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We examined the safety and efficacy of del Nido cardioplegic solution compared with histidine-tryptophan-ketoglutarate cardioplegic solution in minimally invasive cardiac surgery.Patients who underwent minimally invasive cardiac surgery using del Nido or histidine-tryptophan-ketoglutarate from 2015 to 2019 were enrolled. Various clinical outcomes were compared between the groups. Postoperative laboratory findings including the levels of electrolytes, cardiac enzymes (creatine kinase-MB and troponin I), and serial blood lactate were also measured and compared. Based on 28 baseline covariates, propensity score matching was performed to reduce selection bias.Among 766 patients, del Nido and histidine-tryptophan-ketoglutarate were used in 330 patients (43.1%) and 436 patients (56.9%), respectively. There were no significant intergroup differences in postoperative clinical outcomes and early adverse outcomes among 228 pairs of propensity score-matched patients. Immediate postoperative sodium levels were within the normal range in both groups without a significant difference (P = .50). However, peak creatine kinase-MB (median, 31.9 vs 37.7 ng/mL, P = .026) and troponin I (6.9 vs 9.1 ng/mL, P = .014) levels were significantly lower in the del Nido group. Linear regression analysis revealed a significant association between the peak cardiac enzyme levels and the cardiac ischemic time depending on the cardioplegia type, with lower cardiac isoenzymes for del Nido over histidine-tryptophan-ketoglutarate (P .001) until the crossover point at the cardiac ischemic time over 100 minutes.In comparison with histidine-tryptophan-ketoglutarate solution, del Nido solution seems to have acceptable safety and efficacy with good myocardial protection in minimally invasive cardiac surgery. Further studies focusing on complex surgeries requiring longer cardiac ischemic time are needed.

In this study, we present recent trends in heart valve surgery in Korea through analyses of data from the Korea Heart Valve Surgery Registry (KHVSR).We enrolled 8,981 patients who were registered in the KHVSR from 2017 to 2020. Yearly trends in patients' baseline characteristics, surgical profiles, and early mortality rates were explored. The observed/expected mortality ratio (O/E ratio), calculated from the actual mortality in the KHVSR and the predicted mortality estimated using the EuroSCORE II, was also analyzed.The proportion of aortic valve surgery significantly increased from 56.8% in 2017 to 60.3% in 2020. The proportion of all combined procedures and minimally invasive surgery significantly increased over the 4-year study period. The operative mortality rate was 2.9% in the entire cohort, while mitral valve repair showed the lowest mortality risk (0.9%). The mortality rates of isolated aortic valve replacement (AVR) significantly decreased from 2.1% in 2017 to 0.8% in 2020 (p=0.016). Overall, the O/E ratio was 0.784 (95% confidence interval [CI], 0.677-0.902) demonstrating significantly lower actual mortality risks than expected based on the EuroSCORE II. In particular, the O/E ratios were as low as 0.364 (95% CI, 0.208-0.591) for isolated AVR.The recent data from the KHVSR showed increasing trends for complex procedures and minimally invasive surgery in heart valve surgery in Korea, and demonstrated remarkably low risks of operative mortality.

Background While several randomized trials have shown conflicting results regarding the comparative effectiveness of on- and off-pump coronary arterial bypass grafting (CABG), research on long-term outcomes in large-scale, real-world clinical settings are limited. We sought to examine the comparative effectiveness of on- and off-pump CABG in a real-world clinical setting. Methods Using the nationwide claims database of the Korean National Health Insurance Service, we identified patients who underwent isolated CABG from 2004 to 2013. Propensity-score matching with multivariable adjustment was used to assemble a cohort of patients with similar baseline characteristics. Results Among 23,828 patients, 12,639 in the off-pump (53.0%) and 11,189 in the on-pump (47.0%) groups were enrolled. After matching, 6,483 pairs were included in the final analysis. At 30 days, there was no significant difference in adjusted mortality between the off- and on-pump groups (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.87-1.16). During long-term follow-up (100% complete; median 5.3yrs, maximum 13.2yrs), however, off-pump CABG was associated with a higher risk of mortality than on-pump CABG (HR, 1.09; 95% CI, 1.03-1.15). The risks of myocardial infarction (MI) (HR, 1.3; 95% CI, 1.16-1.45) and repeat revascularization (HR, 1.50; 95% CI, 1.37-1.63) were also significantly higher in the off-pump CABG group than in the on-pump CABG group, while the stroke risk was similar inter-groups (HR, 0.99; 95% CI, 0.87-1.13). Conclusions In this contemporary, nationwide, clinical practice claim registry, off-pump CABG was associated with higher long-term risks of mortality, MI, and repeat revascularization than on-pump CABG.

OBJECTIVES Comparisons of long-term clinical outcomes of mitral valve replacement between bovine pericardial and porcine bioprostheses are conflicting, with limited research in large-scale real-world clinical settings. This study examined clinical outcomes in mitral valve replacement according to bioprosthesis type using a national administrative claims database. METHODS This study included adult patients undergoing bioprosthetic mitral valve replacement between 2003 and 2018 using administrative health care data from the Korean National Health Insurance Service database. Propensity score matching with competing risk analysis was used to compare the clinical outcomes according to the type of bioprosthesis. The end-points were death, cardiac death, and valve-related events, including the incidence of reoperation, endocarditis, systemic thromboembolism, and major bleeding. RESULTS A total of 3151 patients underwent bioprosthetic mitral valve replacement with bovine pericardial (n = 1628, 51.7%) or porcine (n = 1523, 48.3%) bioprostheses. After matching, 1170 pairs were included in the final analysis. During follow-up (median 4.49 years, interquartile range [IQR] 1.87 –8.75 years), death occurred in 1178 patients (6.8%/patient-year [PY]), comprising 730 (4.3%/PY) cardiac death. No significant differences were noted between the bovine and porcine groups in the cumulative incidences of death from any cause (adjusted HR [aHR], 1.00; 95% CI, 0.87–1.14), cardiac mortality (aHR, 0.96; 95% CI, 0.81–1.14), or reoperation (aHR, 1.01; 95% CI, 0.72–1.41). CONCLUSIONS This study on a nationwide comparison between bovine and porcine bioprostheses in mitral valve replacement found no significant differences in clinical outcomes including mortality, and valve related reoperation.

Background: While the use of bioprosthetic valves for mitral valve replacement (MVR) is increasing, very few studies have compared bovine pericardial and porcine valves in the mitral position to help guide bioprosthetic selection. Methods: In the present study, patients who underwent MVR using bovine pericardial valves were compared with those who underwent MVR with porcine bioprostheses between January 1996 and July 2018. Those with prior MVR, infective endocarditis, congenital mitral valve disease, or ischemic mitral regurgitation were excluded. The primary outcomes were structural valve deterioration (SVD) and mitral valve reoperation from any cause, and death was regarded as a competing risk. Competing risk analysis and propensity score-matching were used for comparisons. Results: Among the 388 patients enrolled, pericardial and porcine bioprostheses were implanted in 217 (55.9%) and 171 (44.1%), respectively. Propensity score-matching yielded 122 pairs of patients that were well-balanced for all baseline covariates. No significant differences were observed between the groups in unadjusted (p=0.09) and adjusted overall survival (hazard ratio [HR], 1.13; 95% confidence interval [CI], 0.72–1.76; p=0.60). Competing risk analysis revealed no significant differences in the risks of mitral reoperation (HR, 1.07; 95% CI, 0.50–2.27; p=0.86) and development of SVD (HR, 1.57; 95% CI, 0.56–4.36; p=0.39) between the groups. Matched population analysis confirmed similar results regarding reoperation (HR, 0.99; 95% CI, 0.40–3.22; p=0.98) and SVD (HR, 1.39; 95% CI, 0.41– 4.73; p=0.60). Conclusion: No significant differences in survival or valve durability were observed between bovine pericardial and porcine bioprosthetic MVR. These findings require further validation through studies with larger sample sizes.

The benefit of avoiding lifelong anticoagulation therapy in patients with bioprosthetic heart valve implantation may potentially be offset by atrial fibrillation (AF); however, clinical impact of surgical AF ablation in such patients remains controversial. We enrolled 426 patients (aged 72.0 ± 7.8 years) with AF who underwent left-side valve replacement with bioprostheses between 2001 and 2018. Of these, 297 underwent concomitant surgical ablation (ablation group) and 129 underwent valve replacement alone (non-ablation group). Clinical outcomes were compared, and mortality was considered as a competing risk factor against valve-related complications. Inverse-probability weighting (IPTW) was adopted to reduce selection bias. The ablation group had lower baseline risk profiles than the non-ablation group. In crude analysis, early mortality rates were 3.4% and 7.0% in the ablation and non-ablation groups, respectively (P = 0.104). During follow-up (1521.9 patient-years), the ablation group showed lower AF-recurrence (P0.001) and anticoagulant medication rate (P = 0.021), and lower overall mortality risk (subdistribution hazard ratio [SHR], 0.63; 95% confidence interval [CI], 0.42-0.94), but higher risk of permanent pacemaker implantation (SHR, 4.67; 95% CI, 1.36-16.05). No significant difference in the risk of stroke (SHR, 1.27; 95% CI, 0.55-2.95) was observed between the groups. After baseline IPTW-adjustment, findings of the clinical outcomes were analogous to those from crude analyses. In patients undergoing bioprosthetic valve replacement, the addition of surgical ablation was associated with improved rhythm outcomes and survival but at the expense of a higher risk of pacemaker implantation. The underlying mechanism of improved survival by AF ablation needs further investigation.

Enlarged left atrium (LA) is a risk factor for ablation failure after atrial fibrillation (AF) surgery. It predisposes patients to thromboembolic events, even in successful ablation; therefore, concomitant resection of the LA wall during surgical ablation was introduced. This study examined the clinical impacts of LA reduction in patients undergoing concomitant ablation for AF. This study enrolled 1484 patients with enlarged LA (≥50 mm) who underwent surgical AF ablation during major cardiac surgery between January 2001 and August 2018. Among them, 876 (59%) patients underwent concomitant LA reduction (Reduction group), whereas in the remaining 608 (41%), the LA wall was unresected (Preservation group). The primary outcome of interest was overall stroke. The secondary outcomes were overall mortality, late recurrence of AF, early postoperative complications and postoperative echocardiographic parameters. Outcomes were compared after adjusting baseline characteristics with inverse probability of treatment weighting (IPTW) using propensity score. The median follow-up was 60.1 months. After IPTW adjustment, long-term mortality (P = 0.250) and AF-free rates (P = 0.196) did not significantly differ between groups. However, the Reduction group showed a decreased risk of stroke (hazard ratio 0.54; 95% confidence interval 0.32-0.90; P = 0.018). Early postoperative complications rate such as mortality or reoperation for bleeding, was not significantly different between the 2 groups. The Reduction group showed smaller LA diameter (50.6 ± 8.0 mm vs 53.6 ± 8.9 mm; P0.001) on follow-up echocardiography. LA reduction effectively decreased LA size and appeared to decrease the stroke risk in patients with enlarged LA undergoing ablation for AF.

OBJECTIVES Right mini-thoracotomy approach may enhance the visualization of mitral valve (MV) visualization during redo MV surgery, thereby minimizing the risk of reoperative median sternotomy. We described the clinical outcomes of redo MV surgery by mini-thoracotomy and full-sternotomy approach. METHODS Of 730 consecutive adult patients who underwent redo MV surgery between 2002 and 2018 at our institution, we identified 380 patients (age: 56.0 [14.8] years) after excluding those who underwent concomitant aortic valve or coronary artery surgeries. RESULTS The clinical outcomes in patients who underwent mini-thoracotomy (MINI group; n = 168) and full-sternotomy (STERN group; n = 218) were described. The early and overall mortality in the MINI group was 4.3% (7/162) and 17.3% (28/162), with the rates of early major complications as follows: low cardiac output syndrome, 5.6% (9/162); early stroke, 6.8% (11/162); new-onset dialysis, 6.2% (10/162); prolonged ventilation, 15.4% (25/162); and postoperative bleeding requiring exploration, 7.4% (12/162). In the STERN group, the early mortality was 11.0% (24/218), whereas the risk of low cardiac output syndrome, early stroke, new-onset dialysis, prolonged ventilation, and postoperative bleeding was 12.4% (27/218), 14.2% (31/218), 17.0% (37/218), 33.0% (72/218), and 10.1% (22/218), respectively. The duration of intensive care unit and hospital stay was 2.0 [range 1.0, 3.0] and 8.0 [6.0, 13.0], respectively, in the MINI group and 3.0 [2.0, 7.0] and 14.0 [8.0, 29.0], respectively, in the STERN group. CONCLUSIONS Mini-thoracotomy may be a viable alternative to conventional sternotomy for redo MV surgery.

OBJECTIVES Complications like complete atrioventricular block (CAVB) and paravalvular leakage (PVL) following rapid deployment aortic valve (AV) replacement (RDAVR) remain unresolved. Selecting an optimal size of the valve might be important to minimize the incidence of these complications. We sought to determine the impact of prosthesis size relative to the anatomic profile of the AV on the occurrence of CAVB or PVL after RDAVR. METHODS Preoperative computed tomographic (CT) images were evaluated in patients receiving RDAVR (INTUITY ELITE) between February 2016 and December 2019. The occurrence of CAVB requiring permanent pacemaker implantation and PVL (≥ mild) was evaluated. The relative size of implants against the cross-sectional dimensions of recipients’ AV annulus and left ventricular outflow tract (LVOT) were calculated. RESULTS Among 187 eligible patients, CAVB and PVL (≥ mild) occurred in 12 (6.4%) and 11 patients (5.9%), respectively. CAVB was associated with oversized RDAVR (RDAVR frame width minus average diameter of LVOT calculated from the cross-sectional area [ΔLVOTarea]: odds ratio, 2.05; 95% confidence interval, 1.28–3.30): this was with an area under the curve of 0.78 (P = 0.005). The projected probability of CAVB was CONCLUSIONS CT parameters of the AV annulus and LVOT are highly reliable in the prediction of CAVB or PVL after RDAVR. Our data might justify CT-based sizing of prosthesis for RDAVR.

Background: Sutureless and rapid deployment valves for aortic valve replacement (AVR) were introduced in Korea in December 2016. This study evaluated changing trends in the prosthetic valves used for AVR in Korea after the introduction of sutureless and rapid deployment valves. Methods: From December 2016 to December 2018, 4,899 patients underwent AVR in Korea. After applying the exclusion criteria, 4,872 patients were analyzed to determine changes in the type of prosthetic valve used for AVR. The study period was divided into 5 groups corresponding to 5-month intervals. Results: The total number of AVR cases was 194.88±28.78 per month during the study period. Mechanical valves were used in approximately 27% to 33% of cases, and the proportion of mechanical valve use showed a tendency to decrease, with marginal significance overall (p=0.078) and significant decreases in patients less than 60 years of age and in men (p=0.013 and p=0.023, respectively). The use of sutureless valves increased from 13.4% to 25.8% of cases (p70 years) and those requiring concomitant surgery. In a comparison between sutureless and rapid deployment valves, the use of Perceval S valves (a type of sutureless valve), gradually increased (p

BACKGROUND AND AIM OF THE STUDY Although dopamine and norepinephrine are recommended as first-line agents in the treatment of shock, it is unclear which is the optimal vasoactive inotropic agent (VIA) to manage postcardiotomy circulatory shock. This single-center, randomized clinical trial aimed to investigate the efficacy and safety of dopamine versus norepinephrine in postcardiotomy circulatory shock. METHODS We randomly assigned the patients with postcardiotomy circulatory shock to receive either dopamine or norepinephrine. When shock persisted despite the dose of 20 μg/kg/min of dopamine or the dose of 0.2 μg/kg/min of norepinephrine, epinephrine or vasopressin could be added. The primary endpoint was new-onset tachyarrhythmic event during drug infusion. Secondary endpoints included requirement of additional VIAs, postoperative complications, and all-cause mortality within 30 days of drug initiation. RESULTS At the planned interim analysis of 100 patients, the boundary for the benefit of norepinephrine has been crossed, and the study was stopped early. Excluding two patients withdrawing a consent, 48 patients were assigned to dopamine and 50 patients to norepinephrine. New-onset tachyarrhythmic event occurred in 12 (25%) patients in the dopamine and one (2%) patient in the norepinephrine group (p = .009). The requirement for additional VIAs was more common in the dopamine group (p

Although it is attractive, a limitation of aortic valve (AV) replacement (AVR) through a mini-thoracotomy approach (mini-AVR) is the limited exposure of the AV. Here, we present a simple exposure technique named "suspending commissural sutures" for a more efficient mini-AVR. The technique involves making 3 half-depth stitches with 1-0 silk at each of the commissures, which are anchored to each corresponding pericardial surface. These stitches are tightened up so that the aortic root is axially expanded and is pulled upward. The technique of suspending commissural stitches seems to offer reasonable exposure of the AV in mini-AVR, and shows excellent early surgical outcomes.

Background This study aimed to develop a new risk prediction model for operative mortality in a Korean cohort undergoing heart valve surgery using the Korea Heart Valve Surgery Registry (KHVSR) database. Methods We analyzed data from 4,742 patients registered in the KHVSR who underwent heart valve surgery at 9 institutions between 2017 and 2018. A risk prediction model was developed for operative mortality, defined as death within 30 days after surgery or during the same hospitalization. A statistical model was generated with a scoring system by multiple logistic regression analyses. The performance of the model was evaluated by its discrimination and calibration abilities. Results Operative mortality occurred in 142 patients. The final regression models identified 13 risk variables. The risk prediction model showed good discrimination, with a c-statistic of 0.805 and calibration with Hosmer-Lemeshow goodness-of-fit p-value of 0.630. The risk scores ranged from -1 to 15, and were associated with an increase in predicted mortality. The predicted mortality across the risk scores ranged from 0.3% to 80.6%. Conclusion This risk prediction model using a scoring system specific to heart valve surgery was developed from the KHVSR database. The risk prediction model showed that operative mortality could be predicted well in a Korean cohort.

Background Malignant primary cardiac tumors are extremely rare, but have a poor prognosis. This study evaluated the surgical outcomes of patients with this disease. Methods Forty patients who underwent surgery for malignant primary cardiac tumors between January 1998 and December 2018 were enrolled. Participants were divided into 3 groups based on resection margins (R0, 14 patients; R1, 11 patients; and R2, 11 patients) and their surgical outcomes were compared. Heart transplantation was performed in 4 patients with unresectable tumors. Results Early mortality was reported in 2 cases (5%) due to postoperative bleeding and cerebral hemorrhage secondary to brain metastasis. The 1- and 2-year survival rates were 67.5% and 42.5%, respectively. The median survival time of the patients was 20.3 months (range, 9.2-37.6 months). The median survival time was 48.7, 20.3, and 4.8 months in patients with R0, R1, and R2 resections, respectively (p=0.023). Tumor recurrence occurred in 21 patients (61.7%), including 4 cases of local recurrence and 17 cases of distant metastasis. In patients who underwent heart transplantation, the median survival time was 29.5 months, with 3 cases of distant metastasis. Conclusion Although surgery for malignant primary cardiac tumors has a poor prognosis, complete resection of the tumor may improve surgical outcomes.

Background We aimed to assess the clinical outcomes of patients who underwent surgical repair of Kommerell diverticulum (KD) with individualized surgical methods. Methods A retrospective analysis was performed of adult patients (aged ≥17 years) who underwent surgery to treat KD between June 2008 and October 2019. Results Nine patients (median age, 45 years; range, 19-67 years; 7 men) underwent surgical repair. The indications for surgical therapy were acute aortic dissection in 2 patients, the presence of compressive symptoms due to dilated KD in 4 patients, and aneurysm growth in 3 patients. Various surgical techniques were used: (1) resection of the diverticulum stump and revascularization of the aberrant subclavian artery (n=3), (2) one-stage total-arch replacement including the diverticulum segment (n=3), and (3) hybrid repair (n=3). Early mortality occurred in 1 case of hybrid repair. Transient paraparesis occurred in a patient who underwent total arch repair as part of complicated acute aortic dissection. During follow-up (median duration, 30 months; range, 7-130 months), no late death or associated aortic complications were documented. All survivors were free from symptoms and had no abnormal findings on follow-up computed tomography. Conclusion With a customized surgical approach and appropriate consideration of patient- specific anatomy and associated comorbidities, KD can be repaired with favorable outcomes.

BACKGROUND: Obtaining adequate effective orifice area (EOA) in surgical aortic valve replacement (SAVR) is important to minimize pressure gradients across the prosthetic aortic valve (AV) and improve clinical outcomes. However, the predictors of EOA are unclear. METHODS: From July 2011 to March 2016, patients undergoing SAVR who were preoperatively evaluated using a computed tomography (CT) on the aortic root were enrolled. Indexed EOA (iEOA) was used as an indicator of prosthetic AV opening area. The aortic root parameters investigated were the annular diameter (max and min), annular perimeter, annular area, and maximal dimensions of the proximal ascending aorta. These variables were evaluated as predictors of EOA, and an individual surgeon was incorporated in analysis for verifying surgeon dependent factors. RESULTS: Among the 710 patients included in this study [age: 64.9±10.8 years; females: n=285 (40.1%)], 370 (52.1%) were implanted with bio-prosthesis. Mean prosthetic iEOA was 1.1±0.3 cm(2)/m(2). Univariable linear regression analysis showed that all indexed aortic root parameters (maximal and minimal annular diameters, annular perimeter, annular area, and sinus dimensions) were significantly associated with iEOA (P

Various staffing models have been applied in intensive care units (ICUs) to improve outcomes. However, there is a lack of evidence regarding the effect of staffing models in cardiac surgery ICUs. Thus, we aimed to evaluate the efficacy of high-intensity staffing in cardiac surgery ICUs.From January 2013 to December 2016, 4676 adult patients were admitted to our cardiac surgery ICU after surgery. Excluding patients undergoing minor surgery or noncardiac-related surgery, 4038 patients were analyzed. Beginning in January 2015, patients were divided into low-intensity group (n = 1784) and high-intensity group (n = 2254) according to the study period. Primary outcomes were ICU and hospital length of stay, rates of transfusion and infection, and readmission to the ICU. Secondary outcomes were 30-day and ICU mortality. To reduce potential confounders, propensity score-matched analysis was performed.In the high-intensity group, ICU and hospital length of stay were significantly shorter (P .001). Incidence of readmission was lower in the high-intensity group (3.1% vs 12.5%; P .05). Infection rate in respiratory tract and bloodstream was lower in the high-intensity group (3.1% vs 5.0%; P .05). Transfusion rate and amount were also significantly lower in the high-intensity group (P .05). However, 30-day (1.9% vs 2.1%; P = .71) and ICU mortality (2.1% vs 2.7%; P = .31) were comparable between the groups.High-intensity staffing model during daytime hours by cardiac surgery intensivists significantly improved ICU-related outcomes. However, high-intensity staffing did not affect early mortality after cardiac surgery.

There is limited evidence on the effectiveness of surgical atrial fibrillation ablation in reducing mortality or thromboembolic events during aortic/mitral valve surgery. We evaluated the association of surgical ablation versus no ablation with risks of all-cause death and ischemic stroke or systemic embolization among patients with preoperative atrial fibrillation undergoing concomitant aortic valve or mitral valve surgery.With the use of administrative healthcare datasets from the Korean National Health Insurance Service database between 2003 and 2018, adult patients with atrial fibrillation undergoing aortic/mitral valve replacement or mitral valve repair were enrolled, and their outcomes were compared according to the performance of concomitant surgical ablation. The primary end points were all-cause death and thromboembolic event of ischemic stroke or systemic embolization.Among 17,247 patients with atrial fibrillation undergoing aortic/mitral valve surgery, 8716 (50.5%) received surgical ablation, whereas 8531 (49.5%) did not. During a median follow-up of 6.7 years (124,842.2 patient-years), death was less in the ablation group than in the no-ablation group (2.7 vs 4.1 patient-years; P .001). The incidence of ischemic stroke or systemic embolization was also lower in the ablation group (0.9 vs 1.3 patient-years; P .001). After adjustment with inverse probability of treatment weighting, surgical ablation was associated with decreased risks of all-cause death (hazard ratio, 0.86; 95% confidence interval, 0.80-0.92), ischemic stroke or systemic embolization (hazard ratio, 0.62; 95% confidence interval, 0.55-0.71), and hospitalization from heart failure (hazard ratio, 0.87; 95% confidence interval, 0.79-0.96).In patients with atrial fibrillation undergoing aortic/mitral valve surgery, concomitant surgical ablation was significantly associated with lower risks of mortality and thromboembolic events.

Surgery for acute type A aortic dissection remains challenging with considerable mortality and morbidity despite the remarkable advances in this field. Particularly, surgical outcomes of acute type A aortic dissection are known to be associated with the hospital volume. The optimal cerebral protective method and extent of surgery have been long-standing controversies in acute type A aortic dissection surgery. Given that data from randomized trial are not available and future trials are also unrealistic, observational data based on large registry or meta-analyses may alternatively provide reliable and reasonable evidence. With regard to neuroprotective methods for arch repair, currently available observational data strongly suggest that there are no overt superiority among unilateral-antegrade cerebral perfusion, bilateral-antegrade cerebral perfusion, and retrograde cerebral perfusion, by which their availabilities are still open in real clinical practices depending on institutional preferences. When deciding the extent of arch repair in acute DeBakey type I aortic dissection, multiple factors should be considered altogether such as aortic anatomic characteristics as well as patient's risk profiles for optimizing early safety and late aortic longevity.

A mild-to-moderate aortic root aneurysm might be overlooked during the assessment of the donor heart. The use of the Z-score in such cases may be helpful in guiding clinical decision-making. To make a diagnosis of genetic aortopathy, a genetic panel study and matching with clinical criteria such as Ghent nosology are essential. Valve-sparing root reimplantation may be a viable option in cases with aortic root aneurysm developing after heart transplant.

Background Surgical management of the mitral valve (MV) in patients with mild-to-moderate mitral dysfunction undergoing aortic valve replacement is still controversial. We investigated the echocardiographic data from patients with mild-to-moderate mitral dysfunction who did not undergo MV surgery. Materials and methods From January 1989 to June 2012, a total of 2731 patients underwent aortic valve replacement. Among these, 560 patients with mild-to-moderate mitral dysfunction were screened. Of these, 292 patients (61.9 ± 13.0 years; 113 females) who had not undergone MV surgery formed our study cohort. Survival, valve-related complication, and echocardiographic data were evaluated. Results There were three early deaths. During the mean follow-up period of 56.9 ± 46.5 months, there were 23 late deaths and 28 valve-related complications. Valve-related event-free survival at 5 years was 85.9% ± 2.4%. In serial postoperative echocardiographic evaluations (mean follow-up duration: 40.8 ± 44.5 months), 21 patients experienced a progression in late mitral dysfunction. At 5 years, 88.8% ± 2.7% of patients did not suffer from late mitral dysfunction. Based on multivariate analysis, rheumatic pathology of MV (Hazard Ratio: 3.88, 95% confidence intervals 1.60–9.39, p = 0.003) was an independent predictor of late mitral dysfunction. Conclusions Conservatively treated patients with mild-to-moderate mitral dysfunction exhibited acceptable clinical outcomes. Rheumatic pathology of MV is associated with a higher risk of progressive native MV dysfunction.

Background An optimal treatment for aortic regurgitation in Behcet’s disease has not been established. We investigated the effect of operative technique, prosthetic material, and immunomodulation therapy on surgical outcomes. Methods In this study, 23 patients with Behcet’s disease surgically treated for aortic regurgitation were assessed. Significant postoperative events were defined as death, aortic valve or graft-related problem(s), infective endocarditis, disabling stroke, and aortic valve or root reoperation. Surgical procedures were classified as isolated aortic valve replacement, bioprosthetic root replacement, and mechanical root replacement. Allograft root replacements were included in the bioprosthetic root replacement group. Results A total of 40 operations, including 39 aortic valve or root surgeries and 1 orthotopic heart transplantation, were performed on patients confirmed with Behcet’s disease. However, the study only reviewed 35 of the 40 cases (4 cases with inadequately documented medical records and 1 heart transplantation case were excluded). Significant adverse events occurred in 8 of 11 (73%) isolated aortic valve replacement, 9 of 12 (75%) bioprosthetic root replacement (5 xenografts and 7 allografts), and 4 of 12 (33%) mechanical root replacement cases. Multivariate analysis revealed that the 1-month postdischarge C-reactive protein level and operative age were independent predictive factors for postoperative event-free survival. Mechanical root replacement was identified as the most significant predictive factor leading to positive outcomes (hazard ratio, 0.147; 95% confidence interval, 0.028 to 0.766; p = 0.023). Conclusions The findings suggest that mechanical root replacement combined with a low postoperative C-reactive protein level maintained through adjunctive immunomodulation therapy may lead to optimal surgical outcomes in Behcet’s disease associated with severe aortic regurgitation.

Background Data on robotic-assisted surgical atrial fibrillation (AF) ablation in patients undergoing mitral valve (MV) operations are lacking. This study aimed to evaluate early and late outcomes after robotic-assisted ablation of AF combined with MV surgery. Methods Between 2007 and 2017, this study enrolled 94 patients (age: 53.9 ± 12.7 years; 67 men) undergoing AF ablation by using an argon-based flexible cryoablation system during robotic-assisted MV surgical procedures. Persistent (n = 34, 36.2%) or long-standing persistent (n = 38, 40.4%) AF was present in most patients. Primary valve procedures included isolated mitral repair in 58 patients, isolate mitral replacement in 2 patients, and combined mitral and tricuspid repair in 34 patients. Results Sixty patients (63.8%) received left-side-only AF ablation, whereas the others (n = 34, 36.2%) received biatrial ablation. The operation times for cardiopulmonary bypass and aortic cross-clamping were 222.7 ± 57.8 minutes and 134.1 ± 30.4 minutes, respectively. No early death was seen. Major early complications included neurologic injury in 2 patients (2.1%) and low cardiac output syndrome in 2 patients (2.1%). No patients required permanent pacemaker implantation. Early AF occurred in 14 patients (14.9%) during a postablation blanking period (90 days). During a median follow-up of 49.6 months (quartiles 1 to 3: 17.2 to 79.4 months, 95.7% complete), there were two late deaths (0.49% per patient-year) and one stroke (0.25% per patient-year). Five-year survival was greater than 96%, and results from largely electrocardiograms showed a low recurrence of AF (2.2% at 1 year, 6.7% at 5 years). Conclusions Surgical AF ablation with the use of robotic-assistance in the setting of mitral valve surgery showed excellent safety and favorable long-term clinical outcomes.

The study objective was to evaluate the clinical implication of left ventricular diastolic dysfunction in patients with chronic severe aortic regurgitation undergoing aortic valve replacement.We reviewed the medical records of 323 patients (age, 56.3 ± 14.1 years; 111 female) who underwent aortic valve replacement for chronic severe aortic regurgitation between 2005 and 2019. Left ventricular diastolic dysfunction was assessed by the ratio of peak left ventricular inflow velocity over mitral annular velocity (E/e'). The study end point was the composite of death and heart failure requiring hospital admission.The E/e' ratio was significantly correlated with age, left atrial dimension, left ventricular end-diastolic volume, mitral regurgitation grade, and tricuspid regurgitation grade (all P .001). During follow-up (1748.3 patient-years), death and heart failure occurred in 36 patients (2.06/patient-year) and 9 patients (0.53/patient-year), respectively. In multivariable analysis, E/e' ratio (per 5 increment, hazard ratio, 1.32; 95% confidence interval, 1.02-1.71; P = .03), age (hazard ratio, 1.06; 95% confidence interval, 1.03-1.10; P .001), and left ventricular ejection fraction (hazard ratio, 0.94; 95% confidence interval, 0.90-0.98; P = .002) were independent predictors of death and heart failure. The 5-year heart failure-free survival was 94.9% ± 1.7% in patients with E/e' less than 15% and 84.2% ± 4.2% in patients with E/e' 15 or greater (P .001).The E/e' ratio was significantly associated with adverse outcomes in patients with chronic severe aortic regurgitation undergoing aortic valve replacement and may be useful as a prognostic marker in such patients.

The 2020 American College of Cardiology focused update on the mitral regurgitation (MR) pathway provides an excellent summary of the decision-making trees in the treatment of severe MR, in which 2 main branches of the flowchart are suggested depending on whether MR is primary or secondary. Surgery is suggested as preferable over transcatheter edge-to-edge repair (TEER) in primary MR that needs intervention. The decision-making for secondary MR generally prioritizes TEER over surgery according to the guidelines, but further stratification is necessary based on the pathophysiologic mechanisms of MR. TEER is probably the more suitable option in secondary MR caused by left ventricular dysfunction or dilatation, given the high perceived surgical risks, despite the lack of sufficient evidence in support of overt clinical benefits from surgical therapy in these patients. In atrial functional MR associated with atrial fibrillation (AF), however, concomitant ablation of AF seems to be a desirable option, as it has been demonstrated to be a key factor leading to improved survival, reduced stroke risk, and more durable mitral and tricuspid function in patients undergoing mitral surgery. Therefore, atrial functional MR requiring intervention may be best treated by surgical therapy that combines mitral repair and AF ablation in the majority of patients. This particular issue, however, needs further research to obtain scientific evidence to guide optimal management strategies.

Background The use of minimally invasive approaches is scarce in open aortic arch repair because of its perceived high operative risk and technical difficulty. Methods This study enrolled 59 consecutive patients (aged 58.2±13.2 years) undergoing elective arch replacement either through upper hemi-sternotomy (n=58) or mini-thoracotomy (n=1) between 2015 and 2020. Of these, 44 underwent hemiarch replacement and 15 underwent total arch replacement. Moderate hypothermic circulatory arrest was used for all patients while antegrade cerebral perfusion was selectively used for total arch repair. For more efficient distal aortic anastomosis in limited spaces, inverted graft anastomosis was utilized whenever possible. Results Hemi-sternotomy involved upper sternal separation down to the second, third, and fourth intercostal spaces in 1 (1.7%), 30 (50.8%), and 27 (45.8%) patients, respectively. Concomitant cardiac procedures included root replacement in 19 patients (32.2%) and aortic valve replacement in 21 patients (35.6%). Circulatory arrest, cardiac ischemic, cardiopulmonary bypass, and total procedural times were 8.9±3.4, 91.1±31.1, 114.6±46.2, and 250.3±79.5 min, respectively for total arch repair, and 25.0±12.1, 72.3±16.6, 106.0±16.9, and 249.1±41.7 min, respectively for hemiarch repair. Conversion to full-sternotomy was required in 1 patient (1.7%) due to bleeding. There was one case of mortality (1.7%) attributable to low-cardiac output syndrome following hemiarch repair concomitantly with Bentall procedure. Major complications included requirement for mechanical support in 1 (1.7%), temporary neurologic deficit in 1 (1.7%), newly initiated dialysis in 3 (5.1%), and re-exploration due to bleeding in 2 (3.4%). Conclusions Mini-access open arch repair is technically feasible and achieved excellent early outcomes.

Reconstruction of the visceral and segmental arteries is a challenging part of open surgical repair of extensive thoracoabdominal aortic aneurysm (TAAA). For more efficient reconstruction of these branching vessels, a technique of using pre-hand-sewn multi-branched aortic graft (octopod technique) has been adopted with the aid of 3D-printing-guidance in latest cases. The octopod graft has been employed for the extent II or III TAAA repair, in which the commercially available two 4-branched aortic grafts were interconnected before surgery. Since January 2017, 3D-printed-aortic model has been used to efficiently replicate the projected aorta shape fitted to patient's anatomy. From May 2015 through Oct 2019, 20 patients (median age, 40years; range, 23-65; 5 females) underwent extent II or III TAAA repair using the octopod technique with (n = 9) or without (n=11) 3D-printing-guidance. Thirteen patients (65%) were diagnosed as Marfan syndrome. Eighteen patients (90%) had undergone prior aorta repair including 4 patients (20%) undergoing redo-thoracotomy. Revascularization of segmental arteries was conducted in 19 patients (95%, median, N = 2; range, 1-4). Median pump and entire procedural times were 173.5 minutes (interquartile range [IQR], 136.8-187.8) and 441 minutes (IQR, 392.8-492.3), respectively. There was no operative mortality or stroke, however, permanent paraplegia occurred in one patient (5%). During follow-up (median 35months, range 1-56 months), all of reconstructed branched vessels remained wide patent on CT. The octopod technique for open TAAA repair showed favorable early and mid-term results with high feasibility of procedural efficiency. 3D-printing guidance is expected to improve the flow of surgical procedures especially in challenging anatomy.

Background B-type natriuretic peptide (BNP) is a biomarker predicting morbidity and mortality in patients with congestive heart failure. However, the usefulness of pre- or postoperative BNP levels in patients undergoing cardiac surgery remains uncertain. We sought to determine the association of pre- or postoperative BNP levels on mortality in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). Methods This study retrospectively evaluated 1,642 patients undergoing cardiac surgery under CPB over 2 years. The primary outcomes were 30-day and overall mortality after cardiac surgery. Results The 30-day mortality rate was 3.0% (n=49), and the overall mortality occurred in 118 patients during the mean follow-up period of 24.9±8.9 months. In multivariable analyses, preoperative BNP level was not significantly associated with 30-day [odds ratio (OR), 1.03; 95% confidence interval (CI), 0.99-1.06; P=0.06] or overall [hazard ratio (HR), 1.01; 95% CI, 0.98-1.03; P=0.50] mortalities. However, the postoperative BNP level was significantly associated with 30-day (OR, 1.05; 95% CI, 1.02-1.09; P=0.001) and overall (HR, 1.03; 95% CI, 1.01-1.04; P=0.01) mortalities. As a sensitivity analysis, postoperative BNP levels were divided into quartiles. The top quartile (≥484 pg/mL) was identified as a strong predictor of overall mortality (HR, 2.18; 95% CI, 1.14-4.19; P=0.02). Conclusions Preoperative BNP level was not associated with mortality after cardiac surgery. However, postoperative BNP level was associated with mortality after cardiac surgery, especially in patients with high levels (≥484 pg/mL). Further studies in larger cohorts are necessary to validate these results.

We report a case of recurrent left atrial (LA) intimal sarcoma invading pulmonary veins (PV) which was treated by a novel surgical approach—resecting LA wall and PVs down to segmental levels, and then creating neo-LA using lung hilum and posterior mediastinal soft tissue without further reconstructive procedures. This surgical approach may be useful in selected cases with primary cardiac malignancy involving LA and PVs in the aim of achieving complete resection of the tumor. Left heart sarcoma is an extremely uncommon but lethal disease which poses challenges to physicians due to its equivocal presentation, limited treatment option and dismal prognosis. Although the mainstay of treatment is a complete resection, it is technically demanding due to a lack of extensive experience in cardiac malignancy surgery and its very location or involvement in vital structures. Therefore, establishing a creative surgical strategy to overcome aforementioned obstacles and to achieve complete resection with tumor-free resection margin is needed. Here in, we report a case of recurrent left atrial sarcoma which was removed by noteworthy surgical technique.

Background Sarcopenia, known as physical frailty, is highly prevalent in older patients and is related to adverse outcomes post-cardiac surgery. However, whether sarcopenia assessment can reclassify an individual patients’ risk, which is estimated by Society of Thoracic Surgeons-predicted risk of mortality scores in patients who undergo surgical aortic valve replacement, is unclear. Methods This retrospective, single center, cohort study comprised 874 patients aged ≥65 years who underwent surgical aortic valve replacement between 2009 and 2016. Total skeletal muscle area was calculated using height-squared and was measured by preoperative computed tomography at the third lumbar vertebra inferior border using machine learning-based analysis. Sex-specific Z-scores were calculated and patients in the lowest Z-score tertile were considered to have sarcopenia. The primary endpoint was 30-day mortality, and secondary endpoints were in-hospital events, 1-year mortality, and long-term mortality. Results Thirty-day mortality, 30-day in-hospital events, and one-year mortality rates were 4.7%, 17.6%, and 8.0%, respectively. As the Z-score decreased, early adverse event odds showed a stepwise increase. Sarcopenia were independently associated with higher 30-day mortality, 30-day in-hospital events, and 1-year mortality. Reclassification analyses showed improvements in the ability to predict early adverse events after adding the Z-scores over and above the Society of Thoracic Surgeons-predicted risk of mortality scores (All, p Conclusions Sarcopenic patients had significantly higher risks of early adverse events and long-term mortality after undergoing surgical aortic valve replacement than non-sarcopenic patients. Sarcopenia determined by preoperative computed tomography can enhance the prediction of postoperative outcome risk.

OBJECTIVES With the goal of evaluating the impact of experiences at our centre on comparative outcomes between total arch and hemiarch repairs, we reviewed our 21 years of experience with operations for acute type I aortic dissection. METHODS Between 1999 and 2019, a total of 365 patients (177 women; 56.8 ± 12.9 years) with acute type I aortic dissection who had a hemiarch (n = 248) or a total arch replacement (n = 117) were evaluated, and the trends in comparative outcomes were analysed. RESULTS Over time, deep hypothermic circulatory arrest and retrograde cerebral perfusion were replaced by moderate hypothermia and antegrade cerebral perfusion with the introduction of dedicated aortic surgeons. Overall, operative deaths decreased from 11.0% in time quartile 1 to 2.2% in time quartile 4 (P = 0.090). After adjustment with the use of inverse probability weighting, the total arch group compared with the hemiarch group was at a similar risk of mortality [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.22–2.43; P = 0.71] but at a greater risk of neurological deficit (OR 3.28, 95% CI 1.23–8.98; P = 0.017) in the earlier half period (1999–2009). In the later period (2009–2019), however, both the risks of mortality (OR 0.32, 95% CI 0.03–1.59; P = 0.23) and of neurological injuries (OR 0.42, 95% CI 0.12–1.18; P = 0.13) were comparable between the 2 groups (P for interaction in terms of neurological deficit = 0.007). The multivariable logistic regression model revealed that dedicated aortic surgeons independently contributed to decreased risk of death (OR 0.30, 95% CI 0.09–0.84; P = 0.036). CONCLUSIONS These findings indicate that accumulating institutional experiences, along with resultant improvements in surgical strategies and outcomes, may neutralize the surgical risk gap between total arch and hemiarch repair in acute type I aortic dissection.

Background We aimed to evaluate the effect of limited volume of hydroxyethyl starch (HES) administration on postoperative renal function in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). Methods One thousand six hundred fifty-seven patients undergoing cardiac surgery under CPB over two years were included. The patients were divided according to the amount of HES administrated during the first 2 days post-surgery; moderate dose HES (≥20 ml/kg) versus low dose HES ( Results Incidence of acute kidney injury (AKI) was higher in the moderate HES group (p = .02). However, new renal replacement therapy (RRT) (P = .30) and early mortality (p = .97) was similar between the groups. When adjusted, the moderate HES use was associated with AKI (OR, 1.66; 95% CI, 1.12–2.44; p = .01), but did not increase the risk of new RRT (OR, 1.27; 95% CI, 0.71–2.18; p = .40) or early mortality (HR, 0.73; 95% CI, 0.29–1.81; p = .50). Conclusions The moderate dose administration of HES (≥20 ml/kg) in the postoperative period following cardiac surgery might be associated with the risk of AKI. However, it was not associated with serious adverse outcomes such as new RRT or mortality. Further randomized controlled studies are needed to validate study results.

Deterioration of the native aortic valve function by a late progression of rheumatic disease is not infrequent in patients who underwent rheumatic mitral valve surgery; however, this phenomenon has not been clearly quantified.A total of 1155 consecutive patients (age 52.0 ± 12.9 years; 807 female) who underwent rheumatic mitral valve surgery without concomitant aortic valve surgery from 1997 to 2015 were enrolled. The primary end point was the composite of progression to severe aortic valve dysfunction or a requirement of subsequent aortic valve replacements during follow-up. To determine the risk factors of the primary outcome, we performed the generalized linear mixed model.The baseline severities of aortic valve were none to trivial in 880 patients (76.2%), mild in 256 patients (22.2%), and moderate in 19 patients (1.6%). The latest 1062 echocardiographic assessments (91.9%; median, 81.2 postoperative months; interquartile range, 37.3-132.1 months) demonstrated 26 cases (0.33%/patient-year) meeting the primary end point during follow-up. Cumulative incidence of the primary end point at 10 years was 0.4% ± 0.3% and 7.4% ± 2.5% depending on the presence of mild or greater aortic valve dysfunction at baseline (P .01). In multivariable analyses, aortic valve peak pressure gradient (odds ratio, 1.14; 95% confidence interval, 1.10-1.20), aortic regurgitation degree (mild over none: odds ratio, 3.26; 95% confidence interval, 1.15-9.23), and time (odds ratio, 1.30; 95% confidence interval 1.19-1.41) were significantly associated with the occurrence of the primary end point.Progression of severe aortic valve dysfunction and the need for aortic valve replacement are uncommon in patients undergoing rheumatic mitral valve surgery. However, such events were relatively common among those with mild or greater aortic valve dysfunction at the time of mitral valve surgery.

Background: Attaining an adequate effective orifice area (EOA) is definitive goal in aortic valve replacement (AVR). The simple interrupted suture (SIS) technique could be a solution to achieve this goal, but limited data are available in the literature. This study aimed to compare hemodynamic differences between the SIS and non-everting mattress suture (NMS) techniques. Methods: From our database, 215 patients who underwent AVR for severe aortic stenosis were extracted to form the overall cohort. From March 2015 to November 2016, the SIS technique was used in 79 patients, while the NMS technique was used in 136 patients. Hemodynamic outcomes were evaluated, as detected by transthoracic echocardiography and computed tomography. Results: There were no significant differences in baseline characteristics between the 2 groups. On immediate postoperative echocardiography, the SIS group showed a significantly wider EOA (1.6±0.4 vs. 1.4±0.5 cm2, p=0.007) and a lower mean pressure gradient (PG) (13.3±5.4 vs. 17.0±6.0 mm Hg, p

Complete surgical resection is the most critical factor to achieve better long-term outcomes in treating primary cardiac sarcomas; however, it is oftentimes hampered when there is extensive tumor involvement into important cardiac apparatus. Here, we report a case of successful complete resection of a cardiac sarcoma infiltrating the right atrioventricle, tricuspid valve, and right coronary artery.

Neo-aortic insufficiency associated with root enlargement following an arterial switch operation is a serious late complication. To achieve successful surgical correction of this condition, multiple factors should be considered, including the individual patient’s anatomy, the challenging nature of the redo procedure, and the patient’s young age. However, limited publications have described the use of valve-sparing techniques for the treatment of neo-aortic insufficiency associated with root enlargement following an arterial switch operation. Herein, we report our recent experience of a valve-sparing aortic root procedure with ascending aorta and hemiarch replacement despite the presence of a discrepancy in leaflet size and nearby severe adhesions.

A 61-year-old woman who presented with claudication and dyspnea on exertion was found to have severe calcified narrowing of the descending aorta and severe insufficiency of the aortic valve. These findings were compatible with Takayasu arteritis. To treat these hemodynamic abnormalities, extra-aortic bypass surgery combined with replacement of the aortic valve and ascending aorta-to-hemiarch replacement was performed through a separated upper hemi-sternotomy and limited median laparotomy. We present our successful surgical experience with this case.

Background: Fluid resuscitation is critical to perioperative maintenance of adequate preload and cardiac output after cardiac surgery. Liberal use of saline, however, is reportedly associated with an increased risk of acute kidney injury (AKI) in critically ill patients. This study examined the effects of high- versus low-volume saline administration on AKI after cardiac surgery. Methods: In this retrospective study, we evaluated 1,740 consecutive patients who underwent cardiac surgery over a 2-year period. The patients were divided into high-volume saline (n=328, 18.8%) and low-volume saline (n=1,412, 81.2%) groups based on the amount of saline (>1 or ≤1 L, respectively) administered during the first 48 postoperative hours. Results: AKI, the primary outcome, was defined according to the Risk, Injury, Failure, Loss, End Stage classification. There were no significant differences in the incidence of AKI (P=0.46), new renal replacement therapy (RRT) (P=0.39), and early mortality (P=0.52) between the 2 groups. Adjustment of baseline characteristics using propensity score matching showed that high-volume of saline administration was not significantly associated with an increased risk of AKI (OR, 1.22; 95% CI, 0.77–1.93; P=0.38), new RRT (OR, 1.25; 95% CI, 0.68–2.28; P=0.45), or early mortality (HR, 0.98; 95% CI, 0.48–2.02; P=0.97). These results were validated by further adjustments for significant covariates. Conclusions: High-volume administration of saline in the period following cardiac surgery was not associated with a significant increase in the risk of AKI.