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Transcatheter aortic valve replacement (TAVR) for severe symptomatic aortic stenosis (AS) does not benefit all patients. We performed a prospective multicenter study to investigate the cost-effectiveness of TAVR in a Japanese cohort. We prospectively enrolled 110 symptomatic patients with severe AS who underwent TAVR from five institutions. The quality of life measurement (QOL) was performed for each patient before and at 6 months after TAVR. Patients without an improvement in QOL at 6 months after TAVR were defined as non-responders. Pre-TAVR higher QOL, higher clinical frailty scale predicted the non-responders. Three models, 1) conservative treatment for all patients strategy, 2) TAVR for all patients strategy, and 3) TAVR for a selected patient strategy who is expected to be a responder, were simulated. Lifetime cost-effectiveness was estimated using incremental cost-effectiveness ratio (ICER) and cost per quality-adjusted life-year (QALY) gained. In comparison to conservative therapy for all patients, ICER was estimated to be 5,765,800 yen/QALY for TAVR for all patients and 2,342,175 yen/QALY for TAVR for selected patient strategy patients, which is less than the commonly accepted ICER threshold of 5,000,000 yen/QALY. TAVR for selected patient strategy model is more cost-effective than TAVR for all patient strategy without reducing QOL in the Japanese healthcare system. TAVR for selected patient strategy has potential benefit for optimizing the TAVR treatment in patients with high frailty and may direct our resources toward beneficial interventions. [Display omitted] • Nearly half of the patients who underwent TAVR had worsened quality of life even after the procedure. • Higher frailty scale before TAVR predicted poor improvement in quality of life after TAVR. • TAVR performed in selective patient model was the most cost-effective model. • Cost-effective simulation model may direct our resources toward beneficial interventions. [ABSTRACT FROM AUTHOR]

We present the case of an 82-year-old man whose left coronary ostium became obstructed 15 months after transcatheter aortic valve replacement (TAVR) with a balloon-expandable valve. The patient underwent TAVR for symptomatic severe aortic stenosis with no complications. Fifteen months after the initial TAVR, the patient complained of chest pain while exercising, and the exercise stress myocardial perfusion scintigraphy demonstrated the development of regional myocardial ischemia in the region of the left coronary artery. Coronary angiography implied severe stenosis in the ostium of the left coronary artery. Computed tomography angiography and intravascular ultrasonography indicated a soft tissue component along with stent struts, which was considered to cause delayed coronary obstruction. Our report emphasizes the importance of having a low threshold for clinically suspecting delayed coronary obstruction in patients who have undergone TAVR, even after several years of the procedure. < Learning objective: Delayed coronary obstruction (DCO) should be suspected in patients presenting with new ischemic symptoms after transcatheter aortic valve replacement (TAVR). DCO may occur even in the case of TAVR with a balloon-expandable prosthetic valve, on antithrombotic regimens, and several years after the initial procedure.> [ABSTRACT FROM AUTHOR]

l Minimally invasive stand-alone Maze procedure is promising but not standard treatment for atrial fibrillation worldwide. l We successfully performed minimally invasive stand-alone Maze procedure for 20 cases as an institutional first case series. l Sinus rhythm was well restored for one year postoperatively. l Catheter ablations post-Maze procedure successfully restored sinus rhythm in three cases. Background: Minimally invasive Maze procedure via right mini-thoracotomy approach is reportedly a promising option for paroxysmal and non-paroxysmal atrial fibrillation (AF), although it is not widely performed. This study aimed to validate feasibility and safety of minimally invasive stand-alone Maze procedure in an institutional first case series. Methods: This study enrolled an institutional consecutive series of 20 cases who underwent minimally invasive Maze procedure between November 2018 and January 2021. Concomitant tricuspid annuloplasty was performed in five cases who showed moderate tricuspid regurgitation preoperatively. Results: Minimally invasive Maze procedure using cryo-energy source was successfully accomplished with sinus rhythm being restored at the intensive care unit entry in all cases without conversion to the sternotomy approach. All cases were discharged home, while one case was complicated with stroke postoperatively. Nineteen cases (95%) showed sinus rhythm at the last follow-up, whereas one case, who had large left atrium, showed recurrent persistent AF despite optimum medical therapy. Catheter ablations were performed for residual conductions at box lesions and/or mitral/tricuspid isthmus in three cases, who showed medically refractory atrial tachycardia post-Maze procedure. Consequently, these three cases showed sinus rhythm restoration at the last follow-up Conclusions: Minimally invasive stand-alone Maze procedure with or without tricuspid annuloplasty was feasible and safe for AF in the institutional first case series. Catheter ablations for recurrent AF post-Maze procedure would be warranted. Graphical Abstract [Display omitted] [ABSTRACT FROM AUTHOR]

There is no definitive parameter for left ventricular (LV) preload in patients with a continuous-flow left ventricular assist device (LVAD). The intraventricular pressure difference (IVPD) is the maximum pressure difference between the mitral valve and LV apex during diastole; and, in past studies, the IVPD was influenced by volume loading. The authors hypothesized that IVPD in LVAD patients correlates with indexed LVAD flow and that IVPD can serve as a novel parameter of LV preload in this population. A single-center, retrospective, observational study. A tertiary-care hospital from August 2019 to July 2020. Sixteen ramp tests for adjustment of LVAD pump speed in 14 adult patients undergoing continuous-flow LVAD implantation. Measurement of IVPD during ramp tests. LVAD flow and IVPD were measured at each LVAD pump speed during the ramp test for the adjustment of LVAD pump speed after patients came off cardiopulmonary bypass during LVAD implantation. A straight, longitudinal view of the left atrium and left ventricle was obtained, and the pressure difference between the mitral valve and LV apex during diastole was measured by transesophageal echocardiography. The maximum pressure difference during diastole was recorded as IVPD. The relationship between indexed LVAD flow (LVAD flow/body surface area) and IVPD was assessed by a multivariate nonlinear regression analysis with the Huber-White sandwich estimator. IVPD correlated with indexed LVAD flow (p < 0.001). IVPD is a useful indicator of LV preload during LVAD implantation. [ABSTRACT FROM AUTHOR]

Investigate differences in the prevalence and severity of chronic postsurgical pain (CPSP) after cardiac surgery via thoracotomy versus sternotomy are not well-understood. An observational cohort study. A tertiary care hospital. Four hundred twenty-eight patients (sternotomy: 192 patients, thoracotomy: 236 patients) who underwent mitral valve repair. A questionnaire about the severity of surgical wound pain evaluated with a numerical rating scale (NRS) was sent. NRS responses for current pain, peak pain in the last four weeks, and average pain in the last four weeks were evaluated. The main outcomes were the severity of CPSP evaluated using NRS and the prevalence of CPSP. CPSP was defined as pain >0 that developed after a surgical procedure. During the median follow-up of 29 months, 79 patients complained of CPSP. (sternotomy: 15 patients, thoracotomy: 64 patients). Multivariate ordinal logistic regression showed that NRS responses for current pain (adjusted odds ratio [aOR], 3.17; 95% confidence interval [CI] 1.64-6.12; p = 0.001), peak pain in the last four weeks (aOR, 2.00; 95% CI 1.11-3.61; p = 0.021), and average pain in the last four weeks (aOR, 2.21; 95% CI 1.31-3.72; p = 0.003) were significantly higher in patients who underwent thoracotomy. Multivariate logistic regression showed that thoracotomy was an independent predictor of CPSP (aOR, 3.63; 95% CI 1.67-7.88; p = 0.001). The prevalence and severity of CPSP were higher among patients who underwent mitral valve repair via thoracotomy than sternotomy. [ABSTRACT FROM AUTHOR]

Balloon postdilation (BPD) is one strategy for decreasing paravalvular leakage, but its effect on long-term mortality remains unclear. The authors sought to clarify whether BPD influences long-term mortality of patients with transcatheter aortic valve replacement (TAVR). Single-center retrospective study. National heart center; single institution. Participants were patients who underwent TAVR in the authors' hospital from January 2014 to December 2016. A balloon-expandable Sapien XT or Sapien3, or self-expandable CoreValve or Evolute R, was implanted according to the decision of the surgeon considering degree of calcification of the aortic valve. No interventions. Multivariate Cox regression analysis and inverse probability weighted estimation were performed using a propensity score to examine whether BPD influenced six-year mortality. Ultimately, 180 patients were analyzed. During the follow-up period, with a median of 1104 (interquartile range: 730-1463) days, 41 patients died and cumulative incidence of mortality at six years was 22.8%. Society of Thoracic Surgeons score (odds ratio [OR]: 2.257, 95% CI: 1.213-4.197, p = 0.010)], BPD (OR: 0.306, 95% CI: 0.098-0.953, p = 0.041), and paravalvular regurgitation of at least moderate-to-mild severity after deploying (OR: 5.407, 95% CI: 1.626-17.978, p = 0.006) were significant factors of mortality. BPD is associated with reduced six-year mortality. [ABSTRACT FROM AUTHOR]

The ability of perioperative fluid management to prevent postoperative recurrence of atrial tachyarrhythmia remains controversial. The aim of the present study was to assess if intraoperative net fluid balance was associated with atrial tachyarrhythmia recurrence after the Cryo-Maze procedure. An observational cohort study. A tertiary care hospital from April 2007 to May 2019. Four hundred forty-four patients undergoing the Cryo-Maze procedure in conjunction with other cardiac surgeries. The Cryo-Maze procedure in conjunction with other cardiac surgeries. The main outcome was early atrial tachyarrhythmia recurrence, consisting of atrial fibrillation, atrial flutter, or atrial tachycardia, within the first three months after surgery. Complete follow-up was achieved in 443 patients (99.8%), of them 127 (28.6%) developed early atrial tachyarrhythmia recurrence. The median intraoperative net fluid balance was 1,627 mL (interquartile range, −215 to 3,557 mL). Multivariate logistic regression showed that intraoperative net fluid balance (p = 0. 001), preoperative AF duration (adjusted odds ratio, 1.40; 95% CI, 1.17-1.68; p < 0.001) and left atrial volume index (aOR, 1.61; 95% CI, 1.06-2.45; p = 0.025) were independent predictors of early atrial tachyarrhythmia recurrence. The adjusted log odds were lowest (–1.52) when net fluid balance was 1,557 mL. There is a significant U-shaped association between intraoperative net fluid balance and early atrial tachyarrhythmia recurrence among patients undergoing the Cryo-Maze procedure. [ABSTRACT FROM AUTHOR]

• We reviewed outcomes in patients with left ventricular assist devices (LVAD). • Patients underwent bridge to bridge (BTB) strategy or primary implantable LVAD (iLVAD). • Overall survival was not different between the BTB and iLVAD groups. • BTB group had lower 1-year survival and freedom from the composite events rates. • BTB strategy and preoperative bilirubin were independent predictors of 1-year outcome. In Japan, patients with heart failure who have a paracorporeal left ventricular assist device (pLVAD) and cannot be weaned from the VAD may undergo conversion to implantable continuous-flow LVAD (iLVAD) via a bridge-to-bridge (BTB) strategy for bridge-to-transplantation (BTT). This study aimed to evaluate the real-world clinical status of BTB strategies. Among 134 patients who underwent iLVAD implantation for BTT, 34 patients underwent conversion from pLVAD to iLVAD (BTB group) and 100 patients underwent iLVAD implantation primarily (primary iLVAD group). The clinical characteristics and outcomes were compared between the two groups. No significant difference was found in the overall survival between the two groups (p = 0.26; log-rank test). However, the 1-year survival rate and the 1-year freedom from the composite events of death, stroke, systemic infection, and bleeding rate were lower in the BTB group than in the primary iLVAD group (survival rate, 88.2% vs. 99.0%, p = 0.0040; composite event-free survival rate, 26.1% vs. 49.8%, p = 0.030; log-rank test). Multivariate analysis indicated that the BTB strategy [hazard ratio (HR) 1.70, 95% confidence intervals (CI) 1.03–2.72; p =0.036] and serum total bilirubin levels at iLVAD implantation [HR 1.31, 95% CI 1.00–1.65; p =0.043] were independent predictors of 1-year composite events. The BTB strategy is useful in providing long-term survival in patients with acute critical diseases. However, the early mortality rate after conversion is higher in patients who underwent the BTB strategy. [ABSTRACT FROM AUTHOR]

High transprosthetic valvular peak velocity (PV) is indicative of prosthesis–patient mismatch (PPM), which exacerbates mortality and morbidity after surgical aortic valve replacement (AVR). During surgical AVR, a high intraoperative PV sometimes is detected, but whether it affects mortality and morbidity is unknown. The aims of this study were to determine whether intraoperative and postoperative PV were correlated and what factors predicted postoperative PPM. Retrospective, observational, cohort study. Tertiary medical center. None. The study comprised 556 patients who underwent AVR with a bioprosthetic valve. PV was measured intraoperatively, 1 month after surgery, and 1 year after surgery. The occurrence of PPM was defined as an effective orifice area index of less than 0.85 cm2/m2. The associations between PV values at the aforementioned 3 time points were analyzed using a multivariable nonlinear regression model. A multivariable logistic regression model was used to identify the predictors of PPM at 1 year. There was no significant association between intraoperative PV and PV at 1 month (p = 0.419) or 1 year (p = 0.115). The implanted valve type (p < 0.001) and size (p < 0.001), but not intraoperative PV (p = 0.503), were independent predictors of PPM. There was no significant association between intraoperative and postoperative PV values. Implanted valve type and size, but not intraoperative PV, predicted postoperative PPM. [ABSTRACT FROM AUTHOR]

Background: Percutaneous driveline infection is a major complication of left ventricular assist device (LVAD). This study evaluated the role of gallium-67 single-photon emission computed tomography (Ga-SPECT)-CT in LVAD-specific percutaneous driveline infection.Methods: Thirty-six patients with implantable continuous-flow LVAD, who underwent Ga-SPECT-CT to evaluate percutaneous driveline infections, were enrolled and divided into uptake and no-uptake groups based on tracer concentration uptake on Ga-SPECT-CT. Primary outcomes were surgical intervention and readmission for driveline infection.Results: Twenty-two patients had uptake on Ga-SPECT-CT. No significant differences were noted in patient characteristics, wound appearance, or laboratory results. The prevalence of positive skin culture at the driveline exit site (DLES), and usage and duration of antibiotics did not differ. However, the uptake group had higher 1-year event rates (surgical intervention: 39% vs 0%, P = .019; readmission: 74% vs 6.9%, P = .0016). In addition to positive skin culture at DLES and short duration of antibiotic therapy, uptake on Ga-SPECT-CT was a risk factor for surgical intervention (odds ratio 9.00; P = .018) and readmission (odds ratio 7.86; P = .0051).Conclusions: Ga-SPECT-CT could be one of the clinical modalities for guiding the treatment of driveline infection in patients with a LVAD. [ABSTRACT FROM AUTHOR]

Although coronary artery bypass grafting (CABG) is the preferred choice for advanced Kawasaki disease (KD)-associated coronary artery disease, graft design such as number of grafts or type of conduits has not been fully established. We reviewed a series of patients who underwent single or multiple CABG for coronary artery disease of KD sequelae to investigate the optimum revascularization strategy. We enrolled a consecutive series of 102 CABG surgeries in 92 patients during the last 36 years. Mean patient age at CABG was 14.9 ± 10.4 years. Internal thoracic artery, radial artery, and gastroepiploic artery were used in 100 (98%), 18 (15%), and 4 (4%) cases, respectively. Patients were divided into 2 groups by single (n = 53) or multiple (n = 49) CABG. Actuarial survival was 93% in single CABG and 91% in multiple CABG at 30 years (P =.71). There was no in-hospital mortality, but 6 deaths occurred long term, with no significant difference between the groups. Freedom from cardiac events was 45.2% in single CABG and 68.5% in multiple CABG at 25 years (P =.228), and reintervention to the left anterior descending (LAD) artery territory was the most common event. Graft patency of the internal thoracic artery–LAD artery graft was 81% in single CABG and 85% in multiple CABG at 25 years. Patency of the radial artery in the non-LAD artery territories was significantly greater than that of the saphenous vein graft at 10 years (91% vs 46%, P =.013). Multiple CABG using arterial conduits is feasible, safe, and therapeutically effective long term for patients with advanced KD-associated coronary artery disease. [ABSTRACT FROM AUTHOR]

Highlights • Left ventricular intracavitary gradient decreased postoperatively (16.8 mmHg vs. 107.4 mmHg). • Freedom from cardiac death was 92.8%, 89.0%, and 80.1% at 5, 10, and 15 years. • Freedom from heart-failure hospitalization was 87.7% and 82.2% at 5 and 10 years. • Mitral valve replacement remains a viable option in certain situations. • Optimal postoperative medical treatment and close clinical follow-up are necessary. Abstract Background Although transaortic septal myectomy (TASM) is recognized as a standard procedure for treating hypertrophic obstructive cardiomyopathy (HOCM), occasionally the left ventricle (LV) intracavitary gradient remains postoperatively because of this technically demanding procedure. Mitral valve replacement (MVR) is sometimes chosen as an alternative option, but data on its long-term outcomes are lacking. Methods and results Between 1991 and 2016, 29 patients [age, 14–82 (mean 58.9 ± 15.9) years; 22 female patients (75.9%)] underwent combined mechanical MVR and transmitral myectomy. Of these, six patients had undergone MVR following a second cardiac arrest because of the residual LV outflow gradient or residual mitral regurgitation following TASM. Concomitant TASM was performed in 13 patients. The LV intracavitary gradient at rest assessed by transthoracic echocardiography significantly decreased postoperatively (16.8 ± 19.1 mmHg vs. 107.4 ± 52.5 mmHg, p < 0.0001). Actuarial freedom rates from cardiac death were 92.8%, 89.0%, and 80.1% at 5, 10, and 15 years postoperatively, respectively. Sudden death occurred in three of the four patients who died of late cardiac complications. None of these patients with sudden death had implantable cardioverter-defibrillators. Most patients had maintained their LV end-diastolic dimension at <50 mm for 10–15 years postoperatively. Actuarial freedom rates from hospitalization for heart failure were 87.7%, 82.2%, and 54.8% at 5, 10, and 15 years postoperatively, respectively. Occurrence rates of cerebral hemorrhage and infarction were 0.6% per patient-year and 1.3% per patient-year, respectively. Conclusions Combined mechanical MVR and myectomy is an effective procedure to eliminate the LV intracavitary gradient in patients with HOCM. Although this procedure remains a viable option in certain situations, optimal medical treatment and close clinical follow-up along with the cooperation between cardiac surgeons and cardiologists are necessary to achieve favorable long-term outcomes. [ABSTRACT FROM AUTHOR]

Highlights • The overall incidence of de novo malignancy after heart transplantation (HTx) was 6.8% in Japan. • Prevalence of post-transplant lymphoproliferative disorders and colon cancer were higher compared to that of skin cancer. • Long follow-up time and previous antibody mediated rejection ≥1 were risk factors of malignancy after HTx. • Japanese heart transplant recipients with de novo malignancy have a worse prognosis. Abstract Background Because of aggressive immunosuppression, heart transplant recipients have a high risk of de novo malignancy, which is a major cause of death and worse prognosis, regardless of the type. However, the impact of de novo malignancy on Japanese heart transplant recipients is unknown. Methods We analyzed 103 Japanese heart transplant recipients over 18-years-old at the time of transplantation between April 1999 and April 2017. Patient characteristics and prognosis were compared between heart transplant recipients with or without de novo malignancy after heart transplantation (HTx). Additionally, univariate and multivariate analyses for the risk factors of de novo malignancy after HTx were performed. Results De novo malignancy developed in 7 patients (6.8%; post-transplant lymphoproliferative disorders, n = 3; Bowen's disease, n = 1; colon cancer, n = 2; bladder cancer, n = 1). Follow-up time and previous antibody mediated rejection (AMR) ≥ grade 1 were risk factors of de novo malignancy after HTx in multivariate analysis (OR: 1.19, 95% CI: 1.00–1.42, p = 0.043; and OR: 10.7, 95% CI: 1.37–83.68, p = 0.038, respectively). History of malignancy was a potential risk factor, albeit not significant (OR: 23.05, 95% CI: 0.99–534.53, p = 0.071). The survival rates in patients with de novo malignancy was significantly lower than in those without de novo malignancy (3-year survival rate: 100% versus 67%, p = 0.0025). Conclusions Long follow-up time and previous AMR ≥ grade 1 were risk factors of de novo malignancy after HTx. Japanese heart transplant recipients with de novo malignancy have worse prognosis; therefore, screening examinations are important for early diagnosis. [ABSTRACT FROM AUTHOR]

Despite great advances in caring for patients with congenitally corrected transposition of the great arteries (ccTGA), a high proportion of these patients go on to develop heart failure and death in early adulthood. Adults with congenital heart disease (ACHD) only comprise a small number of patients receiving ventricular assist devices (VAD), but ccTGA accounted for 36% of ACHD patients in the INTERMACS database. Review of the literature describing ccTGA patients receiving VAD therapy shows promising results. With newer devices and the assistance of advanced imaging, mechanical circulatory support is becoming a desirable option for this population of patients and has the potential to provide significant long-term support, relieving them of heart failure symptoms and delaying and perhaps in the future avoiding, the need for cardiac transplantation. [ABSTRACT FROM AUTHOR]

The Maze procedure is a well-established treatment for atrial fibrillation. However, it is sometimes associated with bradycardia requiring pacemaker implantation. We assessed the rates of in-hospital and late-onset pacemaker implantation after the modified Cryo-Maze procedure and explored the risk factors for pacemaker implantation. This study enrolled a series of 751 patients who underwent the modified Cryo-Maze procedure at our institution between 2001 and 2020. Multivariable Fine-Gray regression was used to analyze the risk factors for late-onset pacemaker implantation. Twelve patients (1.6%) underwent in-hospital pacemaker implantation, and 55 patients (7.3%) underwent late-onset pacemaker implantation during a median follow-up of 4.5 years (interquartile range, 1.4-10.0). The most common primary indication for pacemaker implantation was sick sinus syndrome (56 patients [7.5%]), followed by complete atrioventricular block (11 patients [1.5%]). The cumulative incidence of late-onset pacemaker implantation with death as a competing risk was 2.8% at 1 year, 7.7% at 5 years, and 10.8% at 10 years. Risk factors for late-onset pacemaker implantation included a longer preoperative atrial fibrillation duration (hazard ratio, 1.14; P <.001) and an older age (hazard ratio, 1.05; P =.001). The mortality, cumulative incidence of cerebrovascular accidents, and rate of atrial fibrillation recurrence were not significantly different between patients with and without pacemaker implantation. Longer preoperative atrial fibrillation duration and older age are risk factors for late-onset pacemaker implantation after the modified Cryo-Maze procedure. However, the incidence of pacemaker implantation is not associated with increased morbidity or atrial fibrillation recurrence. [Display omitted] [ABSTRACT FROM AUTHOR]

This study aimed to elucidate whether the use of bilateral internal thoracic arteries (BITAs) confers additional survival benefits compared with a single internal thoracic artery (SITA) in total arterial grafting with the radial artery. Between 2002 and 2016, 617 patients underwent a bilateral in situ internal thoracic artery grafting with the radial artery as a composite I-graft (BITA-I group) and 516 patients underwent single in situ internal thoracic artery grafting with the radial artery as a composite Y-graft (SITA-Y group). All anastomoses were performed without cardiopulmonary bypass and aortic manipulation. Propensity score matching was performed to adjust covariates and compared the outcomes between the 2 groups. Subanalysis was also performed to evaluate the effects of the BITA-I group on survival according to the covariates using Cox proportional hazards regression analysis. Propensity score matching yielded 348 well-matched pairs. Early postoperative outcomes were similar in the 2 groups. The BITA-I group showed significantly better survival than the SITA-Y group (79.3% vs 70.2% at 10 years, P =.015). The subanalysis revealed a significantly better survival in the BITA-I group among overall patients (hazard ratio, 0.68; 95% confidence interval, 0.49-0.93). There was a significant positive effect on survival in the BITA-I group among patients without comorbidities or those aged <77 years. BITA grafting with the radial artery provides better long-term survival than SITA grafting with the radial artery, which is enhanced among patients aged <77 years with minimum comorbidities. [Display omitted] [ABSTRACT FROM AUTHOR]

Background There are few reports regarding factors related to late-onset of atrial fibrillation (Af) after mitral valve repair, which can compromise long-term outcome. We analyzed the risk factors for late Af after mitral valve repair. Methods and results Between 2001 and 2015, 318 patients (214 males; median, 57.7 years) underwent mitral valve repair for degenerative mitral insufficiency (MI) without concomitant aortic valve disease in our institute. Patients with a history of paroxysmal or chronic Af preoperatively were excluded. Serial follow-up echocardiography was used to evaluate cardiac function. The follow-up rate was 99%. The mean follow-up period was 6.0 ± 4.1 years. There was no early death and there were nine late deaths. A total of 29 (9.1%) patients developed late Af. Freedom from late Af was 94.0% at 5 years and 82.9% at 10 years. Small ring annuloplasty, left atrial diameter, and pressure half time, which were measured at follow-up echocardiography, were considered as significant ( p < 0.05) risk factors for late Af. Patients who had late Af developed recurrent MI more frequently than those who did not ( p < 0.05). Conclusions Remodeling of the atrium caused by functional mitral stenosis is important for late Af, as well as recurrent MI. To prevent these problems, avoiding selection of a small ring at primary mitral repair for type II dysfunction and durable repair are required. [ABSTRACT FROM AUTHOR]

Background The best management strategy for patients with coronary disease and mild to moderate AS requires the clinician to consider the operative risks of isolated coronary artery bypass grafting (CABG) against the risks of untreated aortic stenosis (AS). Methods Between 2000 and 2014, isolated off-pump CABG (OPCAB) was performed in 2023 patients. Of these patients, 103 presented with mild or moderate AS (mean age 72.7 ± 6.3 years; 23 females), 96 (93.2%) presented with mild AS and seven (6.8%) presented with moderate AS. We compared the long-term outcome of these 103 patients undergoing isolated OPCAB with 13 patients who presented with moderate AS and coronary artery disease (CAD) and underwent concomitant aortic valve replacement (AVR) and CABG during the same period. Results Mean number of distal anastomoses was 3.7 ± 0.9 per patient, and early graft patency was 98.9% (365 of 369 grafts). No patient required on-pump CABG or concomitant AVR. There were two in-hospital deaths (1.9%). Cumulative 5- and 10-year survival rates were 78.3% and 56.6%, respectively. The respective 5- and 10-year rates of freedom from severe AS were 38.1% and 0.0% in patients with moderate AS, and 73.2% and 65.4% in patients with mild AS (log-rank test, p < 0.01). Twelve patients required subsequent AVR, including eight who underwent transcatheter AVR. There were no significant differences between patients undergoing isolated OPCAB and patients undergoing concomitant AVR and CABG according to cumulative survival rate (log rank test, p = 0.78) and freedom from major adverse cardiac and cerebrovascular events (log rank test, p = 0.59). Conclusions Isolated OPCAB is a reasonable staged strategy in coronary disease with mild AS, as the less invasive option of transcatheter AVR is available later if required. [ABSTRACT FROM AUTHOR]

Background Avoidance of prosthesis–patient mismatch (PPM) is important when selecting a mitral valve prosthesis. This study investigated the effect of PPM after small ring mitral valve annuloplasty on postoperative hemodynamics and the clinical course. Methods This study retrospectively reviewed 227 patients with symptomatic severe mitral insufficiency (MI) who underwent mitral valve repair for degenerative MI using an Edwards ring or band (size: 26–32 mm) between 2003 and 2012. Echocardiography was performed postoperatively and at follow-up to evaluate cardiac function, including residual MI, mean transmitral pressure gradient, left atrial diameter (LAD), and tricuspid regurgitant pressure gradient (TRPG). Results There were no operative deaths. Actuarial freedom from major adverse cardiac events was 91% at 10 years. The postoperative MI grade was not significantly different between different sizes of prosthesis (26 mm, 0.67 ± 0.8; 28 mm, 0.73 ± 0.9; 30 mm, 0.85 ± 0.9; 32 mm, 0.3 ± 0.6). LAD and TRPG were significantly lower for each size of prosthesis at follow-up (all p < 0.05). Patients with a smaller body surface area received a significantly smaller prosthesis ( p < 0.05). The transmitral pressure gradient was significantly higher in patients with a 26-mm prosthesis than in patients with a larger size of prosthesis. Thirty-three patients had a follow-up transmitral pressure gradient ≥5 mmHg. The follow-up LAD was larger in patients with a transmitral pressure gradient <5 mmHg than in patients with that ≥5 mmHg (43.2 ± 9.4 mm vs 47.1 ± 9.6 mm, p < 0.05). Conclusions Mitral valve repair results in excellent clinical outcomes with significant reductions in MI, LAD, and TRPG for all sizes of prosthesis. However, use of a smaller prosthesis may result in a higher mean transmitral pressure gradient, and may inhibit reverse remodeling of the left atrium. Therefore, PPM should be avoided. [ABSTRACT FROM AUTHOR]

For the weight reduction of drive train in automotive, it is necessary to fabricate circular weld of die casting aluminum alloy and carbon steel with high welding efficiency. In this study, friction stir welding of ADC12 and S45C with circular weld line was evaluated, and the effect of welding tool shape was investigated for improving the weldability. The welding tool with flat shoulder was possible to fabricate the weld of ADC12 and S45C with a thin reaction layer with less than 1 μm. However, the mechanical strength of the weld was lower than that of ADC12. This is attributed to the microstructure of weld interface. Thus, material flow during FSW was enhanced by using a welding tool with a screw probe and a scroll shoulder. The fabricated weld by the welding tool achieved high weld strength equivalent to ADC12. In this weld, uniform and thin reaction layer about 50 nm was formed on the weld interface. [ABSTRACT FROM AUTHOR]

We report a patient who underwent simultaneous transcatheter aortic valve implantation and off-pump coronary artery bypass grafting for Takayasu arteritis with diffuse porcelain aorta. The patient was a 59-year-old female with severe aortic stenosis and regurgitation, as well as both coronary ostial stenosis and porcelain aorta. Bilateral internal thoracic arteries were unavailable due to Takayasu arteritis. Therefore, composite radial artery with in-situ gastroepiploic artery was used as graft material. Radial artery was anastomosed to left anterior descending artery and posterior descending artery sequentially. Surgical procedures were successfully accomplished and major perioperative complications did not occur. < Learning objective: Takayasu arteritis is a rare disease with vasculitis of aorta and its main branches. In addition, it is associated with a low incidence of coronary ostial stenosis and coronary ischemia can be fatal. Porcelain aorta with aortic valve lesion also complicates with Takayasu arteritis and it makes difficult to perform cardiac surgery. The optimal surgical strategy and process for those who combined with coronary ostial stenosis, aortic valve lesion and porcelain aorta remains a subject of debate.> [ABSTRACT FROM AUTHOR]

Background Infants with a single ventricle who require a modified Blalock-Taussig shunt can have stenosis at the ductal insertion site on the pulmonary artery (PA). We hypothesized that primary PA plasty in the first palliation would limit PA stenosis and unbalanced pulmonary perfusion, and thereby facilitate safe accomplishment of the next operation. Methods From 1998 to 2012, functional single-ventricle patients with pulmonary atresia were managed as follows: initial operative strategy based on midline approach, using cardiopulmonary bypass, and central PA plasty (resection of all ductal tissue). All patients underwent catheter study and lung perfusion test before bidirectional cavopulmonary shunt (BCPS). Results Forty consecutive patients (heterotaxy, n = 27; others, n = 13) were enrolled in this study. Seven patients (17.5%) had repair of obstructed total anomalous pulmonary venous drainage, and 4 (10%) had repair of common atrioventricular valve at the first palliative operation. Fifteen patients (37.5%) underwent first palliation in the neonatal period. The mean PA index (mm 2 /m 2 ) before BCPS was 230.7 ± 101.7. No pulmonary stenosis was detected before BCPS. Pulmonary artery diameter ratio (nonshunt side/shunt side) was 0.93 ± 0.25; pulmonary lung perfusion ratio (nonshunt side/shunt side) was 0.9 ± 0.2. A multivariate analysis identified persistent total anomalous pulmonary venous drainage (extracardiac type; p = 0.002) as a factor associated with unbalanced branch pulmonary arteries at BCPS. Thirty-five patients underwent BCPS, and 31 underwent Fontan procedures. There were 4 early deaths and 4 late deaths. Conclusions The strategies we have employed facilitate safe accomplishment of the next-stage operation in diverse anatomic groups, with avoidance of unbalanced pulmonary vascular bed. [ABSTRACT FROM AUTHOR]

Background: Infection during left ventricular assist device (LVAD) support is associated with a high mortality. This study investigated the effect of bloodstream infection on survival of patients with LVAD support and assessed risk factors for survival in LVAD patients with bloodstream infection. Methods: Between 1999 and 2010, 109 consecutive patients with end-stage heart failure were supported by an LVAD as a bridge to transplantation. Overall survival was compared between those with and without a bloodstream infection. Risk factors for survival of patients with bloodstream infection were analyzed. Results: A bloodstream infection developed in 65 patients (60%) during 584 ± 389 days of LVAD support. Compared with patients without a bloodstream infection, overall survival was significantly worse in those with bloodstream infection (68% vs 84% at 2 years after LVAD implantation, p = 0.0117). However, of 22 patients bridged to transplantation, none had bloodstream infection recurrence after transplantation, and their 3-year survival rate after transplantation was 100%. Cox multivariate analysis (hazard ratio [95% confidence interval]) identified postoperative right ventricular failure (2.890 [1.238 to 6.757]; p = 0.0141) and bloodstream infection caused by a pathogen other than gram-positive cocci (3.336 [1.390 to 8.006] p = 0.0070) as significant risk factors for death in LVAD patients with a bloodstream infection. Conclusions: Bloodstream infection had a significant effect on survival after LVAD implantation. Our results suggest that urgent cardiac transplantation should be considered for LVAD patients with a bloodstream infection based on the causative organism and right ventricular function. [ABSTRACT FROM AUTHOR]

Background: Left ventricular assist system (LVAS) implantation is an established treatment for patients with advanced heart failure. We investigated the clinical implication of serial changes in renal function after LVAS implantation. Methods: This study included 110 patients who underwent pulsatile LVAS implantation intended as a bridge to transplantation and were alive more than 2 weeks after implantation. Data collection of demographic and hematologic values was performed 1 day before (baseline) and 2 weeks after implantation. All patients were monitored for 2 years or until death. Results: The 2-year postimplantation mortality rate was 31.8%. Multivariate Cox regression analysis showed the baseline estimated glomerular filtration rate (eGFR) was an independent predictor of death (hazard ratio, 0.90 for each 10 mL/min increase, p < 0.05). The eGFR significantly increased at 2 weeks after LVAS implantation (70.5 ± 37.8 to 121.0 ± 78.8 mL/min, p < 0.01). Kaplan-Meier curves with log-rank tests showed significantly poorer event-free survival rates in the group with an inframedian value of change in eGFR at 2 weeks after implantation (ΔeGFR; p = 0.03) as well as in the group with the lowest tertile of eGFR at 2 weeks after implantation (2w-eGFR; p < 0.01). Multivariate Cox regression analysis showed that ΔeGFR (hazard ratio, 0.89 for each 10 mL/min increase) and 2w-eGFR (hazard ratio, 0.92 for each 10 mL/min increase) were independent predictors of death (p < 0.01, respectively). Conclusions: Impaired renal function, and in particular, a poor response of eGFR to LVAS implantation, may have a strong association with worse outcome. [ABSTRACT FROM AUTHOR]

Background: Management of native aortic insufficiency (AI) during left ventricular assist device (LVAD) support is challenging. We investigated the occurrence of de novo AI during long-term LVAD support to identify its effect on late clinical and echocardiographic outcomes. Methods: Left ventricular assist devices were implanted in 99 patients with dilated cardiomyopathy, of whom 47 without preoperative AI were investigated using serial echocardiography examinations for more than 1 year after the operation. Results: The mean duration of LVAD support was 838 ± 327 days, and 26 patients (55%) were supported for more than 2 years. Twenty-nine patients (62%) had no AI (group A), whereas de novo AI developed in the remaining 18 (38%; group B) at 1 year after LVAD implantation (≥ grade 2 in 5, grade 1 in 13). The LV end-diastolic diameter was significantly reduced after LVAD implantation in both groups, with no significant difference between them. Overall survival was better in group A (p = 0.0195). Multivariate analysis revealed that preoperative mitral regurgitation of more than grade 2 (odds ratio, 7.8; 95% confidence interval, 1.2 to 48.6; p = 0.028) and an aortic valve that remained closed at 1 month after implantation (odds ratio, 6.7; 95% confidence interval, 1.0 to 43.9; p = 0.048) were significant independent predictors of de novo AI at 1 year after LVAD implantation. Conclusions: Survival was significantly worse when de novo AI developed in patients during long-term LVAD. Our findings indicate that preoperative functional mitral regurgitation and postoperative aortic valve opening are related to the progression of AI during long-term LVAD support. [ABSTRACT FROM AUTHOR]

Objective: The long-term outcomes of combined mitral repair and maze procedure for patients with nonrheumatic mitral regurgitation and chronic atrial fibrillation were evaluated. Methods: Between June 1992 and December 2008, 187 patients underwent a combined mitral repair and maze procedure. The mean follow-up period was 7.4 ± 4.3 years. Chordal reconstruction was performed in 69 patients, leaflet resection in 91, edge-to-edge leaflet suture in 30, and ring annuloplasty in 156. In addition, a cryo-maze procedure was applied in 110, and a Cox–Kosakai maze and radiofrequency maze were applied in the others. Results: There were 2 operative deaths and the 15-year survival was 71%. The 15-year freedom from greater than grade 3 mitral regurgitation was 61%; rates of freedom from heart failure (New York Heart Association class ≥ III) and reoperations were 79% and 91%, respectively. Cardiac function was improved and left ventricular size was decreased significantly postoperatively. Multivariate analysis showed that a large left ventricular diastolic diameter (≥65 mm) was an independent risk factor for recurrent mitral regurgitation. Eleven thromboembolic episodes (0.79%/patient-year) were detected during follow-up examinations, of which 7 occurred in patients with recurrent atrial fibrillation. Sinus rhythm was regained in 86% after 6 months and in 63% after 15 years. Multivariate analysis showed that a small-voltage f wave was an independent risk factor for AF recurrence. Conclusions: A combined mitral valve repair and maze procedure provided low rates of morbidity and mortality and led to well-preserved cardiac function. Left ventricular diastolic diameter and f-wave voltage can be accurate predictors of good long-term outcome. [Copyright &y& Elsevier]

Abstract: To evaluate the nutritional advantages of quinoa seeds (Chenopodium quinoa Willd.) cultivated in Japan, antioxidative properties and flavonoid composition were determined and compared to corresponding data for conventionally-used cereals and pseudo-cereals, including quinoa seeds from South America. The antioxidant activities of these grains against DPPH radicals were strongly associated with the total phenolic content of the tested samples. The crude extracts of quinoa seeds cultivated in Japan exhibited higher antioxidative effects than those from South America and other cereals, excluding buckwheat. Four flavonol glycosides were isolated and identified from the Japanese quinoa seeds, and the chemical composition of the flavonoids – quercetin and kaempferol 3-O-(2″,6″-di-O-α-rhamnopyranosyl)-β-galactopyranosides (1 and 4), quercetin 3-O-(2″,6″-di-O-α-rhamnopyranosyl)-β-glucopyranoside (2), and quercetin 3-O-(2″-O-β-apiofuranosyl-6″-O-α-rhamnopyranosyl)-β-galactopyranoside (3) – was evaluated through quantitative determination. Trioside 2 was isolated for the first time from quinoa seeds. These glycosides were not detected in extracts from any of the tested grains except quinoa. The aglycone quercetin content of the Japanese quinoa seeds is higher than in the seeds from South America and buckwheat. The amounts of quercetin and kaempferol formed via acidic hydrolysis in quinoa are much higher than those of conventionally-used edible plants. The quinoa seeds cultivated in Japan are the most effective functional foodstuff – in terms of being a source of antioxidative and bioactive flavonoids – among cereals and pseudo-cereals. [Copyright &y& Elsevier]

Objective: Preserved myocardial function remote from surgical site is crucial for good outcome after surgical ventricular restoration in ischemic cardiomyopathy. We hypothesized that left ventricular scarring untouched by operation would negatively affect postoperative outcome. Methods: In 15 consecutive patients (mean age 61 ± 12 years, mean left ventricular ejection fraction 20% ± 7.5%), left ventricular assessments by magnetic resonance imaging and right heart catheterization were performed before and after operation. Left ventricular basal scarring remote from surgical exclusion site was quantified from hyperenhancement area on preoperative delayed-enhancement magnetic resonance imaging as percentage of fibrosis (total infarct size relative to ventricular mass). Results: Calculated percentage of fibrosis varied from 0% to 29.9% (mean 12% ± 9.6%). Percentage of fibrosis linearly correlated with significantly worse postoperative hemodynamic variables and left ventricular function recovery: left ventricular ejection fraction (P = .0005, R = −0.79), left ventricular end-systolic volume index (P = .05, R = 0.51), mean pulmonary arterial pressure (P = .004, R = 0.70), pulmonary capillary wedge pressure (P = .009, R = 0.65), and cardiac index (P = .005, R = −0.69). At mean 30-month follow-up, 4 patients with recurrent heart failure had significantly greater percentage of fibrosis than did those without recurrence (19% ± 8.2% vs 8.8% ± 8.6%, P = .04). Conclusion: Amount of myocardial scarring at left ventricular base affected postoperative left ventricular function and hemodynamic improvements. Preoperative quantitative assessment of remote myocardial status with delayed-enhancement magnetic resonance imaging may predict outcomes for patients undergoing surgical ventricular restoration. [Copyright &y& Elsevier]

Background: The feasibility of left ventricular restoration for patients with ischemic cardiomyopathy complicated with cardiogenic shock remains unclear. We report early and mid-term outcomes of surgical interventions including left ventricular restoration for patients with cardiogenic shock. Methods: From April 2001 to June 2007, 10 patients with ischemic cardiomyopathy who developed cardiogenic shock underwent left ventricular restoration combined with mitral annuloplasty or coronary artery bypass grafting. All had been supported by a maximum dose of inotropic agents, 8 had required an intraaortic balloon pump, and 1 had required extracorporeal life support. Mean left ventricular end-diastolic and end-systolic volume indices were 142 ± 33 mL/m2 and 113 ± 28 mL/m2, respectively, and ejection fraction was 0.21 ± 0.059. Results: There was no mortality at 30 days. Five patients demonstrated significant recovery after the operation. Three patients simultaneously underwent left ventricular assist system (LVAS) implantation with left ventricular restoration because of preexisting severe end-organ failure, and 2 of them were subsequently weaned from LVAS, although 1 required reimplantation. The other 2 patients eventually underwent LVAS implantation in the early postoperative period. Two patients who required prolonged LVAS support underwent successful heart transplantation. Seven patients are alive at a mean follow-up of 1.9 years. Patients who required prolonged LVAS support had significantly longer duration of heart failure symptoms (p = 0.04) and higher mean pulmonary artery pressure (p = 0.02) preoperatively. Conclusions: Early combined surgical interventions including left ventricular restoration can be a choice of treatment even in patients with ischemic cardiomyopathy complicated with cardiogenic shock. Additional use of the LVAS followed by bridge to recovery or transplantation should be appropriately applied in these critically ill patients. [Copyright &y& Elsevier]

Abstract: Several 1- and 2-substituted thianthrene sulfilimine derivatives were prepared and the selectivity toward oxidation and N-tosylimination under several conditions was studied. In the photolysis of trans-5-(N-p-tosyl)iminothianthrene 10-oxide (trans-10), photo isomerization to cis-10 was observed. Further, photoimino-transfer reaction of sulfilimines and their 10-mono- and -dioxide derivatives to sulfides was intensively studied to make clear the ability as nitrene precursors. [Copyright &y& Elsevier]

Penicillium chrysogenum exo-arabinanase (Abnx), which releases arabinobiose from the nonreducing terminus of α-1,5-l-arabinan, was found to possess trans-arabinobiosylation activity on various acceptors, such as aliphatic alcohols, sugars, and sugar alcohols. Abnx was found to prefer primary hydroxyl groups in polyhydric alcohols as acceptors over primary hydroxyl groups in monohydric alcohols. Among the 21 different compounds tested, glycerol was the best acceptor for the enzyme. The transfer product of glycerol was identified as O-α-l-arabinosyl-(1→5)-O-α-l-arabinosyl-(1→1)-glycerol on the basis of the spectral data, fast atom bombardment-mass and 1H- and 13C-NMR. Unlike endo-arabinanases, Abnx catalyzed the hydrolysis of linear arabinan without inverting the anomeric configuration. [Copyright &y& Elsevier]

Approximately 20% of familial amyotrophic lateral sclerosis (FALS) arises from germ-line mutations in the superoxide dismutase-1 (SOD1) gene. However, the molecular mechanisms underlying the process have been elusive. Here, we show that a neuronal homologous to E6AP carboxyl terminus (HECT)-type ubiquitin-protein isopeptide ligase (NEDL1) physically binds translocon-associated protein-δ and also binds and ubiquitinates mutant (but not wild-type) SOD1 proportionately to the disease severity caused by that particular mutant. Immunohistochemically, NEDL1 is present in the central region of the Lewy body-like hyaline inclusions in the spinal cord ventral horn motor neurons of both FALS patients and mutant SOD1 transgenic mice. Two-hybrid screening for the physiological targets of NEDL1 has identified Dishevelled-1, one of the key transducers in the Wnt signaling pathway. Mutant SOD1 also interacted with Dishevelled-1 in the presence of NEDL1 and caused its dysfunction. Thus, our results suggest that an adverse interaction among misfolded SOD1, NEDL1, translocon-associated protein-δ, and Dishevelled-1 forms a ubiquitinated protein complex that is included in potentially cytotoxic protein aggregates and that mutually affects their functions, leading to motor neuron death in FALS. [ABSTRACT FROM AUTHOR]

A 40-year-old patient with Ehlers-Danlos syndrome type VI (ocular type) had mitral regurgitation due to mitral valve prolapse. Because the patient’s tissue was fragile, we replaced the mitral valve with a reinforced prosthetic valve to prevent paravalvular leakage. The excised mitral leaflet showed significant myxomatous change and decrease in collagen fibers. We believe this is the first report of cardiac surgery in a patient with Ehlers-Danlos syndrome type VI. [Copyright &y& Elsevier]

Homozygous familial hypercholesterolemia is a rare autosomal dominant disorder caused by gene mutations of the low-density lipoprotein receptor, generally characterized by three major signs—hyper low-density lipoprotein cholesterolemia, tendon/skin xanthomas, and premature atherosclerosis disease—beginning in childhood and including supravalvular aortic stenosis. To the best of our knowledge, only a few successful surgical cases for supravalvular aortic stenosis in these patients have been reported. We report two cases of homozygous familial hypercholesterolemia with severe supravalvular aortic stenosis and coronary artery disease associated with very small aortic root, managed by aortic root replacement concomitant with coronary artery bypass graft surgery, which resulted in excellent postoperative outcomes. [ABSTRACT FROM AUTHOR]

Objective This study explored the influence of prosthesis selection on long-term outcomes in patients who underwent mitral valve repair for mitral insufficiency (MI) due to type II dysfunction. Methods We retrospectively reviewed 452 patients with MI who underwent mitral valve repair for type II dysfunction between 2001 and 2014. Of these, 167 patients (37%) presented with anterior leaflet prolapse (anterior group) and 285 (63%) presented with posterior prolapse (posterior group). Full rings were applied in 95 patients (57%) in the anterior group and in 54 patients (19%) in the posterior group, and partial bands were applied in all others. We compared long-term outcome and change of MI severity over time between patients with partial-band and full-ring repair in the anterior and in the posterior groups using a mixed-effect model with repeated measures and propensity score-matched analysis. Results Ten-year survival of the cohort was 90.5%. Echocardiography revealed MI ≥ 3 at follow-up in 58 patients (12.8%). Twenty-one patients (4.6%) required reoperation; freedom from reoperation was 92.1% at 10 years. The MI severity over time in patients in the anterior group was higher than that in patients in the posterior group ( P < .0001). Moreover, MI severity over time in patients with the partial band was higher than patients with the full ring in the anterior group ( P = .0176). Propensity score-matched analysis in the anterior group, but not in the posterior group, revealed a significantly higher MI severity in patients with the partial band than those with the full ring over the study period ( P = .04). Conclusions Full-ring annuloplasty is indicated in the setting of anterior prolapse to prevent recurrent MI, whereas prosthesis type is not a determinant of recurrent MI in the setting of posterior prolapse. [ABSTRACT FROM AUTHOR]

Scheie''s syndrome is a rare hereditary disorder of proteoglycan-degrading enzymes. Deposition of mucopolysaccharide can cause valvular and other tissue abnormalities. Few studies have reported surgical results for Scheie''s syndrome, and the perioperative course is complicated. This is a report of a 35-year-old woman with Scheie''s syndrome who underwent double-valve replacement with intensive perioperative management. [Copyright &y& Elsevier]