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The concept of hybrid coronary revascularization (HCR) combines the advantages of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) to improve the treatment of patients with complex multivessel disease. This study aimed to investigate a 1-year clinical follow-up of a prospective multicenter registry of HCR combined with non-saphenous vein graft surgical bypass and PCI using everolimus-eluting metallic stents (the PRIDE-METAL study). From June 2016 to June 2018, a total of 54 patients with multivessel coronary disease from six Japanese institutes were enrolled in this study. The primary endpoint of the study was the occurrence of major adverse cardiovascular event (MACE; all-cause death, myocardial infarction, stroke, and repeat revascularization) at 1 year. Three patients declined before complete HCR, and two patients were lost by the 1-year follow-up. All-cause mortality at 30 days and at 1 year was 0% and 4.1%, respectively. The rates of myocardial infarction, repeat revascularization, stroke, and MACE were 0% at 30 days, and 0%, 2.0%, 2.0%, and 8.2% at 1-year follow-up, respectively. No occlusion of arterial bypass graft at the 30-day follow-up was observed, and was observed in 1.7% at the 1-year follow-up. HCR was safe and feasible and associated with a low risk of MACE at the 1-year follow-up. Further validation in multicenter and randomized studies is needed.

Because the prognosis of acute aortic dissection will be often poor, early diagnosis and assessing severity at the first visit is important. An 83-year-old woman was admitted to an emergency department (ED) with complaints of sudden bilateral upper and lower jaw pain during dinner. Finally, the oral pain moved back pain and she requested an ambulance. Although her vital signs were preserved, she has a left-right difference in blood pressure in her upper limbs. A contrast media-enhanced computed tomography revealed that dissection was found in the ascending aorta in thoracic aorta, which reached the brachiocephalic artery. Therefore, the main symptom in the present case was diagnosed as acute aortic dissection (Stanford type A), an urgent ascending aortic replacement was successfully performed. We experienced an acute aortic dissection whose initial symptom was oral pain. It is a symptom that physicians and dentists need to be aware of that there is a fatal disease where the pain source is different from the patient complaining of pain.

BACKGROUND Collagen disease is an important cause of aortic regurgitation (AR). Although aortic valve surgery is recommended for patients with AR and depressed left ventricular (LV) function, there have been few reports about risk factors for LV dysfunction in patients with AR concomitant with collagen disease. METHODS AND RESULTS We conducted this study at Kumamoto University Hospital in Japan. A total of 41 patients who had moderate to severe AR and concomitant collagen disease between January 2014 and December 2019 were enrolled. With regard to baseline characteristics, there were no significant differences in the type of collagen disease or El Khoury class between patients with preserved LV function and those with reduced LV function. B-type natriuretic peptide (375.2 [257.9-3852.6]pg/ml vs. 64.0 [33.3-133.6]pg/ml, p

OBJECTIVES This study aimed to assess the long-term outcomes and investigate the factors related to left ventricular (LV) reverse remodelling after aortic valve replacement (AVR) in patients with chronic aortic regurgitation (AR). METHODS A total of 246 patients who underwent AVR for chronic AR at our institution were included in this retrospective study. Primary end-points included all-cause mortality, cardiac mortality and major adverse cerebral and cardiovascular events. Secondary end-points included cardiac function on echocardiography 1 year after surgery. We explored the predictive factors for reverse remodelling 1 year after surgery. RESULTS The 10-year survival rate was 86.0%, with no cardiac deaths in 93.8% and no major adverse cerebral and cardiovascular events in 79.9% of patients. Postoperative LV function and symptoms were significantly improved 1 year after surgery, but 34 patients (13.8%) did not recover normal function and structure. A significant negative correlation was found between the incidence of cardiac death and major adverse cerebral and cardiovascular events and reverse remodelling. Multivariate logistic regression identified preoperative LV ejection fraction (P = 0.001, odds ratio = 1.057) and LV end-systolic dimension index (P = 0.038, odds ratio = 0.912) as significant predictive factors of reverse remodelling 1 year after surgery. CONCLUSIONS Preoperative LV ejection fraction and LV end-systolic dimension index were predictive factors for reverse remodelling after surgery, which was associated with late outcomes. Earlier surgery may thus help to restore normal LV function and achieve better late outcomes after AVR for AR.

We report a 65-year-old man who underwent aortic valve replacement because of severe aortic stenosis associated with de novo iatrogenic variant transthyretin amyloidosis derived from a liver graft extracted from a patient with hereditary transthyretin amyloidosis 9 years after the domino liver transplantation. (Level of Difficulty: Advanced.), Graphical abstract, We report a 65-year-old man who underwent aortic valve replacement because of severe aortic stenosis associated with de novo iatrogenic variant…

Graphical abstract, Highlights • L-wave is caused by abrupt elevation and gradual decrease of LV diastolic pressure. • Color M-mode echocardiography demonstrates “L” wave of LA slow propagation. • Pulmonary venous reservoir function and LA conduit function caused diastolic LA flow.

A 58-year-old woman was referred to our hospital with progressively increasing breathlessness. She reported a history of bioprosthetic valve implantation for tricuspid valve replacement and direct closure of an atrial septal defect for Ebstein's anomaly, 31 years before presentation. Transthoracic echocardiography revealed prosthetic valve failure, an enlarged coronary sinus, and severe mitral regurgitation. Computed tomography revealed a giant coronary sinus with thrombosis and persistent left superior vena cava. She underwent successful mitral and tricuspid valve replacement; however, severe hemodynamic deterioration necessitated mechanical ventilatory support with extracorporeal membrane oxygenation.

BACKGROUND Although bioprosthetic valve (BPV) replacements are becoming more common within our aging society, there are limited prospective data on the appropriate antithrombotic therapy for East Asian patients with atrial fibrillation (AF) and BPV replacement. Antithrombotic therapy and thrombotic and hemorrhagic event rates in Japanese patients with AF and BPV replacement are investigated.Methods and Results:This multicenter, prospective, observational study enrolled patients with BPV replacement and AF. The primary efficacy outcome was stroke or systemic embolism, and the primary safety outcome was major bleeding. Of the 894 patients analyzed, 54.7%, 29.4%, and 9.6%, were treated with warfarin-based therapy, direct oral anticoagulant (DOAC)-based therapy, or antiplatelet therapy without anticoagulants, respectively; 6.3% did not receive any antithrombotic drugs. The mean observation period was 15.3±4.0 months. The event rates for stroke or systemic embolism and major bleeding were 1.95%/year and 1.86%/year, respectively. The multivariate adjusted hazard ratios for DOAC vs. warfarin were 1.02 (95% confidence intervals [CI], 0.30-3.41 [P=0.979]) for systemic embolic events and 0.96 (95% CI, 0.29-3.16 [P=0.945]) for major bleeding. CONCLUSIONS Approximately 30% of patients with AF and BPV replacement were treated with DOAC. The risks of major bleeding and stroke or systemic embolism were similar between warfarin- and DOAC-treated patients with AF who had BPV replacement. Treatment with DOACs could be an alternative to warfarin in this population.

A 68-year-old man who had undergone descending thoracic aortic replacement was referred to our hospital with a thoracoabdominal aortic aneurysm. During the original surgery, the Adamkiewicz artery was directly reconstructed. However, multidetector row computed tomography showed occlusion of the reconstructed artery at its orifice, with supply by a collateral vessel from the left lateral thoracic artery. With careful incision to avoid damage to the collateral vessel, no postoperative neurological deficit was observed.

BACKGROUND While there is a concern about the increase in the occurrence of acute aortic dissection (AAD) caused by the worsening of hypertension, mental stress, etc., there is a lack of data regarding the influence of disasters on this event. The aim of this study was to address this issue in the acute–subacute phase after the Kumamoto Earthquake occurred on 14 April 2016. METHODS We retrospectively investigated the impacts of the Kumamoto Earthquake on various cardiovascular diseases, including AAD, utilizing the medical records of patients in 16 hospitals in Kumamoto Prefecture during the period from 14 April to 30 June (78 days) in 2014, 2015, 2016, and 2017. RESULTS The occurrence of heart failure and venous thromboembolism increased significantly in the acute–subacute phase after the earthquake. When comparing the earthquake year (2016) to the non-earthquake years (2014, 2015, and 2017), the difference in the occurrences and mortalities of AADs were not significant. When other characteristics of the patients were compared between the earthquake year and the non-earthquake years, there were no differences. CONCLUSIONS It might be possible that the Kumamoto Earthquake did not affect the incidence of AAD or deaths from AAD, possibly because the climate was mild and the preventive efforts based on previous experience were successful. REGISTRATION University Hospital Medical Information Network (UMIN)-CTR (http://www.umin.ac.jp/ctr/). IDENTIFIER UMIN000023864. PUBLIC ACCESS INFORMATION Opt-out materials were available at the following website: http://www.kumadai-junnai.com/home/wp-content/uploads/shinsai.pdf.

Highlights • Recurrent embolism originated from the persistent persistent sciatic artery aneurysm. • Distal bypass was required due to the anomaly position of popliteal artery. • Persistent sciatic artery aneurysm is rare, but remember in especially acute limb ischemia., Introduction Persistent sciatic artery (PSA) is a rare congenital vascular anomaly. It has several clinical features with the formation of aneurysms. Among the complications, leg ischemia is severe problem and the management involves revascularization and prevention of recurrence. We herein describe an anatomically annoying case of PSA aneurysm with recurrent embolism that necessitated thrombectomy and bypass surgery. And this work has been reported in line with the SCARE criteria. Case presentation A 76-year-old woman developed leg embolism twice from PSA aneurysm. PSA was complete type and the popliteal artery ran on the lateral side, which was difficult to approach from the standard medial side. Based on these anatomical conditions, thrombectomy of the posterior-tibial artery (PTA) and femoral-PTA bypass were performed. Additionally, the proximal side of PTA from the anastomosis site was ligated to avoid the recurrence of embolism. Residual PSA aneurysm has not yet been treated, but neither clinical complications nor dilatation have occurred. Discussion PSA is a rare disease, but should be remember in acute limb ischemia. Clear treatments have not yet been established; therefore, its plans need to be considered based on clinical symptoms and anatomical conditions. Conclusion Although there were anatomical issues in the present case, thrombectomy and bypass surgery were successful and no complications have occurred one year after surgery.

Left atrial intramural hematoma is a rare complication of percutaneous coronary intervention. The combination treatment with surgery and interventional therapy is one of therapeutic options.

Coronary endarterectomy (CE) is one of the surgical methods for the treatment of diffusely diseased coronary arteries. However, it is technically demanding and has been historically associated with high morbidity and mortality rate. Recent developments in surgical techniques and postoperative management have resulted in improved outcomes after CE. There are two technical methods for endarterectomy: open and closed. Each method has several merits and demerits. In this chapter, we review the technical aspects and outcomes of CE for the diffusely diseased coronary artery.

With the recent and rapid advances in percutaneous coronary intervention, the rate of high-risk patients with diffusely diseased coronary arteries including severe calcifications or soft plaques in the vessel wall has been increasing. Long segmental reconstruction with or without endarterectomy is a surgical method for the treatment of diffusely diseased coronary arteries. However, it has been historically associated with high morbidity and mortality rates, and has not gained widespread acceptance. Recent developments in surgical techniques have resulted in improved outcomes after long segmental reconstruction grafting with or without endarterectomy. In patients with a diffusely diseased left anterior descending artery, this method has the advantage of enhancing the blood supply to the diagonal and septal arteries, thus relieving ischaemia in the anterior and septal territories of the heart. This benefit cannot be obtained with conventional bypass grafting to the distal left anterior descending artery alone, as diffusely diseased segments are left untreated. This chapter reviews the technical aspects and outcomes of long segmental reconstruction with or without endarterectomy of the left anterior descending artery using the left internal thoracic artery.

We aimed to investigate the correlation of graft flow measurements between transit-time flow measurement (TTFM) during coronary artery bypass grafting (CABG) surgery and dynamic cardiac CT after the surgery. Fourteen patients underwent CABG with TTFM and postoperative dynamic cardiac CT; 11 internal thoracic artery (ITA) grafts and 15 saphenous venous grafts (SVGs) were included for analysis. Pearsons correlation analysis was performed for the comparisons of the TTFM and cardiac dynamic CT flow parameters. TTFM was not significantly correlated with the CT flow of the ITA grafts (r = −0.23, P = .49), but it had a very strong correlation with the CT flow of the SVGs (r = 0.83, P

This study sought to assess the disparity between regions and facilities in surgical resident training in Japan via a national level needs-assessment. A survey was sent to all 909 graduating residents of 2016. Residents trained in the six prefectures with a population of 7 million or more were included in the large prefecture (LP) group. Residents trained in the other 41 prefectures were included in the small prefecture (SP) group. Each group was further divided into a university hospital (UH) group and a non-university hospital (NUH) group. The response rate was 56.3% (n = 512). Excluding nine residents who did not report their prefectures and facilities, surveys from 503 residents were analyzed. The UH group received significantly more years of training. In the SP and UH groups, there were significantly fewer residents who had performed 150 procedures or more under general anesthesia in comparison to the LP and NUH groups, respectively. Self-assessed competencies for several procedures were significantly lower in the SP and UH groups. Disparity in surgical resident training was found between regions and facilities in Japan. The surgical residency curriculum in Japan could be improved to address this problem.

Aims: Although the bacterial virulent factor of cytotoxin-associated gene-A (CagA)-seropositivity and the host genetic factors of interleukin (IL)-1 polymorphisms have been suggested to influence Helicobacter pylori (HP) -related diseases, the underlying mechanisms of the association between HP infection and acute coronary syndrome (ACS) remain unknown. Methods and results: Among 341 consecutive ACS patients, the clinical outcomes after ACS included composite cardiovascular events within the 2-year follow-up period.A significantly higher probability of primary outcomes was observed in HP positive patients than in HP negative patients. There were no significant differences in the rate of cardiovascular events between HP positive and HP negative patients in the absence of an IL-polymorphism, while there were significant differences in the presence of an IL-polymorphism. There were significant differences in the rate of cardiovascular events among CagA positive, CagA negative/ HP positive and CagA negative/HP negative patients. Moreover, via immunohistochemical staining, aortic CagA positive cells were confirmed in the vasa vasorum in CagA positive patients, whereas they could not be identified in CagA negative patients. Conclusions: The bacterial virulence factor CagA and host genetic IL-1 polymorphisms influence the incidence of adverse cardiovascular events, possibly through infection of atherosclerotic lesions.Registration: University Hospital Medical Information Network (UMIN)-CTR (http://www.umin.ac.jp/ctr/).Identifier: UMIN000035696. Keywords: Helicobacter pylori, CagA, Interleukin-1, MACE

Aims Bleeding is a serious complication in patients with continuous‐flow left ventricular assist device (CF‐LVAD). Acquired von Willebrand syndrome (AVWS; type 2A) develops because of high shear stress inside the pumps and is a cause of bleeding complication. Although von Willebrand factor (vWF) multimer analysis is useful for diagnosing AVWS, it is only performed in specialized research institutes. A novel microchip flow chamber system, the total thrombus‐formation analysis system (T‐TAS), is a point‐of‐care system to evaluate the thrombus‐formation process and useful for monitoring platelet thrombus‐formation capacity in patients receiving antiplatelet therapy and the diagnosis and evaluation of the clinical severity of von Willebrand disease type 1. However, little is known about the association between AVWS and platelet thrombus‐formation capacity evaluated by T‐TAS in patients with CF‐LVAD. We aimed to evaluate the utility of T‐TAS for easy detection of AVWS in patients with CF‐LVAD. Methods and results We simultaneously evaluated the vWF large multimers and T‐TAS parameters in four consecutive patients with axial‐type CF‐LVAD and eight control patients treated with aspirin and warfarin. vWF large multimer index was defined as the proportion of large multimers in total vWF derived from a normal control plasma. T‐TAS analyses different thrombus‐formation processes using two microchips with different thrombogenic surfaces. PL24‐AUC10 levels in the platelet (PL) chip are highly sensitive for platelet functions, while AR10‐AUC30 levels in the atheroma (AR) chip allow the assessment of the overall haemostatic ability. vWF large multimer index and T‐TAS parameters were decreased in all patients with CF‐LVAD. The mean PL24‐AUC10 level (5.4 ± 2.9 vs. 219 ± 67; P

Objectives This study aimed to evaluate the causes of initial mitral valve (MV) repair failure, the details of reoperation and the long-term outcomes of mitral valve re-repair (Re-MVP). Methods We retrospectively reviewed 86 patients who underwent reoperation after MV repair for MR due to degenerative disease from October 1991 to December 2015. First, we analysed the initial MV repair data, causes of MV repair failure, reoperation data and long-term outcomes including survival. Second, the patients were classified into 2 groups based on valve related failure or procedure related failure , and the differences between the groups were analysed. Results Leaflet prolapse at the initial operation affected the bilateral leaflets in 37 (43%) patients, the anterior leaflet in 30 (35%) patients and the posterior leaftlet in 19 (22%) patients. Median duration from first operation to reoperation was 47.5 (interquartile range 4.8-85.8) months. Reoperation indication included recurrent mitral regurgitation alone in 59 patients, haemolysis combined with recurrent mitral regurgitation in 15 patients, infectious endocarditis combined with recurrent mitral regurgitation in 8 patients, mitral stenosis in 2 patients and left ventricular pseudoaneurysm in 2 patients. The cause of MV repair failure was valve-related in 61 (71%) patients, procedure-related in 20 (23%) patients and both in 5 (6%) patients. Re-MVP was successful in 23 (27%) patients. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Freedom from all-cause death was significantly better after Re-MVP. The 5-year freedom from reoperation after Re-MVP was 95.7%. Conclusions Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Durability of re-repaired MVs and survival of re-repaired patients were acceptable.

Objective: To evaluate limb-salvage surgery including vascular resection for lower-extremity soft-tissue sarcomas and carcinomas for adult patients. Materials and Methods: Eight consecutive patients (median age, 59 years) who underwent vascular replacement during surgery for malignant tumors in the lower limbs between November 2006 and March 2018 were evaluated. Patient data were retrospectively obtained in a computerized database. Arterial and venous reconstructions were performed for seven patients, with one additional patient receiving venous reconstruction only. Autologous-vein (n=6) and synthetic bypasses were used for arterial repairs, whereas only autologous veins were implanted for venous repairs. Results: Morbidity was 62.5%, and in-hospital mortality was 12.5%. At a median follow-up of 24 months, the primary patency rates of arterial and venous reconstructions were 85.7% and 62.5%, respectively. Limb salvage was achieved in all cases. Conclusion: Early and mid-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of soft-tissue tumors involving major vessels of the lower limbs. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma and carcinoma resections. However, efforts to achieve better control over systemic spread are required for long-term survival.

OBJECTIVES To evaluate whether the preoperative Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) score was associated with late outcomes of coronary endarterectomy (CE) for the diffusely diseased left anterior descending artery (LAD). METHODS We retrospectively analysed 205 of 212 patients undergoing CE for the diffusely diseased LAD between September 2004 and May 2016, excluding 2 patients without preoperative angiographic data and 5 redo cases. The mean SYNTAX score was 34.6. Patients were divided into 3 groups according to their SYNTAX score: low (≤22, n = 26), intermediate (23-32, n = 58) and high (≥33, n = 121). The study end-points were cardiac death and major adverse cardiac and cerebrovascular events, defined as all-cause death, cerebrovascular accidents, non-fatal myocardial infarction and repeat revascularization. All CEs involved long arteriotomy and the reconstruction of the endarterectomized LAD using the skeletonized internal thoracic artery. RESULTS Postoperative mortality and morbidity were similar between the groups. The median follow-up period was 5.4 years. We found no significant difference in the cumulative cardiac death-free survival rate at 5 years (91.1% vs 100% vs 98.3%; log-rank, P = 0.196) or major adverse cardiac and cerebrovascular events (61.6% vs 71.5% vs 76.7%; log-rank, P = 0.258) in the low, intermediate and high SYNTAX score groups, respectively. Univariate and multivariate Cox proportional hazard analyses revealed no significant association between the study end-points and individual components of the SYNTAX score for the LAD. CONCLUSIONS The preoperative SYNTAX score and its individual components for the LAD were not associated with late outcomes following CE for the diffusely diseased LAD.

A 74-year-old man was admitted to our hospital with chest pain and dyspnea associated with ST elevation in leads II, III and aVF. An echocardiogram showed an enlarged mass lesion measuring nearly 80 mm. Coronary angiography showed two giant coronary artery aneurysms (CAAs) in the right coronary artery (RCA). CAAs were also seen in the left main trunk and left anterior descending artery. Computed tomography showed the CAA in the RCA was ruptured into the right atrium. We therefore diagnosed this patient with multiple CAAs, myocardial infarction and coronary artery rupture. He underwent successful surgical excision and coronary bypass surgery.

Although radiation therapy is widely used to treat breast cancer, high doses of radiation may cause various complications. We report a case of a left ventricular aneurysm complicated with an intractable skin ulcer caused by radiation therapy for breast cancer. The communication between the aneurysm and skin ulcer caused severe bleeding. An urgent left ventricular repair and chest wall reconstruction with a rectus abdominis flap were performed successfully.

OBJECTIVES This study was aimed to investigate the impact of preoperative renal malperfusion on early and late outcomes after surgery for acute type A aortic dissection (AAAD). METHODS Of 915 patients who underwent surgery for AAAD between September 2004 and September 2017, we enrolled 534 patients whose preoperative enhanced computed tomography images were retrospectively available in this study. Exclusion criteria were single kidney (n = 3) and dialysis-dependent preoperatively (n = 12). We compared early and late outcomes between patients who had preoperative renal malperfusion (n = 64) and those who did not have renal malperfusion (n = 470). RESULTS The incidence of postoperative acute kidney injury, defined using the Kidney Disease: Improving Global Outcomes criteria, was higher in the renal malperfusion group than in the no renal malperfusion group (76.6% vs 39.4%; P CONCLUSIONS Preoperative renal malperfusion is an independent predictor for postoperative acute kidney injury and operative death but not associated with late mortality after surgery for acute type A aortic dissection.

Objectives Early saphenous vein graft (SVG) occlusion is typically attributed to technical factors. We aimed at exploring clinical, anatomical, and operative factors associated with the risk of early SVG occlusion (within 12 months postsurgery). Methods Published literature in MEDLINE was searched for studies reporting the incidence of early SVG occlusion. Individual patient data (IPD) on early SVG occlusion were used from the SAFINOUS-CABG Consortium. A derivation (n = 1492 patients) and validation (n = 372 patients) cohort were used for model training (with 10-fold cross-validation) and external validation respectively. Results In aggregate data meta-analysis (48 studies, 41,530 SVGs) the pooled estimate for early SVG occlusion was 11%. The developed IPD model for early SVG occlusion, which included clinical, anatomical, and operative characteristics (age, sex, dyslipidemia, diabetes mellitus, smoking, serum creatinine, endoscopic vein harvesting, use of complex grafts, grafted target vessel, and number of SVGs), had good performance in the derivation (c-index = 0.744; 95% confidence interval [CI], 0.701-0.774) and validation cohort (c-index = 0.734; 95% CI, 0.659-0.809). Based on this model. we constructed a simplified 12-variable risk score system (SAFINOUS score) with good performance for early SVG occlusion (c-index = 0.700, 95% CI, 0.684-0.716). Conclusions From a large international IPD collaboration, we developed a novel risk score to assess the individualized risk for early SVG occlusion. The SAFINOUS risk score could be used to identify patients that are more likely to benefit from aggressive treatment strategies.

Background Mitral valve surgery in patients with severe mitral annular calcification can be challenging. We investigated surgical outcomes of mitral valve surgery with complete annular decalcification and reconstruction. Methods Between January 2004 and December 2013, 2,104 patients underwent mitral valve surgery at our institution. Of these, 61 patients (mean age 70 years) with severe mitral annular calcification were reviewed. Valve lesions were stenosis in 20 patients (32.8%), regurgitation in 16 (26.2%), mixed in 19 (31.1%), and prosthetic valve dehiscence in 6 (9.8%). Calcified annulus was resected completely and reconstructed with equine pericardium in 48 patients (78.7%), autologous pericardium in 10 (16.4%), and polytetrafluoroethylene felt pledgets in 3 (4.9%). Mitral valve repair was attempted in 4 patients (6.6%) and mitral valve replacement in 57 (93.4%). One patient (1.6%) had conversion from repair to replacement due to cardiac rupture. Concomitant procedures included aortic valve replacement in 36 patients (56.3%), tricuspid valve surgery in 28 (43.8%), and coronary artery bypass graft surgery in 18 (28.1%). Mean follow-up was 3.5 ± 2.5 years. Results There was no 30-day hospital death. Early complications were left ventricular pseudoaneurysm in 1 patient, pericardial patch dehiscence in 1, severe arrhythmia in 6, and stroke in 2. At 5 years, rates of survival and freedom from cardiac death and major adverse valve-related events were 75.6%, 79.7%, and 72.7%, respectively. Multivariate analysis indicated coronary artery disease as an independent predictor of cardiac death. Conclusions In patients with severe mitral annular calcification undergoing mitral valve surgery, complete annular decalcification and reconstruction yields favorable outcomes.

Background The aim of this study was to determine early and mid-term outcomes after open repair of thoracoabdominal aortic aneurysm, with moderate to deep hypothermia as part of proximal aortic management. Methods Between April 2009 and March 2015, 44 patients underwent thoracoabdominal aortic repair by total cardiopulmonary bypass at our institute. Our strategy was to use deep (

Background Atherosclerotic stenosis of the brachiocephalic artery sometimes occurs in patients with coronary artery disease, and can cause stroke during the perioperative period of coronary artery bypass grafting. Case presentation We describe the case of a 77-year old male with severe stenosis of the brachiocephalic artery and severe coronary artery disease. He successfully underwent aorto-right subclavian artery bypass that was performed concomitantly with off-pump coronary artery bypass. Conclusion Concomitant aorto-subclavian artery bypass with off-pump coronary artery bypass grafting is a therapeutic option that minimizes the risk of perioperative stroke in patients with brachiocephalic artery stenosis and coronary artery disease.

OBJECTIVES This study aimed to compare the mid-term results of coronary artery bypass grafting (CABG) with those of percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DESs) for triple-vessel disease. METHODS Between February 2010 and December 2015, 607 patients underwent primary isolated CABG and 264 patients underwent PCI with second-generation DESs (everolimus-eluting stent, biolimus-eluting stent or zotarolimus-eluting stent) for triple-vessel disease with or without left main disease. We compared the CABG group with the second-generation DES group using propensity score matching analysis. The study end points were major adverse cardiac and cerebrovascular events. RESULTS After propensity score matching, 238 pairs of patients were successfully matched (C-statistic 0.762). The mean number of distal anastomoses in the CABG group was 4.7 and that of implanted stents in the second-generation DES group was 2.8. The 30-day mortality was similar between the groups (0.8% vs 0.4%; P = 0.564). The median follow-up period was 3.4 years in the CABG group and 3.8 years in the second-generation DES group. Although there was no significant difference in the incidence of all-cause death and cerebrovascular accidents, the incidence of myocardial infarction [hazard ratio (HR) 11.76; 95% confidence interval (CI) 2.32-214.15, P = 0.003] and repeat revascularization (HR 3.78; 95% CI 2.35-6.38; P

Background Both acute aortic dissection and ruptured aortic aneurysm are leading causes of death in cardiovascular disease. These life-threatening conditions have recently been categorized as acute aortic syndrome. This review describes the etiology, clinical presentation, and therapeutic options for acute aortic syndrome including acute aortic dissection and ruptured aortic aneurysm. Main body Several diagnostic tools for detecting these critical conditions have been developed including computed tomography, ultrasonography, magnetic resonance imaging, and laboratory tests. Early and accurate diagnosis is most important to determine appropriate treatment. Initial treatment for these conditions should be aimed at controlling pain and the hemodynamic state with further treatment based on the imaging diagnosis and hematological assessment. Surgical outcomes after acute aortic syndrome are improving gradually; however, mortality remains high. Recently, thoracic endovascular aortic repair has become an alternative technique to treat complicated type B aortic dissection. Rapid treatment after early diagnosis is essential to save patients’ lives. Conclusions Continuous advances in imaging and treatment technologies are improving short- and long-term outcomes in patients with acute aortic syndrome. Knowledge and interest in intensive care medicine in this area are contributing to improved outcomes, and further research into this life-threatening disease will lead to improvements in diagnosis and management.

Acute kidney injury (AKI) is relatively common after cardiothoracic surgery for type A acute aortic dissection (TA-AAD) and increases mortality. We investigated the incidence and risk factors for AKI in patients with TA-AAD and its impact on their outcomes. The records of 375 consecutive patients who underwent surgical treatment for TA-AAD from October 2007 to March 2013 were analyzed retrospectively. We defined AKI using the Kidney Disease Improving Global Outcomes criteria, which are based on serum creatinine concentration or glomerular filtration rate. We used Kaplan-Meier methods and multivariate Cox proportional hazards regression to assess the impact of AKI on both mortality and major adverse cardiovascular and cerebrovascular events. We also examined the association between risk factors and AKI using logistic regression modeling. Postoperative AKI was observed in 165 patients (44.0%). The overall 30-day and mid- to long-term mortality was 1.6% and 8.8%, respectively. Mortality and major adverse cardiovascular and cerebrovascular events correlated significantly with the severity of AKI, and multivariate analysis showed that AKI stage 3 (the most sever stage) was an independent risk factor for mortality (hazard ratio 6.83, 95% confidence interval 2.52 to 18.52) after adjustment for important confounding factors. Extracorporeal circulation time, body mass index, perioperative peak serum C-reactive protein concentration, renal malperfusion, and perioperative sepsis were found to be risk factors for AKI. In conclusion, AKI was common in patients who underwent surgery for type A acute aortic dissection. The severity of AKI strongly influences patient outcomes, so it should be recognized promptly and treated aggressively when possible.

OBJECTIVES: We evaluated the influence of the complexity of coronary artery disease stratified by the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score on early or late outcomes after complete revascularization with long segmental reconstruction of the left anterior descending artery using the left internal thoracic artery. METHODS: From March 1995 to December 2003, a total of 102 patients with triple-vessel and/or left main disease underwent complete revascularization with long segmental left anterior descending artery reconstruction (≥2 cm) with or without endarterectomy using the left internal thoracic artery. The patients were divided into two groups according to the median SYNTAX score: the low group (SYNTAX score of

OBJECTIVES: Composite grafting using the right internal thoracic artery (RITA) is occasionally performed when the in situ RITA does not have sufficient length to reach the target vessel. In this study, we assessed the clinical and angiographic outcomes of coronary artery bypass grafting (CABG) with V-composite grafting (defined as a distance between the proximal anastomosis of the RITA and the ascending aorta of ≤1 cm) using the RITA anastomosed to aortocoronary (A-C) bypass grafts. METHODS: Between September 2004 and December 2012, 177 patients underwent CABG with V-composite grafting using the RITA and the A-C bypass graft [radial artery (RA) or saphenous vein graft (SVG)] at our institution. The mean age was 69.2 ± 8.5 years and 149 (84.2%) were men. The clinical outcomes and patency rates of distal anastomoses of the composite RITAwere retrospectively evaluated. RESULTS: Mean distal anastomoses per patient were 4.6 ± 1.0, and mean distal anastomoses of the RITA per patient were 1.3 ± 0.5. Inflow conduit of the RITA was the RA in 16 (9.0%) patients and an SVG in 161 (91.0%) patients. The 30-day mortality rate was 1.1% (2/177). The overall patency rate of distal anastomoses of the composite RITA on early (before discharge) and follow-up (at 1 year) angiography was 97.6 and 93.6%, respectively. The inflow conduit (RA or SVG), stenosis grade of target vessel and sequential grafting did not affect the patency rate of the composite RITA. CONCLUSIONS: V-composite grafting using the RITA and the A-C bypass graft provides excellent clinical outcomes with satisfactory early and 1-year patency rates.

Coronary artery bypass grafting (CABG) is an established revascularization method for treating multivessel coronary artery disease. The goal of CABG is to achieve complete revascularization with a durable, patent graft without reintervention. However, early graft failure, including that associated with technical errors, has been reported. This makes intraoperative verification of graft patency one of the most important ways in which surgeons can reduce the rate of early graft failure. Conventional angiography is considered the gold standard for graft assessment. However, because it is invasive and inconvenient, several alternatives to intraoperative graft assessment have become available that help reduce early graft failure by allowing revision of the anastomosis intraoperatively. The aim of this article is to review the advantages and disadvantages of several intraoperative graft assessment methods for CABG.

Background Mitral valve repair has been shown to be effective for degenerative mitral regurgitation (MR). However, outcomes of mitral valve repair for commissural prolapse has not been well defined. Commissural prolapse has been often categorized into the groups of posterior leaflet prolapse or bileaflet prolapse, and outcomes and prognosis of isolated commissural prolapse has been rarely reported. We aimed to determine clinical and echocardiographic outcomes of mitral valve repair for isolated commissural lesion. Methods Between 1992 and 2010, 1,112 patients underwent mitral valve repair for degenerative MR at our institution. Among those, we reviewed 122 patients with isolated commissural prolapse. We analyzed operative outcomes, long-term survival rate, freedom from reoperation rate, and freedom from recurrent moderate or severe MR rate. Results The mean age was 57.0 ± 14.4 years old, 83 patients (68.0%) were men, 16 patients (13.1%) had infective endocarditis, 43 patients (35.2%) had atrial fibrillation, 27 patients (22.1%) had anterolateral commissural prolapse, 91 (74.6%) had posteromedial commissural prolapse, and 4 (3.3%) had bilateral commissural prolapse. We performed leaflet resection in 111 (91.0%) (concomitant sliding plasty in 43), chordal replacement in 94 (77.0%), and ring annuloplasty in 121 patients (99.2%). Residual mild MR was confirmed in 7 patients (5.7%) on predischarge echocardiography. No patients had moderate or severe MR at the time of discharge. Fifteen-year survival and freedom from mitral reoperation were 87.6% and 93.0%, respectively. Freedom from recurrent moderate or severe MR at 15 years was 87.4%. Conclusions Mitral valve repair for isolated commissural prolapse demonstrated excellent early and late outcomes.

Purpose: Early and long-term outcomes of coronary artery bypass grafting (CABG) in patients with left main disease (LMD) with acute coronary syndrome (ACS) have never been assessed. Methods: Between September 2004 and April 2012, 459 patients with LMD underwent first-time isolated CABG. Of those, 191 patients had ACS and 268 did not. Early and late postoperative outcomes were compared between two groups. Results: Patients in the LMD+ACS group were older and more likely to be female. Left ventricular ejection fraction was lower in the LMD+ACS group. In both groups, bilateral internal thoracic artery grafts were used in over 90% of patients and off-pump technique in over 95%. Operative death rate was not significantly different between the groups (LMD+ACS: 2.1% vs. LMD–ACS: 0.4%). Log-rank test revealed that the actuarial survival rate (79.2 ± 3.7% vs. 81.5 ± 3.5%) and freedom from major adverse cardiac and cerebrovascular events (MACCE) (69.2 ± 4.2% vs. 67.0 ± 4.1%) were similar between groups at 7 years. Multivariate analyses demonstrated that ACS was not identified as an independent predictor of operative death, late mortality, and late MACCE. Conclusion: ACS did not have a negative impact on early and late outcomes of CABG in patients with LMD.

Functional tricuspid regurgitation (TR) is a serious pathology to be noted for severe right heart failure (HF) and poor prognosis; however, the conventional assessment of TR has some limitations and the optimal timing of surgical intervention remains unclear. A 79-year-old Japanese female was admitted to our hospital to undergo cardiac surgery, because edema gradually got worse despite the increase in diuretics. She had a history of atrial fibrillation (AF) and chronic HF due to severe TR and had been treated with a furosemide for leg edema 4 years ago. A transthoracic echocardiogram (TTE), transesophageal echocardiogram, cardiac magnetic resonance imaging, and cardiac pool scintigraphy demonstrated severe functional TR with tricuspid annular dilation, insufficient tricuspid valve coaptation, and reduced right ventricular ejection fraction (EF) but preserved left ventricular EF. In addition, Swan-Ganz catheter study showed normal pulmonary arterial wedge pressure and mean pulmonary arterial pressure. Tricuspid ring annuloplasty was performed with MC3 ring. Postoperative TTE showed trivial TR, and she had no edema with normal sinus rhythm two months later. Annuloplasty to severe functional TR caused by tricuspid annular dilation due to AF dramatically improved right HF. Cardiologist should pay strict attention to the optimal timing of surgical intervention for TR.

Background and aim of the study We retrospectively studied outcomes after mitral annuloplasty (MAP) combined with subvalvular procedures for patients with functional mitral regurgitation and ischemic dilated cardiomyopathy. We focused on changes in mitral regurgitation (MR) grade, mitral valve tethering, and left ventricular (LV) volume before and after surgery. Methods Thirty-one patients underwent MAP combined with subvalvular procedures including papillary muscle (PM) approximation, PM relocation, and chordal cutting. Fifteen patients underwent left ventriculoplasty. Twenty patients underwent PM approximation, and 11 patients underwent PM relocation. Two patients underwent chordal cutting in addition to PM approximation or relocation. In 25 patients, echocardiographic measurements of MR grade, mitral valve tethering, and LV volume were compared among three time points: before, immediately after, and one year after surgery. Results There were no in-hospital deaths. LV volume as well as both tenting height and area were significantly reduced immediately after and at one year after surgery. Five patients developed recurrent MR at one year after surgery. In comparison with the other 20 patients, the preoperative MR grade was significantly higher (p = 0.018). The postoperative reduction of LV volume was significant in patients without recurrent MR. Conclusions Both tenting height and area could be significantly reduced and maintained after MAP combined with subvalvular procedures. The preoperative MR grade and the presence of a large postoperative LV volume were more likely to result in recurrent MR. However, among patients with recurrent MR, the MR grade does not increase during mid-term follow-up. doi: 10.1111/jocs.12459 (J Card Surg 2015;30:27–34)

The diffusely diseased coronary artery is challenging for cardiac surgeons because diffuse atheromatous lesions frequently render it unsuitable for conventional distal grafting. Coronary endarterectomy was introduced in the 1950s as a treatment option for diffusely diseased coronary arteries. However, initial studies demonstrated high operative mortality and morbidity associated with coronary endarterectomy; therefore, many cardiac surgeons have been reluctant to perform this procedure. With percutaneous coronary interventions increasingly being applied to coronary artery disease, the incidence of complex and diffuse coronary artery disease in patients referred for coronary artery bypass surgery has been increasing, and recent advances in the surgical technique and perioperative management have improved the surgical outcomes of coronary endarterectomy. In this review article, we sought to discuss coronary endarterectomy for the diffusely diseased coronary artery.

Purpose Magnitude of functional recovery of the left ventricle (LV) is one of the critical determinants of prognosis post-implantation of ventricular assist device (iVAD) for non-ischemic dilated cardiomyopathy (NIDCM). Although predictive factors of the functional recovery are not fully understood, presence of immunocompetent cells in the myocardium is reported to be associated with the pathological stage and/or the myocardial viability. We aimed to explore relationships between functional recovery post-iVAD implantation and distribution of the immunocompetent cells in NIDCM. Methods In the last 5 years, iVAD such as HeartMateII was implanted in 50 patients with NIDCM for bridge-to-transplantation purpose, followed by β blocker and/or ACE inhibitor in the aim to enhance functional recovery. Results During the iVAD support, 12 patients (24%) underwent heart transplantation, while 2 patients (4%) died due to cerebral infarction. Four patients (8%) were treated for congestive heart failure in-hospital, while freedom from heart failure was 96±0.0% at 1 year and 89±0.1% at 5 years. Echocardiographical dimension of the LV was a significant predictive factor of heart failure post-iVAD implantation (P Conclusion Despite aggressive medical treatments post-iVAD implantation, functional recovery was not frequently seen in advanced stage of NIDCM. Immunocompetent cells in the LV myocardium might be a key to predict myocardial viability of this pathology.