) compared to the non-DM group. These findings were consistent after multiple sensitivity analyses. In the subgroup analysis, the well-controlled DM group, which is defined as preoperative hemoglobin A1c (HbA1c) of < 7%, showed lower postoperative wound infection rates (well-controlled DM vs. poorly controlled DM, 3.7% vs. 7.3%, HR 0.411, 95% CI 0.225-0.751; P = 0.004) compared to the poorly controlled DM group, which was consistent after propensity-score matched analysis. CONCLUSIONS: OPCAB with BITA grafts showed excellent and comparable long-term clinical outcomes in patients with and without DM. DM might have a protective effect on competition and graft failure of ITA. Strict preoperative hyperglycemia control with target HbA1c of < 7% might reduce postoperative wound infection and facilitate the use of BITA in CABG.

Optimal Timing of Venoarterial-Extracorporeal Membrane Oxygenation in Acute Myocardial Infarction Patients Suffering From Refractory Cardiogenic Shock.

BACKGROUND: Although there is an increase in the use of mechanical circulatory support devices to rescue patients with acute myocardial infarction (AMI) complicated by refractory cardiogenic shock (CS), the optimal timing of the application remains controversial. Therefore, this study aimed to compare the clinical outcomes between venoarterial-extracorporeal membrane oxygenation (VA-ECMO) insertion before and after coronary revascularization in AMI patients with refractory CS.Methods and Results:A total of 253 patients with AMI who underwent revascularization therapy with VA-ECMO were included. The study population was stratified into extracorporeal cardiopulmonary resuscitation (E-CPR) before revascularization (N=106, reference cohort) and refractory CS without E-CPR before revascularization (n=147, comparison cohort). Patients with refractory CS but without E-CPR before revascularization were further divided into VA-ECMO before revascularization (N=50) and VA-ECMO after revascularization (n=97). The primary endpoint was a composite of in-hospital mortality, left ventricular assist device implantation, and heart transplantation. The primary endpoint occurred in 60 patients (40.8%) of the comparison cohort and 51 patients (48.1%) of the reference cohort. Among the comparison cohort, the primary endpoint was significantly lower in VA-ECMO before revascularization than in VA-ECMO after revascularization (32.0% vs. 49.5%, OR 0.480, 95% CI 0.235-0.982, P=0.045). A similar trend was observed after a 1-year follow up. CONCLUSIONS: Early initiation of VA-ECMO before revascularization therapy might improve clinical outcomes in patients with AMI complicated by refractory CS.

Mild Ischemic Mitral Regurgitation: Is Revascularization Enough for Every Patient?

BACKGROUND: The progress of mild ischemic mitral regurgitation (MR) after isolated coronary artery bypass is not clear. We aimed to determine the proportion of patients with mild ischemic MR undergoing isolated coronary artery bypass grafting (CABG) presenting with regression of or persistent MR one year after CABG and to identify the significantly different echocardiographic variables between regressing and persistent MR. METHODS: Sixty-three patients with preoperative mild ischemic MR were categorized into an MR- regression or an MR-persistence group one year after isolated CABG. The echocardiographic indices, indicating mitral leaflet configuration and remodeling of the left ventricle (LV), were measured before and one year after the surgery. RESULTS: One year after CABG, MR regressed in 60% (38/63) and persisted in 40% (25/63) of the patients. The left ventricular diameter, volume, and sphericity and anteroposterior diameter of the mitral annulus improved only in the MR-regression group, while the ejection fraction improved in both groups (47.7% ± 12.4% from 40.1% ± 11.3%, P < .001 in the regression group and 43.2% ± 14.0% from 39.3% ± 11.6%, P = .035 in the persistence group). A >15% decrease in the LV end-systolic volume was noted more frequently in the MR-regression group (60.5% versus 30%, P = .027). The leaflet angle did not show asymmetry or significant changes in both groups. CONCLUSIONS: Isolated CABG improved mild MR in most patients with mild ischemic MR. These patients showed greater reverse remodeling after revascularization than the patients with persistent MR after isolated CABG. Additional tests, which can predict LV reverse remodeling, are needed to predict persistent MR.

Off-Pump Coronary Artery Bypass Graft Versus Drug-Eluting Stent Implantation in Patients with Multivessel Disease Involving the Right Coronary Artery.

BACKGROUND: Whether percutaneous coronary intervention (PCI) is superior to coronary artery bypass grafting (CABG) for the right coronary territory is unknown. The aim of this study was to compare the outcomes and patency in the right coronary territory after CABG or PCI. METHODS: We studied 2,467 multivessel coronary artery disease patients from January 2001 to December 2011; 1,672 were off-pump CABG patients and 795 were PCI. The graft patency and the presence of major adverse cardiac and cerebrovascular events (MACCEs) including death, myocardial infarction, target vessel revascularization, and stroke were analyzed. RESULTS: After propensity score matching, cardiac-related survival was found to be significantly higher in the CABG group than in the PCI group (hazard ratio (HR) for the PCI group: 2.445, p = 0.006). The PCI group showed higher rates of myocardial infarction (HR: 2.571, p = 0.011) and target vessel revascularization (HR: 3.337, p < 0.001). In the right coronary territory, the right internal thoracic artery patency was not different in the PCI group compared with the CABG group (p = 0.248). In CABG group, low right coronary artery graft patency was associated with cardiac-related death (HR: 0.17, p = 0.003) and the occurrence of MACCEs (HR: 0.22, p < 0.001). CONCLUSION: CABG was superior to PCI in patients with multivessel disease. Low graft patency in the right coronary territory was associated with cardiac-related death and the occurrence of MACCEs.

Clinical Outcomes of Repeat Aortic Valve Replacement for Subaortic Pannus in Mechanical Aortic Valve.

BACKGROUND: This study aimed to evaluate the early and late clinical outcomes after repeat aortic valve replacement (AVR) for subaortic pannus in patients with mechanical valves. Methods and Results: Between 2001 and 2017, 51 patients (median age, 59 years; 42 women) with prosthetic aortic stenosis (AS) caused by pannus ingrowth underwent repeat AVR because of acute malfunction of monoleaflet valve (3 patients), severe prosthetic AS (30 patients), and moderate prosthetic AS at the time of tricuspid or mitral valve surgery (18 patients). The median follow-up duration was 100 (interquartile range, 64-138) months. Double valve replacement was performed in 45 (88%) patients. Median time interval from previous operation was 161 (interquartile range, 121-194) months. The explanted mechanical AV was monoleaflet and bileaflet in 16 (31%) and 34 (67%) patients, respectively. Concomitant procedures included 16 mitral valve replacements (14 repeat) and 36 tricuspid valve surgeries (15 replacements, 21 repairs). No hospital deaths or cases of heart block occurred. Overall survival and event-free survival rates at 10 years were 88% and 51%, respectively. Late complications included recurrent prosthetic AS (4 patients), new paravalvular leakage of the mitral valve (5 patients), and severe tricuspid regurgitation (2 patients). CONCLUSIONS: Although repeat AVR for subaortic pannus had acceptable early and late survival, recurrent prosthetic AS was frequently observed during late follow-up.

Coronary Artery Bypass Grafting with Arterial Grafts in Patients with Kawasaki Disease Affecting the Coronary Artery: a Korean Single-Center Study.

BACKGROUND: This study aimed to review the long-term clinical outcomes and graft patency of coronary artery bypass grafting (CABG) using arterial grafts in patients with Kawasaki disease (KD) affecting the coronary artery. METHODS: Twenty patients with KD who underwent CABG from January 2002 to June 2014 were enrolled. There were 4 male (20%) and 16 female (80%) patients with ages at operation ranging from 2 to 42 years (median, 17.5 years). Our routine operative strategy was off-pump CABG with arterial grafts. The mean follow-up duration was 59.5 ± 48.5 months (range, 1-159 months). Coronary angiogram or computed tomography angiogram was used to evaluate graft patency in 16 patients (80%). RESULTS: All patients survived CABG without late mortality. Left internal thoracic arteries were used in 19 patients, while right internal thoracic arteries were used in 10 patients. Right gastroepiploic arteries were used in 3 patients, and a saphenous vein graft (SVG) was used in 1 patient. Among the 20 patients, 2 patients underwent coronary reintervention with balloon angioplasty because of graft failure. Two patients underwent coronary reintervention because of new obstructive lesions that were not significant at the time of the initial operation. Patency rates at 5 and 10 years were 94% and 87%, respectively. The rate of freedom from coronary reintervention at 10 years was 82%. CONCLUSION: Off-pump CABG with mainly arterial graft revascularization may be considered a good surgical option for coronary lesions caused by KD.

Surgical outcomes of mitral valve replacement with concomitant mitral annular reconstruction.

BACKGROUND AND AIM OF THE STUDY: We evaluated the early and long-term outcomes of mitral annular reconstruction (MAR) with pericardium during mitral valve replacement (MVR), and analyzed the risk factors associated with post-operative mortality. METHODS: Between May 1997 and April 2013, 78 consecutive patients underwent MVR with MAR. The indications for MAR were treatment for annular infection in native valve endocarditis (n = 23, 29.5%) or prosthetic valve endocarditis (n = 26, 33.3%), reinforcement of damaged annulus resulting from a previous operation (n = 17, 21.8%), complete excision of extensive calcification (n = 9, 11.5%), and left ventricular or left atrial rupture (n = 3, 3.8%). Patients were classified into infective endocarditis (n = 49) and non-endocarditis groups (n = 29). The mean follow-up period was 59.4 ± 47.3 months. RESULTS: There were two operative deaths and 11 cases of late mortality in the endocarditis group and five cases in the non-endocarditis group. Late prosthetic valve endocarditis occurred in four patients. The overall survival rate at 1 and 10 years was 94.8% and 65.1%, respectively. There was no statistical difference in the overall survival, freedom from reoperation, and freedom from endocarditis rates between the groups (P = 0.565, P = 0.635, and P = 0.449, respectively). Univariable and multivariable analyses revealed that pre-operative left ventricular dysfunction (ejection fraction <40%) was an independent predictor of overall mortality. CONCLUSIONS: The early and long-term results of MAR with pericardium during MVR are acceptable in both endocarditis and non-endocarditis patients.

Perioperative Outcomes of Repeated Open Surgery on the Thoracic Aorta.

BACKGROUND: Repeated thoracic aorta repair is increasingly common. With the increase in hybrid procedures, determination of the best treatment strategy requires evaluation of the clinical outcomes of classic open surgery. METHODS: We retrospectively reviewed 119 patients (84 men and 35 women, aged 51.0 ± 16.7 years) with a history of open repair involving the thoracic aorta above the diaphragm. The patients underwent an average of 1.3 ± 0.8 surgeries (range: 1-8) on the thoracic aorta before the final operation. Clinical outcomes were evaluated on the basis of the need for emergency surgery, indications for surgery, pathologic causes, and other operative variables. RESULTS: Hospital mortality was 6.7% (n = 8). Postoperative bleeding occurred in 16% (n = 19). On multivariable analysis, emergency surgery (odds ratio [OR], 19.005; P = .003; 95% confidence interval [CI], 2.710-133.305) and cardiopulmonary bypass (CPB) time (OR, 1.562 per 30 minutes; P = .007; 95% CI, 1.126-2.165) were predictors of hospital death. Emergency surgery (OR, 4.105; P = .029; 95% CI, 1.157-14.567) and CPB time (OR, 1.189 per 30 minutes; P = .035; 95% CI, 1.012-1.396) were also associated with postoperative bleeding, in addition to surgery for an infectious cause (OR, 10.824; P = .010; 95% CI, 1.755-66.770). Estimated survival at 1, 5, and 7 years was 86.6%, 80.5%, and 78.2%, respectively. CONCLUSION: Despite the variety of preoperative conditions and operations performed, repeated open surgery for thoracic aorta repair can be performed with acceptable early and late outcomes.

Tricuspid Valve Replacement vs. Repair in Severe Tricuspid Regurgitation.

BACKGROUND: The aim of this study was to compare early and late outcomes of tricuspid valve replacement (TVR) and tricuspid valve repair (TVr) for severe tricuspid regurgitation (TR).Methods and Results:From 1994 to 2012, 360 patients (mean age, 58±13 years) with severe TR underwent TVR (n=97, 27%) or TVr (n=263, 73%). Among them, 282 patients (78%) had initial rheumatic etiology, and 307 patients (85%) had preoperative atrial fibrillation. The TVR group had higher total bilirubin, higher baseline central venous pressure, and higher incidence of previous cardiac operation. There was no difference in early mortality (TVR:TVr, 3.1%:3.4%, P=0.877). Ten-year overall survival (TVR:TVr, 72%:70%, P=0.532) and 10-year freedom from cardiac death (TVR:TVr, 76%:77%, P=0.715) were not significantly different between groups. After applying stabilized inverse probability of treatment weighting methods, there were still no significant differences in early mortality (P=0.293), overall survival (P=0.649) or freedom from cardiac death (P=0.870). Higher NYHA functional class, total bilirubin (>2 mg/dL), initial central venous pressure, and cardiopulmonary bypass time were independent predictors of early mortality. Older age, LV dysfunction (EF <40%), and hemoglobin <10 g/dL were independent predictors of late cardiac mortality. CONCLUSIONS: Compared with TVr, TVR had acceptable early and late outcomes in patients with severe TR. TVR can be considered as a valid option with acceptable clinical outcomes in patients who are not suitable candidates for TVr.

Favorable Outcomes of Open Surgical Repair for Blunt Aortic Injury in the Era of Endovascular Repair.

Background Long-term outcomes of open surgical repair with distal aortic perfusion for blunt aortic injury (BAI) remain undefined in this era of preferential thoracic endovascular aortic repair (TEVAR). Methods We retrospectively reviewed data from 31 consecutive patients (23 males; mean age, 46 ± 16 years) who underwent open surgical repair with distal aortic perfusion for acute BAI between 1998 and 2012 at our center and were followed up for 83 ± 47 months. Results In the 31 patients studied, BAI was most commonly secondary to traffic accidents (87%), with median accident-to-surgery time of 1 day. It was most commonly (90%) located at the isthmus. All patients had other injuries (injury severity score, 25 ± 6), 68% of which required surgery. The aorta was approached by left (84%) or bilateral (3%) thoracotomy, or median sternotomy (13%). During aortic cross-clamping (73 ± 47 minutes), distal aortic perfusion was maintained in all patients by left heart or cardiopulmonary bypass (extracorporeal circulation time, 93 ± 63 minutes). Circulatory arrest was required in 19% of patients. There was no in-hospital mortality or paraplegia. The estimated 5- and 10-year survival rates were 92 ± 6% and 80 ± 12%, respectively. One patient underwent reoperation for aortoesophageal fistula at 75 months postoperatively. Conclusion Open repair with distal aortic perfusion for BAI yielded favorable early and late outcomes, and is thus a viable option even in the era of TEVAR.

Evaluation of augmented pulse pressure variation using the Valsalva manoeuvre as a predictor of fluid responsiveness under open-chest conditions: A prospective observational study.

BACKGROUND: Pulse pressure variation (PPV) is a well known dynamic preload indicator of fluid responsiveness. However, its usefulness in open-chest conditions remains controversial. OBJECTIVE: We evaluated whether augmented PPV during a Valsalva manoeuvre can predict fluid responsiveness after sternotomy. DESIGN: A prospective, observational study. SETTING: Single-centre trial, study period from October 2014 to June 2015. PATIENTS: Forty-nine adult patients who underwent off-pump coronary arterial bypass grafting. INTERVENTION: After midline sternotomy, haemodynamic parameters were measured before and after volume expansion (6 ml kg of crystalloids). PPV was calculated both automatically (PPVauto) and manually (PPVmanual). For PPV augmentation, we performed Valsalva manoeuvres with manual holding of the rebreathing bag and constant airway pressure of 30 cmH2O for 10 s before fluid loading and calculated PPV during the Valsalva manoeuvre (PPVVM). MAIN OUTCOME MEASURES: The predictive ability of PPVVM for fluid responsiveness using receiver-operating characteristic curve analysis. Responders were identified when an increase in cardiac index of at least 12% occurred after fluid loading. RESULTS: Twenty-one patients were responders and 28 were nonresponders. PPVVM successfully predicted fluid responsiveness with an area under the curve (AUC) of 0.88 [95% confidence interval (95% CI) 0.75 to 0.95; sensitivity 91%, specificity 79%, P < 0.0001] and a threshold value of 55%. Baseline PPVauto and PPVmanual also predicted fluid responsiveness [AUC 0.75 (0.62 to 0.88); sensitivity 79%, specificity 75%; and 0.76 (0.61 to 0.87]; sensitivity 71%, specificity 71%, respectively). However, only PPVVM showed a significant AUC-difference from that of central venous pressure (P = 0.008) and correlated with the change of cardiac index induced by volume expansion (r = 0.6, P < 0.001). CONCLUSION: Augmented PPV using a Valsalva manoeuvre can be used as a clinically reliable predictor of fluid responsiveness under open-chest condition. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02457572.

Association of periprocedural myocardial infarction with long-term survival in patients treated with coronary revascularization therapy of chronic total occlusion.

OBJECTIVE: To evaluate the impact of periprocedural myocardial infarction (PMI) on long-term survival after coronary revascularization in patients with chronic total occlusion (CTO). BACKGROUND: Little is known about the clinical impact of PMI on long-term cardiac mortality after CTO revascularization in patients with stable angina. METHODS: We analyzed data from 927 patients with CTO and stable angina who were treated with coronary artery bypass grafting (CABG, n = 367) or percutaneous coronary intervention (PCI, n = 560). PMI was defined as a peak CK-MB ≥ 3 times the upper limit of normal (ULN) after PCI or a CK-MB ≥ 5 times the ULN after CABG. The primary outcome was cardiac death in patients with PMI (PMI group, n = 118 [12.7%]) or without PMI (no-PMI group, n = 809 [87.3%]) after revascularization. RESULTS: During a median follow-up of 42 months, PMI occurred in 118 patients (12.7% of the overall study population). Fifty-nine patients treated with PCI (10.5% of PCI subgroup) and 59 patients treated with CABG (16.1% of CABG subgroup) suffered from PMI. In multivariate analysis, the PMI group and the no-PMI group had a similar incidence of cardiac death (hazard ratio [HR] 0.57; 95% confidence interval [CI] 0.20 to 1.62; P = 0.29). CONCLUSIONS: PMI may not be associated with increased cardiac mortality after coronary revascularization in patients with stable CTO. © 2015 Wiley Periodicals, Inc.

Aortic wrapping for a dilated ascending aorta in bicuspid aortic stenosis.

BACKGROUND: Ascending aorta wrapping is rarely recommended for the management of dilated aorta, because of late complications. The aim of the present study was to analyze the early and late outcomes of the aortic wrapping technique at the time of aortic valve replacement (AVR) for bicuspid aortic stenosis (BAS). METHODS AND RESULTS: Among patients who underwent primary AVR for BAS between 2002 and 2011, 79 who underwent ascending aortic wrapping (wrapping group) were compared with 144 patients who underwent AVR alone. The preoperative ascending aortic diameters were larger in the wrapping group (40.9±4.2 mm vs. 48.6±4.0 mm, P<0.001). Operative technique was to wrap the ascending aorta transversely with a semi-elliptically resected Dacron graft. The follow-up for the wrapping group was 76.5±35.5 (median 71.1) months. There were no early deaths. Early and late morbidity did not differ between groups. The 24 late deaths, including 10 cardiac-related deaths, occurred in the entire group; 3 sudden deaths occurred only in the AVR group. The 10-year overall survival in the wrapping group was higher than the AVR group (88.1±6.8% vs. 80.0±4.6%, P=0.048). No late aortic complications were detected. The aortic diameter was reduced from 49.5±4.1 mm to 45.3±5.0 mm after wrapping (P<0.001). CONCLUSIONS: The aortic wrapping technique may be an option for treating a moderately dilated ascending aorta in selected patients undergoing AVR for BAS. Longer follow-up, however, is necessary to verify later complications.

Long-Term Clinical Outcomes of Medical Therapy for Coronary Chronic Total Occlusions in Elderly Patients (≥75 Years).

BACKGROUND: Limited data are available on the clinical outcomes of medical therapy (MT) compared with revascularization in elderly patients with coronary chronic total occlusion (CTO). METHODS AND RESULTS: Between March 2003 and February 2012, we retrospectively analyzed 311 patients aged ≥75 years in the Samsung Medical Center CTO registry. Among these, 153 patients were treated with MT and 158 patients with revascularization by intervention or surgery. Inverse probability of treatment weighting (IPTW) and propensity score-matching were performed. The primary outcome was cardiac death during follow-up. Median follow-up duration was 34 (interquartile range: 15-58) months. Overall, patients in the MT group were high-risk subjects. Cardiac death of 30 patients (19.6%) occurred in the MT group vs. 17 patients (10.8%) in revascularization group (P=0.027). In the multivariate analysis, there was no significant difference between groups in the rate of cardiac death (hazard ratio [HR], 1.67; 95% confidence interval [CI], 0.86-3.24, P=0.13). After adjustment with IPTW, MT showed comparable risk of cardiac death with revascularization therapy (HR, 1.26; 95% CI, 0.71-2.21, P=0.43). In the propensity score-matched population, there was no significant difference in the rate of cardiac death between the MT and revascularization groups (HR, 1.52; 95% CI, 0.76-3.07, P=0.24). CONCLUSIONS: In the treatment of CTO in elderly patients, MT alone did not increase the risk of long-term cardiac death when compared with aggressive revascularization treatment.

Prophylactic Tricuspid Annuloplasty in Patients Undergoing Double Valve Revlacement.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the effect of prophylactic tricuspid annuloplasty (TAP) on late tricuspid regurgitation (TR) after double valve (aortic and mitral) replacement (DVR). METHODS: Among 239 patients undergoing DVR at the authors' institution between 1994 and 2009, a total of 93 patients who had a less than moderate degree of preoperative TR was analyzed. Concomitant TAP was performed in 55 patients (TAP group). The mean follow up duration was 7.3 +/- 4.1 years (maximum 15.9 years). Serial echocardiographic data at one, three, five and more than seven years were analyzed. RESULTS: There was no early mortality, but eight late cardiac-related mortalities occurred (8.6%). In the aortic position, the transprosthetic mean pressure gradient (TMPG) was increased during follow up (13.5 +/- 5.3 mmHg versus 16.4 +/- 10.2 mmHg, p = 0.006). However, the mitral TMPG did not change significantly (3.7 +/- 1.4 mmHg versus 3.8 +/- 1.6 mmHg, p = 0.677). Freedom from valve-related events at 10 years was higher in the TAP group than in the non-TAP group (85.2 +/- 5.9% versus 63.3 +/- 0.9%; p = 0.05). Freedom from more than moderate TR at 10 years was also higher in the TAP group (93.6 +/- 4.7% versus 66.3 +/- 10.3%; p = 0.03). The transmitral pressure gradient was associated with valve-related events (p = 0.025; HR, 1.367). An absence of TAP was predictive of late TR (p = 0.020; HR, 4.4). CONCLUSION: The study results suggested that TAP can be considered in patients who require DVR, even if the TR grade is less than moderate, in order to prevent the late occurrence of TR.

Clinical outcomes of valve-sparing root replacement in acute type A aortic dissection.

OBJECTIVES: The early and late outcomes of valve-sparing root replacement (VSR) in type A aortic dissection (AAD) are unknown. The aim of this study was to review the outcomes of VSR in AAD. We also compared the outcomes of VSR with the Bentall operation, which served as a standard reference technique. DESIGN: We retrospectively reviewed 52 patients who underwent surgery for AAD and concomitant root replacement between 1998 and 2013 at Samsung Medical Center. Patients were divided into two groups: Bentall (n = 34) and VSR (n = 18). Two out of six surgeons performed VSR. The mean follow-up duration was 62.3 ± 46.5 months. RESULTS: Preoperative characteristics were similar between the two groups except age (Bentall, 48 ± 11 years; VSR, 37 ± 11 years, p = 0.011). The aortic cross-clamping time was longer in the VSR group (Bentall, 185.8 ± 63.8; VSR, 241.4 ± 44.3 min, p = 0.002). There was no early death in the VSR group, but there was one in the Bentall group (p = 1.000). Despite the higher reoperation rate for aortic valve in the VSR group (Three reoperations) than in the Bentall group (no reoperation), major valve-related events and overall mortality did not differ between the two groups(p = 0.876 and 0.119, respectively). In multivariable analysis, the root replacement technique was not a risk factor for major valve-related events. CONCLUSIONS: VSR seems to be equivalent to the Bentall procedure for AAD in terms of early and late outcomes. VSR can be considered as a viable option, particularly for young patients with favorable aortic valve leaflets undergoing surgery at an experienced center.

Effect of left atrial activity after the maze procedure on clinical and echocardiographic outcomes.

BACKGROUND: Although the maze procedure reduces the risk of adverse cardiac events, the clinical importance of post-maze left atrial (LA) activity on long-term surgical outcomes is not well defined. METHODS AND RESULTS: Between January 2000 and December 2009, 416 consecutive patients with sinus conversion after a modified Cox III procedure with cryoablation were enrolled and subdivided into patients with restored LA activity (group ReA; n=231) and those without LA activity (group NoA; n=185) assessed using Doppler echocardiographic examination at 3-6 months after the maze procedure. During the long-term follow-up (4.6±2.6 years), the NoA group showed more frequent major adverse events (P=0.001) including cardiac death (P=0.145), heart failure events (P=0.032), and thromboembolic stroke (P=0.048) than the ReA group. In multivariate analysis, lack of LA activity was associated with a 2.2-fold increased risk for major adverse events (95% confidence interval [CI], 1.1-6.8; P=0.029) and with a 2.4-fold increased risk for late progression of tricuspid regurgitation (95% CI, 1.0-3.5; P=0.041). CONCLUSIONS: Absence of LA activity after the maze procedure was independently associated with a significantly increased risk of major adverse events and late progression of tricuspid regurgitation.

Stroke is not a treatment dilemma for early valve surgery in active infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: While early valve surgery for active infective endocarditis (AIE) is recommended, surgeons have hesitated to operate on patients complicated by cerebral septic embolism resulting in cerebral bleeding when cardiopulmonary bypass is required intraoperatively. The study aim was to review the outcomes of operations for AIE, and to determine the risks of neurologic complications resulting from cerebral septic embolism. METHODS: Between 1994 and June 2011, among 278 patients who underwent heart valve surgery for AIE at the authors' institution, 39 (14%) had cerebral septic embolisms. Cerebral lesions were verified by imaging, and were predominantly multiple embolic infarctions (34 patients; 87.2%). Five patients had brain abscess, and 10 had hemorrhage with or without infarction. The mean interval between the recent onset of a stroke and surgery was 10.1 ± 10.1 days (range: 0-43 days). RESULTS: One patient died postoperatively of septic shock. New neurologic complications occurred in five patients, including secondary hemorrhagic transformation in the previous lesions (n = 2), newly developed subdural and subarachnoid hemorrhage (n = 2), and an increased degree of subarachnoid hemorrhage (n = 1). One patient needed a craniotomy, and the others were treated medically. There were five late deaths, including one cardiac death, and one redo valve surgery due to repaired valve failure during the follow up period of 46.3 ± 40.4 months (range: 1.9-127.4 months). The overall and event-free survival rates at five and 10 years were 84.3 ± 6.5% and 75.9 ± 9.9%, and 81.7 ± 6.8% and 73.6 ± 9.9%, respectively. CONCLUSION: Surgery for AIE with cerebral septic embolisms can be performed safely, with good early and mid-term follow-up results. When urgent or emergent surgery for AIE is needed, neurologic complications should not be a reason for delay.

Clinical impact of intra-aortic balloon pump during extracorporeal life support in patients with acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: There is no available data on clinical outcome in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock who are supported by an intra-aortic balloon pump (IABP) in combination with extracorporeal life support (ECLS). METHODS: We analysed 96 consecutive patients with AMI and complicating cardiogenic shock who were assisted by an ECLS system between January 2004 and December 2011. The primary outcome was in-hospital mortality. The secondary outcomes were the success rate of weaning from ECLS and the lactate clearance for 48 hours (%). RESULTS: A combination of IABP and ECLS was used in 41 (42.7%) patients. In-hospital mortality occurred for 51 patients (ECLS with IABP versus ECLS alone; 51.2% vs. 54.5%, p = 0.747). The success rate of weaning from ECLS was similar between the two groups (63.4% vs. 58.2%, p = 0.604). Complications such as ischemia of a lower extremity or bleeding at the ECLS insertion site (p = 0.521 and p = 0.667, respectively) did not increase when ECLS was combined with IABP. Among patients who survived for 24 hours after intervention, lactate clearance was not significantly different between patients who received ECLS alone and those who received ECLS with IABP (p = 0.918). CONCLUSIONS: The combined use of ECLS and IABP did not improve in-hospital survival in patients with AMI complicated by cardiogenic shock.

Outcomes of off-pump coronary bypass grafting with the bilateral internal thoracic artery for left ventricular dysfunction.

This study evaluated the outcomes of off-pump coronary artery bypass surgery (OPCAB) with severe left ventricular dysfunction using composite bilateral internal thoracic artery grafting. From January 2001 to December 2008, 1,842 patients underwent primary isolated OPCAB with composite bilateral internal thoracic artery grafting. A total of 131 of these patients were diagnosed with a severely depressed preoperative left ventricle ejection fraction (LVEF) (≤ 0.35). These patient outcomes were compared with the outcomes of 830 patients that had mildly or moderately depressed LVEF (0.36 to 0.59) and 881 patients with normal LVEF (>0.6). The early mortality for patients with severe LVEF was 2.3%. The 3-yr and 7-yr survival rate for patients with severe LV dysfunction was 86.0% and 82.8%, respectively. Multivariate analysis showed that severe LV dysfunction EF increased the risk of all-cause death (P=0.012; hazard ratio [HR],2.14; 95% confidence interval [CI],1.19-3.88) and the risk of cardiac-related death (P=0.008; HR,3.38; 95% CI, 1.37-8.341). The study identified positive surgical outcomes of OPCAB, although severe LVEF was associated with two-fold increase in mortality risk compared with patients who had normal LVEF.