松浦 馨

BACKGROUND: Limited data are available for clinical outcomes in patients who underwent urgent or emergency transcatheter aortic valve implantation (TAVI). This study investigated in-hospital and 1-year outcomes and explored prognostic covariates in urgent/emergency TAVI using nationwide registry data.Methods and Results: Among 26,775 patients who underwent TAVI between August 2013 and December 2019, 25,495 with 1-year follow-up information were analyzed in this study. Baseline and procedural characteristics, as well as clinical adverse events, were compared between the urgent/emergency and elective TAVI groups. The primary outcome was all-cause mortality within 1 year after TAVI. Multivariable Cox regression models were constructed to identify independent predictors after urgent or emergency TAVI. Urgent or emergency TAVI was performed in 578 (2.3%) patients. The Society of Thoracic Surgeons score was significantly higher in the urgent/emergency than elective TAVI group (13.3% vs. 6.0%; P<0.001). Device success rate was comparable between the 2 groups. All-cause death-free survival within 1 year was lower in the urgent/emergency than elective TAVI group (77.2% vs. 92.2%; log rank P<0.001). Malignancy, albumin and creatinine concentrations, ejection fraction, and mean pressure gradient were associated with 1-year mortality in the urgent/emergency TAVI group. CONCLUSIONS: Despite higher surgical risk and more comorbidities, the procedure was successfully performed in patients undergoing urgent/emergency TAVI, although it should be noted that prognosis was worse than for elective TAVI.

OBJECTIVES: This study analyzed the long-term survival of dialysis patients undergoing AVR using the Japanese National Clinical Database with additional survival data. METHODS: De-novo AVR for dialysis-dependent patients between 2010 and 2012 who were registered in the Japan Cardiovascular Surgery Database were included. Concomitant aortic surgery and transcatheter aortic valve replacement were excluded. An additional questionnaire was sent to each hospital regarding the underlying kidney disease, the duration of dialysis initiation to the surgery, and clinical outcomes. The Kaplan-Meier survival curve was descriptively shown for all cohorts and each renal pathology. Furthermore, we compared the incidence of bioprosthetic valve failure in patients who were < 65 years old (group Y) and ≧65 years old (group O). RESULTS: Of these 1529 patients, diabetic nephropathy was 517, chronic glomerulonephritis was 437, and renal sclerosis was 210, regarding renal pathology. 1, 3, and 5-year survival in each pathology was 78.4%, 58.6%, 45.9% in diabetic nephritis, 78.8%, 68.4%, 58.2% in chronic glomerulonephritis, 79.0%, 67.8%, 52.1% in renal sclerosis, and 74.4%, 62.6%, 49.2% in others. Active infectious endocarditis was more prevalent in group Y (O 2.7% vs. Y 9.6%). The incidence of bioprosthetic valve failure requiring re-hospitalization was too small to analyze. 1, 3, and 5-year survival was 76.0%, 63.4%, 49.2% in group O and 74.3%, 64.2%, and 47.7% in group Y. CONCLUSIONS: Long-term survival of AVR for dialysis-dependent was higher in patients with chronic glomerulonephritis and lower in patients with diabetic nephritis than in other pathologies.

BACKGROUND: Extracellular volume fraction (ECV) on magnetic resonance imaging can predict prognosis after aortic valve replacement in patients with aortic stenosis (AS). However, the usefulness of ECV on computed tomography (CT) for patients who have undergone transcatheter aortic valve replacement (TAVR) is unclear, so we investigated whether ECV analysis on CT is associated with clinical outcomes in TAVR candidates.Methods and Results: We analyzed 127 patients with severe AS who underwent preoperative CT for TAVR. We evaluated the utility of ECV analysis on single-energy CT for predicting patient prognosis after TAVR. The primary outcome was a composite of all-cause death and hospitalization due to heart failure (HF) after TAVR. 15 patients (12%) had composite outcomes: 4 deaths and 11 hospitalizations due to HF. In multivariate survival analysis using the Cox proportional hazard model, atrial fibrillation (AF) (hazard ratio (HR), 7.86; 95% confidence interval (CI), 2.57-24.03; P<0.001), history of congestive HF (HR, 4.91; 95% CI, 1.49-16.2; P=0.009) and ECV ≥32.6% on CT (HR, 6.96; 95% CI, 1.92-25.12; P=0.003) were independent predictors of composite outcomes. On Kaplan-Meier analysis, the higher ECV group (≥32.6%) had a significantly greater number of composite outcomes than the lower ECV group (P<0.001). CONCLUSIONS: ECV on CT is an independent predictor of prognosis after TAVR.

BACKGROUND: We investigated the influence of concomitant mitral regurgitation (MR) in patients undergoing transcatheter aortic valve implantation on the 1-year outcome using Japan Transcatheter Valve Therapy (J-TVT) registry data. METHODS: The patients who underwent the transcatheter aortic valve implantation for aortic stenosis performed from August 2013 to December 2019 in Japan were included. History of previous valve surgery and dialysis patients were excluded. A total of 24,979 patients were included, and 1-year follow-up data were obtained from the registry (follow-up rate 98.5 %). Propensity-score matching, using multivariable logistic regression and 1:1 matching without replacement, was performed between the patients with grade 3-4 MR (MR 3-4 group) and those with grade 0-2 MR (MR 0-2 group). All-cause death and the composite outcome of death and/or heart failure events were compared. RESULTS: After propensity score matching, 3920 cases (1960 cases each in MR 0-2 group and MR 3-4 group) were extracted. The procedure success rate was 96.4 % in MR 0-2 and 96.0 % in MR 3-4 group (p = 0.56) and the surgical conversion rate was 0.7 % in MR 0-2 group and 0.8 % in MR 3-4 group (p = 0.58). Cox regression model showed no statistical difference in 1-year survival rate between MR 0-2 group (89.4 %) and MR 3-4 group (89.6 %) (p = 0.80). However, freedom from 1-year death and/or heart failure event was lower in MR 3-4 (86.3 %) than in MR 0-2 group (88.9 %) (p = 0.01). This trend was also found in the subgroup of New York Heart Association (NYHA) class 1-2 but not in the subgroup of NYHA class 3-4. CONCLUSIONS: One-year survival rate was not different between groups but freedom from death and/or heart failure events was lower in patients with preoperative MR grade 3-4 than in patients with preoperative MR grade 0-2 after transcatheter aortic valve replacement.

A 74-year-old woman with a history of interstitial pneumonia, who had been taking oral corticosteroids for the past 9 years, was diagnosed with severe aortic stenosis. The patient underwent transfemoral transcatheter aortic valve replacement (TAVR) with a balloon-expandable valve under local anesthesia. After deploying a 26-mm SAPIEN 3 valve with 1.5 ml less balloon inflation, transesophageal echocardiography revealed a hemorrhage in the aortic annulus. Intraoperative angiography revealed a small contrast leakage around the ascending aorta. Emergent surgical aortic valve replacement was performed successfully, with a tear at the non-left commissure closed using interrupted sutures. The patient was discharged on postoperative day 14 with no paravalvular leakage. Chronic corticosteroid use may be a risk factor for annular ruptures during TAVR. Careful balloon dilation may be necessary, especially when balloon-expandable valves are used in patients receiving long-term corticosteroids.

Residual pulmonary hypertension (PH) negatively impacts long-term results following pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). We sought to reveal whether modern PH therapy with PH-targeted medicine and balloon pulmonary angioplasty (BPA) improved long-term results of residual PH after PEA. Long-term findings of 80 patients who survived PEA between 2011 and 2019 were retrospectively investigated. One month after PEA, 30 patients developed residual PH defined as mean pulmonary artery pressure (mPAP) ≥25 mmHg, of whom 23 were treated by PH-targeted medicine and 9 by BPA. Patients with residual PH acquired considerably better functional status and exercise capacity after PEA, however, exhibited significantly worse survival rates than those without. Eleven patients died during follow-up: 8 patients with residual PH and 3 controls. Among patients with residual PH, the deceased had a significantly lower %decrease in mPAP from 1 month to 1 year following PEA (7.4 [-32.6 to 8.0] % vs. 10.4 [3.7-27.8] %, p = 0.03) and higher mPAP at 1 year following PEA (39.5 [33.25-42.5] vs. 27 [26-34] mmHg, p < 0.01) despite PH-targeted medicine than the survived. No patients passed away from right heart failure, and there was no difference between the groups in CTEPH-related mortality. Modern PH therapy was used to address the majority of residual PH. Long-term survival after PEA was negatively impacted by residual PH, but it appeared that long-term mortality was also correlated with unrelieved residual PH despite PH-targeted medicine. Modern PH therapy may have enhanced functional status and excercise capacity, and averted fatal right heart failure.

BACKGROUND: This study shows an analysis of long-term survival of dialysis-dependent patients undergoing aortic valve replacement (AVR) using the Japan National Clinical Database and additional data. METHODS: Dialysis-dependent patients with de-novo AVR between 2010 and 2012 registered in the database were included. Concomitant aortic surgery and transcatheter aortic valve replacement were excluded. Additional data on the underlying kidney disease, the duration of dialysis, and clinical outcomes were registered between October 29, 2019, and August 30, 2020. The primary outcome was all-cause mortality. The secondary outcomes were cerebral infarction, cerebral bleeding, gastrointestinal bleeding, and prosthetic valve failure. RESULTS: After propensity score matching, 1016 cases (508 each in bioprosthetic and mechanical valve group) were matched. The median follow-up period was 3.29 years (IQR; 0.59 years, 6.25 years). The median survival time was 5.38 years (IQR 1.20 and 9.26 years) in the mechanical valve group and 4.98 years (IQR 1.69 and 9.62 years) in the bioprosthetic valve group. The Cox regression model showed no significant difference in long-term survival between groups (mechanical valve; HR 0.895, 95% CI 0.719-1.113, p=0.318). The incidence of cerebral infarction and prosthetic valve failure requiring admission were similar between groups. Cerebral (HR 2.143, 95% CI 1.125-4.080, p=0.002) and gastrointestinal bleeding (HR 2.071, 95% CI 1.243-3.451, p=0.0005) were more frequent in the mechanical valve group. CONCLUSIONS: Long-term survival of dialysis-dependent patients was similar regardless of whether mechanical or bioprosthetic valves were implanted. The incidences of cerebral and gastrointestinal bleeding were twofold higher in the mechanical valve group.

PURPOSE: Neurologic adverse events (NAEs) are a major complication after pulmonary endarterectomy (PEA) performed under periods of deep hypothermic circulatory arrest (HCA) for chronic thromboembolic pulmonary hypertension. We modified the PEA strategy to prevent NAEs and evaluated the effectiveness of these modifications. METHODS: We reviewed the surgical outcomes of 87 patients divided into the following three groups based on the surgical strategy used: group S (n = 49), periods of deep HCA with alpha-stat strategy; group M1 (n = 19), deep HCA with modifications of slower cooling and rewarming rates and the pH-stat strategy for cooling: and group M2 (n = 13), multiple short periods of moderate HCA. RESULTS: PEA provided significant improvement of pulmonary hemodynamics in each group. Sixteen (29%) of the 49 group S patients suffered NAEs, associated with total circulatory arrest time (cutoff, 57 min) and Jamieson type I disease. The Group M1 and M2 patients did not suffer NAEs, although the group M1 patients had prolonged cardiopulmonary bypass (CPB) and more frequent respiratory failure. CONCLUSIONS: NAEs were common after PEA performed under periods of deep HCA. The modified surgical strategy could decrease the risk of NAEs but increase the risk of respiratory failure. Multiple short periods of moderate HCA may be useful for patients at risk of NAEs.

BACKGROUND: Some attempts have been made to detect atrial fibrillation (AF) with a wearable device equipped with photoelectric volumetric pulse wave technology, and it is expected to be applied under real clinical conditions. OBJECTIVE: This study is the second part of a 2-phase study aimed at developing a method for immediate detection of paroxysmal AF, using a wearable device with built-in photoplethysmography (PPG). The objective of this study is to develop an algorithm to immediately diagnose AF by an Apple Watch equipped with a PPG sensor that is worn by patients undergoing cardiac surgery and to use machine learning on the pulse data output from the device. METHODS: A total of 80 patients who underwent cardiac surgery at a single institution between June 2020 and March 2021 were monitored for postoperative AF, using a telemetry-monitored electrocardiogram (ECG) and an Apple Watch. AF was diagnosed by qualified physicians from telemetry-monitored ECGs and 12-lead ECGs; a diagnostic algorithm was developed using machine learning on the pulse rate data output from the Apple Watch. RESULTS: One of the 80 patients was excluded from the analysis due to redness caused by wearing the Apple Watch. Of 79 patients, 27 (34.2%) developed AF, and 199 events of AF including brief AF were observed. Of them, 18 events of AF lasting longer than 1 hour were observed, and cross-correlation analysis showed that pulse rate measured by Apple Watch was strongly correlated (cross-correlation functions [CCF]: 0.6-0.8) with 8 events and very strongly correlated (CCF>0.8) with 3 events. The diagnostic accuracy by machine learning was 0.9416 (sensitivity 0.909 and specificity 0.838 at the point closest to the top left) for the area under the receiver operating characteristic curve. CONCLUSIONS: We were able to safely monitor pulse rate in patients who wore an Apple Watch after cardiac surgery. Although the pulse rate measured by the PPG sensor does not follow the heart rate recorded by telemetry-monitored ECGs in some parts, which may reduce the accuracy of AF diagnosis by machine learning, we have shown the possibility of clinical application of using only the pulse rate collected by the PPG sensor for the early detection of AF.

Mucopolysaccharidosis type II, known as Hunter syndrome, is a rare inherited metabolic disorder with glycosaminoglycan accumulation leading to progressive multisystem involvement, such as heart, respiratory, and central nervous systems. In particular, concurrence of major heart and respiratory problems in this syndrome often causes difficulty in performing curative and invasive treatments. Transcatheter aortic valve implantation (TAVI) has been an established therapy for severe aortic stenosis (AS). In patients who cannot undergo surgical aortic valve replacement because of high risk for general anesthesia, TAVI with local anesthesia has become an alternative therapy for severe AS. We report herein a case of 50-year-old man with Hunter syndrome accompanied by severe airway obstruction who underwent TAVI with local anesthesia for severe AS. <Learning objective: Mucopolysaccharidosis is characterized by glycosaminoglycan accumulation leading to progressive multisystem involvement. Heart disease and respiratory problems are often concomitant in patients with mucopolysaccharidosis. When surgical treatment is required, consideration about treatment strategy and perioperative management are important because of its high surgical risk or inoperable status. We describe a case with mucopolysaccharidosis accompanied by severe airway obstruction who underwent transcatheter aortic valve implantation with local anesthesia for severe aortic stenosis.>.

BACKGROUND: To elucidate the impact of tricuspid annuloplasty concomitant with left-sided valve surgery on the right ventricular (RV) function in patients with mild or more tricuspid regurgitation (TR). METHODS: We enrolled 136 patients with mild or more TR who underwent left-sided valve surgery. Seventy-three patients underwent left-sided valve surgery alone (group non-T) and 63 underwent concomitant tricuspid annuloplasty (group T). The echocardiographic data at the latest follow-up (mean 1019 days) were compared using multiple regression analysis to adjust cofounding factors. Propensity score was calculated and included in the analysis as a covariate. In addition, propensity score matching was used for sensitive analysis (12 pairs). RESULTS: In group non-T, there were more aortic valve surgeries, and fewer mitral valve surgeries. At baseline, body surface area, New York Heart Association class, and prevalence of atrial fibrillation were significantly different between groups. On preoperative echocardiography, left and right atrial diameter, RV diameter, and tricuspid annular diameter were larger in group T, whereas there was no significant difference in RV fractional area change. In multiple regression analyses, RV diameter in diastole was significantly lower and RV fractional area change was significantly higher at the follow-up period in group T. These results were not attenuated even in subgroup analysis in patients with only mild TR or mitral valve surgery alone. CONCLUSION: Among patients with mild or more TR, RV dimensional and functional recovery was not obtained with left-sided valve surgery alone. Adding tricuspid annuloplasty may potentially achieve both outcomes.

＜文献概要＞Point ・手術の低侵襲化とカテーテル治療の進化によって,高齢者の弁膜症に対してもリスクやfrailtyなど多方面から評価したうえで治療適応を検討するようになり,全体的に適応は拡大傾向にある.・外科医の役割は多岐にわたり,適応評価に参画するだけでなく,低侵襲化する外科手術のクオリティの向上や複雑化するconventional手術の安全性の担保とともにカテーテル治療を熟知し,また参加することが求められている.

症例は57歳男性。慢性腎臓病精査目的で撮影したCTにおいて60mm径の胸腹部大動脈瘤を指摘されて当科紹介、造影CTで慢性B型大動脈解離の診断となった。遠位弓部のエントリー以下で真腔は著明に狭小化し、大動脈終末で閉塞していた。高度腎機能低下や自己免疫疾患、統合失調症の既往と背景の複雑な若年者において一期的な開胸開腹手術は選択しづらく、TEVARで低侵襲に治療する方法を模索した。狭小化した真腔へのステントグラフト留置は困難であり偽腔への留置を検討したものの、エントリーの閉鎖により真腔全体が閉塞されると肋間動脈や上腸間膜動脈の血流が障害されると想定された。そのため外科的開窓を併用した腹部大動脈人工血管置換術を先行して両腔の交通を確保し、約1ヵ月後に、末梢側を偽腔に留置させる1X debranching zone 2 TEVAR(-Th12)を施行して瘤の空置に成功した。偽腔へのステントグラフト留置による治療成績はこれまでにほぼ報告されていないが、真腔が著明に狭小化し、解剖学的条件を満たした症例に対しては選択肢の1つとして考慮できる。(著者抄録)

症例は48歳男性。解離性大動脈瘤(DeBakey III B型)に対し25歳時に下行大動脈置換術、27歳時に上行大動脈瘤に対し上行大動脈+部分弓部大動脈置換術、28歳時に残存解離による胸腹部大動脈瘤に対し胸腹部大動脈置換術を施行され外来で経過観察されていた。3回目の手術時に腹腔動脈・上腸間膜動脈・右腎動脈がVisceral aortic patch(VAP)を用いて再建されており、同部の残存している自家大動脈壁に瘤化(最大径70mm×61mm)を認めたため手術の方針となった。2回の左開胸手術後であったため2期的にhybrid aortic repairを施行する方針とし1回目にreno-visceral debranching手術、2回目にステントグラフト内挿術を行い、瘤の空置に成功した。(著者抄録)

Left ventricular assist device (LVAD) is an established therapy for patients with severe heart failure. Because the incidence of cardiotoxicity owing to anticancer agents is low, it is difficult to predict the recovery prospects when the cause of heart failure is due to anticancer agents. In this context, cancer patients who present with severe symptoms of heart failure and who fail medical therapy for heart failure may pose a dilemma, especially in countries such as Japan where implantable LVADs are not approved for purposes other than bridging to transplant. Recently, we encountered a 32-year-old woman with chemotherapy-related cardiomyopathy that developed after anticancer treatment using trastuzumab and anthracycline. LVAD therapy was the only option to save the young woman. The patient received an extracorporeal LVAD, her cardiac function gradually recovered while on support, and the device was successfully removed.

BACKGROUND: The objective of this study was to evaluate the hemodynamic characteristics of multiple sequential coronary artery bypass grafting using a computational fluid dynamics study. METHODS: First anastomosis was configured into parallel and diamond anastomoses, and the second anastomosis was set as end-side anastomosis. The anastomosis incision lengths were fixed at 2 mm. Various combinations of the degree of first and second stenoses were studied. The diameter of both the native and graft vessels was set at 2 mm. The inlet boundary condition was set by a sample of the transient time flow measurement, which was measured intraoperatively. RESULTS: Both swirl and stagnation were observed at the outlets of the stenosis and the anastomosis sites. When the severity of the second stenosis was larger than that of the first, the flow at the outlet of the second stenosis was more unstable. Higher wall shear stress and larger oscillatory shear index regions were observed when the severe stenosis was bypassed by the first anastomosis, especially with diamond anastomoses. Less energy loss and higher energy efficiency were present when the vessel with more severe stenosis was bypassed as the second anastomosis. Energy loss was lower and energy efficiency was higher with parallel anastomosis than diamond anastomosis when the severity of the two stenoses was the same. CONCLUSIONS: It is ideal to bypass the less severe stenosis vessel first with a parallel anastomosis method when employing multiple sequential bypass grafting. This improves hemodynamic stability and energy efficiency, according to a computational fluid dynamics model.

Pulmonary embolectomy is an effective treatment of acute pulmonary embolism (APE) but not for chronic pulmonary thromboembolism. We described surgical experience of two patients with APE in preexistent unidentified chronic pulmonary thromboembolism. One patient who presented with severe hypoxia but stable hemodynamics underwent successful pulmonary endarterectomy for proximal organized thrombus instead of pulmonary embolectomy. The other patient who required extracorporeal membrane oxygenation for severe hypoxia developed right heart failure because of residual distal organized thrombus after pulmonary embolectomy. Clinical and radiographical presentation of APE in chronic pulmonary thromboembolism mimics APE, and thus, candidates of pulmonary embolectomy should be carefully selected.

BACKGROUND: Wearable devices with photoplethysmography (PPG) technology can be useful for detecting paroxysmal atrial fibrillation (AF), which often goes uncaptured despite being a leading cause of stroke. OBJECTIVE: This study is the first part of a 2-phase study that aimed at developing a method for immediate detection of paroxysmal AF using PPG-integrated wearable devices. In this study, the diagnostic performance of 2 major smart watches, Apple Watch Series 3 and Fitbit (FBT) Charge HR Wireless Activity Wristband, each equipped with a PPG sensor, was compared, and the pulse rate data outputted from those devices were analyzed for precision and accuracy in reference to the heart rate data from electrocardiography (ECG) during AF. METHODS: A total of 40 subjects from patients who underwent cardiac surgery at a single center between September 2017 and March 2018 were monitored for postoperative AF using telemetric ECG and PPG devices. AF was diagnosed using a 12-lead ECG by qualified physicians. Each subject was given a pair of smart watches, Apple Watch and FBT, for simultaneous pulse rate monitoring. The heart rate of all subjects was also recorded on the telemetry system. Time series pulse rate trends and heart rate trends were created and analyzed for trend pattern similarities. Those trend data were then used to determine the accuracy of PPG-based pulse rate measurements in reference to ECG-based heart rate measurements during AF. RESULTS: Of the 20 AF events in group FBT, 6 (30%) showed a moderate or higher correlation (cross-correlation function>0.40) between pulse rate trend patterns and heart rate trend patterns. Of the 16 AF events in group Apple Watch (workout [W] mode), 12 (75%) showed a moderate or higher correlation between the 2 trend patterns. Linear regression analyses also showed a significant correlation between the pulse rates and the heart rates during AF in the subjects with Apple Watch. This correlation was not observed with FBT. The regression formula for Apple Watch W mode and FBT was X=14.203 + 0.841Y and X=58.225 + 0.228Y, respectively (where X denotes the mean of all average pulse rates during AF and Y denotes the mean of all corresponding average heart rates during AF), and the coefficient of determination (R2) was 0.685 and 0.057, respectively (P<.001 and .29, respectively). CONCLUSIONS: In this validation study, the detection precision of AF and measurement accuracy during AF were both better with Apple Watch W mode than with FBT.

Trans-catheter aortic valve implantation (TAVI) has been recognized as a useful treatment for patients with severe aortic valve stenosis, particularly those with moderate to high risks of open heart surgery. A thorough evaluation of the aortic valve complex, including the size or presence of calcifications of the leaflets and annulus, is important for the selection of appropriate candidates, artificial valve types and approach. Echocardiography is useful for the precise evaluation of aortic valve stenosis severity and aortic valve complex morphology, but it is not useful to evaluate three-dimensional aortic valve anatomy and pathway for the catheter of aortic valve implantation. Electrocardiography (ECG)-gating computed tomography (CT) has recently been recognized as a useful modality for evaluating significant coronary artery stenosis because of its higher spatial and temporal resolution and diagnostic accuracy based on recent studies. ECG-gating CT is also useful for evaluating aortic valve complex morphology, including calcifications and whole aorta and iliac arteries, as the access route of catheter in TAVI. TAVI candidates, who are at high risk of open surgery, tend to be old and require anti-platelet after TAVI; therefore CT, is also useful for screening for non-cardiac diseases including malignant tumors just before TAVI. Therefore, here we introduce the utility of cardiac and whole body CT in cases of severe aortic valve stenosis before and after TAVI.

The surgical indication and optimal approach for ischemic mitral regurgitation with ventricular septal defect remain uncertain. Very few studies have reported the occurrence of left ventricular aneurysms after repair of ischemic ventricular septal defects. We report a case of a left posterior ventricular aneurysm that developed after an urgent operation to repair an acute ischemic posterior ventricular septal defect using the double-patch sandwich technique via a right ventriculotomy.

Background: The objective of this study was to evaluate hemodynamic patterns in end-side coronary artery bypass grafting with different anastomosis length by computational fluid dynamic study in the native coronary stenosis model. Methods: The fluid dynamic computations were carried out using ANSYS CFX. Incision length was set to be 2, 4, 6, 8, 10 mm. The angle between the two blood vessels corresponded to the length of the incision. Native vessels were set to be 90% stenosis. The radius of both native and graft vessels was set to be 2 mm. The inlet boundary condition was set by the sample of the transient time flow which was measured intraoperatively. Results: The energy efficiency was higher and energy loss was lower when the anastomosis length was longer until 8 mm. However, energy efficiency was lowest and energy loss was highest in the 10-mm model. In the 10-mm incision model, the streamline showed the scanty bypass flow in the bottom. Vortex showed that only 10-mm model showed the vortex just distal to the stenosis in the native inlet, and more vortex in native outlet than other length models. The oscillatory shear index (OSI) was higher in the outlet top in all models. And only 10-mm model showed high oscillatory index just distal to the stenosis. Conclusions: In the end-side anastomosis, an anastomosis length of 8 mm was the ideal length with less flow complexity, low OSI, and less energy loss and high energy efficiency in the native 90% stenosis model.

OBJECTIVES: The objective of this study was to evaluate the haemodynamic patterns in each anastomosis fashion using a computational fluid dynamic study in a native coronary occlusion model. METHODS: Fluid dynamic computations were carried out with ANSYS CFX (ANSYS Inc., Canonsburg, PA, USA) software. The incision lengths for parallel and diamond anastomoses were fixed at 2 mm. Native vessels were set to be totally occluded. The diameter of both the native and graft vessels was set to be 2 mm. The inlet boundary condition was set by a sample of the transient time flow measurement which was measured intraoperatively. RESULTS: The diamond anastomosis was observed to reduce flow to the native outlet and increase flow to the bypass outlet; the opposite was observed in the parallel anastomosis. Total energy efficiency was higher in the diamond anastomosis than the parallel anastomosis. Wall shear stress was higher in the diamond anastomosis than in the parallel anastomosis; it was the highest at the top of the outlet. A high oscillatory shear index was observed at the bypass inlet in the parallel anastomosis and at the native inlet in the diamond anastomosis. CONCLUSIONS: The diamond sequential anastomosis would be an effective option for multiple sequential bypasses because of the better flow to the bypass outlet than with the parallel anastomosis. However, flow competition should be kept in mind while using the diamond anastomosis for moderately stenotic vessels because of worsened flow to the native outlet. Care should be taken to ensure that the fluid dynamics patterns are optimal and prevent future native and bypass vessel disease progression.

Recurrent tricuspid regurgitation (TR) can occur after tricuspid annuloplasty if severe leaflet tethering persists. To reduce the tethering, we applied right ventricular papillary muscle approximation in 7 patients with severe functional TR associated with significant leaflet tethering. Postoperative echocardiogram revealed mild or less TR and a significant reduction in the tethering effect. In conclusion, this adjunctive technique can improve functional TR associated with leaflet tethering.

The purpose of this study is to compare the late outcome of aortic valve replacement with or without preoperative coronary artery disease, and with or without coronary artery bypass. Between 2014 and 2015, 291 patients underwent aortic valve replacement. Average follow-up term was 2.5 ± 2.2 years. The retrospective comparative study was performed between the patients with (n = 115) or without (n = 176) preoperative coronary artery disease (Study 1) and with (n = 93) or without (n = 198) coronary artery bypass grafting (Study 2). Study 1: male patients were more, and diabetes was more in the patients with coronary artery disease. Long-term survival rate was significantly low in the patients with coronary artery disease (p = 0.0002 by log rank test). Freedom from repeat coronary revascularization rate was lower in the patients with coronary artery disease (p = 0.02 by log rank test). Study 2: operation time (419 ± 130 vs 290 ± 101; p = 0.0001) was longer in the patients with coronary artery bypass grafting. Improvement of ejection fraction at follow-up was more in the patients with coronary artery bypass(114 ± 43 vs 104 ± 26%; p = 0.03). Long-term survival rate and freedom from major adverse cardiac event rater were not different with or without coronary artery bypass grafting (p = 0.26 and p = 0.59, respectively, by log rank test). Although prevalence of coronary artery disease inversely affected the long-term outcome of the aortic valve replacement, simultaneous coronary artery bypass did not. Aggressive simultaneous coronary revascularization would be important to improve the long-term outcome of aortic valve replacement.

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital cardiovascular anomaly. A 68-year-old woman was referred to our hospital for detailed examination for pulmonary hypertension (PH). She had been diagnosed as having pulmonary artery dilation and suspected to have PH during a health check seven years prior. A contrast computed tomography showed that the right upper pulmonary vein (RUPV) returned to the superior vena cava (SVC) with a preserved normal connection to the left atrium (LA). Surgical repair was performed. We reported an extremely rare case of isolated PAPVR with PH showing dual drainage into the SVC and LA.

BACKGROUND: Nonbacterial thrombotic endocarditis is commonly seen on heart valves in patients with malignant or collagen diseases. The natural prognosis of nonbacterial thrombotic endocarditis is reported to be poor due to underlying malignancy. Surgical indications and appropriate timing for surgery for nonbacterial thrombotic endocarditis and underlying malignancy have not been formally studied. CASE PRESENTATION: The case was a 45-year-old woman who presented with a history of systemic embolization associated with occult malignancy. A preoperative transesophageal echocardiogram showed multiple mobile vegetations on the aortic and mitral valves. She underwent valve surgery to prevent recurrent embolization. Based on the histopathologic findings, she was diagnosed with nonbacterial thrombotic endocarditis. She subsequently underwent surgery for occult malignancy, which was diagnosed as endometrioid adenocarcinoma. CONCLUSIONS: Although surgical indications for nonbacterial thrombotic endocarditis remain unclear, valve replacement or repair and multidisciplinary treatment including surgical intervention are essential to prevent recurrent embolization in patients with nonbacterial thrombotic endocarditis associated with malignancy.

Cerebrovascular complication is the one of the most dreadful complication after open heart surgery which leads to significant decrease of quality of life even if the patients survived. To decrease these complications, carotid doppler echo as one of the non-invasive carotid screening modalities is effective. Carotid artery stenosis is common in the patients with coronary artery disease, and it is more frequent in the patients with more complexed coronary artery lesions. The more the patients indicated for coronary artery bypass grafting has complexed lesions these days, the more the patients have carotid artery lesions. In case of presence of significant carotid artery stenosis with symptom, carotid artery intervention, either carotid endarterectomy or carotid artery stenting, should be considered by multidisciplinary team. The carotid artery stenosis could cause cerebral infarction by 2 major mechanisms, which are emboli, and low perfusion pressure. In open heart surgery, it is very important to avoid these occasions. Although It is still controversial whether off-pump coronary artery bypass grafting is superior to conventional on-pump coronary artery bypass grafting in randomized trial, it is necessary in common to avoid atheromatous emboli from aorta and to avoid low perfusion pressure by all means.

We report a case of structural valve deterioration, which occurred 7 years after aortic valve replacement in a 78-year-old male with cardiac sarcoidosis. His echocardiography showed low transprosthetic valve gradient and depressed left ventricular function. A dobutamine stress echocardiography was performed to identify his pathophysiology, and it revealed that his depressed left ventricular function was not due to cardiac sarcoidosis but to structural valve deterioration. Reoperation for structural valve deterioration was performed, and his left ventricular function recovered.

OBJECTIVES: Pulmonary endarterectomy (PEA) is an effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH), but postoperative residual hypertension leads to in-hospital mortality. Inhaled epoprostenol sodium (PGI2) and NO are administered for pulmonary hypertension after cardiothoracic surgery. This prospective study provides the first comparative evaluation of the effects of inhaled PGI2 and NO on pulmonary hemodynamics, systemic hemodynamics, and gas exchange in patients developing residual pulmonary hypertension after PEA. METHODS: Thirteen patients were randomized to receive either NO (n = 6) or PGI2 (n = 7) inhalation when pulmonary hypertension persisted after weaning from cardiopulmonary bypass. Hemodynamic and respiratory variables were measured before inhalation of the agent (T0); 30 min (T1), 3 h (T2), and 6 h after inhalation (T3); and the next morning (T4). The NO dose was started at 20 ppm and gradually tapered until extubation, and PGI2 was administered at a dose of 10 ng kg-1 min-1. RESULTS: In both groups, mean pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) significantly decreased over time until T4 (mean PAP: p < 0.0001; PVR: p = 0.003), while mean systemic arterial blood pressure significantly increased (p = 0.028). There were no significant between-group differences in patient characteristics, cardiac index, left atrial pressure, or ratio of arterial oxygen tension to fraction of inspired oxygen. There were no in-hospital deaths. CONCLUSIONS: Both inhaled PGI2 and NO significantly reduced PAP and PVR without adverse effects on systemic hemodynamics in patients who developed residual pulmonary hypertension after PEA. Inhaled PGI2 can be offered as alternative treatment option for residual pulmonary hypertension.

Background Atrial fibrillation is a common complication after cardiac surgery, but the risk factors and long-term outcome after primary isolated aortic valve replacement remains to be clarified. Methods A single-center retrospective study was conducted on 157 patients who underwent first-time isolated aortic valve replacement between April 1999 and February 2015. Fifty-eight patients developed new-onset atrial fibrillation within 6 months postoperatively, and they were compared with patients who remained in sinus rhythm. Multivariate analyses, which incorporated the propensity score patient matching technique, were conducted to evaluate the long-term outcome of new-onset postoperative atrial fibrillation and identify patients at risk of developing this arrhythmia. Results At a mean follow-up of 52.4 months (range 8.4-200.7 months), mortality was significantly higher in patients who developed atrial fibrillation compared to those who remained in sinus rhythm (2.8%/patient-year vs. 0.2%/patient-year, respectively; p < 0.05). Patients developing atrial fibrillation were also at an independently increased risk of stroke and readmission during follow-up. Risk analysis revealed that advanced age (>70 years) and absence of a postoperative β-blocker were predictors of atrial fibrillation. Conclusions New-onset atrial fibrillation after first-time isolated aortic valve replacement correlated significantly with late morbidity and mortality. Advanced age and absence of a postoperative β-blocker may increase the incidence of atrial fibrillation.

Radical pericardiectomy alone is not effective in patients with constrictive pericarditis accompanied by epicardial constriction. However, a waffle procedure is very effective in these patients, as we demonstrate in this paper. Firstly, we performed a radical pericardiectomy via a median sternotomy. We used an ultrasonic scalpel for this procedure, and an apical suction device was useful for lifting the heart. This technique is similar to that used in off-pump coronary artery bypass grafting. After the whole heart was dissected from the markedly thickened parietal pericardium, a waffle procedure was performed on the left ventricle first. Multiple longitudinal and transverse incisions were made on the thickened epicardium using an ultrasonic scalpel. After the left ventricle was fully relieved of constriction, the same procedure was performed on the right ventricle. Thereafter, a remarkable improvement of our patient's haemodynamic status was obtained. The whole procedure can be done without cardiopulmonary bypass. We describe tips for performing the waffle procedure without cardiopulmonary bypass using an ultrasonic scalpel and apical suction device, as well as pitfalls to avoid.