Thrombocytopenia Following Perceval Sutureless Aortic Valve Replacement in Asian Patients.

BACKGROUND: This study analyzed the safety and performance of the Perceval valve for aortic valve replacement (AVR) in patients at 1 year after undergoing aortic stenosis (AS) treatment, and its effect on significant declines in the platelet count during the immediate postoperative period.Methods and Results: Data were collected retrospectively for the initial 121 patients (median age 77 years; 47.1% females) who underwent Perceval sutureless AVR between May 2019 and July 2022. Implantation was successful in all (100%), with median cross-clamp and CPB times of 59 and 100 min, respectively. Postoperative thrombocytopenia (platelet count <50×103/µL) was noted in 80 (66.1%) patients. Multivariate analysis showed advanced age (>80 years), preoperative low platelet count (<200×103/µL), and a sternotomy approach as significant risk factors for postoperative thrombocytopenia. One (0.8%) patient died within 30 days after the procedure. The 2-year site-reported event rate was 14% (n=17) for all-cause mortality, 0.8% (n=1) for cardiac mortality, 4.1% (n=5) for stroke, and 1.7% (n=2) for endocarditis and valve-related reoperation; there were no instances of paravalvular leakage or structural valve deterioration. CONCLUSIONS: Thrombocytopenia was common after Perceval sutureless AVR, although its impact was not significant. Although Perceval sutureless AVR was found to be a safe and effective option, preoperative assessment of potential bleeding should be performed and the Perceval valve should not be used for patients with a high bleeding risk.

Effect of Narrow Chest on Minimally Invasive Mitral Valve Surgery via Right Minithoracotomy.

BACKGROUND: The effect of a narrow chest on minimally invasive mitral valve surgery (MIMVS) is unclear.Methods and Results: We enrolled 206 MIMVS patients and measured anteroposterior diameter (APD) between the sternum and vertebra, transverse thoracic diameter (TD), right and left APD of the hemithorax (RD and LD, respectively), and the Haller index (HI; TD/APD ratio) on computed tomography. Preoperative characteristics and operative outcomes were compared between patients with a narrow chest (Group N; HI >2.5; n=53) and those with a normal chest (control [C]; HI ≤2.5; n=153), and the correlations of these measurements with operation time were evaluated in 133 patients undergoing an isolated mitral procedure. Groups N and C differed significantly in APD (89.4 vs. 114.3 mm, respectively; P<0.001), TD (251.5 vs. 240.3 mm, respectively; P=0.002), RD (152.5 vs. 172.5 mm, respectively; P<0.001), LD (155.0 vs. 172.4 mm, respectively; P<0.001), and HI (2.84 vs. 2.12, respectively; P<0.001). Procedural characteristics were comparable, except for a longer aortic cross-clamp time (ACCT) in Group N (118.7 vs. 105.8 min; P=0.047). Rates of surgical death, re-exploration, cerebral infarction, and prolonged ventilation were comparable between the 2 groups. TD was significantly correlated with ACCT (R2=0.037, P=0.028) in patients undergoing an isolated mitral procedure. CONCLUSIONS: Early MIMVS outcomes in patients with narrow chests are satisfactory. TD prolongs ACCT during MIMVS.

Sutureless Aortic Valve Replacement Through Lateral Mini-Thoracotomy　- Feasibility and Effectiveness.

BACKGROUND: Minimally invasive sutureless aortic valve replacement with the Perceval bioprosthetic heart valve (MISUAVR) is commonly performed through a right anterior thoracotomy (AT). However, a lateral thoracotomy (LT) may be superior as it does not require rib and right internal thoracic artery (RITA) cutting.Methods and Results: In total, 38 MISUAVRs performed from May 2019 to approximately August 2021 were retrospectively reviewed; 21 through LT (Group L), and 17 through AT (Group A). In Group L, the skin incision was made on the right anterior axillary line and third intercostal space, and in group A, on the right anterior chest and second or third intercostal space. All other surgical techniques were the same. Age, body surface area, EuroSCORE II, and ejection fraction were similar between the patients. Cardiopulmonary bypass (L: 82±19 vs. A: 93±28 min, P=0.19) and cross-clamp times (L: 57±13, vs. A: 64±23 min, P=0.19) were similar. Rib and/or RITA cutting were required in 94.6% of patients in group A and in none of group L (P<0.001). Surgical visualization score was better in group L (L: 1.19±0.40 vs. A: 1.94±0.69, P<0.01). Total amount of intraoperative bleeding was lower in group L (L: 623±141 vs. A: 838±316 mL, P<0.01). Duration of hospital stay was similar (P=0.30). CONCLUSIONS: MISUAVR through LT has multiple advantages over AT.

Early and midterm results of minimally invasive aortic and mitral valve surgery via right mini-thoracotomy.

OBJECTIVES: There are few reports regarding minimally invasive aortic valve replacement concomitant with mitral valve surgery (MIAMVS). The aim of this study was to evaluate early and midterm MIAMVS results. METHODS: We reviewed the medical records of 21 consecutive patients (nine females, 43%) who underwent MIAMVS through a right mini-thoracotomy from December 2014 to April 2017. Mean patient age was 73 ± 7.4 years and four (19%) were New York Heart Association Class III or IV. Aortic stenosis and mitral valve insufficiency were the most common pathologies. All patients were followed for a mean period of 30 ± 8.5 months. RESULTS: The types of surgery consisted of aortic valve replacement with mitral valve repair in 11 (52%) patients, and replacement of both aortic and mitral valves in 10 (48%), while a tricuspid valve repair, was performed in four. No conversion to a full sternotomy was necessary in any of the cases. Postoperatively, the median intensive care unit and hospital stays were 4.7 and 11.8 days, respectively, with no in-hospital mortality. Following the initial treatment, all 21 patients were followed for a mean period of 30 ± 8.5 months (14-45 months). All patients returned to NYHA Class I or II following the procedure. During the follow-up period, there was no need for a heart valve reoperation for any of the patients and none showed recurrent mitral regurgitation (>mild), though one died from respiratory failure caused by pneumonia. CONCLUSIONS: MIAMVS can be performed via a right mini-thoracotomy, with acceptable early and midterm results expected. This may be a feasible alternative to the standard median sternotomy approach.

Silent brain infarction after minimally invasive cardiac surgery with retrograde perfusion.

BACKGROUND AND AIM: There is no report on silent brain infarction (SBI) after minimally invasive cardiac surgery (MICS) with retrograde perfusion. Thus, the current study aimed to investigate the incidence of SBI after MICS using magnetic resonance imaging (MRI). METHODS: This study included 174 patients who underwent MICS with retrograde perfusion between July 2014 and July 2018. Preoperative computed tomography (CT) angiography was routinely performed and vascular pathology was evaluated for patient selection. Postoperative MRI was performed to investigate the occurrence of SBI. RESULTS: Out of the total 174 patients, 26 (14.9%) presented with SBI. A total of 61 SBI lesions were found in the 26 patients; of these, 34 (56%) SBI lesions were in the right hemisphere and 27 (44%) in the left hemisphere. SBIs were primarily observed in the posterior cerebral artery territory. Multivariate analysis revealed aortic stenosis to be the only risk factor of SBI. CONCLUSIONS: Retrograde perfusion via femoral cannulation may not increase the incidence of SBI in selected MICS patients based on preoperative CT findings.

Push-Up Technique and Anatomical Deployment With the Endurant Stent-Graft System for Severely Angulated Aneurysm Necks.

PURPOSE: To describe a technique suitable for treating severely angulated (>75°) necks during endovascular aneurysm repair using the Endurant stent-graft. TECHNIQUE: In the push-up technique, the suprarenal stent is released early to fix the proximal stent-graft in place so that each stent in the neck can be deployed individually without displacing the device upward. It is important to push the delivery system up after each stent deployment to allow the fabric between the stents to fold up circumferentially. By doing so, there is minimal upward force applied to the suprarenal stent. Because the stents expand along the angulated neck while catching blood flow, this anatomical deployment is feasible, with hardly any change to the proximal neck shape after stent-graft implantation. CONCLUSION: The push-up technique and anatomical deployment with the Endurant stent-graft system are effective and safe methods for treating aneurysms with severely angulated necks.

Totally thoracoscopic atrial fibrillation surgery following massive small bowel resection due to superior mesenteric artery embolization: report of two cases.

BACKGROUND: Thromboembolic occlusion of the superior mesenteric artery (SMA) is a grave complication in individuals diagnosed with atrial fibrillation (AF). This condition often necessitates extensive bowel resection, culminating in short bowel syndrome, which presents challenges for anticoagulant administration and/or antiarrhythmic therapy. CASE PRESENTATION: Presented here are findings of two patients, aged 78 and 72 years, respectively, who underwent comprehensive thoracoscopic AF surgery subsequent to extensive small bowel resection following SMA embolization. In each, onset of AF precipitated an embolic event, while the concurrent presence of short bowel syndrome complicated anticoagulation management. Total thoracoscopic AF surgery, comprised stapler-closure of the left atrial appendage (LAA) and bilateral epicardial clamp-isolation of the pulmonary veins, an operative modality aimed at addressing AF rhythm control and mitigating embolic events such as cerebral infarction, led to favorable outcomes in both cases. Additionally, computed tomography (CT) conducted one month post-surgery revealed the absence of residual tissue in the LAA, with the left atrium demonstrating a well-rounded, spherical shape. At the time of writing, the patients have remained asymptomatic following surgery regarding thromboembolic and arrhythmic manifestations for 29 and 10 months, respectively, notwithstanding the absence of anticoagulant or antiarrhythmic pharmacotherapy. Additionally, electrocardiographic surveillance has revealed persistent sinus rhythm. CONCLUSIONS: The present findings underscore the feasibility and efficacy of a total thoracoscopic AF surgery procedure for patients presented with short bowel syndrome complicating SMA embolization, thus warranting consideration for its broader clinical application.

An elderly case of aortic stenosis associated with double-chambered right ventricle.

Double-chambered right ventricle (DCRV) caused by right ventricular outflow tract obstruction, is a developmental cardiac anomaly in which the anomalous muscle bundles divide the right ventricular cavity into two chambers. Few cases with DCRV coexisting with severe aortic stenosis (AS) have been reported. Moreover, adult cases are extremely uncommon.We report an elderly case of a heavy DCRV with severe AS detected by transthoracic echocardiography and catheterization study. An 85-year-old woman with dyspnea on effort and right-sided heart failure was diagnosed with DCRV and severe AS by echocardiography. She underwent a resection of the anomalous muscle of the right ventricle and aortic valve replacement. Her symptoms disappeared postoperatively and was discharged home. At 2 years postoperatively, she was generally well without recurrence of DCRV. In conclusion, the case of DCRV with AS is rare and surgery is useful to relieve the heart failure symptoms and improve the prognosis of both young and adult patients. Learning objective: Double-chambered right ventricle (DCRV) is uncommon in the older population; however, clinicians should consider DCRV in patients with right-sided heart failure as a differential diagnosis. The case of DCRV with aortic stenosis is rare, surgical treatment is particularly useful for these patients to relieve the heart failure symptoms and improve the prognosis in young and adult cases.

Single direct right axillary artery cannulation using a modified Seldinger technique in minimally invasive cardiac surgery.

OBJECTIVES: Single direct right axillary artery cannulation is uncommon in minimally invasive cardiac surgery; however, the risk of cerebral infarction due to retrograde perfusion using the femoral artery remains high in patients with thoracoabdominal aortic atheroma. In our institution, we perform right axillary artery cannulation using a modified Seldinger technique in patients with atherosclerotic disease. This study aimed to evaluate the safety and effectiveness of this technique in minimally invasive cardiac surgery. METHODS: Data of all peripheral cannulation cases in patients who underwent minimally invasive cardiac surgery between March 2014 and December 2019 were obtained from our institutional database. Right axillary artery cannulation was successfully performed in 175 patients, 112 of whom underwent magnetic resonance imaging. RESULTS: Procedures comprised single-valve 86.3% (n = 151, 86.3%), double-valve (n = 21, 12%), and triple-valve (n = 3, 1.7%) surgeries. In-hospital mortality rate was 1.7% (n = 3). Stroke rate was 1.1% (n = 2); these 2 patients developed stroke at 3 and 5 days postoperatively. Forty-one (36.9%) patients were diagnosed with silent brain infarction on postoperative magnetic resonance imaging. There were no instances of intraoperative local axillary arterial injury, dissection, rupture, or surgical wound infection. Two patients had axillary wound hematoma and 2 had temporary right limb neuropathy, which resolved before discharge. No cases of pseudoaneurysm were found at the cannulation site. Limb ischemia and compartment syndrome were not reported. CONCLUSIONS: There were no complications of postoperative symptomatic cerebral infarction following minimally invasive cardiac surgery with single direct right axillary artery cannulation using a modified Seldinger technique, even though patients had significant atherosclerotic vascular disease.

Surgical outcomes of minimally invasive aortic valve replacement via right mini-thoracotomy for hemodialysis patients.

OBJECTIVES: Minimally invasive valve surgery has become increasingly accepted as an alternative to conventional median sternotomy in low-risk patients. However, there have been no reports regarding the outcomes of this procedure on high-risk hemodialysis patients. The purpose of this investigation was to assess the surgical outcomes of minimally invasive aortic valve replacement (AVR) via right mini-thoracotomy (MIAVR) in hemodialysis patients compared with those of conventional AVR (CAVR) via full sternotomy. METHODS: Two hundred and seventy-four patients underwent isolated AVR for severe AS, and 42 hemodialysis patients were included in this study. MIAVR was performed in 17 cases and CAVR in 25 cases. We compared the short-term surgical outcome among the two groups. RESULTS: There was no difference in the aortic cross-clamp or cardiopulmonary bypass time. However, the procedure time was significantly shorter in the MIAVR group. Patients in the MIAVR group had less bleeding and a smaller amount of transfused red blood cells. There were four hospital deaths (18.2%) in the CAVR group. For postoperative complications, there were 2 (9.1%) cerebrovascular incidents, 2 (9.1%) cases of respiratory failure, 1 (4.5%) re-exploration for bleeding in CAVR group. The postoperative ventilation time was significantly shorter in the MIAVR group. There was no difference in the length of postoperative intensive care unit stay or of postoperative hospital stay. CONCLUSION: The surgical outcomes of MIAVR in hemodialysis patients were acceptable, with a low incidence of morbidity, reasonable lengths of hospital stay, and no mortality among the patients studied.

Collapse of Najuta endograft (aortic arch graft) in patient with intermittent paraparesis.

A 50-year-old male underwent thoracic endovascular aortic repair (TEVAR) for distal arch traumatic aortic dissection. Following placement of a Najuta endograft (Kawasumi Laboratories, Inc., Tokyo, Japan) from zone 0 to zone 4, patency of the three vessels was confirmed. Later, the patient suddenly experienced complete intermittent loss of motor and sensory functions in the bilateral lower extremities. Contrast computed tomography (CT) findings indicated endograft stenosis. Following an additional TEVAR procedure, the paraparesis state was temporarily improved. Thereafter, he was readmitted due to congestive heart failure with intermittent paraparesis and contrast CT findings indicated endograft collapse. An emergency procedure for re-expansion of the collapsed endograft and urgent surgery for replacement of the aortic arch was successful. In cases with intermittent paraparesis, endograft collapse should be considered.

Candesartan with pioglitazone protects against endothelial dysfunction and inflammatory responses in porcine coronary arteries implanted with sirolimus-eluting stents.

BACKGROUND: Sirolimus-eluting stents (SES) are widely used in coronary artery disease as revascularization therapy. Although endothelial dysfunction induced by implanted SES can become a major clinical concern, therapeutic strategies to overcome this disorder remain unclear. The aim of the present study was therefore to identify effective therapies in a clinically relevant animal model. METHODS AND RESULTS: Twenty-one pigs were randomized to control, candesartan (CAN) and candesartan plus pioglitazone (CAN+PIO) groups. Drugs were administered orally for 7 days before SES implantation until the time of death. Forty-two SES were used in porcine coronary arteries. Early inflammatory cell adhesion in SES evaluated on scanning electron microscopy at 3 days was significantly suppressed in the CAN and CAN+PIO groups compared with controls. Bradykinin-induced endothelium-dependent relaxation at an adjacent segment distal to the SES evaluated using organ chambers was reduced compared with intact segments in control coronaries at 28 days. Endothelial dysfunction was reversed by CAN and even more obviously improved in the CAN+PIO group. CONCLUSIONS: Candesartan protected against vascular inflammation and restored endothelial function after SES implantation. The combination of candesartan and pioglitazone was more effective than candesartan monotherapy and might confer vascular protection when administered before SES implantation.

Early and mid-term outcomes of minimally invasive mitral valve repair via right mini-thoracotomy: 5-year experience with 129 consecutive patients.

OBJECTIVES: This study analyzed the experience of a single institution with minimally invasive mitral valve repair (MIMVr) via a right mini-thoracotomy (RT), including short and mid-term morbidity and mortality as surgical outcomes, and rates of reoperation. Late follow-up findings regarding mitral regurgitation (MR) were also assessed. METHODS: Between January 2014 and January 2020, a total of 141 consecutive patients underwent MIMVr for mitral regurgitation at our institution via an RT, with late follow-up results (median 35 ± 15 months) available for 129 (91.4%). Findings regarding surgical approach, complications, reoperations, and late survival were examined. Late echocardiographic results showing recurrence of MR after mitral repair were also noted. Survival, freedom from reoperation, and recurrent MR (grade > 2) were evaluated by Kaplan-Meier analysis. RESULTS: Mean age was 63.9 ± 14.3 years, mean ejection fraction was 66.9 ± 10.4%, and 2 patients (1.6%) underwent a reoperation. Concomitant procedures included atrial fibrillation ablation (18%), tricuspid valve surgery (16%). None (0%) experienced intraoperative conversion to sternotomy. A learning curve was observed as the number of cases increased. Overall in-hospital mortality and stroke incidence were both 0%. Freedom from recurrent MR (grade > 2) at 1, 3, and 5 years was 99.2, 94.9, and 94.9%, respectively, while freedom from reoperation at 1, 3, and 5 years after mitral valve repair was 98.4, 98.4, and 98.4%, respectively. CONCLUSIONS: Early and mid-term results of MIMVr were satisfactory, with low rates of perioperative morbidity and recurrent MR, as well as reoperation and death. Furthermore, the protocols for patient selection and surgical approach were considered to be appropriate.

Perfusion strategy using axillary or femoral cannulation for minimally invasive cardiac surgery: experience in 270 patients with computed tomography-based criteria.

OBJECTIVES: In patients with atherosclerotic disease, minimally invasive cardiac surgery using retrograde perfusion for cardiopulmonary bypass via femoral cannulation (FC) carries a higher risk of brain embolization compared with antegrade perfusion. However, guidelines for selecting antegrade versus retrograde perfusion do not exist. We developed a computed tomography (CT)-based perfusion strategy and assessed outcomes. METHODS: We studied 270 minimally invasive cardiac surgery patients, aged 68 ± 13, 124 female, body surface area 1.6 ± 0.2 m2. Antegrade perfusion using axillary cannulation (AC) was selected if any of the following preoperative enhanced CT scan criteria were satisfied anywhere in the aorta or iliac arteries: thrombosis thickness >3 mm, thrombosis >one-third of the total circumference and calcification present in the total circumference. FC was selected otherwise. Asymptomatic brain injury was assessed by diffusion-weighted magnetic resonance imaging. RESULTS: AC and FC were selected in 95 (35%) and 175 patients, respectively. AC patients were 10 years older (P < 0.001) and had higher EuroSCORE II (2.7 ± 3.4 vs 1.7 ± 1.9, P = 0.002). The median cardiopulmonary time and cross-clamp times were not significantly different. No patients died in hospital. There was no immediate stroke in either group during 48 h after surgery. Asymptomatic brain injury was detected in 25 (26%) and 27 (15%) AC and FC patients, respectively, P = 0.03. CONCLUSIONS: We believe our CT-based perfusion strategy using AC or FC minimized brain embolic rates. AC can be a good alternative to prevent brain embolization for minimally invasive cardiac surgery patients with advanced atherosclerotic disease.

Prognostic significance of glomerular filtration rate estimated by the Japanese equation among patients who underwent complete coronary revascularization.

An equation that accurately estimates the glomerular filtration rate (GFR) in the Japanese population has been proposed; however, the prognostic significance of estimated GFR (eGFR) defined according to this equation has not been reported. In addition, the prognostic significance of eGFR during long-term follow-up after complete coronary revascularization remains unclear. We assessed the prognostic significance of eGFR values, estimated by the new Japanese equation, in a cohort of patients following complete coronary revascularization. We studied consecutive patients with complete revascularization from 1984 to 1992. Patients on dialysis were excluded. A novel Japanese equation was used to estimate the GFR: eGFR=194×(serum creatinine)(-1.094)×(age)(-0.287)(×0.739 if female). Multivariate Cox proportional hazards regression analyses were performed to determine all-cause and cardiac mortality. We analyzed data of 1809 patients, of whom 571 (31.6%) had an eGFR of ≥90 mlmin(-1) per 1.73 m(2), 917 (50.7%) had an eGFR of 60-89 mlmin(-1) per 1.73 m(2), 298 (16.5%) had an eGFR of 30-59 mlmin(-1) per 1.73 m(2) and 23 (1.3%) had an eGFR of <30 mlmin(-1) per 1.73 m(2). During follow-up (11.4±2.9 years), there were 397 (22.0%) all-cause and 123 (6.8%) cardiac deaths overall. Patients with an eGFR of 30-59 mlmin(-1) per 1.73 m(2), and <30 mlmin(-1) per 1.73 m(2) revealed significantly greater risk of all-cause mortality than those with eGFR of ≥90 mlmin(-1) per 1.73 m(2) (hazard ratio (HR) 1.91, P<0.001, HR 3.35, P<0.001, respectively). Furthermore, incidence of cardiac death was higher in patients with an eGFR of 30-59 mlmin(-1) per 1.73 m(2) than those with an eGFR of ≥90 mlmin(-1) per 1.73 m(2) (HR 2.89, P<0.001). GFR as estimated using the new Japanese equation had a prognostic significance among patients with complete coronary revascularization.

Effect of preoperative hemoglobin A1c levels on long-term outcomes for diabetic patients after off-pump coronary artery bypass grafting.

BACKGROUND: Diabetes mellitus is an independent risk factor for cardiovascular events after coronary artery bypass grafting (CABG), and hemoglobin A1c (HbA1c) is the most convenient marker for monitoring glycemic control among diabetic patients. However, few studies have reported the impact of baseline HbA1c levels on outcomes for diabetic patients after CABG. This study therefore aimed to investigate whether preoperative HbA1c levels in diabetic patients are predictive of long-term outcomes after off-pump CABG (OPCAB). METHODS AND RESULTS: Of 893 patients undergoing primary isolated OPCAB at Juntendo University Hospital from July 2002 to December 2007, subjects comprised 306 diabetic patients <80 years old. We divided these patients into 3 groups according to the preoperative HbA1c levels. No significant differences in baseline characteristics, angiographic findings, or operative parameters were apparent among the 3 groups. No operative or in-hospital mortality occurred. All-cause mortality and cardiac mortality rates were 6.2% (19 cases) and 1.3% (4 cases), respectively. Kaplan-Meier's survival showed no significant differences in all-cause or cardiac mortality (log-rank test, p=0.26, p=0.17, respectively). Multivariate analysis by Cox's proportional hazards model also demonstrated that no covariates predicted mortality except for age. CONCLUSIONS: Preoperative HbA1c levels might not predict long-term outcomes for diabetic patients undergoing OPCAB. Careful evaluation for diabetes should be needed in preoperative management of CABG.