[Initial Experiences of Valve-sparing Aortic Root Replacement Using New Designed Valsalva Graft:Report of Three Cases].

Valve sparing aortic root replacement( VSRR) is currently an established option for patients with annuloaortic ectasia( AAE). A newly designed Valsalva graft, the J Graft Shield Neo Valsalva, was used for VSRR in three cases. All operations were successful and postoperative courses were uneventful. Graft designs closer in shape to the native Valsalva may contribute to the improvement of late outcomes in VSRR.

[One-stage Radical Surgery for Aortoesophageal Fistula after Graft Replacement of Descending Aorta].

A 31-year-old woman was referred to our institution because of aortoesophageal fistula (AEF) six months after the descending aortic replacement for acute aortic dissection. We operated one-stage repair of the AEF. Thoracoscopic esophagectomy was firstly performed in prone position from right thoracic cavity, and then the esophagus was reconstructed with gastric conduit via posterior mediastinal route with omental flap. Secondly, graft replacement of the descending aorta using lateral oblique straight incision was performed and the graft was covered with omental flap simultaneously. The postoperative course was uneventful, and she started oral intake on the 13th day after surgery. Although the one-stage surgery for the AEF is highly invasive, it could be a good option for selected cases.

[Valve-sparing Root Reimplantation for Stanford Type A Acute Aortic Dissection Combined with Aortic Root Dilation and Bicuspid Aortic Valve;Report of a Case].

A 45-year-old male developed Stanford type A acute aortic dissection combined with aortic root dilation and congenital bicuspid aortic valve (BAV). He had a Sieveres type 0 BAV, lateral subtype with right and left cusps. Valve-sparing root reimplantation was performed with decalcification of the cusps. Transthoracic echocardiography(TTE) at discharge revealed no aortic regurgitation, and peak velocity of BAV was 2.15 m/second, mean pressure gradient was 9.6 mmHg and aortic valve area was 2.15 cm2. TTE after 6 months revealed only slight elevation of the peak velocity to 2.78 m/second. To perform successful reimplantation in the case of BAV, anatomic orientation of the cusps should be approximately at 180° and the tissue of the cusps should either be normal or have only minor abnormalities. Valve-sparing root reimplantation for BAV needs a careful follow-up for progression of the aortic valve dysfunction.

[Valve-sparing Replacement in Patients with Aortic Root Dilatation].

Valve-sparing root replacement is increasingly used to overcome drawbacks associated with valvular prostheses. In our institution, 7 patients underwent valve-sparing root replacement from August 2016 to July 2017. The mean age was 45 years (range, 14~69 years). Three patients had Marfan syndrome and 1 had Loeys-Dietz syndrome with acute aortic dissection. All patients underwent surgery with reimplantation technique using a Valsalva graft. Two patients required repair of aortic valve leaflet prolapse. All patients had an excellent clinical course, with mild or no aortic regurgitation and a decrease in end-diastolic volume on echocardiography. These results support the continued use of valve-sparing root replacement in selected patients.

Long-Term Outcomes of Mitral Valve Repair for Active Endocarditis.

BACKGROUND: The long-term outcomes of mitral valve (MV) repair for active infective endocarditis (AE) are not well known, so the present study examined results from >5 years. METHODS AND RESULTS: We retrospectively reviewed 43 patients who underwent primary MV repair for AE at a single center between 1991 and 2009. Patients' mean age was 50.9 years, and 39% were female. The mean follow-up was 7.4 years, and 90.7% of the patients had serial echocardiographic studies over the years. We examined the data for mortality, mitral reoperation, and recurrent significant mitral regurgitation (MR). There were no early deaths but 6 late deaths. Survival was 92.6±4.1% for 5 years, and 83.5±7.3% for 10 years. The respective 5- and 10-year rates of freedom from MV reoperation were 90.5±4.5% and 86.6±5.8%, and for freedom from moderate or severe MR were 95.0±3.5 and 86.1±6.7%. Recurrence of endocarditis was observed in 2 patients (4.7%). Most (86%) of the survivors were in New York Heart Association class I. CONCLUSIONS: MV repair for AE is durable and offers acceptable long-term outcomes with low rates of recurrence and reoperation. (Circ J 2016; 80: 1148-1152).

Pulmonary Valvuloplasty by Autologous Pericardium in a Patient with Active Infectious Endocarditis and Osler's Disease.

Osler's disease is a rare condition of autosomal dominant inheritance characterized by bleeding and telangiectasia of the skin and mucosal membranes. A few reports exist of open-heart surgery in patients with Osler's disease. Here, the case is presented of a successful pulmonary valvuloplasty using autologous pericardium to treat active infectious endocarditis of the pulmonary valve in a patient with Osler's disease. Such patients are at higher risk of bacteremia because of their chronic nasal bleeding or pulmonary arteriovenous fistula. In patients with Osler's disease, valuvloplasty using autologous pericardium is considered effective for preventing the later recurrence of IE.

Efficacy of Stentless Aortic Bioprosthesis Implantation for Aortic Stenosis with Small Aortic Annulus.

BACKGROUND: In patients with small aortic annulus, sufficient size of stented aortic bioprosthesis cannot be implanted without additional procedures. In such cases, we use stentless aortic bioprosthesis to obtain sufficient effective orifice area. In this study, we investigated long-term impact of stentless aortic bioprosthesis on clinical outcomes, compared with stented aortic bioprosthesis. MATERIALS AND METHODS: We retrospectively investigated 140 patients who underwent aortic valve replacement (AVR) with porcine bioprosthesis for severe aortic stenosis between 1999 and 2010. Patients who had moderate or more aortic regurgitation and who underwent concomitant mitral procedures were excluded. A total of 69 patients (49%) were implanted stentless bioprosthesis (Freestyle group; Medtronic Inc, Minneapolis, Minnesota, United States) and 71 patients (51%) were implanted stented bioprosthesis (Mosaic group; Medtronic Inc). Follow-up was complete in 97.9% patients. Median follow-up period was 4.2 years. RESULTS: Patients in Freestyle group had smaller body surface area, smaller aortic annulus diameter, smaller aortic valve area, larger mean pressure gradient, higher peak velocity across aortic valve, larger left ventricular mass index (LVMI), and lower left ventricular ejection fraction (LVEF). Mean size of implanted prosthesis was larger in Freestyle group. In-hospital mortality was 1.4% in Freestyle group and 2.8% in Mosaic group (p = 0.980). Five-year survival rate was not different between two groups (5-year survival rate was 87.5 ± 4.7% in Freestyle group and 84.1 ± 7.5% in Mosaic group; log rank, p = 0.619). Late New York Heart Association functional class was lower in Freestyle group. Late LVMI and LVEF became similar between two groups. CONCLUSION: Stentless aortic bioprosthesis is superior in left ventricular remodeling after AVR for aortic stenosis and is especially effective for small aortic annulus.

Long-term outcomes after mitral valve repair for degenerative mitral regurgitation with persistent atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) adversely affects surgical outcomes of mitral valve surgery. However, the long-term impact of Maze procedure has not been clear yet. PATIENTS AND METHODS: We retrospectively investigated 159 patients who underwent mitral valve repair for degenerative mitral regurgitation with persistent AF between 1991 and 2010. The mean age of patients was 63.1 ± 10.5 years. After we started performing Maze procedure in 2002, 65 patients underwent concomitant Maze procedure. The median follow-up time was 7.5 years. RESULTS: There was one operative death (0.63%). The overall survival rate was 91.0 ± 2.6% at 5 years and 79.1 ± 4.7% at 10 years. Survival was significantly better in patients who underwent Maze procedure than those who did not. The rate of freedom from AF in patients who underwent Maze procedure was 86.4 ± 4.5% at 1 year and 81.1 ± 5.6% at 5 years. The freedom rate from stroke was higher in patients who underwent Maze procedure than those who did not. Patients with postoperative AF had larger left ventricular systolic and diastolic diameters at follow-up and higher New York Heart Association functional class than patients without postoperative AF (1.4 ± 0.5 vs. 1.1 ± 0.3, p < 0.001). CONCLUSION: Maze procedure can have a positive effect on long-term survival, freedom from stroke, and cardiac function.

Long-term outcomes of mitral valve repair with the Duran flexible ring.

BACKGROUND: Mitral annuloplasty is a reliable mitral valve repair technique. There are two types of annuloplasy rings: the rigid ring and the flexible ring. This study sought to examine the long-term results of mitral valve repair using a Duran flexible ring. METHODS: We retrospectively reviewed 226 patients who underwent primary mitral valve repair using the Duran flexible ring for mitral regurgitation between September 1994 and March 2003. Patients' mean age was 56.7 years, and 39% were female. The mean follow-up was 10.6 years (0.04 ∼ 18.3), and echocardiographic follow-up was 83.3% complete. RESULTS: There were three early and 25 late deaths. Survival was 89.3 ± 2.2 for 10 years, and 83.5 ± 3.2% for 15 years. The 10- and 15-year freedom from reoperation on the mitral valve were 96.4 ± 1.4 and 95.3 ± 1.7%, respectively. The 10- and 15-year freedom from moderate or severe mitral regurgitation were 92.5 ± 2.2 and 73.7 ± 7.1%, respectively. Cox regression analysis revealed that age, male gender, and isolated anterior leaflet prolapse were predictive of recurrent moderate or severe mitral regurgitation. CONCLUSIONS: Mitral valve repair for mitral regurgitation using a flexible Duran ring is safe and durable for more than 10 years.

Redo valvular surgery in elderly patients aged > 75 years.

BACKGROUND AND AIM OF THE STUDY: Very few data exist regarding the clinical outcome of redo valvular surgery in patients aged > 75 years. METHODS: A retrospective analysis was conducted of 42 consecutive patients (mean age 78.3 years) who had undergone redo valvular surgery between January 1991 and December 2010, and who had been followed up for a mean of 2.5 years. Factors associated with early outcomes were analyzed using logistic regression analysis, while predictors of late death and valve-related events were identified using Cox regression analysis. RESULTS: The overall hospital mortality rate of redo procedures was 17%. Multivariate logistic regression analysis showed that prolonged ventilator support (OR 1.007; 95% CI: 1.000-1.014; p < 0.0464) was an independent risk factor for hospital mortality. Overall survival rates at one and three years were 78.3 +/- 6.8% and 67.1 +/- 8.6%, respectively. Multivariate Cox regression analysis of survival revealed that age (HR 1.399; 95% CI: 1.044-1.875; p < 0.0238) and prolonged ventilator support (HR 1.004; 95% CI: 1.001-1.006; p < 0.0051) were negative predictors of mid-term survival. Rates of freedom for valve-related events at one and three years were 77.4 +/- 7.5% and 60.2 +/- 9.6%, respectively. An absence of peripheral artery disease protected against valve-related events (HR 0.045; 95% CI: 0.004-0.44; p < 0.0080). CONCLUSION: Early and late outcomes for elderly patients who had undergone redo valvular surgery were relatively poor and satisfactory, respectively. Hence, an optimal referral for redo surgery is important to achieve better outcomes.

Mitral valve repair for severe organic mitral regurgitation in the elderly.

BACKGROUND AND AIM OF THE STUDY: Although mitral valve repair has become the standard surgical procedure for mitral regurgitation (MR), the procedure does not necessarily apply to elderly patients aged > 75 years because of high morbidity and mortality. METHODS: A total of 104 patients aged > 75 years who underwent mitral valve repair between January 1991 and December 2011 was reviewed retrospectively. The mean age was 78 years, and the mean follow up was 3.7 years. Possible risk factors for hospital death and morbidity were identified, and valve-related events during the follow up period were analyzed. RESULTS: The overall hospital mortality rate was 4.8% (5/104). Multivariate logistic regression analysis identified serum creatinine level > 2.0 mg/dl as the only independent predictor of hospital mortality. A total of 33 patients had postoperative complications. Infective endocarditis was the only independent predictor of hospital morbidity. Actual survival at five years was 85.6 +/- 4.1%. By Cox regression analysis, age (HR 1.195; p <0.012) proved to be a negative predictor of late survival, whereas the absence of chronic obstructive pulmonary disease (HR 0.129; p <0.014) was a positive predictor. Rates of freedom from thromboembolic events and bleeding at five years were 87.9 +/- 4.2% and 97.9 +/- 1.5%, respectively. Rates of freedom from moderate-to-severe MR and reoperation at five years were 80.3 +/- 6.5% and 97.5 +/- 2.5%, respectively. CONCLUSION: Late survival and freedom from valve-related events were favorable, in addition to hospital outcome, in patients aged > 75 years. Mitral valve repair is an acceptable surgical procedure in terms of hospital mortality/morbidity and freedom from valve-related events.

[Successful treatment of Candida albicans mediastinitis after open-heart surgery using vacuum-assisted closure device].

An 82-year-old man suffered from Candida albicans mediastinitis following emergency aortic valve replacement. After repeated debridement of the anterior portion of the mediastinum, we applied a vacuum assisted closure device with UrgoTul Absorb placed on the right ventricle. Despite relatively short-term application of this device, mediastinitis was cured in combination with transposition of the great omentum.

Fate of functional tricuspid regurgitation after mitral valve repair for degenerative mitral regurgitation.

BACKGROUND: The issue of whether functional tricuspid regurgitation (TR) should be repaired at the time of mitral valve surgery is controversial, and the long-term durability of tricuspid valve (TV) annuloplasty remains unknown. METHODS AND RESULTS: We retrospectively reviewed 654 patients who underwent mitral valve repair for degenerative mitral regurgitation between 1991 and 2010. Preoperative TR was classed as mild, trivial or absent in 479 (73.2%) patients, moderate in 125 (19.1%) patients and severe in 50 (7.7%) patients. Concomitant TV annuloplasty was performed in 162 patients (24.8%). The mean follow up duration was 7.5±4.9 years. Postoperative transthoracic echocardiography was performed according to a fixed schedule. The long-term survival rate and freedom from re-admission for congestive heart failure were affected by the severity of TR. Although the durability of ring annuloplasty was excellent up to 10 years after surgery, the mean TR grade started to increase after 10 years. Sixteen out of 492 patients who did not undergo TV annuloplasty (3.2%) revealed progression to severe TR. Preoperative atrial fibrillation (odds ratio (OR), 4.85; 95% confidence interval (CI), 1.38-17.1; P=0.014) and preoperative TR grade (OR, 5.16; 95% CI, 1.78-14.9; P=0.003) were predictors for progression to severe TR. CONCLUSIONS: Aggressive treatment with concomitant TV annuloplasty should be advocated in cases with atrial fibrillation and more than moderate TR.

Mechanism of and risk factors for reoperation after mitral valve repair for degenerative mitral regurgitation.

BACKGROUND: We reviewed our 20-year experience of mitral valve (MV) repair for degenerative mitral regurgitation (MR) and analyzed the mechanisms and risk factors of reoperation. METHODS AND RESULTS: Six hundred and fifty-four patients who underwent MV repair for degenerative MR between 1991 and 2010 were retrospectively reviewed. The mean follow-up duration was 7.5 ± 4.9 years. Late echocardiography was obtained at a fixed schedule. Standard procedures for MV repair were resection and suture for posterior prolapse, artificial chordal reconstruction for anterior prolapse and a combination of them for prolapse of both. Ring annuloplasty was performed in most cases. We encountered 2 early and 23 late reoperations. Fifteen (60%) were valve-related failure, 9 (36%) were procedure-related failure and 1 was unknown. Valve-related failure was characterized with recurrence of MR due to new prolapse region and progression of mitral stenosis due to leaflet thickening. For them, reoperation was performed at 7.6 years and 14.3 years after the initial operation, respectively. Multivariate analysis identified preoperative left ventricular diastolic diameter and residual regurgitation at discharge as risk factors for reoperation. CONCLUSIONS: Valve-related failure occurred late due to slow progression of degenerative disease. Long-term follow-up after surgery is mandatory. Given that progression and severity of MR were identified as risk factors for reoperation, early surgical intervention is desirable for degenerative MR.

Single-stage repair of the right aortic arch with Kommerell diverticulum through the right thoracotomy with SIRC approach.

Kommerell diverticulum (KD) is a congenital vascular disease associated with dilatation at an aberrant subclavian artery's origin. The surgical repair should be considered for the symptomatic patients due to the adjacent organ's compression by the aneurysmal change of KD. An appropriate approach should be selected for the open repair to suit the anatomical type of disease. We reported a 50-year-old female diagnosed with KD undergoing the single-stage open repair through the right thoracotomy with the straight skin incision with rib cross.

En bloc excision of giant polycystic liver with hepatic cava and its auto-transplant caval reconstruction as a safe surgical procedure for liver transplantation.

Safely excising a giant liver while leaving the hepatic inferior vena cava intact is difficult. Hata et al. present images and videos describing their novel technique consisting of total hepatectomy including the hepatic cava; extracorporeal retrieval; and auto-transplant inferior vena cava reconstruction, for an extremely enlarged polycystic liver weighing 24 kg.

A novel approach for the endothelialization of xenogeneic decellularized vascular tissues by human cells utilizing surface modification and dynamic culture.

Decellularized xenogeneic vascular grafts can be used in revascularization surgeries. We have developed decellularization methods using high hydrostatic pressure (HHP), which preserves the extracellular structure. Here, we attempted ex vivo endothelialization of HHP-decellularized xenogeneic tissues using human endothelial cells (ECs) to prevent clot formation against human blood. Slices of porcine aortic endothelium were decellularized using HHP and coated with gelatin. Human umbilical vein ECs were directly seeded and cultured under dynamic flow or static conditions for 14 days. Dynamic flow cultures tend to demonstrate higher cell coverage. We then coated the tissues with the E8 fragment of human laminin-411 (hL411), which has high affinity for ECs, and found that Dynamic/hL411showed high area coverage, almost reaching 100% (Dynamic/Gelatin vs Dynamic/hL411; 58.7 ± 11.4 vs 97.5 ± 1.9%, P = 0.0017). Immunostaining revealed sufficient endothelial cell coverage as a single cell layer in Dynamic/hL411. A clot formation assay using human whole blood showed low clot formation in Dynamic/hL411, almost similar to that in the negative control, polytetrafluoroethylene. Surface modification of HHP-decellularized xenogeneic endothelial tissues combined with dynamic culture achieved sufficient ex vivo endothelialization along with prevention of clot formation, indicating their potential for clinical use as vascular grafts in the future.

Pharmacist-physician collaborative care for outpatients with left ventricular assist devices using a cloud-based home medical management information-sharing system: a case report.

BACKGROUND: The standard anticoagulation therapy for patients implanted with left ventricular assist devices (LVADs) includes warfarin therapy. We developed a cloud-based home medical management information-sharing system named as LVAD@home. The LVAD@home system is an application designed to be used on iPad tablet computers. This system enables the sharing of daily information between a patient and care providers in real time. In this study, we reported cases of outpatients with LVADs using this system to manage anticoagulation therapy. CASE PRESENTATION: The patient, a man in his 40s with end-stage heart failure owing to non-ischemic dilated cardiomyopathy, underwent LVAD implantation and warfarin was started on postoperative day 1. He started to use LVAD@home to manage warfarin therapy after discharge (postoperative day 47). He sent his data to care providers daily. By using this system, the pharmacist observed his signs of reduced dietary intake 179 days after discharge, and after consulting the physician, told the patient to change the timing of the next measurement earlier than usual. On the next day, the prothrombin time-international normalized ratio increased from 2.0 to 3.0, and thus the dose was decreased by 0.5 mg. Four patients used this system to monitor warfarin therapy from October 2015 to March 2018. In these patients, the time in therapeutic range was 90.1 ± 1.3, which was higher than that observed in previous studies. Additionally, there were no thromboembolic events or bleeding events. CONCLUSIONS: The cloud-based home management system can be applied to share real-time patient information of factors, including dietary intake that interact with warfarin. It can help to improve long-term anticoagulation outcomes in patients implanted with LVAD.

A case of aggressive aortic prosthetic valve endocarditis aggressive caused by Staphylococcus lugdunensis.

BACKGROUND: Staphylococcus lugdunensis is a coagulase-negative Staphylococcus species, which are weak pathogenic bacteria generally. However, the acute and severe pathogenicity of Staphylococcus lugdunensis infective endocarditis may be due to the rapid growth of large vegetation and consequent valve destruction. CASE PRESENTATION: The patient was an 81-year-old male who visited our hospital with chief complaints of low back pain and high fever. Four years before this visit, he had undergone aortic valve replacement for aortic regurgitation. He was found to be hypotensive. Although there is no heart murmur on auscultation and echocardiography revealed negative findings with aortic valve, a blood test showed increases in the white blood cell count and C-reactive protein concentration. On the next day, Gram-positive cocci were detected in a blood culture and echocardiography detected a large vegetation on the prosthetic valve with increased flow velocity. Therefore, he underwent redo aortic valve replacement emergently. Staphylococcus lugdunensis was identified in blood samples and vegetation culture. Consequently, the patient was treated with antibiotics for 5 weeks after the operation and discharged home. CONCLUSIONS: We experienced rapidly progressive prosthetic valve endocarditis caused by Staphylococcus lugdunensis. Hence, Staphylococcus lugdunensis infective endocarditis requires aggressive treatment, and the pathogenicity of this coagulase-negative Staphylococcus with high drug susceptibility should not be underestimated.

Chronic chymase inhibition preserves cardiac function after left ventricular repair in rats.

OBJECTIVE: Although left ventricular repair (LVR) has been widely performed, the initial improvement of LV function does not last because of LV remodeling. Recent studies have demonstrated that chymase, a local enzyme in the heart, promotes angiotensin II formation as well as activation of transforming growth factor (TGF)-beta, both of which facilitate myocardial fibrosis. Therefore, chymase blockade may play an important role in the prevention of cardiac remodeling after LVR. In this study, the effects of chronic chymase inhibition (Chy-I) after LVR were evaluated in a rat LV aneurysm model. METHODS: Rats that developed LV aneurysms 4 weeks after coronary artery ligation underwent LVR by plicating the LV aneurysm, and were randomized into two groups, the LVR group and the LVR + Chy-I group that received an oral chymase inhibitor (10 mg/kg/day) for 4 weeks. RESULTS: Echocardiography revealed better LV function in the LVR + Chy-I group than in the LVR group at 4 weeks. Four weeks after LVR, LV end-diastolic pressure and the time constant of LV isovolumic pressure decay, were significantly lower in the LVR+Chy-I group. The end-systolic pressure-volume relationship was higher in the LVR+Chy-I group. In the LVR+Chy-I group, mRNA expressions of TGF-beta1 and BNP significantly decreased in the LV myocardium. Histology showed reduced interstitial fibrosis in the LVR+Chy-I group. CONCLUSIONS: Chronic chymase inhibition prevented myocardial fibrosis and preserved cardiac function after LVR. A chymase inhibition could be an important strategy for management after LV repair surgery.