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Various perivascular drug delivery techniques have been demonstrated for localized post-treatment of intimal hyperplasia: a vascular inflammatory response caused by endothelial damages. Although most perivascular devices have focused on controlling the delivery duration of anti-proliferation drug, the confined and unidirectional delivery of the drug to the target tissue has become increasingly important. In addition, careful attention should also be paid to the luminal stability and the adequate exchange of vascular protein or cell between the blood vessel and extravascular tissue to avoid any side effect from the long-term application of any perivascular device. Here, a highly flexible and porous silk fibroin microneedle wrap (Silk MN wrap) is proposed to directly inject antiproliferative drug to the anastomosis sites while ensuring sufficient vascular exchanges. Drug-embedded silk MNs were transfer-molded on a highly flexible and porous silk wrap. The enhanced cell compatibility, molecular permeability, and flexibility of silk MN wrap guaranteed the structural integrity of blood vessels. Silk wrap successfully supported the silk MNs and induced multiple MN penetration to the target tissue. Over 28 days, silk MN wrap significantly inhibited intimal hyperplasia with a 62.1% reduction in neointimal formation.

Background Flowable hemostatic agents are advantageous in that they can be applied to irregular wound surfaces and to areas that are difficult to approach directly. We sought to compare the effectiveness and safety of the flowable hemostatic sealants Collastat® (collagen hemostatic matrix, [CHM]) and Floseal® (gelatin hemostatic matrix, [GHM]) during off-pump coronary artery bypass (OPCAB). Methods In this prospective, randomized trial, 160 patients undergoing elective OPCAB surgery were enrolled between March 2018 and February 2020. After primary suture of the aortocoronary anastomosis, an area of hemorrhage was identified, and patients were double blind randomized to receive either CHM or GHM (n = 80, each). Study endpoints were the following: rate of successful intraoperative hemostasis and time required for hemostasis overall postoperative bleeding, rate of transfusion of blood products, rate of surgical revision for bleeding, postoperative morbidity, and intensive care unit stay. Results Of the total patients, 23% were female, and the mean age was 63 years (range: 42–81 years). Successful hemostasis within 5 min was achieved for 78 patients (97.5%) in the GHM group, compared to 80 patients (100%) in the CHM group (p = 0.497). Two patients receiving GHM required surgical revision to achieve hemostasis. There were no differences in the mean time required to obtain hemostasis (GHM vs. CHM, 1.49 ± 0.94 vs. 1.35 ± 0.60 min, p = 0.272), as confirmed by time-to-event analysis (p = 0.605). The two groups had similar amounts of mediastinal drainage for 24 h postoperatively (p = 0.298). The CHM group required less packed red blood cells, fresh frozen plasma, and platelets for transfusion than the GHM group (0.5 vs. 0.7 units per patient, p = 0.047; 17.5% vs. 25.0%, p = 0.034; 7.5% vs. 15.0%, p = 0.032; respectively). Conclusions CHM performed similarly to a commonly used hemostatic agent with regard to achieving effective and fast interoperative hemostasis during OPCAB. The topical flowable hemostatic agent, CHM, could be effectively used during cardiac surgery for intraoperative hemostasis of great vessels with high pressure. Trial registration : ClinicalTrials.gov, NCT 04310150

Background This study aimed to evaluate the early outcomes of Perceval sutureless valves in the Korean population and to introduce a modified technique of guiding suture placement during valve deployment.Methods and Results:From December 2014 to April 2019, 121 patients (mean age: 74.7±6.2 years; 53.7% female) received a Perceval sutureless aortic valve replacement. To prevent conduction system injury, the depth of guiding suture placement (1 mm below the nadir of the annulus) was modified. All patients underwent echocardiographic evaluation at discharge and 6-12 months postoperatively, with a mean follow up of 13.7±11.2 months. Concomitant surgeries, such as coronary artery bypass grafting, and other valvular surgeries, were performed in 45.5% of cases. The mean aortic cross-clamp times for isolated and minimal procedures were 32.8±7.9, and 41.2±8.0 min, respectively. The overall transvalvular mean gradients were 13.1±3.8 mmHg at discharge and 11.5±4.7 mmHg at the last follow up. After modifying the guiding suture placement, permanent pacemaker implantation risk decreased from 9.9% to 2.5%. Cardiac-related mortality was 0.8%, with no patient developing valvular or paravalvular aortic regurgitation, valve thrombosis, or endocarditis. Conclusions Perceval valve implantation provided a significant cardiac-related survival benefit with excellent early hemodynamic and clinical outcomes. Further research is needed to determine whether adjusting the implantation depth, such as modification of the guiding suture technique, can reduce the risk of permanent pacemaker implantation.

Background The extracorporeal ventricular assist device (e-VAD) system is designed for left ventricular support using a permanent life support console. This study aimed to determine the impact of temporary e-VAD implantation bridging on posttransplant outcomes. Methods We reviewed the clinical records of 6 patients with the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1, awaiting heart transplantation, who were provided with temporary e-VAD from 2018 to 2019. The circuit comprised a single centrifugal pump without an oxygenator. The e-VAD inflow cannula was inserted into the apex of the left ventricle, and the outflow cannula was positioned in the ascending aorta. The median follow-up duration was 8.4±6.9 months. Results After e-VAD implantation, lactate dehydrogenase levels significantly decreased, and Sequential Organ Failure Assessment scores significantly improved. Bedside rehabilitation was possible in 5 patients. After a mean e-VAD support duration of 14.5±17.3 days, all patients were successfully bridged to transplantation. After transplantation, 5 patients survived for at least 6 months. Conclusion e-VAD may reverse end-organ dysfunction and improve outcomes in INTERMACS I heart transplant patients.

Background Many variables may affect the hemodynamic performance of the aortic valve prosthesis, and suture technique remains an important factor for determining maximum valve performance. The objective of this study was to determine the suture technique that produces better hemodynamic performance for aortic valve replacement (AVR). Methods Patients who underwent AVR between January 2015 and September 2018 in our institution were analyzed. We compared the preoperative clinical information and 1-year postoperative hemodynamic data of interrupted pledget mattress sutures (pledgeted group), interrupted nonpledget mattress sutures (nonpledgeted group), and figure-of-8 nonpledget sutures (figure-of-eight group). We compared the incidence of prosthesis-patient mismatch (PPM) and cardiac adverse events among the groups and subanalyzed the PPM rate in a small aortic annulus (18 to 21 mm). Results A total of 439 patients underwent AVR (pledgeted, n = 212; nonpledgeted, n = 122; figure-of-eight, n = 105). The groups were similar in age (P = .359), sex (P = .055), underlying disease, and valve pathology. There was no difference in inhospital mortality or cardiac adverse events in each suture group (P = .282). The nonpledgeted suture had significantly lower moderate (P Conclusions The interrupted nonpledget mattress suture offers complete supraannular implantation, which reduces the incidence of PPM and results in better hemodynamic improvement after small-size AVR.

Cardiac adipose tissue is a well-known risk factor for the recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation, but its correlation with maze surgery remains unknown. The aim of this study was to investigate the correlation between the recurrence of AF and the adipose component of the left atrium (LA) in patients who underwent a modified Cox maze (CM) III procedure. We reviewed the pathology data of resected LA tissues from 115 patients, including the adipose tissue from CM-III procedures. The mean follow-up duration was 30.05 ± 23.96 months. The mean adipose tissue component in the AF recurrence group was 16.17% ± 14.32%, while in the non-recurrence group, it was 9.48% ± 10.79% (p = 0.021), and the cut-off value for the adipose component for AF recurrence was 10% (p = 0.010). The rates of freedom from AF recurrence at 1, 3, and 5 years were 84.8%, 68.8%, and 38.6%, respectively, in the high-adipose group (≥10%), and 96.3%, 89.7%, and 80.3%, respectively, in the low-adipose group (

Background It is unclear at present whether conventional open repair or a hybrid technique is preferential in the treatment of aortic arch diseases. Our intent was to compare early and long-term outcomes of both therapeutic strategies. Methods Between January 2002 and December 2017, 238 patients eligible for total arch replacement (TAR; 174) or hybrid arch repair (HAR; 64) qualified for study. A retrospective analysis of clinical outcomes was undertaken, with propensity matching (48 pairs). Mean follow-up duration was 60.2 months. Results In-hospital mortality rates were 4.6% (8 of 174 patients) and 6.3% (4 of 64 patients) in the TAR and HAR groups, respectively (p = 0.739). The TAR group displayed a lower incidence of permanent stroke (2.9%, 5 of 174 patients) by comparison (HAR: 12.5%, 8 of 64 patients; p = 0.004). Overall survival rates at 5 and 10 years differed significantly by group (TAR: 87.0% ± 5.5% and 81.9% ± 4.8%, respectively; HAR: 69.5% ± 7.4% and 40.8% ± 11.1%, respectively; p = 0.003). After propensity matching, in-hospital mortality (4.2% versus 4.2%, p > 0.99) and patient morbidities showed no statistically significant group differences. For patients undergoing HAR, a tendency for permanent stroke (14.5% versus 2.1%, p = 0.070) was evident. In the TAR (versus HAR) group, 10-year overall survival (74.7% versus 42.6%, p = 0.043) and reintervention-free (93.2% versus 34.0%, p Conclusions In the treatment of aortic arch diseases, HAR showed equivalent short-term outcomes compared with TAR but was limited regarding long-term outcomes beyond 5 years after the procedure. Conventional TAR remains the gold standard of therapy, and our findings suggest that the hybrid approach should be reserved for strictly selected patients with significant comorbidities.

The Trifecta valve has externally mounted leaflets, it differs from classic internally mounted valves (e.g., Carpentier-Edwards [C-E]). We evaluated post-implantation hemodynamics and clinical outcomes of these bioprostheses in small aortic annuli. From January 2015 to April 2019, 490 patients who underwent aortic valve replacement (AVR) were reviewed retrospectively. Altogether, 183 patients received 19 or 21 mm diameter C-E (n = 121) or Trifecta (n = 62) prostheses. To minimize confounding variables, we performed propensity-score matching analysis. The mean transvalvular pressure gradient (TVPG) was significantly lower in the Trifecta than in the C-E group at discharge (12.9 ± 4.8 vs. 15.0 ± 5.3 mmHg, p = 0.044). TVPG change over time was not significantly different between groups (p = 0.357). Left ventricular mass index decreased postoperatively (reduction: C-E, 28.1%, Trifecta, 30.1%, p = 0.879). No late mortality, severe patient–prosthesis mismatch, moderate-to-severe paravalvular leakage, structural valve degeneration, or valve thromboses were observed. Freedom from valve-related events at 3 years were similar for C-E (97.9% ± 2.1%) and Trifecta (97.7% ± 2.2%) patients (log-rank p = 0.993). Bioprosthesis design for small annuli significantly affected TVPG immediately after AVR. However, hemodynamics over time and clinical outcomes did not differ between the two designs.

Background The objectives of the present study were (1) to evaluate the echocardiographic prognostic factors associated with improved left ventricular (LV) systolic function after aortic valve replacement, and (2) to compare the long‐term outcomes after aortic valve replacement in chronic aortic regurgitation (AR) patients with or without LV dysfunction. Methods and Results A total of 280 patients who underwent aortic valve replacement because of chronic aortic regurgitation were studied. Patients with reduced LV systolic function (LV ejection fraction [LVEF] P =0.036 and P =0.058, respectively). LVEF tended to decrease in the early postoperative period but improved thereafter in both groups. Preoperative early diastolic transmitral flow velocity/mitral annular tissue velocity ratio was a parameter of postoperative improvement or normalization of LVEF in all patients (area under the curve, 0.719; P =0.003) and in group rEF patients (area under the curve, 0.726; P =0.011) with a cutoff value of 12.73. Preoperative early diastolic transmitral flow velocity/mitral annular tissue velocity ratio also was the parameter of overall survival in all patients (hazard ratio [HR], 1.08; P =0.001) and in group rEF patients (HR, 1.08; P =0.005). Conclusions Long‐term outcomes and survival after aortic valve replacement were related to preoperative LV function in patients with chronic aortic regurgitation. Preoperative early diastolic transmitral flow velocity/mitral annular tissue velocity ratio was correlated with the postoperative improvement or normalization of LVEF and long‐term survival, especially in group rEF patients.

The study objective was to examine the long-term fate of aortic diameter expansion at 4 cardiac regions (annulus, sinus, ascending aorta, and proximal arch) after wrapping or replacement during aortic valve surgery of the moderately dilated ascending aorta.From January 1995 to December 2018, 964 consecutive patients who underwent aortic valve replacement at our institution were reviewed. Of them, 204 (mean age, 60.7 ± 7.4 years) underwent ascending aorta wrapping (n = 96) or replacement (n = 108) for a moderately dilated ascending aorta (40 to 55 mm). The overall fate of the aortic diameter was analyzed with a linear mixed-effect model. The median follow-up duration was 7.1 years.After propensity score matching, the baseline maximal ascending aortic diameter median value was 47.3 ± 3.1 mm and 49.4 ± 13.5 mm in the wrapping and replacement groups, respectively. The annulus, sinus, and ascending aorta did not redilate in either group. The proximal aortic arch diameter significantly increased over time (0.343 mm/year; P = .006) in the wrapping group but not in the replacement group (0.066 mm/year; P = .649). Multivariable competing risk analysis identified the initial ascending aorta diameter at the wrapping procedure as an independent risk factor of proximal arch redilation (0.071 ± 0.037, P .001). The cutoff value was an initial ascending aorta diameter of 47.2 mm for the prediction proximal arch redilation (area under the curve, 0.703; P = .014).Aortic wrapping and replacement may be long-term durable treatment options in patients with a moderately enlarged ascending aorta. We suggest careful evaluation of redilation in the proximal arch after an aorta wrapping procedure.

We compared the long-term outcomes and difference in dilatation rates of the ascending aorta after aortic valve (AV) replacement (AVR) between bicuspid and tricuspid AV patients, and evaluated risk factors associated with ascending aorta dilatation and aortic events during the follow-up. Of 1,127 patients who underwent AVR from 1995 to 2015, 259 patients with a dilated ascending aorta (≥40 mm in diameter) were included. The patients were divided into those with bicuspid (group bicuspid aortic valve [BAV], n = 105) and with tricuspid (group tricuspid aortic valve [TAV], n = 154) AV, and a propensity score-matched analysis was performed to match 98 patients in each group. The differences in the dilation rate of the ascending aorta and long-term outcomes were analyzed. Risk factors for ascending aorta dilatation, mortality, and aortic events were identified. Follow-up was completed in 100% of patients with a median follow-up duration of 106.1 [68.8, 163.0] months. The early clinical outcomes and dilation rate of the ascending aorta were similar between the groups. Overall survivals up to 15 years postoperatively were similar between groups BAV and TAV (p = 0.223). Aortic events occurred in 6 patients (groups BAV vs TAV, 2 vs 4;p = 0.678). Preoperative ascending aorta diameter showed a linear relationship with the dilatation rate of ascending aorta (p0.001) and was related to progressive aortic dilatation and aortic events (odds ratio: 1.25, p0.001 and hazard ratio = 1.56, p0.001, respectively). In conclusion, the long-term outcomes and ascending aorta dilatation rate were similar between the BAV and TAV patients up to 15 years after AVR. Bicuspid AV was not a risk factor of mortality or aortic events.

The relationship between functional mitral stenosis (MS) after mitral valve (MV) repair and long-term clinical outcomes is not fully understood. Therefore, we reviewed an institutional series to identify the determinants of functional MS and its effect on long-term clinical outcomes after MV repair for degenerative mitral regurgitation.Between January 1990 and December 2015, 792 patients who underwent MV repair for degenerative mitral regurgitation were retrospectively enrolled and divided into 2 groups: functional MS (n = 192) (≥5 mm Hg mean diastolic pressure gradient across the MV) and nonfunctional MS (n = 600) (5 mm Hg mean diastolic pressure gradient). Mean follow-up was 11.6 ± 5.8 years.After propensity-score matching, patients' characteristics were comparable between groups (n = 192/group). At 20 years, the functional MS group had significantly lower rates of freedom from new-onset atrial fibrillation (73.0% ± 5.6% versus 93.2% ± 2.3%; P = .003), overall survival (72.1% ± 4.6% versus 85.6% ± 4.3%; P = .010), and freedom from MV reoperation (82.8% ± 4.1% versus 92.5% ± 4.2%; P = .019) than the nonfunctional group. The functional MS group also had a significantly greater postoperative left atrial volume index and tricuspid regurgitation grade. A small left ventricular end-diastolic dimension (hazard ratio = 0.975; 95% confidence interval, 0.955-0.996; P = .022) and annuloplasty ring (hazard ratio = 0.757; 95% confidence interval, 0.685-0.837; P.001) were independent risk factors for functional MS.A small left ventricle and annuloplasty ring increased the risk for functional MS after MV repair and was associated with progressive left atrial enlargement and tricuspid regurgitation exacerbation. As a result, functional MS increased the risk for new-onset atrial fibrillation, MV reoperation, and decreased long-term survival.

The efficacy and safety of off-pump coronary artery bypass grafting (OPCAB) in emergency revascularization remains controversial despite its widespread use. The aim of our study was to examine the applicability and safety of OPCAB in patients who were indicated for emergency surgery.This single-center study reviewed the indication, operative data, and early and long-term outcomes of 113 patients (mean age, 67.2±9.0 years; logistic EuroSCORE, 14.3±13.5) who underwent emergency OPCAB from January 2003 to December 2014 and were followed up (94.6% completion rate) for a mean 51.1±40.3 (range, 1-135) months.Emergency OPCAB was associated with favorable surgical outcomes (number of distal anastomoses per patient, 3.04±0.87; internal thoracic artery (IMA) use, 98.2%; complete revascularization, 79.6%) and in-hospital outcomes (mortality, 5.3%; low cardiac output syndrome, 5.3%; stroke, 2.7%; pulmonary complications, 8.8%; renal failure, 11.5%). Only five patients (4.4%) required on-pump conversion. The 10-year outcomes were also acceptable (survival, 75.4%±5.6%; major cerebral and cardiovascular events, 52.1%±1.8%). The multivariate risk factors for late mortality were peripheral vascular disease (HR 2.95, 95% CI: 1.11-11.83), cardiogenic shock (HR 3.67, 95% CI: 1.35-9.96), and incomplete revascularization (HR 3.41, 95% CI: 1.06-14.26). When patients were separated by whether the procedure was performed early (2010) or late (≥2010) in the study period, the late period cohort had better outcomes despite containing higher-risk patients.Our study suggests that emergency OPCAB can be performed safely and effectively with good hospital outcomes and adequate long-term results. OPCAB strategy can be considered as a good option in emergency revascularization.

OBJECTIVES The purpose of this study was to evaluate mid-term patency and clinical outcomes according to the proximal anastomosis site after off-pump coronary artery bypass using the radial artery (RA). METHODS From January 2001 to December 2015, 1124 patients who underwent isolated off-pump coronary artery bypass using the RA were reviewed and divided into 2 groups: the composite Y-graft (n = 1014, Y group) and aortocoronary graft (n = 110, Aorta group). Graft patency was assessed by computed tomography or coronary angiography. RESULTS Patients receiving Y-grafts had a greater number of RA anastomoses (1.79 ± 0.68 per patient vs 1.40 ± 0.51 per patient, P

Background This study investigated the consequences of recurrent mitral regurgitation (MR) after mitral valve (MV) repair in patients with degenerative MR and risk factors for recurrence.Methods and Results:From January 1990 to December 2015, 792 patients underwent MV repair due to degenerative MR. Recurrent MR was defined as moderate-to-severe MR on follow-up echocardiography. Mean follow-up duration was 8.71±5.58 years. During the follow-up period, MR recurred in 133 (16.8%) patients, and the MR recurrence-free rate at 20 years was 77.5±2.0%. In the recurrence group, the degree of MR decreased in 8 (6.0%) patients and was aggravated in 46 (34.6%) patients. Recurrent MR was associated with increased mortality and adverse left ventricular (LV) remodeling. Independent risk factors for MR recurrence were MV repair performed before 2000, preoperative atrial fibrillation, high LV end-diastolic dimension (LVEDD), prolapse of the isolated anterior leaflet or multiple segments, and absence of ring annuloplasty. Predictors of MR progression were high LVEDD and repair without artificial chordae implantation. Conclusions Recurrent MR after MV repair in patients with degenerative MR showed a tendency to progress and was associated with increased mortality and adverse LV remodeling. Early referral for MV repair before development of atrial fibrillation and LV enlargement may reduce the risk of MR recurrence. Moreover, artificial chordae implantation and ring annuloplasty may assure the long-term durability of MV repair.

The aim of this single-center study is to review the transplant outcomes of patients receiving lung transplantation (LTx) using intraoperative extracorporeal membrane oxygenation (ECMO) according to the perioperative use of ECMO.We retrospectively reviewed the transplant outcomes of 107 consecutive patients who underwent LTx using intraoperative ECMO between March 2013 and August 2016 at Severance Hospital of Yonsei University (Seoul, Korea).Patients were divided into the following three groups according to the use of perioperative ECMO: only intraoperative ECMO (n=47) or extended post-operative ECMO but no bridging and no postoperative ECMO re-implantation (secondary ECMO; n=28) as Group A (n=75); bridging ECMO without secondary ECMO (n=14) as Group B; and secondary ECMO with (n=7) or without (n=11) bridging as Group C. Baseline demographics were comparable among the three groups. The mean duration of preoperative ECMO bridging was 16.4±15.6 (n=21). After a median of 17.7 months (range, 3.1-40.9 months) for survivors, the one year overall survival (OS) rates after LTx for the three groups were 76.3%±5.2% for Group A, 59.9%±14.3% for Group B, and 14.0%±9.0% for Group C (P0.0001). The secondary ECMO (Group C) was established a mean of 7.9±5.3 days after LTx. The main cause of secondary ECMO was acute respiratory failure from pneumonia, and the main cause of death was infection-related events.Our data suggests that the use of perioperative ECMO, including its extended postoperative use during LTx, is feasible and has favorable outcomes. However, as shown by the poor survival outcome after secondary ECMO, the development of solid strategy to reduce the need for secondary ECMO implantation after LTx seems important.

After surgical procedures such as coronary/peripheral bypass grafting or endarterectomy for the treatment of organ ischemia derived from atherosclerosis, intimal hyperplasia (IH) which leads to restenosis or occlusion at the site of graft anastomosis frequently occurs. In order to inhibit IH caused by abnormal growth of smooth muscle cells (SMCs) in tunica media, various perivascular drug delivery devices are reported for delivery of anti-proliferation drugs into vascular tissue. However, there still remain conflicting requirements such as local and unidirectional delivery vs device porosity, and conformal tight device installation vs pulsatile expansion and constriction of blood vessels. In this study, a biodegradable microneedle (MN) array is developed on a flexible woven surgical mesh using a transfer molding method. Mechanical properties of 'wrappable' MN meshes are investigated and compared to the properties of blood vessels. Ex vivo and in vivo animal studies demonstrate enhanced drug delivery efficiency, efficacy for IH reduction, and safety of MN mesh. In particular, MN mesh showed significantly reduced neointiamal formation (11.1%) compared to other competitive groups (23.7 and 22.2%) after 4-week in vivo animal study. Additionally, wrappable MN meshes effectively suppressed side effects such as IH due to mechanical constriction, loss of toxic drug to the surroundings, and cell death that were frequently observed with other previous perivascular drug delivery devices.

Background The purpose of this study was to examine the impact of previous percutaneous coronary intervention with stent on long-term outcomes after off-pump coronary artery bypass grafting (OPCAB). Methods Between January 2001 and December 2014, 1,668 patients with triple-vessel disease undergoing OPCAB were reviewed and divided into 2 groups. The no-stent group (n = 1,409) included patients who underwent OPCAB as a primary revascularization procedure and the stent group (n = 259) included patients with a history of percutaneous coronary intervention with stent. The mean follow-up duration was 5.32 ± 3.39 years. Results After propensity score matching, characteristics of both groups were comparable (n = 259 in each group). In-hospital mortality (n = 3 [1.2%] in both groups; p > 0.999) was similar. The 14-year overall survival rate (75.6% ± 6.6% in the no-stent group versus 71.9% ± 8.5% in the stent group; p = 0.917) and freedom from major adverse cardiac and cerebrovascular events (MACCEs) rate (68.3% ± 6.6% versus 54.6% ± 8.5%; p = 0.239) were also similar. However, freedom from target vessel revascularization (TVR) rate at 14 years was significantly higher in the no-stent group (97.2% ± 1.7% versus 76.9% ± 6.5%; p 0.001). The independent risk factor for late TVR was in-stent restenosis (hazard ratio, 3.355; 95% confidence interval, 1.925 to 5.848; p 0.001) and it also was a risk factor for MACCEs (hazard ratio, 1.645; 95% CI, 1.105 to 2.448; p = 0.014). Conclusions Previous intracoronary stenting does not increase long-term mortality, but grafting to previously stented target vessels with in-stent restenosis increases the risk of repeat TVR and MACCEs.

Background and objectives There are pathophysiologic similarities between calcification and atherosclerosis because both are the product of an active inflammatory process. The aim of this study was to examine the effects of statin treatment on calcification in bovine pericardial tissue valves. Materials and methods Forty Sprague-Dawley rats were randomly divided into 4 groups according to hypercholesterolemia induction and statin intake (Group 1, n=10: normal diet without statin treatment, Group 2, n=10: normal diet with statin treatment, Group 3, n=10: high fat diet without statin treatment, Group 4, n=10: high fat diet with statin treatment). Serum lipid levels were measured just before the experiment and after 4 and 12 weeks. Bovine pericardial tissue valve cusps were surgically implanted in rat dorsal subcutis at 4 weeks. After the surgery, statin was administered daily to Groups 2 and 4. Serum interleukin-6 (IL-6) level was measured at 5 weeks. Cusps were explanted at 12 weeks and calcium levels were determined by atomic absorption spectroscopy. Results Mean IL-6 was significantly higher in Group 3 at 5 weeks (7.14, 2.03, 31.70, and 6.90 pg/dL for each group, respectively). Mean calcium level in Group 3 was significantly higher among groups but Group 4 was significantly lower compared to Group 3 and was similar to Group 1, 2 (1.86, 1.92, 2.55, and 1.80 mg/g for each group, respectively, p Conclusion Hypercholesterolemia may be a significant risk factor for bovine pericardial valve calcification. Statin treatment significantly attenuated calcification of bovine pericardial valve tissue in a rat subdermal implantation model and might prolong the durability of bioprostheses.

Coronary artery disease has historically been a contraindication to lung transplantation. We report a successful combined bilateral lung transplantation and off-pump coronary artery bypass in a 62-year-old man. The patient had a progressive decline in lung function due to idiopathic pulmonary fibrosis and a history of severe occlusive coronary artery disease.

Objective This study aimed to evaluate the changes in postoperative aortic regurgitation (AR) and determine the predictors of significant AR and root reoperation after ascending aortic replacement (AAR) in patients with acute type A aortic dissection. Methods From January 1995 to December 2017, 271 consecutive patients underwent valve/root-preserving AAR (n = 225) and root replacement (n = 46). AR grade trend over time was analyzed by the ordinal mixed-effects model. Significant AR was defined as AR grade ≥3+ during the follow-up period. Predischarge and follow-up echocardiograms were obtained in 95.6% and 88.8% of enrolled patients, respectively. Results At predischarge, postoperative ≥2+ AR was present in 20 (9.3%) and 1 (2.3%) patients in the AAR and root replacement groups, respectively. With increasing time after surgery, the grade of AR increased. At 10 years, 4.6% of patients had developed 3+ or 4+ AR. Considering death as the competing risk, the 10-year cumulative incidence of significant AR was significantly higher in the AAR than in the root replacement group (12.3% vs 2.2%; P = .047). The risk of root reoperation at 10 years was not different between the groups (P = .118). On Cox analysis, preoperative ≥3+ AR (P = .002), postoperative ≥2+ AR (P = .040), and false to true lumen ratio (P = .005) were associated predictors of significant AR. Conclusions Although valve/root-preserving AAR demonstrated reasonable long-term outcomes when compared with root replacement, preoperative ≥3+ AR, postoperative ≥2+ AR, and high false to true lumen ratio significantly increased the risk of significant AR. Therefore, careful echocardiographic surveillance may be warranted in patients with postoperative ≥2+ AR and small true lumen.

Various treatment methods for tracheal defects have been attempted, such as artificial implants, allografts, autogenous grafts, and tissue engineering; however, no perfect method has been established. We attempted to create an effective artificial trachea via a tissue engineering method using 3D bio-printing. A multi-layered scaffold was fabricated using a 3D printer. Polycaprolactone (PCL) and hydrogel were used with nasal epithelial and auricular cartilage cells in the printing process. An artificial trachea was transplanted into 15 rabbits and a PCL scaffold without the addition of cells was transplanted into 6 rabbits (controls). All animals were followed up with radiography, CT, and endoscopy at 3, 6, and 12 months. In the control group, 3 out of 6 rabbits died from respiratory symptoms. Surviving rabbits in control group had narrowed tracheas due to the formation of granulation tissue and absence of epithelium regeneration. In the experimental group, 13 of 15 animals survived, and the histologic examination confirmed the regeneration of epithelial cells. Neonatal cartilage was also confirmed at 6 and 12 months. Our artificial trachea was effective in the regeneration of respiratory epithelium, but not in cartilage regeneration. Additional studies are needed to promote cartilage regeneration and improve implant stability.

Long-term outcomes of mitral valve replacement (MVR) recipients with pulmonary hypertension (PH) remain unclear. We determined the effect of concomitant PH on the clinical outcomes and late-onset progression of tricuspid regurgitation (TR) after MVR for rheumatic mitral stenosis.We retrospectively reviewed 394 patients who underwent MVR between January 2000 and December 2013. PH was defined as systolic pulmonary arterial pressure (sPAP)50 mm Hg. Changes in echocardiographic parameters (preoperative to postoperative), TR progression (grade ≥ II), and long-term survival were evaluated according to the presence of PH at MVR (non-PH, n = 322; PH, n = 72).The 10-year overall survival rate was significantly lower in the PH group (79.7% vs 90.7%, P = .04), whereas the rate of freedom from TR progression was similar between groups (76.9% vs 80.5%, P = .373). High preoperative sPAP and right ventricular systolic pressure (RVSP) did not affect TR progression. However, substantial postoperative reductions in sPAP and RVSP protected against TR progression (hazard ratio [95% confidence interval], 0.966 [0.942-0.991], P = .008, and 0.973 [0.960-0.986], P.001, respectively). The 10-year rate of freedom from TR progression was significantly higher in patients with substantial sPAP and RVSP reductions (sPAP, 84.2% vs 70.6%, P = .003; RVSP, 84.9% vs 71.0%, P .001).Although concomitant PH at MVR is associated with poor long-term survival, adequate sPAP and RVSP reduction can prevent TR progression even in patients with severe PH preoperatively. Therefore, we suggest careful monitoring of PAP and RVSP after MVR and should make an effort to reduce postoperative PAP.

Background With the increasing use of endovascular aortic repair, secondary interventions after aortic stent grafting remain a concern. We retrospectively reviewed open conversion cases with complications following endovascular abdominal aortic repair (EVAR). Methods EVAR due to infra-renal abdominal aortic aneurysm (AAA) was performed in 566 patients between January 1994 and May 2015. A retrospective review of EVAR requiring late open conversion (>1 month after implant) was conducted. Patient demographics, reasons for conversion, operative techniques, operative outcomes, and late survival were reviewed. Results Thirty of these patients (5.3%) required late conversion to open repair. The median interval to open conversion after EVAR was 48.6 months (range: 2-190 months). Indications of open conversion included type I endoleak (N.=10), stent fracture (N.=4), type V endoleak (N.=4), stent graft infection (N.=4), stent limb obstruction (N.=3), stent migration (N.=3), and type II endoleak (N.=2). Twenty-four operations were elective, and six operations (20%) were emergent due to aneurysm rupture. Compete endograft removal was performed in 14 patients (46.6%) and 16 endografts were partially left in situ. The hospital mortality rate was 10% (3/30) overall, 33.3% in the emergency group and 0% the elective group (P=0.03). Overall survival rate at a mean follow-up of 35 months was 80.7%, with a tendency towards lower survival rate after emergency compared with elective open conversion (89.3% vs. 44.4%; P=0.06). Conclusions Open conversion due to late complications after EVAR seems to be a lifesaving procedure with acceptable initial and mid-term outcomes. Elective conversion has better outcomes compared to those in an emergency setting. Therefore, lifelong surveillance is warranted, and an early decision for open conversion, if indicated, is necessary to achieve the best outcomes.

Background Statins reduce aneurysm growth in mouse models of Marfan syndrome, although the mechanism is unknown. In addition to reducing cholesterol, statins block farnesylation and geranylgeranylation, which participate in membrane‐bound G‐protein signaling, including Ras. We dissected the prenylation pathway to define the effect of statins on aneurysm reduction. Methods and Results Fbn1 C1039G/+ mice were treated with (1) pravastatin (HMG‐CoA [3‐hydroxy‐3‐methylglutaryl coenzyme A] reductase inhibitor), (2) manumycin A ( MA ; FPT inhibitor), (3) perillyl alcohol ( GGPT 1 and ‐2 inhibitor), or (4) vehicle control from age 4 to 8 weeks and euthanized at 12 weeks. Histological characterization was performed. Protein analysis was completed on aortic specimens to measure ERK (extracellular signal‐regulated kinase) signaling. In vitro Fbn1 C1039G/+ aortic smooth muscle cells were utilized to measure Ras‐dependent ERK signaling and MMP (matrix metalloproteinase) activity. Pravastatin and MA significantly reduced aneurysm growth compared with vehicle control (n=8 per group). In contrast, PA did not significantly decrease aneurysm size. Histology illustrated reduced elastin breakdown in MA ‐treated mice compared with vehicle control (n=5 per group). Although elevated in control Marfan mice, both phosphorylated c‐Raf and phosphorylated ERK 1/2 were significantly reduced in MA ‐treated mice (4–5 per group). In vitro smooth muscle cell studies confirmed phosphorylated cR af and phosphorylated ERK 1/2 signaling was elevated in Fbn1 C1039G/+ smooth muscle cells (n=5 per group). Fbn1 C1039G/+ smooth muscle cell Ras‐dependent ERK signaling and MMP activity were reduced following MA treatment (n=5 per group). Corroborating in vitro findings, MMP activity was also decreased in pravastatin‐treated mice. Conclusions Aneurysm reduction in Fbn1 C1039G/+ mice following pravastatin and MA treatment was associated with a decrease in Ras‐dependent ERK signaling. MMP activity can be reduced by diminishing Ras signaling.

Background To compare the outcomes of hybrid endovascular and open surgical repair for proximal aortic arch diseases. Methods A total of 55 consecutive patients with aortic arch aneurysm or aortic dissection involving any of zone 0 to 1 (39 male, age 63.4±14.3years) underwent a hybrid endovascular repair (n=35) or open surgical repair (n=20) from 2006 to 2014 were analyzed retrospectively. Perioperative and late outcomes were compared. Results Baseline characteristics were similar between the two groups, except age and EuroSCORE II, which were higher in the hybrid group. Perioperative mortality or stroke was not significantly different between the two groups, however, tended to be lower in the hybrid repair group than in the open repair group (11.4% vs. 30.0%, p=0.144). Incidences of other morbidities did not differ. During follow-up, over-all survival was similar between the hybrid and the open repair was similar (87.3% vs. 79.7% at 1year and 83.8% vs. 72.4% at 3years; p=0.319). However, reintervention-free survival was significantly lower for hybrid repair compared with open repair (83.8% vs. 100% at 1year and 65.7% vs. 100% at 3years; p=0.022). Conclusions Hybrid repair of proximal aortic disease showed comparable perioperative and late outcomes compared with open surgical repair despite a higher reintervention rate during follow-up. Therefore, hybrid repair may be considered as an acceptable treatment alternative to surgery especially in patients at high surgical risk.

BACKGROUND To determine the predictors of aggravated left ventricular diastolic dysfunction (LVDD) in patients undergoing off-pump coronary artery bypass grafting (OPCAB) and to compare late outcomes according to the aggravated LVDD. METHODS AND RESULTS OPCAB was performed in 1,101 patients (2001-2013). LVDD was classified as normal, mild, moderate or severe. Patients were divided into 2 groups: non-aggravated LVDD (group I) and aggravated LVDD (group II). The primary endpoint was aggravation of LVDD. The secondary endpoint was late mortality and morbidity such as major adverse cardiac and cerebrovascular events (MACCE) related to LVDD aggravation postoperatively. There were 894 patients in group I and 207 in group II. Multivariate analysis revealed that preoperative peripheral artery obstructive disease (PAOD) (P=0.04), renal failure (P

Artificial vessels capable of long-term patency are essential clinical tools in vascular surgery that involves small vessels. On-going attempts to develop artificial vessels that complements restenosis have not been entirely successful. Here, we report on the fabrication of small-sized artificial vessels using a three-dimensional bio-printer. The fabrication employed biodegradable polycaprolactone and autologous MSCs harvested from the bone-marrow of canines. The MSCs were cultured and differentiated into endothelial-like cells. After confirming differentiation, artificial vessels comprising three-layers were constructed and implanted into the arteries of canines. The autologous MSCs printed on artificial vessels (cell-derived group) maintained a 64.3% patency (9 of 14 grafts) compared with artificial vessels without cells (control group, 54.5% patency (6 of 11 grafts)). The cell-derived vessels (61.9 cells/mm2 &plusmn, 14.3) had more endothelial cells on their inner surfaces than the control vessels (21 cells/mm2 &plusmn, 11.3). Moreover, the control vessels showed acute inflammation on the porous structures of the implanted artificial vessels, whereas the cell-derived vessels exhibited fibrinous clots with little to no inflammation. We concluded that the minimal rejection of these artificial vessels by the immune system was due to the use of autologous MSCs. We anticipate that this study will be of value in the field of tissue-engineering in clinical practice.

Background: Our aim was to compare the efficacies of conventional open thoracotomy and hybrid endovascular technique in patients with descending thoracic aortic aneurysms involving the distal arch. Methods: Between January 2005 and December 2015, 125 consecutive patients with descending aneurysms involving distal arch underwent open repair via thoracotomy (n=79) or zone 1/2 hybrid endovascular repair (n=46). Surgeries entailing total arch replacement by elephant trunk technique (with sternotomy) and Zone 0 hybrid arch repairs were excluded. Early and late outcomes were compared using propensity scores and inverse-probability-of-treatment weighting (IPTW). Results: In-hospital mortality rates for open repair (10.1%) and hybrid repair (6.5%) did not differ significantly (P=0.49). Major adverse outcomes included stroke (11.4% vs . 8.7%), paraplegia (2.5% vs . 0.0%) and lung complications (19.0% vs . 6.5%). Once adjusted by IPTW, hospital mortality risk for conventional open repair (OR =4.396; P=0.086) tended to be higher, and there was significant risk of lung complications (OR =4.372; P=0.025). However, both techniques were similar in terms of 30-day mortality (OR =2.745; P=0.257), stroke (OR =2.134; P=0.217), paraplegia (OR =3.639; P=0.407), and midterm survival (OR =1.05; P=0.90). Freedom from reintervention at 10 years was significantly better for open repair (85.2%±7.1%) compared with the hybrid approach (46.3%±11.0%; OR =0.13; P Conclusions: Hybrid arch repair conferred a significantly lower incidence of pulmonary complications, without benefitting perioperative mortality and stroke. However, open repair proved more reliable, showing greater durability. Long-term investigations are needed to confirm the viability and safety of hybrid repair as an alternative treatment in this setting.

There seem to be modifiable components of diabetes in terms of glycemic control to improve surgical outcome. The aim of the study was to evaluate impact of preoperative glycated hemoglobin (HbA1c) level in patients with diabetes mellitus undergoing off-pump coronary bypass (OPCAB) on perioperative glycemic variability and short-term outcome.Medical records of 703 patients with diabetes mellitus who underwent OPCAB from 2005 to 2017 were reviewed. The perioperative goal of glycemic control was180 mg/dL. Patients were divided into 2 groups according to HbA1c level (7.0% or ≥7.0%). Glycemic variability during surgery and up to 24 hours after surgery was assessed by coefficient of variation (CV). Primary outcome was defined as composite of postoperative permanent stroke, prolonged ventilation, deep sternal wound infection, renal failure, reoperation, and 30-day mortality.Incidence of composite of postoperative morbidity and mortality endpoints was greater in patients with HbA1c ≥7.0% (21% vs 15%, P = .041). Perioperative time-weighted average glucose concentration was also greater in patients with HbA1c ≥7.0%, whereas the CV did not show any difference. Multivariable logistic regression analysis revealed that congestive heart failure, chronic kidney disease, moderate mitral regurgitation or greater, preoperative hemoglobin level, and preoperative HbA1c ≥7.0% were independently associated with composite of postoperative morbidity and mortality, but perioperative CV and time-weighted average glucose ≥200 mg/dL were not.Increased preoperative HbA1c (≥7.0%) level reflecting long-term glycemic control seems to exert an adverse influence on outcome, whereas the influence of perioperative glycemic variables appear to be abrogated using a target glucose level of180 mg/dL in patients with diabetes mellitus undergoing OPCAB.

Objective To evaluate the efficacy of axillary artery cannulation for early embolic stroke and operative mortality, we retrospectively compared the outcomes between patients with or without axillary artery cannulation during open aortic arch repair with circulatory arrest. Methods Between January 2004 and December 2017, 468 patients underwent open aortic arch repair with circulatory arrest using antegrade cerebral perfusion and were divided into 2 groups according to the site of arterial cannulation: the axillary artery (axillary group, n = 352) or another site (nonaxillary group, n = 116) groups. Embolic stroke was defined as a physician-diagnosed new postoperative neurologic deficit lasting more than 72 hours, generally confirmed by computed tomography or magnetic resonance imaging. Results After propensity score matching, the patients' characteristics were comparable between the groups (n = 116 in each). The incidences of acute type A dissection, aortic rupture, shock, or emergency operation were similar between groups. The incidence of early embolic stroke was significantly lower in axillary group (n = 3 [2.6%] vs n = 10 [8.6%]; P = .046). Also, 30-day mortality (n = 3 [2.6%] vs n = 10 [8.6%]; P = .046) and in-hospital mortality (n = 3 [2.6%] vs n = 11 [9.5%]; P = .027) occurred significantly lower in the axillary group. Conclusions Axillary artery cannulation reduced the early embolic stroke and early mortality after open arch repair with circulatory arrest. Axillary artery cannulation as the arterial cannulation site during open arch repair with circulatory arrest may be helpful in preventing embolic stroke and reducing early mortality.

There is no consensus as to whether a median approach or a lateral approach is better for distal aortic arch aneurysms with distal extensions. The aim of this study was to compare clinical outcomes of these two approaches for distal aortic arch aneurysms with distal extensions.From January 2001 to December 2017, 212 consecutive patients with distal aortic arch aneurysms with distal extensions underwent surgery using different approaches: hemiarch and descending thoracic aneurysm replacement through thoracotomy (group 1, n = 91); and total arch and descending thoracic aneurysm replacement through sternotomy (group 2, n = 121). Early and late outcomes were compared using scores and inverse probability of treatment adjustments to reduce treatment selection bias.The in-hospital mortality was 9.89% (9 of 91) in the thoracotomy group and 2.48% (3 of 121) in the sternotomy group (p = 0.02). The sternotomy group had a lower incidence of permanent stroke (2.48%, 3 of 121) compared with the thoracotomy group (10.99%, 10 of 91, p = 0.01). After adjustment, patients who underwent thoracotomy were at a greater risk of hospital mortality (odds ratio 5.0, p = 0.01), permanent stroke (odds ratio 6.83, p0.01), and pneumonia (odds ratio 2.99, p = 0.04), compared with patients who underwent sternotomy. The overall survival at 10 years was 69.8% ± 7.0% for the thoracotomy group and 83.0% ± 5.0% for the sternotomy group (unadjusted p = 0.049, adjusted p = 0.034).The sternotomy approach showed better outcomes in terms of operative mortality, stroke, and pneumonia, as well as long-term survival compared with the thoracotomy approach. These results suggested that the sternotomy approach was more appropriate for patients with distal aortic arch aneurysms with distal extensions.

Replacement of small-sized vessels is still challenging. This study is aimed at investigating the possibility of small-sized artificial vessels made by 3-dimensional bioprinting and the effect of pulsatile flow on bMSC-derived endothelial-like cells. Cells were harvested from rabbit bone marrow and primary cultured with or without growth factors. Endothelial differentiation was confirmed by the Matrigel tube formation assay, Western blot, and qRT-PCR. In addition, embedment of endothelial-like cells in an artificial vessel was made by 3-dimensional bioprinting, and the pulsatile flow was performed. For pumped and nonpumped groups, qRT-PCR was performed on CD31 and VE-cadherin gene expression. Endothelial-like cells showed increased gene expression of CD31 and VE-cadherin, and tube formation is observed at each week. Endothelial-like cells grow well in a small-sized artificial vessel made by 3-dimensional bioprinting and even express higher endothelial cell markers when they undergo pulsatile flow condition. Moreover, the pulsatile flow condition gives a positive effect for cell observation not only on the sodium alginate hydrogel layer but also on the luminal surface of the artificial vessel wall. We have developed an artificial vessel, which is a mixture of cells and carriers using a 3-dimensional bioprinting method, and applied pulsatile flow using a peristaltic pump, and we also demonstrated cell growth and differentiation into endothelial cells. This study suggests guidelines regarding a small-sized artificial vessel in the field of tissue engineering.

Objective To determine whether plasma cystatin C and creatinine levels after isolated off-pump coronary artery bypass grafting (OPCAB) are predictive of postoperative renal dysfunction and clinical outcomes. Methods Between January 2008 and December 2013, 1033 who underwent isolated OPCAB were recruited. The patients were divided into three groups according to the preoperative level of cystatin C: low (0.83 mg/L>), mid (0.83–1.13 mg/L) and high (1.13 mg/L

Purpose To compare the outcomes of thoracic endovascular aortic repair (TEVAR) with those of open repair for descending thoracic aortic aneurysms (DTAA). Materials and Methods We compared the outcomes of 114 patients with DTAA and proximal landing zones 3 or 4 after TEVAR to those of 53 patients after conventional open repairs. Thirty-day and late mortality were the primary endpoints, and early morbidities, aneurysm-related death, and re-intervention were the secondary endpoints. Results The TEVAR group was older and had more incidences of dissecting aneurysm. The mean follow-up was 36±26 months (follow-up rate, 97.8%). The 30-day mortality in the TEVAR and open repair groups were 3.5% and 9.4% (p=0.11). Perioperative stroke and paraplegia incidences were similar between the groups [5.3% vs. 7.5% (p=0.56) and 7.5% vs. 3.5% (p=0.26), respectively]. Respiratory failure occurred more in the open repair group (1.8% vs. 26.4%, p

Background Prosthesis-patient mismatch (PPM) is characterised by the effects of inadequate prosthesis size relative to body surface area (BSA).The purpose of this study was to determine the impact of PPM on late clinical outcomes after mitral valve replacement (MVR) in rheumatic population. Methods From 2000 to 2013, a total of 445 patients (mean age 54.2 ± 11.7 years) underwent isolated MVR (±tricuspid annuloplasty) for rheumatic disease were investigated. Effective orifice area (EOA) was determined by the continuity equation and PPM was defined as indexed EOA (EOA/BSA) ≤ 1.2 cm2/m2. Clinical and echocardiographic follow-up (mean follow up 8.7 ± 4.0 years) results were compared. Results 37% of patients (n = 165) had PPM. There were no significant differences in baseline and operative characteristics between patients with and without PPM except age and IEOA. A significant decrease in mean trans-valvular pressure gradient (MPG) over time following MVR, however the change of MPG showed no differences between groups (No PPM vs. PPM: 8.9 ± 4.7 mmHg → 3.6 ± 1.2 mmHg vs. 8.7 ± 4.5 mmHg → 3.8 ± 1.4 mmHg, p-value = 0.28). In all patients, there was a reduction of left atrium dimension (58.6 ± 12.0 mm → 53.2 ± 12.0 mm vs. 57.9 ± 8.9 mm → 52.2 ± 8.9 mm, p-value = 0.68) and left ventricular end diastolic diameter (49.9 ± 5.7 mm → 48.9 ± 5.7 mm vs. 49.7 ± 6.0 mm → 48.3 ± 5.0 mm, p = 0.24) without statistical significance. Freedom from TR progression rates at 3 and 5 years (99% vs.98%, 99% vs. 98%, p-value = 0.1), and overall survival rates at 3 and 5 years (97% vs. 96%, 94% vs. 94%, p-value = 0.7) were similar. Conclusion This study shows that mitral PPM is not associated with atrial /ventricular remodeling and might not influence late clinical outcome including late TR progression, survival in rheumatic population.

The aim of this study was to evaluate clinical outcomes of different approaches to patients with proximal descending thoracic aneurysm (DTA) involving the distal arch.From January 2002 to December 2016, 229 consecutive patients with proximal descending aorta aneurysm involving the distal arch underwent surgery using different approaches: total arch and DTA replacement via sternotomy (TAR group; n = 98), hemiarch and DTA replacement via thoracotomy (DTR group; n = 84), or hybrid arch repair (HAR group; n = 47). We retrospectively evaluated the outcomes of the 3 groups with a mean follow-up duration of 60.2 months.The in-hospital mortality rate was 3.1% (3/98) in the TAR group, 11.9% (10/84) in the DTR group, and 4.3% (2/47) in the HAR group (P = .04). The TAR group had a lower incidence of stroke (3.1%, 3/98) compared with the DTR (13.1%, 11/84) and HAR (10.6%, 5/47) groups (P = .03). The overall survival rate at 10 years was 82.8% ± 5.6% for the TAR group, 61.0% ± 8.6% for the DTR group, and 55.9% ± 9.0% for the HAR group (vs DTR [P = .03] and HAR [P .01]). The freedom from composite of aortic events at 10 years was 75.6% ± 8.1% in the TAR group, 43.6% ± 14.9% in the DTR group, and 31.1% ± 11.5% in the HAR group (P .01).The sternotomy approach showed better outcomes in terms of operative mortality, stroke, and long-term survival compared with the thoracotomy or hybrid approaches. This study suggests that the sternotomy approach is the superior option for patients with proximal descending aneurysm involving the distal arch.

Restenosis at a vascular anastomosis site is a major cause of graft failure and is difficult to prevent by conventional treatment. Perivascular drug delivery has advantages as drugs can be diffused to tunica media and subintima while minimizing the direct effect on endothelium. This in vivo study investigated the comparative effectiveness of paclitaxel, sirolimus, and sunitinib using a perivascular biodegradable microneedle cuff. A total of 31 New Zealand white rabbits were used. Rhodamine was used to visualize drug distribution (n = 3). Sirolimus- (n = 7), sunitinib- (n = 7), and paclitaxel-loaded (n = 7) microneedle cuffs were placed at balloon-injured abdominal aortae and compared to drug-free cuffs (n = 7). Basic histological structures were not affected by microneedle devices, and vascular wall thickness of the device-only group was similar to that of normal artery. Quantitative analysis revealed significantly decreased neointima formation in all drug-treated groups (p < 0.001). However, the tunica media layer of the paclitaxel-treated group was significantly thinner than that of other groups and also showed the highest apoptotic ratio (p < 0.001). Proliferating cell nuclear antigen (PCNA)-positive cells were significantly reduced in all drug-treated groups. Sirolimus or sunitinib appeared to be more appropriate for microneedle devices capable of slow drug release because vascular wall thickness was minimally affected.

Background Acute kidney injury (AKI) is a common complication after cardiac surgery. Associations between the time interval (TI) from preoperative coronary angiography (CAG) to cardiac surgery have been investigated, although with conflicting results. Methods We evaluated data collected from a retrospective review of consecutive patients who underwent preoperative CAG and heart valve surgery at our institution between September 2008 and February 2013. A total of 426 patients met the study criteria. Patients were divided into two groups according to the length of time between preoperative CAG and valve surgery: within one day (group A) or longer than one day (group B). Logistic regression was applied to analyze the relationships between TI and postoperative AKI. Results Of 426 patients, 140 (33%) underwent CAG on preoperative day 1, while 286 (67%) underwent CAG on preoperative day 2 or sooner. AKI occurred in 19 (13.6%) patients in group A and in 35 (12.2%) patients in group B (p = 0.70). CAG on preoperative day 1 was not associated an increased risk of AKI relative to CAG on preoperative day 2 or sooner (p = 0.49; odds ratio, 1.26; 95% CI, 0.66 to 2.41). Conclusions Preoperative CAG within one day of elective heart valve surgery is not associated with an increase in postoperative AKI in patients with normal renal function. doi: 10.1111/jocs.12445 (J Card Surg 2015;30:7–12)

Urban farming supplies emotional stability and fresh vegetables to participating persons, however, no information regarding the biosafety of agricultural products from urban farming is available. Here, we collected 260 samples of Chinese cabbages and lettuce from 4 urban community gardens and 6 roof gardens in Seoul from September through October 2012, and monitored the microbiological and parasitological contamination quantitatively and/or qualitatively. The mean counts of total aerobic bacteria and coliforms were ( range, ) and (range, ), respectively. Coliforms were detected on 59.6% among 260 vegetable samples. There were no significant differences in the contamination levels of total aerobic bacteria and coliforms between the Chinese cabbages and lettuce, whereas both levels of vegetables from urban community gardens were higher than those of roof gardens (p > 0.05). Escherichia coli was isolated at 3.1% among whole vegetables, and contamination level was . Among foodborne pathogens, Staphylococcus aureus was detected in 1.5%, however, Salmonella spp., Listeria monocytogenes and E. coli O157:H7 were not detected on any of the vegetable samples. We also found undefined parasite eggs from two samples of Chinese cabbages (0.8% of total vegetables we tested). From these study, we found the presence of microbial contamination of agricultural products from urban farming, thus we need further concern to improve the biosafety during production of agricultural products.

Background: Redo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality as compared to the first-time operation. Further, the application of the off-pump technique to redo CABG is limited due to technical difficulties. The aim of this retrospective study was to analyze early and midterm results after redo CABG and compare the outcome of redo on-pump and off-pump CABG. Methods: From June 1996 to October 2011, elective redo CABG was performed in 32 patients. Mean age was 64.8 years (on pump 64.3 years vs. off pump 65.5 years; p=0.658), and 21 patients were male. Among these patients, 14 (43.8%) underwent on-pump CABG, and 18 (56.2%) underwent off-pump CABG. Results: Internal thoracic artery was used in 22 patients (68.8%), and total arterial revascularization was achieved in 17 patients (53.1%). The average number of distal anastomoses was 2.13, and the rate of incomplete revascularization was 43.8%. The rate of total arterial revascularization was higher in the off-pump group (14.3% vs. 83.3%, p＜0.001), and the use of saphenous vein graft was more in the on-pump group (78.6% vs. 16.7%, p＜0.001). Overall hospital mortality was 3.1% (n=1) and was comparable in both groups (on pump 7.1% vs. off pump 0%; p=0.249). Postoperative complications occurred in 9 patients (64.2%), and the rate of complications was high in the on-pump group without statistical significance (64.2% vs. 33.3%, p=0.082). The mean follow-up duration was 5.4 years, and overall survival at 10 years was 86.0%±10.5%. There was no significant difference in the 10-year survival rate between the two groups (79.6% vs. 100%, p=0.225). Conclusion: Redo CABG can be safely performed with acceptable mortality. Redo off-pump coronary artery bypass is feasible with low mortality and morbidity, comparable target vessel bypass grafting, and long-term survival. The off-pump technique might be considered a safe option for redo CABG in high-risk patients.

Many community gardens in large cities worldwide grow vegetables; however, no information regarding the levels of sanitary indicator bacteria and prevalence of foodborne pathogens in vegetables grown in urban community gardens is available. To evaluate the microbiological quality of vegetables from urban community gardens in Korea, 530 samples (nine types of vegetable, including Chinese cabbage, lettuce, radish leaves, spinach, mustard leaves, crown daisy, leek, Korean cabbage, and chicory) were collected at 11 urban community gardens in Seoul, Korea from September through October 2012. The levels of total aerobic bacteria, Escherichia coli, total coliforms, Salmonella spp. Listeria monocytogenes, and E. coli O157:H7 were evaluated quantitatively and/or qualitatively. The mean numbers of total aerobic bacteria and coliforms were 6.3 log CFU/g (range 3.8-8.1 log CFU/g) and 4.3 log CFU/g (range 2.1-6.4 log CFU/g), respectively. Total coliforms were detected on 67% of whole vegetables. Chicory showed the highest number of total aerobic bacteria and coliforms, whereas the lowest number of coliforms was detected on leeks. E. coli was detected on 2.3% of whole vegetables, including lettuce, radish leaves, mustard leaves, and chicory; however, foodborne pathogenic bacteria were not detected on any of the vegetable samples using this highly sensitive and validated procedure. Based on these findings, the presence of coliforms and E. coli demonstrates that opportunity for improvement of microbiological safety exists throughout the produce production chain, although no major foodborne pathogens were present in vegetables grown in urban community gardens.