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Objective: The benefit of adding ganglionated plexi ablation to the maze procedure remains controversial. This study aims to compare the outcomes of the maze procedure with and without ganglionated plexi ablation., Methods: This multicenter randomized study included 74 patients with atrial fibrillation associated with structural heart disease. Patients were randomly allocated to the ganglionated plexi ablation group (maze with ganglionated plexi ablation) or the maze group (maze without ganglionated plexi ablation). The lesion sets in the maze procedure were unified in all patients. High-frequency stimulation was applied to clearly identify and perform ganglionated plexi ablation. Patients were followed up for at least 6 months. The primary endpoint was a recurrence of atrial fibrillation., Results: The intention-to-treat analysis included 69 patients (34 in the ganglionated plexi ablation group and 35 in the maze group). No surgical mortality was observed in either group. After a mean follow-up period of 16.3 ± 7.9 months, 86.8% of patients in the ganglionated plexi ablation group and 91.4% of those in the maze group did not experience atrial fibrillation recurrence. Kaplan-Meier atrial fibrillation-free curves showed no significant difference between the two groups (P = .685). Cox proportional hazards regression analysis indicated that left atrial dimension was the only risk factor for atrial fibrillation recurrence (hazard ratio: 1.106, 95% confidence interval 1.017-1.024, P = .019)., Conclusion: The addition of ganglionated plexi ablation to the maze procedure does not improve early outcome when treating atrial fibrillation associated with structural heart disease., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Objectives: Acute cholecystitis is a complication in critically ill patients. However, a few studies have described its incidence, risk factors, and mortality in patients who underwent cardiovascular surgery. We investigated the incidence, perioperative predictors, and clinical features of acute cholecystitis after cardiovascular surgery., Methods: This retrospective cohort study examined 7013 patients who underwent cardiovascular surgery between October 2000 and March 2019 at a tertiary care hospital. We collected preoperative, intraoperative, and postoperative data from our database and electronic medical records. The primary outcome was the incidence of postoperative cholecystitis until hospital discharge. A multivariable logistic regression analysis to estimate perioperative predictors of acute cholecystitis was conducted. We described the clinical characteristics of patients complicated with acute cholecystitis., Results: Among the 7013 patients, 51 (0.7%) developed acute cholecystitis. Logistic regression analysis found that circulatory arrest (odds ratio [OR] 1.97; 95% confidence interval [CI] 1.04-3.74; P = 0.037) and intraoperative massive transfusion (OR 2.03; 95% CI 1.03-4.01; P = 0.041) were associated with the incidences of cholecystitis. In-hospital mortality was significantly higher in the cholecystitis group than in the non-cholecystitis group (13.7% vs 3.9%, P = 0.004). Aortic disease was more frequent in the cholecystitis group (54.9% vs 38.6%, P = 0.021). The median time of acute cholecystitis onset from surgery was 12.5 days (interquartile range 7.0-27.75). Twenty-six patients (51.0%) developed asymptomatic cholecystitis., Conclusions: Approximately 1% of patients who underwent cardiovascular surgery developed postoperative cholecystitis; half of them were asymptomatic. Since cholecystitis is associated with high mortality, it is a complication after cardiovascular surgery that needs to be considered., (© 2021. The Japanese Association for Thoracic Surgery.)

Objective: We assessed the clinical effectiveness of coronary artery bypass grafting (CABG) in comparison with that of percutaneous coronary intervention (PCI) in octogenarians with triple-vessel disease (TVD) or left main coronary artery (LMCA) disease., Methods: From the CREDO-Kyoto registry cohort-2, 527 patients, who were ≥ 80 years of age and underwent the first coronary revascularization for TVD or LMCA disease, were divided into the CABG group (N = 151) and the PCI group (N = 376)., Results: The median and interquartile range of patient's age was 82 (81-84) in the CABG group and 83 (81-85) in the PCI group (P = 0.10). Patients >  = 85 years of age accounted for 19% and 31% in the CABG and PCI groups, respectively (P = 0.01). The cumulative 5-year incidence of all-cause death was similar between CABG and PCI groups (35.8% vs. 42.9%, log-rank P = 0.18), while CABG showed a lower rate of the composite of cardiac death/MI than PCI (21.7% vs. 33.9%, log-rank P = 0.005). After adjusting for confounders, the lower risk of CABG relative to PCI was significant for all-cause death (HR 0.61, 95% CI 0.43-0.86, P = 0.005), any coronary revascularization (HR 0.25, 95% CI 0.14-0.43, P < 0.001) and the composite of cardiac death/MI (HR 0.52, 95% CI 0.32-0.85, P = 0.009)., Conclusions: CABG compared with PCI was associated with a lower adjusted risk for all-cause death, any coronary revascularization, and a composite of cardiac death/MI in very elderly patients with TVD or LMCA disease. CABG seemed an acceptable option for selected octogenarians with severe coronary artery disease., (© 2021. The Japanese Association for Thoracic Surgery.)

Objectives: There is uncertainty over the efficacy of additional surgical ventricular reconstruction (SVR) associated with mitral valve operation for non-ischaemic dilated cardiomyopathy (DCM). This study aims to assess mid-term outcomes of these non-heart transplant surgical approaches for DCM., Methods: We reviewed retrospectively 106 patients (median age 64, 44 females) who underwent isolated mitral annular plasty (MAP; n = 34), mitral valve replacement (MVR; n = 29), and SVR associated with MAP (SVR + MAP; n = 43) for DCM, in 11 Japanese hospitals. We analysed mid-term outcomes, specifically freedom from cardiac death and cardiac event., Results: Hospital deaths occurred in 16 patients (15.1%) and cardiac deaths in 36 patients (34.0%) during the study period of 4.4 ± 3.5 years. Freedom from cardiac death at 7 years in patients undergoing MAP, MVR, and SVR + MAP were, respectively, 79.1%, 82.6%, and 29.5% (P < 0.0001). Freedom from cardiac event at 7 years in patients undergoing MAP, MVR, and SVR + MAP were, respectively, 42.8%, 59.9%, 22.6% (P = 0.0004). In the multivariable analyses, preoperative tricuspid regurgitation (TR) grade was the only risk factor for both cardiac death and event, whereas MVR for DCM emerged as a protective factor for cardiac event., Conclusions: This study could not show any benefit of additional SVR, by means of volume reduction, to MAP, because the baseline characteristics were different even after the stratification of DCM grade. MVR can be performed with favorable mid-term outcomes even in patients with advanced DCM, while patients undergoing MAP with/without SVR had more frequent MR recurrence or cardiac events. Interestingly, the right ventricular feature is a predictor of both cardiac death and events, with the TR grade being a predictor of poor mid-term outcomes.

Introduction: The relationship between the distance from the mitral annulus to the left circumflex coronary artery (LCX) and iatrogenic LCX injury has been questioned. This study was designed to determine the high-risk sites of LCX injury with an anatomical approach using multiple detector-computed tomography (MDCT) scanning taken before mitral valve annuloplasty (MVA). The purpose of this study is to prevent LCX injury in patients unable to receive MDCT before mitral valve surgery., Methods: In 2018, we performed MVA on 59 patients, 52 of whom had undergone preoperative MDCT scanning. We retrospectively analyzed the MDCT images of these 52 patients and measured the shortest distance from the mitral annulus to the LCX in three dimensions. Also, we divided the mitral annulus into 12 clockwise areas (A0-A11) to identify the exact location., Results: The site of closest proximity and their numbers of patients were as follows: A6, 1 patient; A8, 2 patients; A9, 32 patients; and A10, 17 patients. Nine (17.3%) of the 52 patients had the shortest distance of less than 2 mm. The shortest distance according to the dominance of coronary artery showed no significant difference (p = 0.81)., Conclusion: The site of closest proximity from the mitral annulus to the LCX was concentrated on the A8 to A10 areas and it is an interesting result that as many as 17% of patients have their coronary arteries less than 2 mm away from the annulus.

Objectives: Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are common procedures for managing coronary artery disease (CAD); however, optimal methods of comparing post-procedure outcomes are unclear. We evaluated the reliability of Synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) scores and investigated differences in long-term outcomes after CABG among groups with different SYNTAX scores., Methods: According to patient selection criteria used in the SYNTAX trial, 368 patients who underwent isolated initial CABG between 2003 and 2014 at Kurashiki Central Hospital were stratified into three SYNTAX score I groups (low: < 23, intermediate: 23 to < 33, and high: ≥ 33) and three SYNTAX score II groups (low: < 30, intermediate: 30 to < 40, and high: ≥ 40). Group outcomes were compared. Overall 4-year mortality data for SYNTAX score II were compared with the cohort data., Results: There were no significant differences in all-cause death, 10-year major adverse cardiac and cerebrovascular events (MACCEs), myocardial infarction, and stroke data in the SYNTAX score I groups. As SYNTAX score II increased, all-cause death and MACCEs rates rose significantly. Four-year mortality at our facility was 11.0 ± 1.7%, whereas that predicted by SYNTAX score II was 12.0 ± 11.1%. The predicted data were close to the clinical data, but not statistically significant, with an area under the curve of 0.769., Conclusions: SYNTAX score II demonstrated reasonable predictive performance for outcomes after CABG, whereas SYNTAX score I did not. With SYNTAX score systems, treatment options should be discussed with a heart team to achieve better outcomes.

Objectives: This study aimed to demonstrate the efficacy and safety of a newly developed elastomeric sealant, which does not require any blood coagulation system to exert its effect, during thoracic aortic surgery., Methods: This is a multicenter, randomized study conducted in six hospitals in Japan. A total of 81 patients undergoing replacement surgery of a thoracic aortic aneurysm using cardiopulmonary bypass were randomized with a ratio of 2-:1 for those patients designated to receive the sealant (Group S, 54 patients) or those without the usage of the sealant (Group C, 27 patients). The primary endpoints were bleeding from each anastomosis at two time points: (1) immediately before applying protamine and (2) 15 min after applying protamine. The patients were followed for 6 months., Results: The number of anastomoses checked for bleeding was 196 in Group S and 117 in Group C. Before protamine sulfate administration, complete hemostasis was obtained in 155 anastomoses (79%) in Group S compared to 45 anastomoses (38%) in Group C (p < 0.001). Fifteen minutes after the administration of protamine sulfate infusion, bleeding stopped completely in 173 anastomoses (88%) in Group S and in 71 anastomoses (61%, p < 0.001) in Group C. Between the two groups, there were no marked differences in the patient background or in the incidence of major adverse events., Conclusions: The sealant is effective in achieving hemostasis, even under fully heparinized conditions. The novel sealant is safe and effective in thoracic aortic surgery, one of the most demanding surgical situations for hemostasis.