Prediction for residual regurgitation after MitraClip for functional mitral regurgitation using leaflet coaptation index.

BACKGROUND: Given the recent growth in the number of MitraClip procedures in patients with functional mitral regurgitation (MR), there is interest in an echocardiographic index to predict technical success before intervention. We investigated the utility of a novel leaflet coaptation index (LCI) to predict outcomes after MitraClip in functional MR patients. METHODS: Forty consecutive patients with functional MR who underwent MitraClip were included. The LCI was defined as the coapted leaflet length divided by the anteroposterior diameter of the mitral annulus. The coapted leaflet length was calculated by separately tracing the total length of the mitral valve leaflets at early and end systole on transesophageal echocardiography. The primary endpoint was defined as residual MR ≥ moderate after MitraClip. RESULTS: The LCI was significantly associated with residual MR ≥ moderate (odds ratio, 0.827; 95% confidence interval, 0.696-0.982; p = .030) with the cut-off LCI value of 0.14 (sensitivity 70.4%, specificity 69.2%, c-statistic 0.815; p = .001). CONCLUSION: This novel index may be a useful adjunct that can be incorporated into the armamentarium of contemporary clinical performance risk prediction tools for MitraClip success.

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.

Serial Changes of Transmitral and Transtricuspid Pressure Gradients After Simultaneous Mitral and Tricuspid Ring Annuloplasty.

BACKGROUND: Although flexible-ring annuloplasty is more inclined to increase the transmitral gradient over time, its effect on the tricuspid annulus is unknown. This study was conducted to evaluate serial changes in mean pressure gradient (mPG) across tricuspid and mitral valves after simultaneous dual implantation of flexible bands. METHODS: Seventy-one (71) patients (median age, 61.6 years; IQR: 50.8-69.0 years) underwent simultaneous mitral/tricuspid annuloplasties using St. Jude Tailor rings. Serial mPGs across mitral and tricuspid valves were evaluated at three postoperative time points: predischarge, 3 years, and 5 years. To gauge the effects and clinical outcomes of prophylactic intervention, patients were categorised as tricuspid regurgitation (TR)≥moderate or TR

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.

Rehabilitation for COVID-19 in conjunction with early awake extracorporeal membrane oxygenation support: a case report.

The coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 can lead to acute respiratory distress syndrome. Awake venovenous extracorporeal membrane oxygenation is known to be effective in patients with critical COVID-19 and respiratory failure. This report describes the rehabilitation course and functional progress of a 63-year-old man who contracted severe COVID-19 and underwent awake venovenous extracorporeal membrane oxygenation. He started rehabilitation from the time of isolation while receiving venovenous extracorporeal membrane oxygenation and underwent a 30-day course of inpatient comprehensive rehabilitation. He regained functional independence and cognitive abilities and was able to walk without assistance at hospital discharge without any complications. This study demonstrates the feasibility of starting rehabilitation for COVID-19 early while the patient is on awake venovenous extracorporeal membrane oxygenation and eventually achieving a favorable outcome.

A step-by-step guide to transseptal valve-in-valve transcatheter mitral valve replacement.

With the recent success of transcatheter aortic valve replacement (TAVR), transcatheter options for the management of mitral valve pathology have also gained considerable attention. Valve-in-valve (ViV) transcatheter mitral valve replacement (TMVR) is one such technique that has emerged as a safe and effective therapeutic option for patients with degenerated mitral valve bioprostheses at high-risk for repeat surgical mitral valve replacement. Several access strategies, including trans-apical, transseptal, trans-jugular, and trans-atrial access have been described for ViV-TMVR. Initial experiences were performed primarily via a trans-apical approach through a left mini-thoracotomy because it offers direct access and coaxial device alignment. With the advancements in TMVR technology, such as the development of smaller delivery catheters with high flexure capabilities, the transseptal approach via the femoral vein has emerged as the preferred option. This technique offers the advantages of a totally percutaneous approach, avoids the need to enter the thoracic cavity or pericardial space, and provides superior outcomes compared to a trans-apical approach. In this review, we outline key aspects of patient selection, imaging, procedural techniques, and examine contemporary clinical outcomes of transseptal ViV-TMVR.

Mechanical Circulatory Support for Acute Heart Failure Complicated by Cardiogenic Shock.

Acute heart failure is a potentially life-threatening condition that can lead to cardiogenic shock, which is associated with hypotension and organ failure. Although there have been many studies on the treatment for cardiogenic shock, early mortality remains high at 40-50%. No new medicines for cardiogenic shock have been developed. Recently, there has been a gradual decline in the use of the intra-aortic balloon pump mainly due to a lack of adequate hemodynamic support. Extracorporeal membrane oxygenation and the percutaneous ventricular assist device have become more widely used in recent years. A thorough understanding of the mechanisms of such mechanical support devices and their hemodynamic effects, components of the devices, implantation technique, management, criteria for indications or contraindications of use, and clinical outcomes as well as multidisciplinary decision making may improve the outcomes in patients experiencing cardiogenic shock.

Contemporary Status of Percutaneous Transcatheter Edge-to-Edge Repair: Is It a Complement or Replacement to Mitral Surgery?

Transcatheter mitral valve repair devices borrow from the concept of surgical edge-to-edge approximation and are becoming increasingly used in patients with both primary and functional mitral regurgitation. The application of these new devices is expanding globally; however, debates between which patients are amenable to surgery vs. percutaneous approaches are ongoing. As new trials and regulatory approvals have evolved, the indications for transcatheter approaches have expanded, in a way that is complementaty to existing indications for surgical repair. In general, the treatment of mitral regurgitation should be stratified based on underlying pathophysiology and anatomy by a multidisciplinary team including cardiac surgeons and interventional cardiologists. This review aims to provide practical approaches to patient selection and treatment strategies for mitral regurgitation based on historical data and recently published trials, with a focus on the distinction between surgical and transcatheter mitral therapies.

A step-by-step guide to trans-axillary transcatheter aortic valve replacement.

The application of transcatheter aortic valve replacement (TAVR) has expanded rapidly over the last decade as a less invasive option for the treatment of severe aortic stenosis. In order to perform successful TAVR, vascular access must be obtained with a large-bore catheter to deliver the transcatheter valve to the aortic annulus. Several techniques have been developed for this purpose including transfemoral (TF), trans-aortic, trans-apical, trans-caval, trans-carotid, and trans-axillary (TAx) with varying degrees of success. Among them, TF access is the most common and preferred method owing to its superior and well-established outcomes. However, in the setting of diseased iliofemoral arterial vessels, severe tortuosity, or iliofemoral arteries of insufficient caliber, TF access may not be possible. In these scenarios, one of the aforementioned alternative access routes needs to be considered. TAx-TAVR is an attractive alternative because it can be accomplished via access to a peripheral vessel as opposed to needing to enter the pericardial space or thoracic cavity. In addition, the open surgical cut-down procedure used to expose the axillary artery is familiar to cardiac surgeons who are accustomed to cannulating it for cardiopulmonary bypass. With advancements in TAVR technology including the evolution of delivery systems and corresponding smaller sheath sizes, total percutaneous access via the axillary artery is gaining substantial attention. In this review, we outline key aspects of patient selection, imaging and procedural techniques, and examine contemporary clinical outcomes with this approach.

Impact of Arteriovenous Fistula for Hemodialysis on Clinical Outcomes of Coronary Artery Bypass.

BACKGROUND: This study compared clinical outcomes between the use of in situ and free internal thoracic artery grafts in patients with upper extremity arteriovenous fistula who underwent coronary artery bypass. METHODS: We reviewed 85 hemodialysis-dependent patients with upper extremity arteriovenous fistula who underwent coronary artery bypass with internal thoracic artery grafts. The patients were categorized into 2 groups; 48 (56%) with in situ graft ipsilateral to the arteriovenous fistula (group I) and 37 (44%) with free grafts anastomosed to the ascending aorta (group F). The follow-up period was 32.0 ± 38.1 months. RESULTS: The estimated overall survival rates at 3, 5, and 10 years were 89.5%, 81.6%, and 53%, respectively, for all discharged patients. There was no significant difference in in-hospital mortality, all-cause mortality, and freedom from major adverse cardiac events between the groups, although cardiac-related deaths occurred only in group I (n = 5). Ipsilateral in situ grafts were associated with hemodialysis-induced chest pain (odds ratio, 5.528; 95% confidence interval, 1.079 to 28.333; p = 0.040). The incidence of dialysis-induced chest pain in patients with in situ noncomposite, in situ composite, and free grafts was 45.5%, 19.4%, and 5.7%, respectively (p = 0.009). CONCLUSIONS: Mortality was not influenced by using the internal thoracic artery as an ipsilateral in situ graft in patients with upper extremity arteriovenous fistula. However, there was a risk of increased incidence of hemodialysis-induced chest pain that is most likely related to coronary steal. A free internal thoracic artery graft would be an alternative option in these patients.

Two-stage correction of type IV total anomalous pulmonary venous connection.

BACKGROUND: The small size of the pulmonary veins in infants increases the risk of pulmonary vein obstruction (PVO) after surgical repair of type IV total anomalous pulmonary venous connection (TAPVC). Here, we described the outcomes of our strategy, which delayed total correction after initial partial correction. METHODS: We reviewed the data of patients who underwent total correction for type IV TAPVC. In total, 11 out of 103 patients with TAPVC had type IV TAPVC with biventricular physiology. Of these 11 patients, we retrospectively reviewed the data of 7 patients who underwent two-stage correction. Major pulmonary venous confluent chambers, with the exception of the left superior pulmonary vein (LSPV), were initially anastomosed to the left atrium (LA), followed by anastomosis between the LSPV and the LA auricle. RESULTS: The median weight, age, and LSPV size were 4.3 kg (range, 3.5-5.4 kg), 40 days (range, 20-103 days), and 4.5 mm (range, 3.0-5.4 mm), respectively, during the first operation and 12.2 kg (range, 8.5-31.5 kg), 1,165 days (range, 280-3,250 days), and 9.8 mm (range, 8.0-12.3 mm), respectively, during the second operation. The median Qp/Qs was 1.61 (range, 1.22-1.65) and the median cardiothoracic ratio was 0.52 (range, 0.49-0.57) at second operation. The median interval between the operations was 1,094 days (range, 196-3,226 days). The median follow-up period was 22 month (range, 7-59 month). No mortality or major morbidities occurred after either operation. The median Vmax at the LSPV anastomosis site was 1.0 m/s (range, 0.8-1.3 m/s) on predischarge echocardiography. This patency was maintained at the last follow-up, showing an identical median Vmax of 1.0 m/s (range, 0.8-1.3 m/s). All 7 patients who underwent two-stage correction were in good condition, without any clinical symptoms of PVO. CONCLUSIONS: Our results suggest that leaving the isolated LSPV uncorrected during infancy and performing a second operation when the LSPV has grown adequately is a viable treatment option for patients with type IV TAPVC.

FDG PET/CT Appearance of Radiation Nephritis.

It is often challenging to assess renal activity on FDG-PET/CT due to intense physiological activity in the collecting system, thus any unusual intrarenal activity should be evaluated carefully. While increased bone tracer uptake in the irradiated region of the kidneys has been reported in the literature, altered biodistribution of FDG in irradiated renal tissue is not well described. We report a case of FDG PET/CT showing increased FDG activity in small portions of the kidneys that were previously irradiated.

Lack of Increased FDG Uptake in the Lacrimal and Salivary Glands in Patients With Sarcoidosis and Potential Underlying Mechanism.

PURPOSE: Increased 67Ga uptake in the mediastinal/hilar lymph nodes ("lambda") and in the lacrimal/parotid/submandibular glands ("panda") often coexists in patients with sarcoidosis (Sarc-Pts). However, we observed that increased lacrimal/salivary uptake is uncommon on 18F-FDG PET/CT (FDG-panda) in many Sarc-Pts who showed increased mediastinal/hilar uptake (FDG-lambda). We evaluated parotid and lacrimal FDG activity in Sarc-Pts who showed FDG-lambda in comparison with a control patient group and attempted to find underlying mechanisms to explain the discrepancy between FDG and Ga uptake in these organs. METHODS: Parotid FDG activity (FDG-P) was assessed visually using a 0- to 3-point scale (0 being = or minimally > background, and 3 > liver) and quantitatively using SUVmean in 52 confirmed Sarc-Pts with FDG-lambda (lambda group) as well as in 52 non-Sarc-Pts (control group). Lacrimal FDG activity (FDG-L) was assessed visually (0 being = or minimally > subcutaneous tissue, and 1 clearly > subcutaneous tissue). RESULTS: There was no significant difference in the parotid SUVmean between lambda (1.88 ± 0.65) and control (1.76 ± 0.62) groups (P = 0.333). Also, there was no difference in visually graded FDG-P between the 2 groups (P = 0.257). None of the patients in all groups showed apparently abnormal (grade 1) FDG-L. CONCLUSIONS: Increased FDG-L/FDG-P is rare in Sarc-Pts demonstrating FDG-lambda, which is strikingly different from the clinical experience as well as the reported data on Ga scintigraphy. Discrepancy in various cytokine levels between lacrimal samples and intrathoracic lesions in Sarc-Pts reported in the literature appears to correlate well with variable Ga and FDG uptake in the lacrimal gland and intrathoracic lesions.

Discrete decreased activity in the lower thoracic spine on FDG PET/CT: another respiration-related artifact.

PURPOSE: We observed that the diaphragmatic motion causing the well-known, so-called banana artifact on PET/CT images may additionally cause decreased FDG activity involving 1 or 2 lower thoracic vertebrae. The aim of this study was (1) to formally evaluate if this observation is indeed true and, if so, (2) to assess its frequency. PATIENTS AND METHODS: One hundred fifty-four PET/CT scans (81 males and 73 females, age 61 ± 13 years) were analyzed. On the coronal CT images, the vertebra above where the hemi-diaphragmatic surfaces abut the vertebral column was defined as the target vertebra (TV). On sagittal PET images, FDG activity in TV was visually and quantitatively assessed. Then, the severity of banana artifact on coronal PET images was graded from 0 to 2: 0 if there was no artifact, 1 if a thin photopenic stripe, and 2 if a thick banana-shaped photopenic artifact in the vicinity of diaphragm. RESULTS: Visually decreased activity in TV was present in 0% (0/93), 3% (1/34), and 59% (16/27) of scans graded as 0, 1, and 2, respectively (grade 0 and/or 1 vs. grade 2, P < 0.001). The SUV ratio of TV to reference vertebrae were 0.99 ± 0.14, 0.99 ± 0.15, and 0.84 ± 0.19 in grade 0, 1, and 2 scans, respectively (P < 0.001). CONCLUSION: Error of attenuation correction from respiratory motion can lead to underestimation of FDG activity in the lower thoracic spine, and this should not be interpreted as possible marrow replacement process requiring further imaging if there is coexisting banana artifact.

Negative Impact of Indwelling Biliary Stent on Gallbladder Visualization on Cholescintigraphy.

PURPOSE: Presence of biliary stent may alter biliary dynamics, which may change the results of cholescintigraphy. We assessed the frequency of gallbladder (GB) nonvisualization and its specificity for acute cholecystitis (AC) in patients with stent. PATIENTS AND METHODS: Of 44 with stent who had cholescintigraphy, 22 were excluded because of prior cholecystectomy or little to no radiotracer excretion from the liver precluding assessment of GB filling. Cholescintigraphy performed on the remaining 22 with stent and their medical records were reviewed. We also assessed the frequency of GB nonvisualization in the comparison group of 1044 without stent who had cholescintigraphy for evaluation of AC. RESULTS: Gallbladder was not visualized in 21 (96%) of 22 with stent, 10 of whom did not have high clinical suspicion of AC. Gallbladder was visualized in only 1 patient on delayed imaging at 4 hours. Four had cholecystectomy, 3 had chronic cholecystitis and 1 AC superimposed on chronic cholecystitis. The highest possible specificity derived from our data assuming an extreme hypothetical scenario was only 25% with the true specificity likely being 7% or lower. In contrast to patients with stents, only 188 (18%) of the 1044 without stent had GB nonvisualization (P < 0.0001). CONCLUSIONS: In patients with stents, cholescintigraphy using morphine augmentation or 4-hour delayed imaging is futile to evaluate for AC because the frequency of GB nonvisualization is high and the specificity of GB visualization is low. It is unknown whether further delayed imaging at 24 hours would improve the study efficacy in this population.

Efficacy of the maze procedure for atrial fibrillation associated with atrial septal defect.

BACKGROUND: Atrial fibrillation (AF) is a common complication in elderly patients with atrial septal defect (ASD). The purpose of this study was to examine the efficacy of the maze procedure in these patients. MATERIALS AND METHODS: Between February 2000 and May 2011, 46 patients underwent the maze procedure as a concomitant operation with ASD closure. Three patients who underwent a right-sided maze were excluded, and one patient was lost to follow-up. The mean follow-up duration was 3.2±2.5 years. Electrocardiography was performed 1 month, 3 months, 6 months, and 1 year after surgery, and checked annually after that. RESULTS: AF persisted in 4 patients after surgery. One year after surgery, among 38 patients, 55.3% remained in sinus rhythm without antiarrhythmic drugs. However, when including the patients who took antiarrhythmic drugs, 92.1% were in sinus rhythm. Freedom from AF recurrence at 3 months, 6 months, 1 year, 2 years, 3 years, and 5 years after surgery were 97.4±2.6, 94.4±3.8, 91.2±4.9, 87.8±5.8, 79.5±7.6, and 68.2±12.4, respectively. There was no early mortality after operation. CONCLUSION: Concomitant treatment with the maze procedure and ASD closure is safe and effective for restoring the sinus rhythm.

Successful management of pulmonary and inferior vena cava tumor embolism from renal cell carcinoma.

Pulmonary tumor embolism can be a cause of respiratory failure in patients with cancer even though it occurs rarely. We describe a 56-year-old man who underwent a pulmonary tumor embolectomy using cardiopulmonary bypass on beating heart combined with inferior vena cava embolectomy and right radical nephrectomy. Aggressive surgical treatment in this severe case is necessary not only to reduce the fatal outcome of pulmonary embolism in the short run, but also to improve the oncological prognosis in the long term.

Diagnosis of Graft Infection Using FDG PET-CT.

Graft infections after aortic replacement are a rare, but severe complication. Because surgical removal of the infection source is essential, an accurate diagnosis is required to prevent unnecessary treatment. Both of the patients described herein were diagnosed with graft infections using dual-modality positron emission tomography-computed tomography; one patient was a false-positive, and the other was confirmed with an infection.

Surgery for Pulmonary Sclerosing Hemangioma: Lobectomy versus Limited Resection.

BACKGROUND: Pulmonary sclerosing hemangioma is a rare thoracic tumor, and pathophysiology or clinical course of this tumor is not yet fully described. Furthermore, there is no consensus on the standard operative procedure for this tumor. MATERIAL AND METHODS: Medical records of thirty-two patients, who underwent surgical resection of pulmonary sclerosing hemangioma from 1996 to 2007, were retrospectively reviewed. RESULTS: Nineteen patients underwent lobectomy and thirteen patients underwent limited resection. Video-assisted thoracoscopic surgery was performed in 9 patients in the latter group. Lymph node dissection was done in 21 patients, and one patient was found to have lymph node metastasis of the tumor. There was no postoperative complication, no early death and no tumor-related late mortality. The mean follow-up duration was 39.3 months (2 months~129 months), and all patients were free of local recurrence and distant metastasis during this period. There was no significant difference in patient's characteristics between the two groups, except that the mean hospital stay was shorter in limited resection group than in lobectomy group (p=0.0031). CONCLUSION: Pulmonary sclerosing hemangioma usually requires surgical resection for both diagnosis and treatment. Limited resection can decrease hospital stay with a surgical outcome comparable to lobectomy, and may be preferred to lobectomy if sufficient resection margin can be achieved.