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Open in new tab Download slide Open in new tab Download slide OBJECTIVES We aimed to analyse the pathology of paravalvular leak (PVL), and determine the long-term outcomes of redo mitral valve replacement and risk factors of all-cause mortality. METHODS Seventy-nine patients (mean age 70 ± 9 years; 54 female, 68%) who underwent redo mitral valve replacement for mitral PVL between January 2000 and May 2019 were retrospectively reviewed. Indications for PVL intervention were haemolytic anaemia (57/79, 72%), New York Heart Association class III/IV congestive heart failure (56/79, 71%) and prosthetic valve endocarditis with PVL (2/79, 3%). RESULTS PVL most commonly occurred at lateral sectors (42/79, 55%). Early mortality occurred in 2 patients (3%) due to low cardiac output syndrome. Two patients (3%) had residual PVL at discharge. Sixteen patients (23%) developed late PVL (mean follow-up, 3.4 ± 2.9 years), among whom 11 (69%) developed PVL at same area as that preoperatively. Additionally, 9 patients (56%) developed PVL at lateral sectors in late follow-up. At 1, 5 and 10 years, the survival rate was 93%, 72% and 45%; rate of freedom from cardiac death was 96%, 92% and 78%; and rate of freedom from PVL recurrence was 94%, 82% and 54%, respectively. Chronic kidney disease was the only risk factor in the multivariate analysis for mortality [ P  = 0.013; hazard ratio 4.0 (1.4–11.0)]. CONCLUSIONS Surgery for mitral PVL confers reasonable early and long-term outcomes. Greater attention to the anterolateral annulus may help prevent PVL. [ABSTRACT FROM AUTHOR]

OBJECTIVES Although right heart failure (RVF) is an important issue in the management of patients with left ventricular assist devices (LVADs), the benefits of performing tricuspid valve repair in conjunction with LVAD implantation have not been demonstrated. METHODS We retrospectively reviewed the records of 141 patients who received LVAD implantation as a bridge to transplant from May 1999 to January 2013. We assessed short- and long-term right heart function in 69 of these patients who underwent tricuspid valve repair because of moderate-to-severe tricuspid regurgitation (TR) or severe dilatation of the tricuspid annulus. RVF was defined as the need for a right ventricular assist device or >30 days of intravenous inotropic support. TR was graded from 0 to 4, while fibrosis in myocardial biopsy samples was graded pathologically from 0 to 3. RESULTS The average duration of LVAD support was 595 days. Twenty-seven patients developed RVF and their survival rate was significantly worse than that of patients who did not develop RVF (65 vs 91% at 1 year). RVF was significantly related to high preoperative ratio of central venous pressure (CVP) to pulmonary capillary wedge pressure, high total bilirubin, high fibrosis score and high TR grade. In patients who underwent tricuspid valve repair, the TR grade was significantly reduced from 2.6 to 1.0, and this decrease was maintained for 2 years. Although patients who underwent tricuspid valve repair had significantly higher TR grades, ratios of CVP to pulmonary capillary wedge pressure and fibrosis scores preoperatively, no survival impairment was seen. CONCLUSIONS Tricuspid valve repair is a useful and durable adjuvant procedure for restoring deteriorated right ventricular function in patients requiring LVAD implantation. [ABSTRACT FROM AUTHOR]

OBJECTIVES Aortic insufficiency (AI) often develops during left ventricular assist device (LVAD) support and is related to a poor prognosis. As LVAD implantation and the support duration increase, the risk of acquired aortic valve lesions may increase. We investigated the pathological changes in the aortic valve and its function after long-term LVAD support. METHODS Thirty-five hearts removed at heart transplantation were investigated. Thirty-one patients were supported by extracorporeal pulsatile devices, and 4 were supported by implantable devices. We compared the histological changes in the aortic valve with the echocardiogram results. RESULTS The mean duration of LVAD support was 961 days. Before device implantation, all patients had a normal aortic valve opening, and only 5 had trivial AI. After LVAD support, trivial AI was observed in 18 patients, mild AI in 4 and mild-to-moderate AI in 2. Pathological examination revealed that the aortic valve had become thinner in all patients, ranging from 120 to 1400 µm. The aortic wall had also become thinner in most patients, ranging from 830 to 2220 µm. Left ventricular wall thickness was ranging from 4 to 13 mm, and aortic annular diameter was ranging from 17 to 27 mm. Partial aortic valve fusion was seen in 17 (48.6%) recipients, and curling with leaflet shortening was detected in 22 (62.9%) patients. Dense collagen accumulation in the spongiosa layer was also present. All aortic valves of the patients with mild and mild-to-moderate AI showed a scarce or no opening before explantation. Conversely, the AI grade of patients whose aortic valve frequently opened remained none or trivial. There was no close correlation between these pathological findings and the development of AI independently. CONCLUSIONS Degenerative aortic valve changes were recognized after long-term LVAD support. There was also an increasing prevalence of mild and mild-to-moderate AI, which may have been associated with continuous aortic valve closure. An optimal strategy to prevent AI development should be determined, and careful periodic echocardiographic follow-up is essential. [ABSTRACT FROM AUTHOR]

OBJECTIVES Due to a serious heart donor shortage, the criteria for acceptance for transplantation have been expanded. This study assesses donor-related factors associated with postoperative low output syndrome (LOS) and long-term survival of recipients. METHODS From 1999 to February 2011, 36 heart transplantations were performed at our institute, of which 28 donor hearts (78%) were considered to be marginal due to high inotropic requirement (n = 11), recent episode of cardiac arrest (n = 11), female to male transplantation (n = 11), reduced left ventricular contraction (n = 6), old age (n = 6), small donor heart (n = 5), donor–recipient size mismatch (n = 2), ventricular hypertrophy (n = 2) or prolonged ischaemic time (n = 1). St Thomas solution (n = 6) and Celsior (n = 30) were used for preservation. Ischaemic damage in post-transplant cardiac patients was graded by perioperative ischaemic myocardial injury (PIMI) score (scores 0–3). RESULTS The donor age was 39 ± 11 years old, which was not significantly different to that of the recipients. 50% of the donors were female. Thirty-three donors (92%) required catecholamine at an average of 8.0 ± 5.2 µg/hg/min and echocardiogram findings showed that left ventricular ejection fraction was 65 ± 10%. All recipients survived during the perioperative period (one patient died from sepsis at 4 years after transplantation) for a 10-year survival rate of 95%. Severe primary graft dysfunction was observed in two patients who required intra-aortic balloon pumping or veno-arterial extra-corporeal membrane oxygenation, and five other patients showed postoperative LOS (cardiac index < 2.2 l/min/m2). Left ventricular diastolic diameter smaller than 36 mm (P = 0.0002), high inotropic requirement (P = 0.0089) and left ventricular ejection fraction less than 55% (P = 0.0383) were related to post-transplant LOS. All patients recovered cardiac function and were discharged from the intensive care unit after an average of 6 days. Although preservation with Celsior was not related to LOS, it had relationships with lower CKMB level (P = 0.0013) and lower PIMI score (P = 0.0054). CONCLUSIONS Cautious donor selection is essential when the donor heart has a small ventricular diameter or requires a high level of inotropic support. However, long-term survival in recipients with marginal donor hearts can be anticipated with adequate treatment. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 73-year-old woman whose transthoracic echocardiography revealed a tumor-like mass located in the mitral annulus.

OBJECTIVES We sought to delineate the effects of the severity of target lesions and their combinations on the occurrence of competitive flow, especially in the composite Y-graft and to establish an optimal strategy for graft arrangement and patient selection. METHODS We reviewed early and late angiograms of 2514 bypass grafts in 601 patients, who underwent off-pump coronary revascularization to three-vessel vascular regions using the internal thoracic artery (ITA) and radial artery (RA) without aortic manipulation. As a standard technique, the left anterior descending artery (LAD) was bypassed with the in situ ITA, and the left circumflex and right coronary arteries (RCA) were bypassed with the composite RA. Bypass flow was graded as antegrade, competitive or no flow. RESULTS The early patency rate was 98.1% (2466/2514), while competitive flow was detected in 6.4% (162/2514). For the LAD, the individual and sequential in situ ITA provided lower incidence of competitive flow than the composite graft (0.3% (1/298) versus 7.6% (23/303), P < 0.0001). Regarding the RA to non-LAD bypass, 86.3% (113/131) of competitive flow occurred at the distal end of the I- or Y-graft, and the cumulative patency rate was significantly lower than that of sequential proximal anastomosis (80.1 versus 56.6% at 5 years, P < 0.0001). The number of sequential anastomoses did not affect the cumulative patency rate (P = 0.09). For the composite Y-graft to three-vessel regions, the rate of antegrade flow in patients with 76–100% stenosis in both the LAD and the RCA was 95.7% (178/186), which was significantly higher than that of 78.1% (100/128) in patients with 76–100% stenosis in the LAD and 51–75% stenosis in RCA (P < 0.0001). CONCLUSIONS Sequential and composite grafting was considered reliable, exclusively in appropriately selected situations. To secure entire patency of the Y-graft to three-vessel regions, balanced bypass flow toward LAD and RCA would be crucial. [ABSTRACT FROM AUTHOR]