BACKGROUND: Transcatheter edge-to-edge mitral valve repair is now available in many countries and has achieved favourable therapeutic outcomes. However, there have been no reported cases of clip opening while locked (COWL) during the acute phase using the MitraClip G4 system (Abbott, Abbott Park, IL, USA). CASE SUMMARY: We present two cases of COWL occurring at different phases: one immediately after clip release and the other 2 days post-procedure. In both cases, the initial treatment involved the use of the XTW system. Subsequently, an additional XT system was deployed for the deterioration of mitral regurgitation caused by COWL, without any complications. DISCUSSION: The MitraClip G4 system offers four size variations, providing a larger grasping area and increased flexibility for accessing complex lesions. Furthermore, the complication rate decreased with increasing operator experience and device generation. However, it has been reported that COWL can occur after the clip is deployed during TEER. Although the mechanism of COWL is unclear, the nature and mobility of the valve leaflets and the product specificity of the MitraClip may be involved.

BACKGROUND: There are a few case reports regarding transcatheter aortic valve implantation (TAVI) for deteriorated surgical homograft. CASE SUMMARY: We present a case of severe structural valve deterioration (SVD) of homograft surgical aortic valve presenting severe aortic regurgitation in an 84-year-old man with decompensated heart failure. We performed TAVI in homograft valve using 23 mm SAPIEN3 Ultra RESILIA. The resulting grade of paravalvular regurgitation was trace, the post-operative effective orifice area (EOA) was 1.66 cm2 (index EOA: 1.19 cm2/m2), and device success was achieved. DISCUSSION: Stented bioprosthetic valves are more commonly implanted than mechanical and stentless bioprosthetic valves. In the 1980s and the early 1990s, homografts became particularly popular as alternatives to stented valves. There are several reports of TAVI for homograft SVD, but the paravalvular leakage grade is worse than that of redo-surgical aortic valve replacement, although the mortality rate is lower. However, the valves used in these reports were from older valves such as SAPIEN XT or SAPIEN3. There are no reports using SAPIEN3 Ultra RESILIA with a significant reduction in paravalvular leak due to an external textured polyethylene terephthalate skirt extending 40% higher above the valve inflow than the classical SAPIEN3, which is now available. Transcatheter aortic valve implantation using SAPIEN3 Ultra RESILIA showed good therapeutic efficacy.

BACKGROUND: Early prediction of aorta-related events is important for determining subsequent treatment strategies in patients with acute aortic dissection. However, most studies evaluated long-term aortic growth rates by annual assessment. The purpose of our study was to determine whether the in-hospital growth rate of aortic volume was associated with aorta-related events. METHODS: We studied 116 patients with uncomplicated type B acute aortic dissection. We analyzed whether changes in aortic volume were associated with aorta-related events during a 5-year follow-up. According to the growth rate from admission to discharge, patients were divided into two groups: Increase >0 (aortic volume: n = 59, aortic diameter: n = 43) and Reduction ≤0 (aortic volume: n = 57, aortic diameter: n = 73) in maximum aortic diameter or aortic volume. The primary endpoint was the discriminative ability of the growth rate of aortic volume for aorta-related events. RESULTS: According to the evaluation of aortic volume changes, the Increase group had significantly higher aorta-related event rates than those in the Reduction group (49.2 % vs. 3.5 %, respectively; p < 0.001). Receiver operating characteristics analysis showed that the growth rate of aortic volume had a clearly useful discrimination, with an area under the curve of 0.84, whereas the discriminative ability of the growth rate of maximum aortic diameter was poor (area under the curve: 0.53). Multivariate analysis showed that the growth rate of aortic volume from admission to discharge was an independent predictor of aorta-related events (hazard ratio, 26.3; 95 % confidence interval, 2.04-286.49; p = 0.001). CONCLUSIONS: In-hospital evaluation of aortic volume was helpful to predict long-term aorta-related events in patients with uncomplicated type B acute aortic dissection.

Recent studies showed that preoperative functional assessment with fractional flow reserve (FFR) could predict a long-term patency of arterial bypass grafts in patients with coronary artery bypass grafting (CABG). Quantitative flow ratio (QFR) is a novel angiography-based approach to estimate FFR. This study aimed to investigate whether preoperative QFR could discriminate arterial bypass function at 1 year after surgery. The PRIDE-METAL registry was a prospective, multicenter observational study that enrolled 54 patients with multivessel coronary artery disease. By protocol, left coronary stenoses were revascularized by CABG with arterial grafts, whereas right coronary stenoses were treated with coronary stenting. Follow-up angiography at 1 year after surgery was scheduled to assess arterial graft patency. QFR was performed using index angiography by certified analysts, blinded to bypass graft function. The primary end point of this sub-study was the discriminative ability of QFR for arterial graft function, as assessed by receiver-operating characteristic curve. Among 54 patients enrolled in the PRIDE-METAL registry, index and follow-up angiography was available in 41 patients with 97 anastomoses. QFR were analyzed in 35 patients (71 anastomoses) with an analyzability of 85.5% (71/83). Five bypass grafts were found to be non-functional at 1 year. The diagnostic performance of QFR was substantial (area under the curve: 0.89; 95% confidence interval: 0.83 to 0.96) with an optimal cutoff of 0.76 to predict functionality of bypass grafts. Preoperative QFR is highly discriminative for predicting postoperative arterial graft function.Trial registration: Clinical.gov reference: NCT02894255.

BACKGROUND: There is a paucity of data regarding shorter life expectancy after aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). METHODS: Among 3815 patients with severe AS enrolled in the CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) registry, there were 1469 patients (initial AVR: n = 647; conservative strategy: n = 822) with low surgical risk, 1642 patients (initial AVR: n = 433; conservative strategy: n = 1209) with intermediate surgical risk, and 704 patients (initial AVR: n = 117; conservative strategy: n = 587) with high surgical risk. Among 1163 patients who actually underwent surgical AVR as the initial strategy, patients were divided into 4 groups according to age <65 years (n = 185), 65 to 74 (n = 394), 75 to 80 (n = 345), and >80 (n = 239). The expected survival of the general Japanese population was obtained from the Statistics Bureau of Japan. The surgical risk was estimated using The Society of Thoracic Surgery (STS) score. RESULTS: The median follow-up was 3.7 years. The cumulative incidences of all-cause death were significantly lower in the initial AVR strategy than in the initial conservative strategy across the 3 STS groups. Shorter life expectancy after surgical AVR was seen especially in younger patients. The observed mortality in low-risk patients was comparable to the expected mortality across all the age-groups, while intermediate-risk patients aged <75 years, and high-risk patients across all age-groups had higher mortality compared with the expected mortality. CONCLUSIONS: The risk stratification according to age and STS score might be useful to estimate shorter life expectancy after AVR, and these findings have implications for decision making in the choice of surgical or transcatheter AVR.

Background: Perioperative management of body fluid levels after cardiovascular surgery with cardiopulmonary bypass is essential. Fluid management using tolvaptan with conventional diuretics is effective in maintaining urine output without worsening renal function. This study aimed to improve the in-out balance in the early perioperative phase using low-dose tolvaptan (3.75 mg/day). Methods and Results: This prospective, single-center, randomized, open-label study included 199 patients who underwent cardiovascular surgery with cardiopulmonary bypass in Kobe City Medical Center General Hospital between September 2018 and December 2020. Treatment with tolvaptan and loop diuretics (tolvaptan group; 99 patients) was compared with treatment with loop diuretics alone (control group; 100 patients) to evaluate achievement of preoperative body weight as the primary outcome. Secondary outcomes were urine volume, the incidence of worsening renal function (WRF), and postoperative paroxysmal atrial fibrillation (POAF). There was no significant difference between groups in the return to preoperative body weight on postoperative Day 6. The tolvaptan group had significantly increased urine volume (2,530 vs. 2,150 mL/day) and decreased total furosemide dose (24 vs. 32 mg) compared with the control group. No significant differences were observed in the development of WRF and POAF between the 2 groups. Conclusions: Although low-dose tolvaptan administration did not shorten the time to achieving preoperative body weight, it did significantly increase urine volume without WRF and POAF.

Epicardial adipose tissue (EAT) is known to affect atherosclerosis and coronary artery disease (CAD) pathogenesis, persistently releasing pro-inflammatory adipokines that affect the myocardium and coronary arteries. Angiopoietin-like 4 (ANGPTL4) is a protein secreted from adipose tissue and plays a critical role in the progression of atherosclerosis. Here, the expression of ANGPTL4 in EAT was investigated in CAD subjects. Thirty-four consecutive patients (13 patients with significant CAD; 21 patients without CAD) undergoing elective open-heart surgery were recruited. EAT and pericardial fluid were obtained at the time of surgery. mRNA expression and ANGPTL4 and IL-1β levels were evaluated by qRT-PCR and ELISA. The expression of ANGPTL4 (p = 0.0180) and IL-1β (p < 0.0001) in EAT significantly increased in the CAD group compared to that in the non-CAD group and positively correlated (p = 0.004). Multiple regression analysis indicated that CAD is a contributing factor for ANGPTL4 expression in EAT. IL-1β level in the pericardial fluid was significantly increased in patients with CAD (p = 0.020). Moreover, the expression of ANGPTL4 (p = 0.004) and IL-1β (p < 0.001) in EAT was significantly increased in non-obese patients with CAD. In summary, ANGPTL4 expression in EAT was increased in CAD patients.

AIM OF THE STUDY: We aimed to determine the outcomes of contemporary mitral valve replacement (MVR) in octogenarians, for rational treatment selection in a patient cohort. METHODS: Between 2007 and 2018, 656 consecutive MVRs were performed. Among these cases, 109 patients were aged 80 years or older, and 547 patients were younger than 80 years. Isolated MVRs were performed in 211 patients, of whom 36 were aged 80 years or older. Perioperative mortality and complications were compared between the two groups, adjusted by propensity score. RESULTS: In-hospital mortality of the entire MVR (<80: 26 [4.8%] vs. ≥80: 6 [5.5%], p = .81) and isolated MVR (<80: 6 [3.4%] vs. ≥80: 1 [2.8%], p > .99) groups were similar. Age >80 years did not influence in-hospital mortality (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.36-3.14, p = .9), stroke (HR, 1.12; 95% CI, 0.19-6.71, p = .9), hemodialysis (HR, 1.44; 95% CI, 0.45-4.66, p = .54), or prolonged ventilation (HR, 1.61; 95% CI, 0.81-3.23, p = .18), but influenced the incidence of reopening for bleeding (HR, 3.97; 95% CI, 1.11-14.19, p = .03). Cox proportional hazard model results showed that age >80 years did not affect cardiac death (HR, 1.45, 95% CI: 0.67-3.12, p = .35), bleeding events (HR, 1.89, 95% CI: 0.84-4.27, p = .13), or stroke (HR, 1.51, 95% CI: 0.54-4.21, p = .44) during the follow-up period. CONCLUSIONS: The perioperative and follow-up outcomes of MVR in octogenarians were not inferior to those of younger patients. We should not hesitate to conduct MVR on the grounds of old age.

BACKGROUND: The clinical significance of concomitant mitral regurgitation (MR) has not been well addressed in patients with severe aortic stenosis (AS).Methods and Results:We analyzed 3,815 patients from a retrospective multicenter registry of severe AS in Japan (CURRENT AS registry). We compared the clinical outcomes between patients with moderate/severe MR and with none/mild MR according to the initial treatment strategy (initial aortic valve replacement [AVR] or conservative strategy). The primary outcome measure was a composite of aortic valve-related death or heart failure hospitalization. At baseline, moderate/severe MR was present in 227/1,197 (19%) patients with initial AVR strategy and in 536/2,618 (20%) patients with a conservative strategy. The crude cumulative 5-year incidence of the primary outcome measure was significantly higher in patients with moderate/severe MR than in those with none/mild MR, regardless of the initial treatment strategy (25.2% vs. 14.4%, P<0.001 in the initial AVR strategy, and 63.3% vs. 40.7%, P<0.001 in the conservative strategy). After adjusting confounders, moderate/severe MR was not independently associated with higher risk for the primary outcome measure in the initial AVR strategy (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.67-1.83, P=0.69), and in the conservative strategy (HR 1.13, 95% CI 0.93-1.37, P=0.22). CONCLUSIONS: Concomitant moderate/severe MR was not independently associated with higher risk for the primary outcome measure regardless of the initial treatment strategy.

BACKGROUND: There are no reports of midterm outcomes after mitral valve replacement with a 25-mm bioprosthesis in a large series of patients. This study aimed to examine perioperative and midterm outcomes of bioprosthetic valve choice, porcine or bovine pericardial, in the mitral position, focusing on 25-mm valves. METHODS: From 2007 to 2018, 467 patients received a mitral bioprosthesis, with or without concomitant procedures. Of these, 111 (23.8%) were porcine, and 356 (76.2%) were bovine pericardial, and 219 patients (46.9%) received a 25-mm valve. A propensity-matched cohort of 192 patients was used for outcome analyses. The influence of the valve type on midterm survival and incidence of cardiac death was assessed. Similarly, subanalysis stratified by valve size was conducted. RESULTS: In matched patients, there were no differences in midterm survival and incidence of cardiac death between the two groups (log-rank test; p = .268 and p = .097, respectively). There were no differences in midterm survival and incidence of cardiac death between the 25-mm valve and larger valve (log-rank test; p = .563 and p = .597, respectively). The Cox proportional-hazards model revealed that the valve type and 25-mm valve did not affect midterm survival (p = .487 and p = .375, respectively) and incidence of cardiac death (p = .678 and p = .562, respectively). CONCLUSIONS: The choice of a porcine or bovine pericardial bioprosthesis does not affect midterm survival and cardiac death. The 25-mm valves, whether bovine or porcine, could be an appropriate alternative when the patient's body size is small.

BACKGROUND: The effect of multiple prior percutaneous coronary interventions (PCIs) before subsequent coronary artery bypass grafting (CABG) on long-term outcomes has not been well elucidated.Methods and Results:Between 2007 and 2016, 1,154 patients undergoing primary isolated CABG in our institution had no prior PCI (Group N), 225 had a single prior PCI (Group S), and 272 had multiple prior PCIs (Group M). Cumulative incidences of all-cause death, cardiac death and myocardial infarction (MI) at 10 years post-CABG were highest in Group M. After adjusting for confounders, the risk of all-cause death was higher in Group M than in Group N (hazard ratio [HR] 1.45; 95% confidence interval [CI], 1.10-1.91; P<0.01). Between Groups N and S, however, the risk of all-cause death was not different. The risks of cardiac death and MI were likewise higher in Group M than in Group N (HR, 2.39; 95% CI, 1.55-3.71; P<0.01 and HR, 3.65; 95% CI, 1.16-11.5; P=0.03, respectively), but not different between Groups N and S. The risk of repeat revascularization was not different among any of the groups. CONCLUSIONS: Multiple prior PCIs was associated with higher risks of long-term death and cardiovascular events. The incidence of repeat revascularization after CABG was low regardless of the history of single/multiple PCIs.

BACKGROUND: Postdilatation after transcatheter heart valve (THV) implantation was associated with larger aortic valve areas in large-scale registries; however, the specific effects of postdilatation are poorly understood. METHODS AND RESULTS: Among a total of 224 consecutive patients who underwent transcatheter aortic valve replacement using SAPIEN 3, 121 patients (54.0%) underwent postdilatation (same contrast volume: N = 101, +1 ml: N = 17, +2 ml: N = 3). THV diameter was assessed (a) during, (b) after implantation, (c) during postdilatation, and (d) after postdilatation by quantitative fluoroscopy. In the overall patients (N = 224), acute recoil was observed from during implantation (23.0 ± 2.0 mm) to after implantation (22.5 ± 2.0 mm, p < .001) with an absolute recoil of 0.52 ± 0.25 mm. After postdilatation (N = 121), THV diameter significantly increased from 22.5 ± 2.0 mm to 22.9 ± 2.1 mm (p < .001), with smaller absolute recoil (0.39 ± 0.21 mm, p < .001). Compared with those who did not undergo postdilatation, patients who underwent postdilatation had larger postprocedural THV area assessed by multi-slice computed tomography (471.4 ± 78.1 mm2 vs. 447.5 ± 76.3 mm2 , p = .02) and larger effective orifice area (EOA) assessed by echocardiography throughout 1 year (at 30 day, 1.66 ± 0.33 cm2 vs. 1.45 ± 0.27 cm2 , p < .001; at 6 month, 1.66 ± 0.33 cm2 vs. 1.44 ± 0.29 cm2 , p < .001; at 1 year, 1.69 ± 0.38 cm2 vs. 1.47 ± 0.30 cm2 , p < .001). CONCLUSIONS: Postdilatation after implantation of the SAPIEN 3 valve produced a larger THV diameter with less acute recoil, followed by larger EOA throughout 1 year. Further studies are needed to evaluate the impact of postdilatation on long-term clinical outcomes.

The effect of patient-prosthesis mismatch (PPM) on late outcomes after mitral valve replacement (MVR) remains unclear. We evaluated the impact of PPM after MVR on the late survival using propensity score matching analysis. From 2007 to 2018, 660 consecutive MVRs were performed. Effective orifice areas were obtained from a literature review of in vivo echocardiographic data, and mitral PPM was defined as an effective orifice area index of ≤1.2 cm2/m2. Propensity score matching yielded a cohort of 126 patients with PPM and 126 patients without PPM. Mitral PPM was found in 37.8% of the patients. In the whole matched patients, there were no differences in late survival (log-rank test, P = 0.629) between 2 groups. Patients aged ≤70 years and those aged >70 years had no differences in late survival (log-rank test, P = 0.073 and 0.572). The Cox proportional hazards model for the overall survival showed that mitral PPM tended to decrease survival in patients aged ≤70 years (P = 0.084, hazard ratio [HR] 2.647, 95% CI: 0.876-7.994). Mitral PPM did not adversely affect long-term survival. There may be a tendency of adverse impact on late survival in patients aged ≤70 years. Implanting a safe size rather than larger size prosthesis in mitral position may be an appropriate option in older patients.

BACKGROUND: The influence of improved mitral regurgitation (MR) on the outcomes of transcatheter aortic valve replacement (TAVR) is unknown. Our aim was to determine the impact of significant preprocedural MR and the improvement of MR after TAVR. METHODS: A population of 1587 patients from the Optimized Catheter Valvular Intervention Transcatheter Aortic Valve Implantation (OCEAN-TAVI) registry were evaluated. Preprocedural MR was mild or less in 1443 patients (90.9%) and moderate or severe in 144 patients (9.1%). RESULTS: Moderate or severe MR was associated with increased risk for all-cause mortality at 1 year (adjusted hazard ratio, 1.85; 95% confidence interval [CI], 1.20-2.84; P = 0.005) and 2 years (adjusted hazard ratio, 1.64; 95% CI, 1.15-2.34; P = 0.007). At 6 months after TAVR, the MR grade improved in 77.4% of the patients with moderate or severe baseline MR. Multivariate analysis showed that the absence of previous myocardial infarction (odds ratio, 8.00; 95% CI, 1.74-36.8; P = 0.008) and beta-blocker use at baseline (odds ratio, 2.71; 95% CI, 1.09-6.70; P = 0.031) were independently associated with improved MR at 6 months (vs unchanged, worsened MR, or death). Patients with improved MR had a significantly lower rate of midterm readmission for heart failure (11.6%) than those with unchanged or worsened MR (30.8%, P = 0.007). CONCLUSIONS: Moderate or severe MR was associated with increased risk of all-cause mortality 2 years after TAVR. Moderate or severe baseline MR was improved in most patients at 6 months after TAVR. Patients with unchanged or worsened MR had an increased rate of readmission for heart failure.

BACKGROUND: There are no data comparing transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) outcomes in real clinical practice in Japan. METHODS AND RESULTS: We combined 2 independent registries, the K-TAVI Registry (a 6-center prospective registry of consecutive patients who underwent TAVI) and the CURRENT AS Registry (a large, 27-center registry of 3,815 consecutive patients with severe aortic stenosis [AS]). In the K-TAVI Registry, 338 patients underwent TAVI with SAPIEN XT balloon-expandable valves from October 2013 to January 2016, whereas in the CURRENT AS Registry 237 patients with severe AS underwent SAVR from January 2003 to December 2011. Propensity score matching was conducted, with final cohort comprising 306 patients. The cumulative 2-year incidence of all-cause death and heart failure (HF) hospitalization did not differ significantly between the TAVI and SAVR groups (13.7% vs. 12.4% [P=0.81] and 7.9% vs 3.9% [P=0.13], respectively). After adjusting for residual confounders, there were no significant differences between the TAVI and SAVR groups in the risk for all-cause death (hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.35-1.58; P=0.43) or HF hospitalization (HR 1.27; 95% CI 0.40-4.59; P=0.69). CONCLUSIONS: These findings from 2 independent Japanese registries suggest that the 2-year risk of all-cause mortality and HF does not differ significantly between TAVI and SAVR groups in real-world practice in Japan.

Transcatheter aortic valve implantation (TAVITAVITAVI ) has been established as a treatment of choice for patients with severe symptomatic aortic stenosis who are considered ineligible or at high risk for surgical aortic valve replacement, so the number of TAVITAVITAVI procedures for patients with prohibitive risk has rapidly increased in the super-aging society. We described two cases of TAVITAVITAVI for patients with low left ventricular ejection fraction under prophylactic use of veno-arterial extracorporeal membrane oxygenation and percutaneous removal using Perclose ProGlide (Abbott Vascular, Clonmel, Ireland).

BACKGROUND: Reoperative aortic valve replacement (AVR) is associated with increased mortality compared with initial surgery, and a smaller valve might be implanted during repeat AVR (re-AVR; AVR after prior AVR). We describe the clinical outcomes and incidence of prosthesis-patient mismatches (PPM) after reoperative AVR. METHODS: Among 113 patients who underwent reoperative AVR between 2007 and 2018, 44 underwent re-AVR and 69 underwent a first replacement of a diseased natural valve after any cardiac surgery except AVR (primary AVR). We then compared early and late outcomes, the impact of re-AVR on the effective orifice areas (EOA), and the incidence and influence of PPM on reoperative AVR. RESULTS: Hospital mortality was 2.7%, and the overall 1-, 3-, and 5-year survival rates were 95, 91 and 86%, respectively. The reference EOA of the newly implanted valve was smaller than that of the previous valve (1.4 ± 0.3 vs. 1.6 ± 0.3 cm2, p < 0.01). The mean pressure gradient was greater (15.2 ± 6.4 vs. 12.7 ± 6.2 mmHg, p = 0.04) and indexed EOA was smaller (0.92 ± 0.26 vs. 1.06 ± 0.36 cm2/m2, p = 0.04) during re-AVR than primary AVR, whereas the incidence of PPM was similar (38.7% vs. 34.8%, p = 0.87) between the groups. CONCLUSIONS: The clinical outcomes of reoperative AVR were acceptable. Although the reference EOA of new implanted valves was smaller than that of previous valves, re-AVR did not increase the incidence of PPM. These findings might serve as a guide for future decisions regarding the surgical approach to treating degenerated prosthetic valves.

OBJECTIVES: The number of end-stage renal disease (ESRD) patients has increased, but there have been few reports of thoracic aortic surgery in patients with ESRD. The purpose of this study was to evaluate the early and late outcomes of open and endovascular thoracic aortic repairs in patients with ESRD. METHODS: A total of 36 patients with ESRD who needed chronic haemodialysis undergoing open surgery (n = 21) or thoracic endovascular aortic repair (TEVAR) (n = 15) of the thoracic aorta from 2007 to 2017 in our hospital were identified. Primary end points were in-hospital mortality and late survival; secondary end points were perioperative complications and late aortic events. RESULTS: Fourteen patients (39%) had aortic dissection, and 16 (44%) had aortic aneurysms. Emergency surgery was performed in 12 patients (33%). There were 3 hospital deaths (8%) (open surgery, n = 1, 5%; TEVAR, n = 2, 13%). The TEVAR group had fewer transfusions than the open surgery group and shorter intensive care unit and hospital stays. The 1-, 3- and 5-year survival rates were 79%, 58% and 40%, respectively, for patients overall. Freedom from aortic events at 1 and 3 years was 97% and 92%, respectively. CONCLUSIONS: The early outcome of thoracic aorta surgery in patients with ESRD was acceptable. However, the long-term mortality in patients with ESRD was still poor. Therefore, whether to perform surgery needs to be considered carefully.

BACKGROUND: Ventricular septal defect (VSD) after myocardial infarction (MI) is a rare but fatal complication. We report patients' characteristics and operative outcomes after surgical repair of post-MI VSD using a national database of Japan.Methods and Results:This was a retrospective review of the Japan Adult Cardiovascular Surgery Database (JCVSD) to identify adults (age ≥18 years) who underwent surgical repair of post-MI VSD between 2008 and 2014. The primary outcome was operative death. We identified 1,397 patients (671 male [48%], 74.1±9.3 years old) undergoing surgical repair of post-MI VSD among 288,736 patients undergoing cardiac surgery enrolled in the JCVSD during the same period. Of these, 1,075 (77.0%) were supported preoperatively with an intra-aortic balloon pump. Surgical status was urgent in 391 (28.0%) and emergency/salvage in 731 (52.3%). Concomitant coronary artery bypass grafting was performed in 475 (34.0%). Overall 30-day and operative mortalities were 24.3% and 33.0%, respectively. Operative mortality varied according to surgical status: 15.6% in elective, 30.9% in urgent, and 40.6% in emergency/salvage cases. Multivariable analysis identified advanced age and emergency/salvage status as being strongly associated with increased odds of operative death. CONCLUSIONS: Post-MI VSD remains a devastating complication in Japan as well as in the USA and Europe.

Objective: To investigate the influence of choice of prosthesis (bioprosthetic valves or mechanical valves) on intermediate-term outcomes in patients on hemodialysis undergoing aortic valve replacement (AVR). Methods: A multi-institutional retrospective cohort study was conducted in 18 Japanese centers. All adult patients on chronic hemodialysis who underwent AVR from 2008 and 2015 were included (n = 491). The early and late results were compared between groups. The hazard ratios were calculated using Cox regression and Fine–Gray models with adjustment for propensity score based on 41 confounders. The mean follow-up period was 2.5 ± 2.1 years (up to 8.3 years) with 98% completeness. Results: There were 323 patients who received a bioprosthetic valve (group B), and 168 patients who received a mechanical valve (group M). There was no significant difference for in-hospital death rate between groups (group B: 12.1% group M: 8.9% P = .29). The overall survival rate at 5 years after surgery was 39.3% in group B and 50.4% in group M (P = .42). Freedom from reoperation at 5 years was 97.1% in group B and 97.8% in group M (P = .88). On propensity-score adjusted analyses, there were no significant differences in overall survival between groups. Conclusions: There were no significant differences in overall survival between bioprosthetic valves and mechanical valves in patients on hemodialysis undergoing AVR.

Aortic complex rupture is one of the most critical complications associated with transcatheter aortic valve implantation (TAVI). Its incidence is rare, and its mechanism varies by case; therefore, it is difficult to identify the predictors of complex rupture. Herein, we report a clinical case series of aortic complex rupture. Within our cohort, the frequency of complex rupture was 0.8% (4/497 consecutive patients) with an in-hospital mortality of 0. Among these four patients with complex rupture, two underwent emergent thoracotomy and surgical hemostasis without a heart-lung machine and surgical aortic valve replacement, whereas the other two were conservatively managed. The case overview revealed the following similarities: all the patients were elderly, small women; balloon-expandable valves were used; the annulus area was small with heavily calcified leaflet; and aggressive treatment strategy was used (i.e., oversizing and post-dilatation). In such cases, TAVI should be performed with a careful strategy. Once aortic complex rupture occurs, damage can be minimized through cooperation with an institutional heart team and calm management.

AIMS: Tricuspid regurgitation (TR) has been reported to be associated with worse survival in various heart diseases, but there are few data in aortic stenosis (AS). METHODS AND RESULTS: In the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) Registry enrolling 3815 consecutive patients with severe AS, there were 628 patients with moderate or severe TR (TR group) and 3187 patients with no or mild TR (no TR group). The study patients were subdivided into the initial aortic valve replacement (AVR) stratum (n = 1197) and the conservative stratum (n = 2618) according to treatment strategy. The primary outcome measure was a composite of aortic valve-related death or hospitalization due to heart failure. The 5-year freedom rate from the primary outcome measure was significantly lower in the TR group than in the no TR group (49.1% vs. 67.3%, P < 0.001). Even after adjusting for confounders, the excess risk of TR relative to no TR for the primary outcome measure remained significant [hazard ratio (HR): 1.25, 95% confidence interval (CI): 1.06-1.48; P = 0.008]. The trend for the excess adjusted risk in the TR group was consistent in the initial AVR and the conservative strata (HR 1.55, 95% CI: 0.97-2.48; P = 0.07; HR 1.22, 95% CI: 1.02-1.46; P = 0.03, respectively). In the initial AVR stratum, the 5-year freedom rate from the primary outcome measure was not different between the two groups with (n = 56) or without (n = 91) concomitant tricuspid annuloplasty (61.5% vs. 72.1%, P = 0.48). CONCLUSION: The presence of clinically significant TR concomitant with severe AS is associated with a poor long-term outcome, regardless of the initial treatment strategy.

Transcatheter aortic valve implantation (TAVI) often causes intraventricular conduction abnormalities (ICA), particularly left bundle branch block (LBBB) and advanced atrioventricular block, requiring pacemaker implantation (PMI). However, the relation between ICA and clinical outcomes after TAVI with balloon-expandable valves remains unclear, particularly in the Asian population. This retrospective study included all patients who underwent TAVI with balloon-expandable valves from October 2013 to September 2016. We defined ICA as new onset of complete LBBB (CLBBB) or PMI within 2 weeks after TAVI. We divided the patients into 2 groups: those with and without ICA (new-ICA and no-ICA groups) and we assessed 1-year outcome. Two hundred one consecutive patients underwent TAVI using balloon-expandable valves (mean age, 84.8 ± 5.7 years; women, 64%). ICA occurred in 47 patients (23%), 37 patients (18%) developed CLBBB, and 34 patients recovered from CLBBB within 1 year after TAVI. Ten patients (5%) who developed symptomatic bradycardia required PMI within 2 weeks after TAVI. At 30 days after PMI, 7 patients already had a very low ventricular pacing rate, and 6 patients who recovered from bradycardia needed pacing at 1 year. Patients with ICA tended to have high 1-year all-cause mortality, but there was no significant difference between the 2 groups (12% vs 7%, p = 0.15). In conclusion, ICA occurred in 23% of patients after TAVI with balloon-expandable valves, and approximately 90% of them recovered from ICA during the follow-up. There was no significant difference in 1-year all-cause mortality between the new-ICA and no-ICA groups.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is criticized by some as an expensive treatment in super-elder patients with limited life expectancy. However, there is a knowledge gap regarding the magnitude of clinical benefit provided by TAVI in comparison with conservative management in patients with severe aortic stenosis (AS) in real clinical practice, which would be important in the decision making for TAVI. METHODS: We combined two independent registries, namely CURRENT AS and K-TAVI registries. CURRENT AS was a multicenter registry enrolling 3815 consecutive patients with severe AS irrespective to treatment modalities between January 2003 and December 2011. K-TAVI was a multicenter, prospective registry including 449 consecutive patients with severe AS, who underwent TAVI with SAPIEN XT balloon-expandable valves between October 2013 and June 2016. In these 2 registries, 449 patients received TAVI and 894 patients were managed with conservative strategy. We conducted propensity score matching and finally obtained a cohort of 556 patients (278 patients for each group) for the analysis. The primary outcome measures were all-cause death and heart failure (HF) hospitalization at 2-year. RESULTS: The cumulative 2-year incidences of all-cause death and HF hospitalization were significantly lower in the TAVI group than in the conservative group (16.8% versus 36.6%, P<0.001, and 10.7% versus 37.2%, P<0.001). After adjusting the residual confounders, TAVI reduced the risks of all-cause death (HR, 0.46; 95%CI, 0.32-0.69; P = 0.0001) and HF hospitalizations (HR, 0.25; 95%CI, 0.16-0.40; P<0.0001) compared with conservative strategy. There was no difference in the cumulative incidence of non-cardiovascular death between the 2 groups. CONCLUSIONS: TAVI in the early Japanese experience was associated with striking risk reduction for all-cause death as well as HF hospitalization as compared with the historical cohort of patients with severe AS who were managed conservatively just before introduction of TAVI in Japan.

BACKGROUND: There is no large-scale study comparing postoperative mortality after aortic valve replacement (AVR) for asymptomatic severe aortic stenosis (AS) between initial treatment with AVR vs. eventual AVR after conservative management. Methods and Results: We analyzed data from a multicenter registry enrolling 3,815 consecutive patients with severe AS. Of 1,808 asymptomatic patients, 286 patients initially underwent AVR (initial AVR group), and 377 patients were initially managed conservatively and eventually underwent AVR (AVR after watchful waiting group). Mortality after AVR was compared between the 2 groups. Subgroup analysis according to peak aortic jet velocity (Vmax) at diagnosis was also conducted. There was no significant difference between the 2 groups in 5-year overall survival (OS; 86.0% vs. 84.1%, P=0.34) or cardiovascular death-free survival (DFS; 91.3% vs. 91.1%, P=0.61), but on subgroup analysis of patients with Vmax ≥4.5 m/s at diagnosis, the initial AVR group was superior to the AVR after watchful waiting group in both 5-year OS (88.4% vs. 70.6%, P=0.003) and cardiovascular DFS (91.9% vs. 81.7%, P=0.023). CONCLUSIONS: Asymptomatic severe AS patients who underwent AVR after watchful waiting had a postoperative survival rate similar to those who initially underwent AVR. In a subgroup of patients with Vmax ≥4.5 m/s at diagnosis, however, the AVR after watchful waiting group had worse postoperative survival rate than the initial AVR group.

OBJECTIVES: Most randomized controlled trials of off-pump versus on-pump coronary artery bypass grafting (CABG) have included limited numbers of patients with preoperative renal failure. This study was performed to evaluate the association between the clinical benefit of the off-pump technique and chronic kidney disease stage. METHODS: We analyzed 38,051 patients with chronic kidney disease who underwent primary nonemergent isolated CABG from 2013 to 2015 as reported in the Japan Cardiovascular Surgery Database-Adult section. These patients were stratified into 4 categories according to their estimated glomerular filtration rate (eGFR) of 60 to 90, 30 to 59, and <30 mL/min/1.73 m2, and hemodialysis-dependent. The clinical outcomes were compared between patients undergoing off-pump and on-pump CABG in each stratum using inverse probability of treatment weighting. RESULTS: In total, 23,634 (62.1%) patients were intended for off-pump CABG. In patients with mildly reduced renal function (eGFR 60-89 mL/min/1.73 m2), there was no significant risk reduction effect of off-pump CABG for surgical mortality. Conversely, in patients with moderate or severe renal disease (eGFR <60 mL/min/1.73 m2), off-pump CABG was associated with a significantly lower incidence of surgical death (odds ratio with 95% confidence interval: eGFR 30-59 mL/min/1.73 m2, 0.66 [0.51-0.84]; eGFR <30 mL/min/1.73 m2, 0.51 [0.37-0.72]; and hemodialysis-dependent, 0.68 [0.51-0.90]). In addition, in patients with severe renal disease (eGFR of <30), off-pump CABG was associated with a significantly lower incidence of de novo dialysis. CONCLUSIONS: The off-pump technique significantly reduced surgical mortality in patients with moderate or severe preoperative renal dysfunction.

Caseous calcification of the mitral annulus is a rare variant of mitral annular calcification (MAC). MAC is detected using conventional echocardiography and is prevalent in the elderly. However, limited information is currently available on the transformation of MAC. We herein report a case of a sudden liquified change in MAC, which was diagnosed using echocardiography and computed tomography. .

Background. Adverse effects of previous percutaneous coronary intervention (PCI) on clinical outcomes after coronary artery bypass grafting (CABG) are unclear. This study aimed to evaluate the effect of previous PCI on early outcomes after subsequent CABG by using data from the Japanese national database. Methods. This study analyzed data from 48,051 consecutive patients that were retrieved from the Japan Adult Cardiovascular Surgery Database. These patients underwent primary, isolated, elective CABG between January 2008 and December 2013. Early mortality and morbidity rates in patients with previous PCI (n = 12,457, 25.9%) were compared with those in patients with no PCI (n = 35,594, 74.1%) by using multivariate logistic regression analysis and propensity score analysis. Results. Operative mortality rates (no PCI, 1.2%; previous PCI, 1.2%; P [ 0.970) and morbidity rates (no PCI, 7.4%; previous PCI, 7.2%; p = 0.436) were similar between the two groups. In risk-adjusted multivariate logistic-regression analysis, previous PCI (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.82 to 1.22; p = 0.995) and morbidity (OR, 0.97; 95% CI, 0.89 to 1.05; p = 0.391) were not significant risk factors of operative mortality. Inverse probability of treatment weighting using the propensity score confirmed these results. Conclusions. This study shows that a previous PCI procedure does not increase postoperative adverse events after subsequent CABG. In the setting of repeat coronary revascularization, the most appropriate method of revascularization should be selected by the heart team, without being affected by a history of a previous PCI procedure. (C) 2017 by The Society of Thoracic Surgeons

Background: There is discordance regarding the effect of symptom status before aortic valve replacement (AVR) on long-term outcome after AVR in severe aortic stenosis (AS). Methods and Results: The CURRENT AS registry is a multicenter retrospective registry enrolling 3,815 consecutive patients with severe AS. Among 1,196 patients managed with the initial AVR strategy, long-term clinical outcomes were compared between the symptomatic patients (n= 905), and asymptomatic patients (n= 291). Median follow-up interval was 1337 days with a 91% follow-up rate at 2 years. AVR was performed in 886 patients (98%) in the symptomatic group and in 287 patients (99%) in the asymptomatic group. Symptomatic patients were older and more often had comorbidities than asymptomatic patients with similar echocardiographic AS severity. The cumulative 5-year incidences of all-cause death and heart failure (HF) hospitalization were significantly higher in symptomatic patients than in asymptomatic patients (25.6% vs. 15.4%, P= 0.001, and 14.2% vs. 3.8%, P< 0.001, respectively). On landmark analysis at 30 days after AVR, the differences in mortality and HF hospitalization between the 2 groups were mainly observed beyond 30 days. Conclusions: When managed with the initial AVR strategy, the long-term outcomes of symptomatic severe AS were worse than those of asymptomatic severe AS. Early AVR strategy might be recommended in some selected asymptomatic severe AS patients with reasonable operative risk.

Objective: In patients with a high risk of fistula immaturity, we created arteriovenous fistulas (AVFs) combined with brachial artery superficialization. With this procedure, the superficialized arteries are used as drawing routes and the AVFs as returning routes. This is a technical report about AVFs combined with brachial artery superficialization. Methods: Twenty-four consecutive patients with a high risk of fistula immaturity who underwent AVFs with brachial artery superficialization were included in this single-center retrospective study. High risk for maturation failure was defined with a combination of the vessel size measured by ultrasound and the length of the straight segment for cannulation. The indications were as follows: (1) a vein diameter of < 2 mm or an artery diameter at the point of anastomosis of < 2 mm(n = 9); and (2) a vein cannulation site of < 10 cm long, which is too short for two cannulations (n = 15). Initially, after careful examination of the vessels by duplex ultrasound imaging, we created an AVF at an appropriate site. Subsequently, the brachial artery was exposed and the side branches were ligated. The brachial artery was mobilized to the ventral aspect of the upper arm, and the subcutaneous tissue under the brachial artery was sutured. A skin flap was then placed over the transposed brachial artery. Results: One patient died of sepsis due to central venous catheter infection before the initial cannulation. All other patients underwent successful two-needle cannulation with a prescribed blood flow. The median age of the patients was 78 years. The first successful cannulation was achieved at a median of 17 days (range, 12-547) after AVF creation. Two patients underwent cannulation > 30 days after surgery (58 and 547 days) because their vascular accesses were created before initiation of hemodialysis treatment. Median postoperative follow-up duration was 524 days (range, 15-1394 days). Nine patients (38%) died during follow-up of unrelated causes. At 12 postoperative months, primary patency was 75% and secondary patency was 94%. Conclusions: AVF with brachial artery superficialization is a safe and effective technique for patients with a high risk of fistula immaturity.

A hybrid procedure of beating-heart coronary artery bypass grafting (CABG) with the concomitant use of cardiopulmonary bypass termed on-pump beating-heart CABG (ON-BH CABG) has emerged as an alternative for high-risk patient populations. Although several studies have reported the advantage of ON-BH CABG in high-risk patients, the clinical benefit of ON-BH CABG is still under discussion. Here, we performed a meta-analysis of the data derived from published studies comparing the clinical outcomes of ON-BH CABG with that of conventional arrested heart CABG. Medline, Embase and Scopus databases were searched for relevant publications up to March 2015. A systematic review of the published literature identified 14 published studies incorporating 2040 patients (884 ON-BH CABG and 1156 conventional CABG). Odds ratios (ORs) for binary variables or weighted mean difference for continuous variables were combined using the inverse variance method in a fixed-effects model. Study heterogeneity was tested using Cochran's Q test and the publication bias was assessed using Begg's and Egger's tests. The fixed-effects meta-analysis for early mortality showed that ON-BH CABG provided a 45% lower risk of early mortality compared with conventional CABG (OR 0.553; 95% confidence interval [CI] 0.376-0.815; P = 0.003). There was minimal heterogeneity in the included studies (P = 0.29) and no evidence of significant publication bias. A sensitivity analysis, including a random-effects meta-analysis (OR 0.552; 95% CI 0.356-0.856; P = 0.008) and a one-study-removed meta-analysis, supported the validity of the primary analysis for early mortality. There was significantly lower perioperative morbidity associated with ON-BH CABG, including myocardial infarction (OR 0.294; 95% CI 0.141-0.613; P = 0.001), renal failure (OR 0.362; 95% CI 0.209-0.626; P < 0.001) and low output syndrome (OR 0.330; 95% CI 0.197-0.551; P < 0.001) with no significant heterogeneity. In conclusion, current evidence from comparative studies indicates that ON-BH CABG is associated with significantly lower early morbidity and mortality. The ON-BH CABG could be an attractive planned alternative for high-risk patient populations.

Objective: Using data from the Japan Adult Cardiovascular Surgery Database, we evaluated the prognostic influence of off-pump technique in patients with low ejection fraction who underwent coronary artery bypass grafting. Methods: We analyzed 2187 patients with an ejection fraction <0.30 who underwent primary, nonemergency, isolated coronary artery bypass grafting between 2008 and 2012, as reported in the Japan Adult Cardiovascular Surgery Database. Patients were divided into on-pump (n = 1134; 51.1%) and off-pump (n = 1053; 48.9%) coronary artery bypass grafting groups. Propensity-score matching for 20 preoperative variables was performed, and early mortality and morbidity were compared between matched groups. Results: Propensity-score matching created 918 pairs. Of the 918 patients in the off-pump group, conversion to an on-pump procedure occurred in 56 (6.1%). Compared with on-pump, off-pump technique was associated with significantly lower incidences of 30-day death (1.7% vs 3.7%; P = .01), operative death (3.3% vs 6.1%; P = .006), mediastinitis (1.9% vs 3.4%; P = .041), reoperation for bleeding (0.9% vs 3.5%; P<.001), and prolonged ventilation (8.2% vs 13.4%; P<.001). Comparison of patients undergoing off-pump versus on-pump procedures demonstrated no significant differences in the incidence of stroke (1.5% vs 2.1%; P = .38), renal failure (6.1% vs 7.4%; P = .26), and postoperative dialysis (3.1% vs 4.4%; P = .14). Institutional volume-adjusted analysis confirmed most of these results. Conclusions: Off-pump coronary artery bypass grafting is associated with significantly reduced early mortality and morbidity in patients with an ejection fraction <0.30.

The prognostic significance of previous percutaneous coronary intervention (PCI) in patients undergoing coronary artery bypass grafting (CABG) is still unclear. Although many studies have reported adverse effects of previous PCI on postoperative mortality in CABG, as yet no meta-analysis has been carried out. We conducted this first meta-analysis to assess whether previous PCI increases postoperative mortality in CABG. MEDLINE and EMBASE were searched for relevant articles up to and including April 2014. Studies published in English satisfying the following criteria were included in the meta-analysis: (i) comparing CABG patients with previous PCI versus without previous PCI; and (ii) reporting hospital mortality. Our search identified 23 comparative studies, including 174 777 patients: 19 179 with previous PCI and 155 598 without previous PCI. Pooled analysis demonstrated that previous PCI had an adverse effect on hospital mortality: odds ratio (OR) 1.187, 95% confidence interval (CI) 1.075-1.312. Furthermore, subgroup analysis stratified by the proportion of multiple previous PCI (i.e. number of patients with multiple previous PCI/number of patients with single or multiple previous PCI) was performed. In the subgroup of studies with the proportion <40%, the adverse effect was not significant: OR 0.897 (95% CI 0.723-1.113); however, in the subgroup of studies with the proportion >= 40%, the adverse effect of previous PCI was significant: OR 1.987 (95% CI 1.563-2.526). A meta-regression coefficient was significantly positive for the proportion of patients with a history of multiple PCI (coefficient 0.841; 95% CI 0.457-1.226; P < 0.001). This meta-analysis would argue that as the proportion of patients with multiple previous PCI in the CABG cohort increases, postoperative mortality also increases. This result re-emphasizes the importance of the heart team approach to coronary revascularization.

We describe a David operation in a 62-year-old renal transplant recipient with valsalva aneurysm and concomitant aortic insufficiency. The risk of postoperative infection seemed significant because he was receiving immunosuppressive therapy; thus, David operation was performed. He recovered uneventfully. David operation appears to be an attractive alternative in transplant recipients.

Background: Few data exist on the results of transcatheter aortic valve implantation (TAVI) via the transfemoral approach in small slightly built Japanese patients with severe aortic stenosis who are ineligible or at high-risk for conventional surgical aortic valve replacement (SAVR). Therefore, the purpose was to investigate the early outcomes of TAVI using the transiliofemoral approach in Japan. Methods and Results: Between June 2010 and June 2013, 21 consecutive patients (mean age, 81.0 years; 81.0% female) underwent TAVI with Edwards SAPIEN XT valves using the transiliofemoral approach. The mean body surface area was 1.44 +/- 0.15 m(2). The device success rate was 90.5%. Although 2 patients did not meet the echocardiographic criteria for device success, no failure to deliver and deploy a valve occurred. The mean effective aortic valve area increased from 0.54 +/- 0.12 cm(2) at baseline to 1.46 +/- 0.29 cm(2) after the procedure (P<0.001), and the mean aortic transvalvular pressure gradient decreased from 51.0 +/- 15.6 at baseline to 11.2 +/- 3.6 after the procedure (P<0.001). The 30-day mortality and combined safety endpoint rates were 0% and 4.8%, respectively. All patients achieved New York Heart Association functional class I or II at 30 days. Conclusions: Early outcome of TAVI with the Edwards-SAPIEN XT valve via the transiliofemoral approach at Kurashiki Central Hospital is satisfactory for patients who are ineligible or at high risk for SAVR.

Background. The benefit of thoracic endovascular aortic repair (TEVAR) for uncomplicated acute type B aortic dissection is unclear. Reliable prognostic factors are needed to identify candidates for prophylactic TEVAR. The aim of this study was to detect prognostic factors in patients with uncomplicated acute type B aortic dissection. Methods. From January 2003 to April 2012, a total of 228 patients with uncomplicated acute type B aortic dissection were admitted to our institute. Cox proportional hazards analysis was performed to identify risk factors for death, dissection-related death, and aortic events. Results. Independent predictors of mortality were age (hazard ratio [HR], 1.08; p < 0.001) and false lumen thickness (mm) (HR, 1.10; p = 0.013), and the risk factor for dissection-related death was false lumen thickness (mm) (HR, 1.14; p < 0.001). Independent risk factors for aortic events were diameter of the descending aorta (mm) (HR, 1.14; p < 0.001) and entry in a proximal site (HR, 2.90; p = 0.02). The actuarial freedom from aortic events in patients with a descending aortic diameter of less than 40 mm and no entry in a proximal site at 1, 3, and 5 years was 96.6%, 90.8%, and 82.5%, respectively, whereas in patients with 1 of these 2 factors, it was 80.1%, 66.8%, and 53.5%, respectively. Conclusions. In uncomplicated acute type B aortic dissection, the diameter of the descending aorta and entry in a proximal site were independent prognostic factors for aortic events. Prophylactic TEVAR should be considered for patients with these risk (C) 2014 by The Society of Thoracic Surgeons

We report a case of redo mitral valve replacement via right thoracotomy for ischemic mitral regurgitation after coronary artery bypass grafting. An 81-year-old woman with a history of multiple coronary artery bypass grafting was admitted to our institute for treatment of severe ischemic mitral valve regurgitation. She had a history of repeated hospitalization for heart failure and complained of worsening dyspnea. Coronary angiography showed patent coronary grafts. Echocardiography revealed severe mitral regurgitation with leaflet tethering and posteroinferior wall asynergy. The patient underwent mitral valve replacement (Mosaic Bioprosthesis 27 mm) via right thoracotomy approach with ventricular fibrillation under moderate hypothermia. The ventricular fibrillation time was 57 min, and the cardiopulmonary bypass time was 126 min. The patients postoperative recovery was uneventful. She was discharged on postoperative day 19. Right thoracotomy approach provided excellent exposure of the mitral valve and minimized the risk of repeat sternotomy, including injury of previous bypass grafts, injury of right ventricle and significant hemorrhage.

An 84-year-old male on oral steroids, coumadin and multiple antiplatelets for stented superficial femoral artery presented to our hospital with chest oppression. His CT scan showed cardiac tamponade with periaortic hematoma. At first, sealed rupture of aortic dissection with thrombosed false lumen was suspected. However, delayed enhancement view revealed extravasation of contrast agent, which appeared to drain into the pericardium or pericardial space. Emergency thoracotomy revealed normal aorta with several small spurting vessels of pulmonary side of the pericardium. To the best of our knowledge, this is the first reported case in the literature of a parietal pleural hematoma without known cause such as malignancy or hematologic disorders. © 2013 The Japanese Association for Thoracic Surgery.

The Medtronic freestyle aortic root bioprosthesis (Medtronic, Inc., Minneapolis, MN, USA) is a stentless valve with an effective orifice area that is larger than that observed on other bioprostheses. However, there have been sporadic reports of structural valve deterioration (SVD), such as aortic root wall rupture, leaflet tearing, and pseudoaneurysm formation. We report five cases of SVD of freestyle aortic root bioprostheses. doi: 10.1111/jocs.12235 (J Card Surg 2014;29:22-25)

We describe the successful repair of a quadricuspid aortic valve in a 64-year-old man after attempted tricuspidization via detachment of a commissure of the accessory cusp failed. Bicuspidization via detachment of another commissure was successful. Quadricuspid aortic valve repair by bicuspidization, which surgically transforms 3 cusps into 1, may be a simple and reproducible technique if tricuspidization repair has failed. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Objective: The impact of diastolic function on the clinical outcome of surgical ventricular restoration remains controversial. Methods: 71 patients undergoing surgical ventricular restoration between 1999 and 2012 were investigated. Perioperative echocardiographic parameters were compared, risk factors for deaths and cardiac events were analyzed, and actuarial freedom from death and cardiac events was computed. Results: Preoperatively, the left ventricular end-systolic volume index was 77±40 mL·m-2 and left ventricular ejection fraction was 33%±11%. Postoperatively, left ventricular systolic function was significantly improved (end-systolic volume index 49±31 mL·m-2, ejection fraction 42.1%±11.7%) with a 33.8%±21.9% reduction in left ventricular end-systolic volume index. The transmitral filling deceleration time decreased from 198±54 to 150±46 ms, and the ratio of early peak filling velocities increased significantly postoperatively (from 16±10 to 21±17). Freedom from death and cardiac events at 5 years was 78%±5% and 64%±6%, respectively. Multivariate analyses revealed that age was a significant risk factor for all-cause death, postoperative transmitral inflow pattern for cardiac death, and preoperative mitral regurgitation and postoperative transmitral inflow pattern for cardiac events. Conclusion: Despite its positive impact on systolic function, surgical ventricular restoration negatively affects postoperative diastolic function. Postoperative severe diastolic dysfunction may correlate with late mortality and cardiac events. © The Author(s) 2013.

A 25-year-old woman committed suicide with a high-rise fall and presented hypovolemic shock caused by blunt thoracic, abdominal injury. Enhanced computed tomography scan showed the pelvic hemorrhage and the transection of the descending thoracic aorta. After urgent transcatheter arterial embolization to stabilize bleeding from pelvic fracture, the thoracic aortic injury was treated with endovascular aortic repair using a GORE TAG endograft. She recovered from her injuries, and there was no evidence of endoleak in the follow-up computed tomography scan. In the treatment of traumatic aortic injury with associated severe injuries, the management of bleeding from associated injuries is important.

We report the successful repair of a bicuspid aortic valve with vegetation on its thickened raphe by using two pericardial patches. After excising the vegetation and thickened raphe, the first patch was sewn between the remaining leaflets. Another patch was then sewn at the base of the cusp to create sufficient geometrical height for good coaptation. Our two-patch technique may facilitate intraoperative accommodation of the 3-D shape of the new cusp. © 2013 The Author 2013.

Objectives: We evaluated the utility of novel simulator for off-pump coronary artery bypass grafting for surgical residents. Methods: The novel simulator system "BEAT, YOUCAN" has 2 components. (1) A pink disposable silicone vessel model having a 3-layer structure mimicking the internal mammary artery. The disposable silicone vessels mimicking the coronary artery are embedded in a 4 × 7-cm yellow silicone piece. (2) A beating table with a holder compatible with the yellow silicone piece. The arbitrary heartbeat pattern and angle are compatible with the controller. With aforementioned simulator, four cardiovascular surgical residents with no experience as an operator in coronary artery bypass grafting performed end-to-side anastomosis with 7-0 polypropylene, simulating the anastomosis of the mammary to the coronary artery. For each anastomosis, the time to complete the anastomosis, the number of sutures placed, and the number of troubles were recorded. The performance of the anastomosis was evaluated and compared between early (1-10th anastomoses) and late phase (30-40 anastomoses) using the special made score with full mark of 25 points. Results: In total, 160 anastomoses were done (early, 40 late, 40). The time to complete anastomosis was significantly shortened with practice, and the number of troubles in each anastomosis was significantly decreased. The number of sutures placed in each anastomosis had become stable at late phase. The performance score also significantly improved with practice. The learning curve for operative time and the number of events plateaued at approximately the 30th anastomosis. Conclusion: The novel simulator is effective for cardiovascular trainees. © 2013 The Japanese Association for Thoracic Surgery.

Background. There has been an increasing use of percutaneous coronary intervention with drug-eluting stent (DES) in patients with unprotected left main coronary artery disease. We assessed whether coronary artery bypass grafting (CABG) would be superior to percutaneous coronary intervention with first-generation DES in patients with unprotected left main coronary artery disease. Methods. Between January 2003 and December 2007, a total of 295 patients with unprotected left main coronary artery disease were treated with Kurashiki Central Hospital, Okayama, Japan. Among these patients, 169 and 126 underwent CABG and percutaneous coronary intervention with DES, respectively. The average Society of Thoracic Surgeons' predictive risk of mortality score was 2.3 +/- 3.8%. We defined higher-risk and lower-risk patients as those with Society of Thoracic Surgeons' predictive risk of mortality scores higher than 2.3% (CABG, n = 48; percutaneous coronary intervention, n = 28) and lower than 2.3% (CABG, n = 121; percutaneous coronary intervention, n = 98), respectively. Survival, major adverse cardiac-related events, and target lesion revascularization were analyzed by the Kaplan-Meier method. Results. Between-group differences in favor of CABG were seen with respect to the rate of major adverse cardiac-related events and target lesion revascularization in both strata. In patients with lower scores according to the Society of Thoracic Surgeons' predictive risk of mortality, the cardiac death-free survival rate was significantly higher in CABG. Conclusions. In this 5-year single-center experience, CABG is recommended for unprotected left main coronary artery disease, especially in patients with low scores in the Society of Thoracic Surgeons' predictive risk of mortality. (Ann Thorac Surg 2012;94:1927-33) (c) 2012 by The Society of Thoracic Surgeons

We report a successful repair of bicuspid aortic valve having thickened raphe using pericardial patch. After excising the thickened portion, the patch was sewn to the remaining leaflet and root. To note, the height the patch was sewn to the root was lowered to the equivalent level of the corresponding portion of the other cusp, to create symmetrical bicuspid configuration. Postoperative echocardiography revealed trivial aortic regurgitation with improved leaflet motion and transvalvular flow. © The Japanese Association for Thoracic Surgery 2012.

(Background): In the current stent era, aggressive repeated percutaneous coronary intervention (PCI) has become more common. The aim of this study was to investigate the impact of previous repeated PCI on the subsequent coronary artery bypass grafting (CABG). (Methods): Between January 1990 and January 2008, a total of 894 patients underwent first-time isolated elective CABG. Among the 894 patients, 515 patients had had no PCI (group A), 179 patients had had single PCI (Group B), and 200 patients had had multiple PCI (2-15 times, mean 3.6 +/- 2.3 times) (group C) before CABG. These groups were compared in terms of early and late clinical results. (Results): Preoperative left ventricular ejection fraction was significantly higher in group A (group A; 58 +/- 13%, group B; 54 +/- 12%, and group C; 54 +/- 12%). Number of bypass grafts was significantly smaller in group C (A: 3.3 +/- 1.0, B 3.4 +/- 0.9, C 3.1 +/- 1.0). Although there was no statistically significant difference among the groups, in-hospital mortality in group C was higher than that in group A and B (A:1.6%, B:1.1%, C:3.5%, p = 0.16). Survival analysis by Kaplan-Meier method (mean follow-up: 58 +/- 43 methods) revealed that freedom from all-cause death and cardiac death was significantly lower in group C in comparison with group A. Freedom from cardiac event was significantly higher in group C than that in group A. Multivariate analysis identified a number of previous PCI as an independent risk factor for cardiac death. (Conclusions): Repeated PCI increased risk for long-term prognosis of subsequent CABG.

Currently, aortic valve replacement is the mainstay treatment for aortic regurgitation due to commissural detachment. Herein, we report a novel technique of aortic root and commissural repair and its intermediate clinical outcome in patients with significant aortic regurgitation caused by commissural detachment. The detached commissure and aortic root were treated concomitantly by en bloc reattachment of the detached commissure and aortic wall by using multiple pledgeted sutures, in addition to aortic root reimplantation. (Ann Thorac Surg 2011;91:1628-9) (C) 2011 by The Society of Thoracic Surgeons

The treatment of aortic root dilatation accompanied by a leaking valve requires a multimodal approach involving root reimplantation or remodeling with tailoring of the sinotubular junction or valvular apparatus, or both. We report a patient with annuloaortic ectasia with a leaking valve that was successfully treated by performing aortic valve repair and root reimplantation. The operation was performed by placing a thin Gore-Tex CV7 suture (W. L. Gore and Assoc, Flagstaff, AZ) halfway along the prolapsed right coronary leaflet to suspend the leaflet. By using this surgical technique, we easily repaired the prolapsed leaflet by meticulously adjusting the length of the edge of the diseased leaflet. (Ann Thorac Surg 2011;91:907-8) (C) 2011 by The Society of Thoracic Surgeons

Postinfarction ventricular septal perforation (VSP) remains a surgical challenge. The present study describes the use of an interrupted suture technique with the goal of reducing the incidence of postoperative residual shunt. Thirty-four consecutive cases of patients who underwent David's procedure for VSP between 1996 and 2008 were reviewed. A running suture technique was used to close the ruptured septum (C-group: 14 patients) prior to 2002, while the interrupted suture technique (I-group: 20 patients) was used after that point. The overall 30-day mortality was 26.5%, and the mortality rate was not different when comparing the two groups. Postoperative residual shunt was present in five patients (36%) in the C-group and in two patients (10%) in the I-group. In conclusion, use of the interrupted suture technique resulted in a lower incidence of postoperative residual shunt rate. However, the mortality associated with surgical repair of VSP remains high. (C) 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Background. Improvements in the results of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) have been extending their use in patients with all forms of coronary artery disease. The purpose of this study was to compare the midterm clinical results of coronary artery bypass surgery (CABG) and PCI with DES in patients with chronic renal failure on hemodialysis. Methods. From January 2002 to December 2006, 29 patients underwent CABG, and 75 patients underwent PCI with DES. For CABG, 24 patients had off-pump surgery. The mean follow-up was 32.0 +/- 22.0 months for CABG and 23.5 +/- 14.8 months for PCI. Survival, cardiac death, major adverse cardiac events (cardiac death, myocardial infarction, revascularization), and target lesion revascularization were analyzed using the Kaplan-Meier method. Results. Preoperative characteristics and risk factors were compatible between the groups except for the European System for Cardiac Operative Risk Evaluation (7.3 +/- 2.7 for CABG and 5.0 +/- 2.4 for PCI, p < 0.0001) and the presence of a left main trunk lesion (53.3% for CABG and 18.7% for PCI). Thirty-day mortality was 3.3% for CABG and 4.0% for PCI. The 2-year survival rate was 84.0% for CABG and 67.6% for PCI (p = 0.0271). The cardiac death-free curve at 2 years was 100% for CABG and 84.1% for PCI (p = 0.0122). The major adverse cardiac events-free rate at 2 years was 75.8% for CABG and 31.5% for PCI (p < 0.0001). During the follow-up period, there were 6 late deaths in the CABG group and 27 late deaths (including 6 sudden deaths) in the PCI group. Conclusions. Coronary artery bypass grafting was superior to PCI with DES in patients with chronic renal failure on hemodialysis in terms of long-term outcomes for cardiac death, major adverse cardiac events, and target lesion revascularization. The DES carried a higher risk for sudden death, which might be associated with stent thrombosis. (Ann Thorac Surg 2010; 89: 1896-900) (C) 2010 by The Society of Thoracic Surgeons

Objective: Clinical outcomes after open heart surgery in patients with liver cirrhosis are not satisfactory. For evaluating hepatic function, the Child-Pugh classification has been widely used. It has been reported that open heart surgery can be performed safely in patients with mild liver cirrhosis. In this study, we examined the clinical outcomes after open heart surgery in patients with liver cirrhosis and evaluated the usefulness of the Child-Pugh classification. Methods: There were 12 liver cirrhosis patients who underwent open heart surgery between January 2002 and December 2006 at our institution. The severity of cirrhosis was graded according to the Child-Pugh classification. We reviewed clinical outcomes, such as postoperative mortality and morbidity, and tried to determine the risk factors. Finally, we assessed the usefulness of the Child-Pugh classification. Results: Six patients were classified as having Child class A, and the other six patients were classified as B. The overall mortality of group A was 50%, and that of group B was 17%. Postoperative major morbidities occurred in half of the patients of Child class A and in all of the patients of Child class B. Patients who experienced major morbidities had markedly lower levels of serum cholinesterase (106 ± 46 vs. 199 ± 72 IU/l P = 0.02) and lower platelet level (7.5 ± 2.9 vs. 11.9 ± 3.6 × 104/μl P = 0.04). Conclusion: The mortality and morbidity rates were high even in the Child class A patients. The Child classification may be an insufficient method for evaluating hepatic function. We have to assess other factors, such as the serum cholinesterase level or the platelet count. © 2009 The Japanese Association for Thoracic Surgery.

Emergency surgery for acute type A dissection is extremely difficult when the sinuses of Valsalva are widely dissected. Indications for the various proposed surgical approaches are controversial. Here, we describe modified partial aortic root remodeling to overcome bleeding. We retrospectively reviewed 13 consecutive patients who underwent the following operative procedure. We did not resect the sinus but sutured a U-shaped Dacron patch to the inside of the sinus to reinforce the dissected weakened wall. The indications for reconstruction of the aortic root with this technique are extension of an intimal tear into a sinus, a fully dissected sinus as far as the level of the aortic annulus or mild annuloaortic ectasia. One patient died of multiorgan failure. No patient had more than mild aortic regurgitation. Mean follow-up duration was 22 months and there was no late death. Two patients underwent repeated surgery due to graft infection and redissection. Our modified partial aortic root remodeling technique might be a useful surgical procedure if one or two Valsalva sinuses are affected in type A acute aortic dissection. © 2009 Published by European Association for Cardio-Thoracic Surgery.

A 20-year-old male was referred to our hospital to undergo operative treatment due to aortic valve insufficiency which had gradually worsened. The patient's chief complaint was a loss of breath upon effort which had progressively worsened after undergoing aortic valve plasty (AVP) for aortic valve insufficiency with infective endocarditis at another institution. AVP by the cusp extension method had been performed because of the patient's youth and there had been no change in the morbid state, except for the presence of a non-coronary cusp. In addition, the aortic valve insufficiency was controlable and postoperative course was also excellent. The cusp extension method was therefore considered to be an appropriate procedure for this case since it would allow the patient to return it to a state with a more normal heart, since the valve organization after this procedure would be able to reach a maximum level.

A 69-year-old woman was admitted with fever and dyspnea. We diagnosed the congestive heart failure due to infective endocarditis (IE) with mitral valve regurgitation and stenosis. We immediately started medical therapy in order to control both the heart failure and the infection. However, we had to semi-emergency mitral valve replacement additionally perform a days after the initial hospitalized due to a progression of the heart failure. The operative findings showed an area of vegetation to be incarcerated in the mitral orifice. In cases of IE which are associated with mitral stenosis, we therefore should consider the possibility that vegetation may be present in the mitral orifice and closely follow such patients by echocardiography.

Objective: We describe our strategy and the outcomes of simultaneous coronary artery bypass grafting (CABG) during surgery for thoracic aortic aneurysms in patients with coronary artery disease. Patients and Methods: We enrolled 34 consecutive patients (age: 70.6 +/- 10.9 years) who underwent simultaneous elective surgeries between June 2000 and June 2007. The aorta was replaced under cardiopulmonary bypass with moderate or profound hypothermia. We performed CABG while waiting for, and/or during recovery from hypothermia. The mean number of anastomoses was 1.8 +/- 0.9, and the complete revascularization rate was 88.2%. Results: One patient underwent postoperative percutaneous coronary intervention (PCI) for an occluded left internal thoracic artery. Three patients who underwent PCI and I who underwent pacemaker implantation because of SSS were defined as having late cardiac events. There were no in-hospital deaths, but 4 late deaths occurred due to non-cardiac problems (mean follow-up: 28.6 +/- 22.2 months). The 3-year survival and cardiac-related event-free rates were 90.6% and 83.0%, respectively. Conclusions: The early and late outcomes of simultaneous surgery for thoracic aortic aneurysm with coronary artery disease were satisfactory.

A 59-year-old woman with a history of bronchiectasis was admitted due to a two-day history of fever and hemosputum. A permanent pacemaker (DDD mode, screw-in lead) had been implanted three months previously to treat complete atrioventricular block. On computed tomography, pneumopericardium was seen, and the right atrium pacing lead was stuck into the right lung. A semi-emergency operation to remove the pacing lead and part of the right middle lobe was performed through a right thoracotomy. Although pneumopericardium caused by pacing lead perforation is rare, the possibility of perforation by the pacing lead should always be considered. © 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Background Recent studies have revealed that bone marrow cell (BMC) transplantation is effective not only for myocardial infarction (MI), but also for dilated cardiomyopathy (DCM). However, the method of administering donor cells remains unknown, and may differ between MI and DCM. In the present study, intramyocardial (IM) injection and intravenous (IV) delivery of BMC were compared in each etiological model. Methods and Results MI was induced in 72 mice and DCM in another 36 mice by doxorubicin. BMCs were administered IV or IM in an acute MI (AMI), old MI (OMI) or DCM model. In the AMI model, left ventricular (LV) remodeling was reduced in both the IM- and IV-groups, but only in the IM-group in the OMI model. In the DCM model, the LV dimension of the IV-group was smaller than that of the IM-group. Histological examination showed that green fluorescent protein (GFP) cells were equally distributed in the infarct area of the IV- and IM-groups in AMI, and in the IM-group in the OMI model. In the DCM model, GFP cells were diffusely scattered throughout the ventricular wall in the IV-group, but were confined to the injection site in the IM-group. Conclusions In OMI, IM delivery of BMCs was more effective than IV; however, IV delivery was superior in DCM. Delivery route should be selected according to the etiology of heart disease to optimize the efficacy of BMC transplantation.

A 69-year-old man was given a diagnosis with rupture of an abdominal aortic aneurysm associated with sigmoid and rectal colons ischemia. He was admitted to our hospital about 30 hours after rupture, and underwent an emergency operation. The infra-renal abdominal aorta was ruptured with a huge hematoma in the retroperitoneal space. Sigmoid and rectal colons were necrotic. The abdominal aortic aneurysm was replaced with a prosthetic Y-graft. The sigmoid and rectal colons were resected and colostomy was performed. He recovered from postoperative complications including acute renal failure, acute respiratory failure, and liver failure and was discharged in good condition 23 days after the operation.

Background. Left ventricular (LV) free wall rupture is a catastrophic complication after acute myocardial infarction. The optimal therapeutic strategy is controversial and the midterm results are unknown. Methods. Between June 1993 and May 2006, 32 patients with an average age of 73 years (range, from 55 to 96 years) were surgically treated for LV free wall rupture. Sutureless technique (gluing autologous patch to the tear) was applied in all patients. Results. The interval between acute myocardial infarction and the rupture was 33 +/- 42 hours and the interval between the rupture and the operation was 3.6 +/- 2.6 hours. Preoperatively, cardiopulmonary resuscitation was performed in eight cases. Percutaneous cardiopulmonary support was placed in six cases and intraaortic balloon pumping in 20 cases preoperatively. The in-hospital mortality was 15.6%. Two patients died of rerupture within ten days. While there was no rerupture during the follow-up period, five patients developed dyskinetic LV aneurysm and one patient developed LV pseudoaneurysm. Conclusions. The sutureless technique is a simple and effective option for the surgical treatment for LV free wall rupture. The preoperative moribund condition was highly associated with the operative mortality.

We presented here 2 cases of rare nonvascular tumor involving the aorta. Case 1: A 69-year-old woman. She presented leg edema and dyspnea on admission. Computed tomography revealed abdominal aortic aneurysm perforating left common iliac vein. Abdominal aortic aneurysm replacement and fistula closure were done on an emergency basis. Immunohistologic examination revealed that malignant mesothelioma invaded the aortic wall. Case 2: A 47-year-old woman presented with dyspnea. Enhanced computed tomography revealed rupture of the descending aortic aneurysm (saccular type). Aortic replacement was done on an emergency basis. One year after the operation, computed tomography revealed a giant mass (160×70mm) surrounding the descending thoracic aorta. On biopsy, malignant schwannoma was found to invade the descending aorta. Sometimes nonvascular tumors form aneurysms. So we should be careful in diagnosis before operation. Jpn. J. Cardiovasc. Surg. 37: 56-59 (2008)

We assessed the hypotheses that extension of aortic replacement would reduce the patency of the false lumen of the descending aorta and that postoperative patency of the false lumen would result in poor prognosis. One hundred and twenty-four consecutive patients underwent surgical repair for acute type A acute dissection on an emergency basis. Among the 124 patients, 89 patients had De Bakey type I dissection. Among the patients with De Bakey type I dissection, the false lumen of the descending aorta was preoperatively patent in 52 patients. Distal extent of aortic replacement was ascending aorta in 16 patients, hemiarch in 15 patients, partial arch in seven patients, and total arch in 11 patients. Patency of the false lumen was not influenced by distal extent of the aortic replacement. In a one-year follow-up, the maximum diameter of the descending aorta with patent false lumen had increased significantly than that with closed false lumen. Survival rates were 96% at one year and 67% at five years in the patients with patent false lumen and no mortality in the patients with closed false lumen. Patency of the false lumen was not influenced by extension of aortic replacement and associated with poor prognosis. © 2007 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

We report a new anastomotic 'turn-up' technique in the surgery for acute aortic dissection. This technique includes eversion of the ends of the graft which allows excellent cross-sectional exposure of the aorta and the graft. In our experiences of consecutive 30 cases, this technique reduced perioperative bleeding and resulted in satisfactory clinical outcomes. (c) 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Case 1. Forty nine years woman was given a diagnosis of acute myocardial infarction. Coronary angiography and trans-esophageal echocardiography showed left main trunk dissection due to local aortic root dissection. We operated surgical repair at left main trunk by pericardium after percutaneous coronary intervention. Case 2. Forty nine years man was given a diagnosis of acute myocardial infarction caused by left main trunk dissection due to traumatic local aortic root dissection. We operated coronary artery bypass grafting after insertion of perfusion catheter to left main trunk for maintain coronary perfusion. Although local dissection of aortic aorta is relatively rare, it is potentially complicated with coronary malperfusion. We describe 2 success a cases of surgical treatment for local acute type A aortic dissection complicated with coronary malperfusion.

Cardiac function is evaluated with pressure-volume diagram, wall thickening function, and cardiac output. These are approximately estimated by using echocardiography and cardiac catheterizations. In order to make a surgical plan for left ventricular plasty, surgeons palpate the ventricular wall i.e. cardiac muscle of a patient's heart, where the ventricular thickness, elasticity, and contractile stiffness of the left heart are diagnosed. Cardiovascular surgeons are requested to have the skill to estimate postoperative cardiac function according to the surgical plan determined in the surgery. We present a simulation system for cardiac function evaluation, where left ventricle models made of finite elements are built and estimate surgical efficiency for left ventricular plasty. It is assumed that the ventricular wall of the models is composed of one-layer, elastic and isotropic material. We employed a simple systemic circulation model, Windkessel, in order to compute the PV diagram of the left heart model. This paper presents a heart modeling method based on finite elements, simulation algorism, and its online use of the FEM computation results. Realistic trends of PV diagram are computed in the simulation.

Although careful planning of surgical approach is a key for success of surgery, conventional planning and simulation tools cannot support detailed discussion. This issue is derived from the difficulty of estimating complex physical behavior of soft tissues provided by a series of surgical procedures like cutting and deformation. This paper proposes an adaptive physics-based framework that simulates both interactive cutting and accurate deformation on virtual bodies, and performs preoperative planning for supporting strategic discussion. We focus on limited use of the two models: A particle-based model and an FEM-based model considering required quality and performance in different situations. FEM-based deformation of incision accurately produces estimated surgical fields. Based on the framework, a strategic planning system was developed for supporting decision of surgical approach using 3D representation of the surgical fields. We applied clinical CT dataset of an aortic aneurysm case to the system. Some experiments and usability tests confirmed that the system contributes to grasping 3D shape and location of the target organs and performs detailed discussion on patient-specific surgical approaches.

Background Several clinical trials are underway to determine whether autologous skeletal myoblast transplantation is an effective and safe therapeutic strategy for severe heart failure due to myocardial infarction (MI). It remains unclear whether repeated skeletal myoblast implantation is a feasible and effective cell delivery method for the infarcted myocardium. Methods and Results Four weeks after a coronary ligation, male syngeneic Lewis rats were assigned to 3 treatment groups: 3 episodes of skeletal myoblasts (6x10(6)) transplantation (group I), a bolus transplantation of myoblasts (18x10(6)) (group II), or culture medium injection (group III). Eight weeks after the first treatment, echocardiography, cardiac catheterization and histological examination were performed to compare the therapeutic effects on left ventricular (LV) systolic and diastolic functions, and the engrafted myoblast volume. Repeated myoblast implantation significantly improved LV function and resulted in significantly larger engrafted volume and LV contractility compared with a bolus transplantation with the same number of myoblasts. Conclusions Repeated skeletal myoblast transplantation is a safe and effective therapeutic strategy for the infarcted myocardium.

Background-We investigated whether simultaneous administration of control-released hepatocyte growth factor (HGF) enhances the efficacy of skeletal myoblast (SM) transplantation (Tx) through its antiapoptotic, angiogenic, and antifibrotic effects in myocardial infarction (MI). Methods and Results-Forty-eight Lewis rats with chronic MI were divided into 4 groups. In Group I (n = 14), neonatal SMs (5 X 10(6)) were transplanted in the MI area with a gelatin sheet incorporating 40 mu g (I g[L) of HGF applied. Group II (n= 14) had SM Tx and placement of a saline sheet. Groups III (n= 10) and IV (n= 10) had culture medium injection plus HGF and saline sheet application, respectively. Four rats each from Groups I and 11 were sacrificed at day I for TUNEL assay on donor SNIs. The percentage of TUNEL-positive donor cells was much lower in Group I than in Group 11 (P<0.05). At 4 weeks, in Group I, left ventricular diastolic dimension was smallest in echocardiography, end-systolic elastance was highest, and tau was the lowest (both P<0.0005 in ANOVA) in cardiac catheterization. Vascular density inside the graft was higher in Group I than in Group 11 (P<0.0001). The percentage of fibrotic area inside the graft was smaller in Group I than in Group II (P<0.001). The graft volume as estimated by fast skeletal myosin heavy chain-positive areas was approximate to 7-fold larger in Group I than in Group 11 (P<0.0001). Conclusions-In SM Tx, HGF can greatly increase the graft volume and vascularity and reduce fibrosis inside the graft, which enhances the efficacy of SM Tx to infarcted hearts.

Background. We have developed a hepatocyte growth factor (HGF)-incorporating gelatin hydrogel sheet (HGF sheet), which was designed to release HGF more than 2 weeks in vivo. The present study investigated whether the HGF sheet could prevent the progression of heart failure in stroke-prone spontaneously hypertensive rats. Methods. Stroke-prone spontaneously hypertensive rats at the age of 25 weeks received placement of an HGF sheet on the left ventricular free wall (HGF, n = 10) or sham-operation (control, n = 10). All animals were followed up with Doppler echocardiography during the next 4 weeks and then underwent histologic analysis. The influence of the hydrogel sheet alone was assessed by echocardiography and left ventricular pressure measurements. Survival study was performed (each group, n 11) at the age of 30 weeks. Results. There were two deaths in the control group and no deaths in the HGF group during the 4 weeks. Fractional shortening was significantly higher, and left ventricular diastolic dimension was significantly smaller in the HGF than in the control group. The slope of the peak early diastolic filling velocity and the ratio of that slope to the slope of the peak filling velocity at atrial contraction were significantly lower in the HGF than the control group. Myocardial fibrosis was lower and capillary density was significantly higher in the HGF than the control group. Placement of the hydrogel sheet alone did not affect any cardiac function compared with sham operation. The survival rate at 10 weeks after the surgery was much higher in the HGF than the control group. Conclusions. The HGF sheet improves cardiac function, reverses left ventricular remodeling, and markedly improves survival in spontaneously hypertensive rats. These beneficial effects are associated with angiogenesis and reduced fibrosis in the left ventricular myocardium. (Ann Thorac Surg 2005;79:1627-34) © 2005 by The Society of Thoracic Surgeons.

正中切開での多枝冠動脈バイパス(OPCAB)が心拍動下に行えるようになり急速に普及しているが,その遠隔成績はまだ明らかではない.1997年から2003年4月までに当院で行った単独冠動脈バイパス術(CABG)は390例で,268例がOPCABであった.早期冠動脈造影,および遠隔期冠動脈造影の結果により,OPCABにおけるグラフト選択を検討した.待機CABGでの病院死亡率はon pumpで1.2%,OPCABで1.8%であった(N.S).緊急CABGでの病院死亡率はon pumpで14.3%,OPCABは4%であった(p=0.05).大動脈部分遮断を行ったのは全体の67%であった.周術期脳梗塞は大動脈遮断例にはなかったが,大動脈非遮断の4例に発生した(p=0.006).早期開存率は,撓骨動脈( RA)によるACバイパスは99%,in situの左内胸動脈(LITA)では96%と良好であった.遠隔期開存率はin situのLITAで86%,in situのRITA/IGEAでは80%,RAのACバイパスは82%,SVGのACバイパスは77%,I compositeでは75%で各グラフト間には有意差はなかった.しかし,Y compositeの早期開存率は93%であるが,遠隔期開存率は25%であった.OPCABにおいてin situ LITAとRAによるACバイパスの成績は良好である.

Therapeutic angiogenesis is an important treatment option in patients with severe ischemic heart disease because they have diffusely stenosed coronary arteries that are not suitable targets for conventional revascularization. Among such therapies, we mainly addressed administration of control-released, basic fibroblast growth factor (bFGF) as a safe and effective treatment. We applied this method in various animal models with satisfactory results, and the clinical trial will soon be started. Based on our experiments, we concluded that both control-released bFGF administration and bone marrow cell (BMC) transplantation induce angiogenesis, but only bFGF produces arteriogenesis. Future study is warranted for safe and effective clinical application of the bFGF control-release system. © 2004, Elsevier Science B.V. All rights reserved.

This paper describe a simulation tool for estimating pre- and postoperative cardiac functions for a diseased heart due to myocardial infarction. Cardiac function is able to be evaluated obviously by a pressure-volume (PV) loop including Emax, computed based on FEM. For a normal model, a left ventricular finite element model is built from patient's cine CT images. It is assumed that the ventricular wall of the model is of one-layer, elastic and isotropic. An infarcted region set up for the left ventricular wall with abnormal Young modulus is removed to estimate the postoperative cardiac function in terms of PV loop. In our simulation, realistic trends of a PV loop are computed. The method of its online use using a multidimensional spline interpolation is presented.

Background - It is not clear how many skeletal myoblsts (SM) can survive and exert beneficial effects in the host myocardial infarction (MI) area. We assessed the hypothesis that a large number of SM can replace the MI area with reverse left ventricular (LV) remodeling. Methods and Results - MI was created by left coronary artery ligation in male Lewis rats. Four weeks after ligation, 45 rats had skeletal myoblast transplantation in the MI area. They were randomized into 3 groups according to the number of SM: group I ( n = 15), 5 x 10(7); group II ( n = 15), 5 x 10(6); and group III ( n = 15), 5 x 10(5) cells. Donor SM were obtained from neonatal Lewis rats and directly used without expansion. Another four weeks later, all rats were sacrificed following hemodynamic assessment. All heart sections were stained with anti-fast skeletal myosin heavy chain (FSMHC) antibody to determine the spacial extent of donor myocytes. Results - Four weeks after transplantation, LV diastolic dimension was decreased, fractional area change was increased, and MI size was decreased maximally in group I. Histological study showed that donor cells positive for FSMHC occupied the MI area with nearly normal wall thickness in group I, in which estimated volume of donor-derived muscle tissue was 40 mm(3). In the other groups, FSMHC-positive cells were found only partly in the MI area. Conclusions - A large number of freshly isolated neonatal SM can survive in the host and fully replace the infarcted myocardium with reverse LV remodeling in rats with MI.

Objective: Therapeutic angiogenesis using basic fibroblast growth factor (bFGF) in coronary artery disease has been documented in a number of papers. However. the effectiveness is discrepant artiong documents. In this study, we evaluated the distribution of bFGF in the rat heart by different administration methods, and investigated the efficacy of slow-released administration of bFGF using biodegradable hydrogel microspheres (bFGF microspheres) in a pig infarction model toward an enhanced coronary bypass surgery. Methods: Heart failure due to myocardial infarction was induced in rats and pigs. In the rat study, free form of bFGF (central venous injection, intracoronary injection, and intramyocardial administration) and bFGF microspheres (intramyocardial administration) were given 4 weeks later. The remaining radioactivity of bFGF in the hearts was estimated 1, 24, and 72 It later. On the other hand, the pigs were randomized into two groups 4 weeks after myocardial infarction. While the control group (n = 8) had gelatin hydrogel microspheres with saline, the FGF group (n = 8) received bFGF microspheres in the left ventricular (LV) wall. Results: In the rat study, after intramyocardial administration of bFGF microspheres. more bFGF remained in the rat heart 72 h later compared with the other methods (P < 0.0001). In the pig study, 4 weeks after the treatment. the FGF roup had smaller LV diastolic diameter (48.7 +/- 5.3 vs. 56.7 +/- 5.2 mm, P < 0.01) than the control group. LV end-systolic elastance was higher in the FGF group (2.96 +/- 1.2 vs. 1.06 +/- 0.3 mmHg/ml, P < 0.01). In microscopic examinations, many neovessels were found in and around the scar tissue, and the vascular density in the FGF group was significantly higher (61.5 +/- 18.3 vs. 153.0 +/- 29.0/mm(2). P < 0.01). In addition, the infarcted LV walls were less expanded and more thickened in the FGF group. Conclusions: Biodegradable hydrogel microspheres with bFGF improved LV function and inhibited LV remodeling by angiogenesis in pigs with chronic myocardial infarction. bFGF microspheres into ischemic myocardium may revascularize small ungraftable vessels and may potentially increase distal run-off when applied in coronary bypass surgery. (C) 2003 Elsevier Science B.V. All rights reserved.

Background. We produced a large-animal model of left ventricular (LV) failure induced by transcatheter embolization of the left coronary artery using a gelatin sponge. Methods. Fourteen male pigs underwent transcatheter embolization of the left anterior descending artery (LAD) using gelatin sponge to produce anteroapical myocardial infarction. Coronary angiography was performed I week after the coronary embolization. The animals were followed up with echocardiography and LV pressure-volume study for the subsequent 8 weeks, and the data were compared with those of the control group (n = 13). Results. The procedure mortality was 2 of 14 (14%). Coronary angiography revealed the occluded LAD was recanalized with poor run-off. The LV end-diastolic dimension progressively increased (control versus myocardial infarction: 39 +/- 2 mm versus 49 +/- 4 mm, p < 0.001 at week 4; and 40 2 rum versus 57 6 mm, p < 0.001 at week 8). Fractional area change decreased over 8 weeks (77% +/- 10% versus 43% +/- 6%, p < 0.001 at week 4; and 77% +/- 10% versus 40% +/- 8%, p < 0.001 at week 8). End-systolic elastance progressively decreased over 8 weeks (3.04 +/- 0.73 mm Hg/mL versus 1.54 +/- 0.51 mm Hg/mL, p < 0.0001 at week 4; and 2.88 +/- 0.44 mm Hg/mL versus 1.05 +/- 0.21 rum Hg/mL, p < 0.001 at week 8). The plasma levels of brain natriuretic peptide were significantly higher in the study group (543 131 pg/mL versus 1,321 +/- 364 pg/mL, p < 0.001 at week 4; and 610 +/- 152 pg/mL versus 1,523 232 pg/mL, p < 0.001 at week 8). Conclusions. This pig model of chronic heart failure is reliable, reproducible, and amenable to investigate other surgical procedures. (C) 2003 by The Society of Thoracic Surgeons.

In cardiac plastic surgery, the cardiac surgeon touches the cardiac muscle to diagnose the patient's heart that may be diseased due to infarction or dilate cardiomyopathy to determine the regions where it needs plastic surgery. In other words, the cardiac surgeon needs to recognize the mechanical characteristics of the thin muscle regions by the haptic sensitivity of his/her fingertips. Cardiac images available before cardiac surgery could enable a qualitative estimation of the patient's heart. However, cardiac palpation is the only accurate way for making surgical plans for ventricular plastic surgery in the operating theater. Since young inexperienced cardiac surgeons have few occasions to perform cardiac palpation. even in operation cases, a cardiac palpation training system is highly desired. The training system for a cardiac palpation system we have developed consists of a virtual heart based on human left ventricular magnetic resonance images and a one-dimensional manipulator as a haptic device. Mechanical properties of the cardiac muscles of a pig and a dog are embedded into the virtual heart linked to a Windkessel model for the systemic circulation. Our experiments show that the developed training system enables users to feel the elasticity of the cardiac muscle wall through the manipulator in real-time.

© 2003 IEEE. Dilated ventricular volumes due to myocardial infarct ion and dilated cardiomyopathy are reduced by excising and sewing up the infarcted regions The surgical plans for each patients" heart are determined in the operating ioom. Using a heart-Jung machine, a volume reduction test estimates the suited ventricular volume for beating and thickening The cardiac surgeons palpate a cardiac muscle in order for identifying the cardiac muscular regions that should be excised, and resects and stitches up the ventricle. Opportunities to learn these surgical processes are limited in rhe operation, and the conditions of the diseased cardiac muscle can not be declared even if the latest medical measuring techniques. MRI, XCT, and Echo are used before the surgery. The cardiac surgeons, therefore, highly desire a system which can produccthe braining opportunity of the surgical process of the volume reduction surgery. We have developed a training system for cardiac muscle palpation which is composed of a virtual heart and a hupric device, and they ue appreciated from the cardiac surgeons. This paper introduces the training system we have developed, and some improvements of the virtual heart to make more practical.

This paper aims to achieve haptic reproduction and real-time visualization of a beating heart for cardiac surgery simulation. Unlike most forgoing approaches, the authors focus on time series datasets and propose a new framework for interactive simulation of active tissues. The framework handles both detection and response of collisions between a manipulator and a beating virtual heart. Physics-based force feedback of autonomous cardiac motion is also produced based on a stress-pressure model, which is adapted to elastic objects filled with fluid. Time series datasets of an adult man were applied to an integrated simulation system with a force feedback device. The system displays multidimensional representation of a beating heart and provides a basic training environment for surgical palpation. Finally, results of measurement and medical assessment confirm the achieved quality and performance of the presented framework. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.

Background-This study was designed to investigate the efficacy of the combined procedure of left ventricular (LV) repair and fetal cardiomyocyte transplantation (CM-TX) in a rat myocardial infarction model. Methods and Results-A moderate-sized LV aneurysm was created by proximal ligation of the left coronary artery in 47 Lewis rats. Four weeks later, they were underwent another operation and received culture medium injection (n=10; group I), fetal CM-TX (n=10; group II), purse-string LV repair with culture medium injection (n=14; group III), or LV repair with fetal CM-TX (n=13; group IV). They were echocardiographically followed-up during the subsequent 4 weeks, and cardiac catheterization was performed in the final week. In the late period, LV dimension in group IV was smaller than that in group III (end-diastolic dimension, 0.92+/-0.02 versus 1.01+/-0.03 cm, P=0.0090; end-systolic dimension, 0.62+/-0.02 versus 0.74+/-0.04 cm, P=0.0093; at the fourth week), although they initially showed similar decreases in both groups. At the final week, end-systolic elastance was higher in group IV than in groups I, II, or III (0.61+/-0.10 versus 0.19+/-0.03, 0.30+/-0.09, 0.33+/-0.07 mm Hg/muL, P=0.0002, 0.0037, and 0.0042, respectively). Conclusions-Fetal CM-TX exerted preventive effects against late LV dilation and dysfunction after LV repair in the rat model. The results suggest that repair surgery combined with fetal CM-TX may enhance the surgical benefits for patients with LV aneurysm in the long term.

Background. It is not known whether a composite Y graft of the left internal thoracic artery can provide sufficient blood flow to the whole left coronary system. The aim of this study was to compare regional myocardial blood flow (MBF) and coronary flow reserve after coronary artery bypass grafting using arterial composite Y graft or independent arterial grafts. Methods. Positron emission tomography was performed at rest and after dipyridamole infusion using oxygen-15-labeled water 2 weeks after coronary artery bypass grafting. Regional MBF was calculated in seven segments of the left ventricle. Coronary flow reserve was defined as the ratio of MBF after dipyridamole infusion to MBF at rest. In the Y graft group (n = 22), a free arterial graft to obtuse marginal arteries was anastomosed to the proximal side of in situ left internal thoracic artery, which was anastomosed to the left anterior descending artery. In the independent graft group (n = 13), left anterior descending and obtuse marginal arteries were independently revascularized using in situ left internal thoracic artery and a free arterial graft. Results. There was no difference between the groups in MBF at rest. Coronary flow reserve in the Y graft group was lower than that in the independent group in the anterobasal (1.43 +/- 0.07 versus 1.90 +/- 0.13, p = 0.038), apical (1.24 +/- 0.06 versus 1.64 +/- 0.12, p = 0.003), septal (1.34 +/- 0.05 versus 1.75 +/- 0.13, p = 0.023), and lateral regions (1.19 +/- 0.04 versus 1.66 +/- 0.09, p = 0.001). Conclusions. Although arterial composite Y graft improved MBF at rest, it was not as effective as independent grafts for improving coronary flow reserve soon after coronary artery bypass grafting.

Background: There is evidence that adrenomedullin has autocrine or paracrine activities that oppose cardiac remodelling. However, it remains unclear whether it exerts those local functions in heart failure patients. Objective: To investigate the relation between plasma and pericardial fluid concentrations of adrenomedullin and left ventricular haemodynamic variables. Design: Samples of plasma and pericardial fluid were obtained from 50 patients undergoing cardiac surgery. They were classified into two groups: group N (n = 27) with a left ventricular end diastolic volume index (LVEDVI) less than or equal to 90 ml/m(2); and group R (n = 23) with LVEDVI > 90 ml/m(2). Plasma and pericordial fluid concentrations of total adrenomedullin (tAM) and mature adrenomedullin (mAM) were measured and related to the preoperative haemodynamic variables. Results: Pericardial fluid concentrations of mAM were much higher than the plasma concentration in both group N and group R (mean (SEM), 10.6 (1.7) v 3.3 (0.2) fmol/ml, p = 0.0001; and 21.2 (2.8) v 3.9 (0.3) fmol/ml, p < 0.0001, respectively). The ratio mAM/tAM in pericardial fluid was significantly higher than in plasma (0.56 (0.02) v 0.28 (0.02), p < 0.0001). Pericardial fluid concentrations of mAM, but not plasma concentrations, were significantly correlated with LVEDVI, left ventricular end systolic volume index, left ventricular ejection fraction, and left ventricular mass index (r = 0.60, 0.63, -0.54, and 0.47, respectively). Conclusions: Raised pericardial fluid concentrations of mAM may reflect the actions of adrenomedullin as a local mediator against cardiac remodelling in patients with left ventricular dysfunction.

For the cardiac plastic surgery, cardiac muscle palpation is certainly needed to determine the surgical plan. The opportunity to palpate the cardiac muscle is limited in the operative scene, so that the cardiac surgeons desire the training systems for cardiac muscle palpation. For building the cardiac muscle palpation training system, the virtual heart model which enables to give its mechanical elasticities to the trainees in real-time is necessary. The virtual heart is composed of cine CT imaging data for human beating heart, a simple systemic circulation system, and a set of the low dimension dynamic model for real-time processing. In order to identity the mechanical parameters of cardiac muscle, we measured the cardiac characteristics from animals' heart. The large deformation model will make our virtual heart more practical. The proposed virtual heart took a good evaluation from the cardiac surgeons.

Minimally invasive surgeries have become popular in the fields of cardiovascular and abdominal surgery. Since dificulty of the surgeries depends on their approaches, the system that enables surgeons to rehearse procedures in constructing surgical fields is useful and required. However, most of current surgical planning systems are not applicable to simulate whole process of the procedures because they cannot deal with complex physical behaviour of soft tissues. This paper proposes to establish a virtual reality based planning system of surgical approaches using an adaptive physics-based framework. The framework provides finite element based deformation in real time inaddition to interactive soft tissue cutting, and generates virtual surgery fields effectively. Also, the developed system gives a palpation environment to identify arterial sclerosis in the reconstructed surgical field. This paper evaluates characteristics of the visual and haptic framework and verifies the performance of the proposed system.

© Springer-Verlag Berlin Heidelberg 2002. Touching the cardiac muscle is necessary to get mechanical conditions of muscle before cardiac surgery. The cardiac palpation is the only way to make surgical plans for left ventricular plastic surgery. The training system for cardiac palpation we have developed consists of a MRI-based virtual left ventricular image and a one-dimensional manipulator as a haptic device. Mechanical properties of the cardiac muscles of a dog and a pig are embedded in the virtual heart. Our experiments show that the developed training system enables users to feel the reactional force to the virtual heart surface from the manipulator in real time.

OBJECTIVES: This study examined the effects of aneurysm repair in a rat model of myocardial infarction on functional indices and on the spatiotemporal distribution of cardiac contractile protein and natriuretic peptide messenger RNA. METHODS: In a rat infarct model, expanded left ventricular aneurysms were plicated 4 weeks after infarction. At 30 weeks, transverse heart sections were taken at 4 levels (apex [level 1] through base [level 4]) and assessed by in situ hybridization histochemistry to determine regional messenger RNA levels of pre-pro-atrial natriuretic peptide, cardiac alpha-actin, skeletal alpha-actin, myosin light chain-2v, and beta-myosin heavy chain. RESULTS: Rats with plicated left ventricular aneurysms had reduced left ventricular endocardial circumference (19%, P <.005), lower heart weight ratio (31%, P <.05), left ventricular end-diastolic pressures (51%, P <.05), and increased +/-dP/dt (34%-38%, P <.05). Cardiac messenger RNA levels of pre-pro-atrial natriuretic peptide were reduced in the septum (levels 2 and 3), and skeletal alpha-actin levels were reduced in the septum and left ventricular free wall of plicated rats (level 3). beta-Myosin heavy chain levels were markedly reduced in peri-infarct regions of the left ventricular free wall, septum, and right ventricle in plicated rats at level 4, whereas myosin light chain-2v levels were reduced at levels 2 and 4 in the left ventricular free wall and at level 4 in the right ventricle. CONCLUSIONS: Plication of left ventricular aneurysm after infarction in the rat significantly reduced cardiac hypertrophy, improved cardiac function, and reduced the upregulation of pre-pro-atrial natriuretic peptide and both fetal and adult contractile protein isoforms associated with cardiac hypertrophy.

BACKGROUND: Traditionally, repair of left ventricular aneurysms has been limited to patients with large localized ventricular aneurysms. Repair of dyskinetic segments in the setting of poor left ventricular function is still contentious. METHODS: Forty patients underwent geometric endoventricular repair, a new technique of ventricular aneurysm repair, over a 2-year period. Two groups of patients undergoing coronary artery bypass grafting (CABG) for left ventricular dysfunction in the same time period were reviewed. Group 1 comprised 23 consecutive patients who underwent geometric endo-ventricular repair along with CABGs, whereas group II consisted of 22 patients who underwent CABG alone. RESULTS: The early mortality was 9.1% in group I (1 cardiac, 1 noncardiac) and 0 in group II (NS). New York Heart Association class was remarkably improved from 3.4 to 1.4 (p < 0.05) in group I and to a lesser extent in group II (3.7+/-0.5 versus 2.3+/-0.5). Diastolic dimension of left ventricle was significantly reduced from 5.6 cm to 4.4 cm (p < 0.05) in group I and virtually unchanged in group II. There was one late death in each of the groups. CONCLUSIONS: This technique of geometric left ventricular aneurysm repair is useful in patients with dyskinetic segments and may help in reducing cardiac size.

A 71-year-old man, who had received coronary angioplasty to right coronary artery 1 year before, was admitted because of unstable angina. An urgent CABG was performed using the left internal thoracic artery and the right gastroepiploic artery. Coronary anastomosis was performed under ventricular fibrillation due to porcelain aorta. Seven days after surgery, abdominal pain was suddenly experienced. A chest X-P showed subphrenic free air. So an emergent laparotomy was performed, and a 2 x 2 cm gastric perforation was found on the anterior wall of the greater gastric curvature. Partial gastrectomy was performed. However, he unfortunately died on the 58th postoperative day for multiple organ failure. Pathological examination of the excised gastric wall revealed ischemic change, not ulcer. This gastric perforation was possibly caused by ischemia after harvesting the right gastroepiploic artery.

We report a 55-year-old female patient with antiphospholipid syndrome secondary to systemic lupus erythematosus. The patient had undergone coronary artery bypass grafting for myocardial infarction due to left main trunk stenosis at the age of 52. Subsequently, she developed aortic insufficiency and underwent aortic valve replacement without any hemodynamic or hemostatic problems. Both coronary and valve disease should be considered in patients with antiphospholipid syndrome secondary to systemic lupus erythematosus.

Aortoesophageal fistulas due to thoracic aneurysms are usually fatal, with few reported survivors. A 57-year-old man with aortoesophageal fistula due to thoracoabdominal aortic aneurysm underwent the graft replacement of thoracoabdominal aorta. In the postoperative course, prosthetic graft infection had occurred in the result of residual esophageal fistula. On the 32nd postoperative day (POD), a subtotal esophagectomy was performed and the esophagus was reconstructed by gastrointestinal interposition technique via a retrosternal route. Following the second operative procedure, inflammatory reactions had been improved with systemic administration of antibiotics and continuous irrigation of the infected cavity. On 77th POD, he was discharged.

様々な物性性状のハイドロジェルを左室心筋内に注入したシュミレーションモデルを構築し、応力分布を比較検討を継続している。 さらに、立命館大学;生命科学部/生命情報学科との共同研究を開始した。 胸部CT画像より大動脈の三角メッシュモデルを作成し、形状モデルに対して血流シミュレーションを行っている。血管形状モデルの全ての点について、曲面の曲率半径を求め、主曲率となる円周方向の曲率半径と管路方向の曲率半径をその分布から、血流シミュレーションから得られた血圧の情報をラプラス則に適用することで、壁張力を求める方法を開発した。 本手法の問題点として血管壁の形状が鞍点を持つ場合や、血管壁の形状が綺麗な半円形状でない場合、曲率半径を正確に推定することができないため、この問題を解決し曲率半径推定の精度向上を目指す。