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Representative neonatal surgical diseases are often complicated by congenital heart disease (CHD). We reviewed our decade of experience from the perspective of the prognosis and report on the management of infants with CHD.Cases with and without CHD between 2011 and 2020 were retrospectively compared. Qualitative data were analyzed using a chi-square test with Yates' correction, and quantitative data were compared using Student's t-test.Of the 275 neonatal surgical cases, 36 had CHD (13.1%). Ventricular septal defect was the most common cardiac anomaly, followed by atrial septal defect. Esophageal atresia showed the highest complication rate of CHD (43.8%, 14/32) followed by duodenal atresia (38.5%, 10/26). The mortality rates of patients with and without CHD (22.2% [8/36] vs. 1.3% [3/239]) were significantly different (χConsidering its high-mortality, the presence of CHD, especially cyanotic heart disease, is an important issue to consider in the treatment of neonatal surgical diseases. Pediatric surgeons should be alert for changes in hemodynamics after surgery, as these may affect mortality.

Background and aim of the study: Coronary artery fistula (CAF) is a relatively rare cardiac anomaly. We investigated long-term outcomes following surgical repair of CAF in adults. Methods: We retrospectively investigated 13 consecutive patients undergoing surgical repair of CAF in our institution between 2008 and 2019 (67.3±10.4 years old, 38% male). CAF types were coronary artery-pulmonary artery fistula (77%), coronary artery-coronary sinus fistula (15%), and both (8%). CAFs originated from the left coronary artery (38%), right coronary artery (8%), and bilateral coronary arteries (38%). Pulmonary and systemic flow (Qp/Qs) was measured in seven patients (54%), with a mean value of 1.52. Seven patients underwent surgery for CAFs alone, and others simultaneously underwent surgery for comorbid cardiac diseases. Results: All procedures were conducted under cardiopulmonary bypass. Surgical procedures were direct epicardial ligation of fistula (92%), direct closure of CAF through pulmonary artery incision (38%), direct closure of CAF through coronary sinus incision (8%), or patch closure of CAF through coronary artery incision (8%). Myocardial perfusion scintigraphy showed asymptomatic myocardial ischemia in the right coronary area after surgery in one patient. There were no deaths perioperatively or during follow-up (mean 66.6 months). There were no coronary or other CAF-related events. Conclusions: Several anatomical variations in CAF were observed which coexist with cardiac disease. Long-term outcomes following surgical repair were satisfactory, and the concurrent intervention of CAFs during surgery for comorbid cardiac disease is useful to prevent future complications related CAFs in adults.

The treatment of coronary artery disease has substantially changed over the past two decades. However, it is unknown whether and how much these changes have contributed to the improvement of long-term outcomes after coronary revascularization. We assessed trends in the demographics, practice patterns and long-term outcomes in 24,951 patients who underwent their first percutaneous coronary intervention (PCI) (n = 20,106), or isolated coronary artery bypass grafting (CABG) (n = 4,845) using the data in a series of the CREDO-Kyoto PCI/CABG Registries (Cohort-1 [2000 to 2002]: n = 7,435, Cohort-2 [2005 to 2007]: n = 8,435, and Cohort-3 [2011 to 2013]: n = 9,081). From Cohort-1 to Cohort-3, the patients got progressively older across subsequent cohorts (67.0 ± 10.0, 68.4 ± 9.9, and 69.8 ± 10.2 years, ptrend

BACKGROUND The effect of multiple prior percutaneous coronary interventions (PCIs) before subsequent coronary artery bypass grafting (CABG) on long-term outcomes has not been well elucidated.Methods and Results:Between 2007 and 2016, 1,154 patients undergoing primary isolated CABG in our institution had no prior PCI (Group N), 225 had a single prior PCI (Group S), and 272 had multiple prior PCIs (Group M). Cumulative incidences of all-cause death, cardiac death and myocardial infarction (MI) at 10 years post-CABG were highest in Group M. After adjusting for confounders, the risk of all-cause death was higher in Group M than in Group N (hazard ratio [HR] 1.45; 95% confidence interval [CI], 1.10-1.91; P

There is a scarcity of data comparing long-term clinical outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three-vessel coronary artery disease (3VD) in the new-generation drug-eluting stents era. CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who had undergone first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. We identified 2525 patients with 3VD (PCI: n = 1747 [69%], and CABG: n = 778 [31%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.7 (interquartile range: 4.4 to 6.6) years. The cumulative 5-year incidence of all-cause death was significantly higher in the PCI group than in the CABG group (19.8% vs 13.2%, log-rank p = 0.001). After adjusting confounders, the excess risk of PCI relative to CABG for all-cause death remained significant (HR, 1.45; 95% CI, 1.14 to 1.86; p = 0.003), which was mainly driven by the excess risk for non-cardiovascular death (HR, 1.88; 95% CI, 1.30 to 2.79; p = 0.001), while there was no excess risk for cardiovascular death between PCI and CABG (HR, 1.19; 95% CI, 0.87 to 1.64; p = 0.29). There was significant excess risk of PCI relative to CABG for myocardial infarction (HR, 1.77; 95% CI, 1.19 to 2.69; p = 0.006), whereas there was no excess risk of PCI relative to CABG for stroke (HR, 1.24; 95% CI, 0.83 to 1.88; p = 0.30). In conclusion, in the present study population reflecting real-world clinical practice in Japan, PCI compared with CABG was associated with significantly higher risk for all-cause death, while there was no excess risk for cardiovascular death between PCI and CABG.

There is a scarcity of data on incidence, risk factors, especially clinical severity, and long-term prognostic impact of periprocedural stroke after coronary revascularization in contemporary real-world practice. Among 14,867 consecutive patients undergoing first coronary revascularization between January 2011 and December 2013 (percutaneous coronary intervention [PCI]: N = 13258, and coronary artery bypass grafting [CABG]: N = 1609) in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG registry Cohort-3, we evaluated the details on periprocedural stroke. Periprocedural stroke was defined as stroke within 30 days after the index procedure. Incidence of periprocedural stroke was 0.96% after PCI and 2.13% after CABG (log-rank p0.001). Proportions of major stroke defined by modified Rankin Scale ≥2 at hospital discharge were 68% after PCI, and 77% after CABG. Independent risk factors of periprocedural stroke were acute coronary syndrome (ACS), carotid artery disease, advanced age, heart failure, and end-stage renal disease after PCI, whereas they were ACS, carotid artery disease, atrial fibrillation, chronic obstructive pulmonary disease, malignancy, and frailty after CABG. There was excess long-term mortality risk of patients with periprocedural stroke relative to those without after both PCI and CABG (hazard ratio 1.71 [1.25 to 2.33], and hazard ratio 4.55 [2.79 to 7.43]). In conclusion, incidence of periprocedural stroke was not negligible not only after CABG, but also after PCI in contemporary real-world practice. Majority of patients with periprocedural stroke had at least mild disability at hospital discharge. ACS and carotid artery disease were independent strong risk factors of periprocedural stroke after both PCI and CABG. Periprocedural stroke was associated with significant long-term mortality risk after both PCI and CABG.

Cardiac myxoma is a benign primary cardiac tumor. Herein, we report a case of mitral regurgitation due to annular dilatation caused by giant left atrial myxoma. The transthoracic echocardiogram performed in a 65-year-old man who suffered from worsening exertional dyspnea detected a large mass of 81 × 31 mm in the left atrium, causing functional severe mitral stenosis. Radical mass resection was performed. After removal of the aortic clamp, an intraoperative transesophageal echocardiogram revealed moderate mitral regurgitation due to annulus dilatation. Mitral annuloplasty was performed, and mitral regurgitation was controlled. The mass was diagnosed as myxoma histologically. A large myxoma that affects mitral annulus dilatation is rarely reported. Mitral regurgitation may be masked by the presence of a large myxoma. Therefore, it should be carefully evaluated after resection, and mitral annuloplasty should be considered in the presence of significant mitral regurgitation due to mechanical annulus dilatation caused by myxoma.

BackgroundOptimal treatment for aortic thrombus remains to be determined, but surgical treatment is indicated when there is a risk for thromboembolism. Case PresentationA 47-year-old male presented with weakness in his left arm upon awakening. Contrast-enhanced computed tomography and transesophageal echocardiography revealed a mobile pedunculated object suggestive of a thrombus arising from the ascending aorta and extending to the left common carotid artery. It was removed under hypothermic circulatory arrest and direct cannulation of the left carotid artery to avoid carotid thromboembolism. Histopathological examination revealed that the object was a thrombus. The patient had an uneventful postoperative course and was discharged 9 days after surgery. ConclusionWhen a thrombus in the aortic arch extends to the neck arteries, direct cannulation of the neck arteries with selective cerebral perfusion via cervical incision is a useful technique.

Diabetes is a well-known risk factor for adverse outcomes after coronary revascularization.This study sought to determine high-risk subgroups in whom the excess risks of diabetes relative to nondiabetes are particularly prominent and thus may benefit from more aggressive interventions.The study population consisted of 39,427 patients (diabetes: n = 15,561; nondiabetes: n = 23,866) who underwent first percutaneous coronary intervention (n = 33,144) or coronary artery bypass graft (n = 6,283) in the pooled CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Graft) registry. The primary outcome measure was major adverse cardiovascular and cerebral endpoints (MACCE), which was defined as a composite of all-cause death, myocardial infarction, and stroke.With median follow-up of 5.6 years, diabetes was associated with significantly higher adjusted risks for MACCE. The excess adjusted risks of diabetes relative to nondiabetes for MACCE increased with younger age (≤64 years: adjusted HR: 1.30; 95% CI: 1.19-1.41;The excess risk of diabetes relative to nondiabetes for MACCE was profound in the younger population. This observation suggests more aggressive interventions for secondary prevention in patients with diabetes might be particularly relevant in younger patients.

In the era of expanding transcatheter aortic valve implantation (TAVI) indications for low surgical risk patients, conduction disturbances requiring permanent pacemaker implantation (PPI) after TAVI remain a serious concern. We aimed to assess the impact of the radiolucent line-guided technique for the SAPIEN 3 implantation on reducing the rates of new-onset PPI after TAVI. A total of 326 patients treated with the SAPIEN 3 using either the radiolucent line-guided technique (lucent group, 170 patients [52.1%]) or the center marker-guided technique (conventional group, 156 patients [47.9%]) were prospectively included in our database. The prosthesis position, and 30-day and 3-year clinical outcomes were retrospectively assessed. Compared with the conventional group, the lucent group had a higher prosthesis position (1.7 ± 0.9 mm vs 4.2±1.5 mm, p0.001) and lower 30-day PPI rates (2.9% vs 13.5%, p0.001). The other periprocedural complications including valve dislodgement and coronary obstruction, and 30-day and 3-year mortality were comparable between the groups. However, the prosthesis frame extending above sinotubular junction was more frequently observed in the lucent group on the side of left coronary sinus (53.4% vs 31.4%, p0.001) and right coronary sinus (35.0% vs 20.2%, p = 0.001), signifying a potential risk for "subsequent difficulties to access coronary ostia" and "coronary obstruction during future redo TAVI." In conclusion, the radiolucent line-guided technique predictably provided an extremely high position of the SAPIEN 3, reducing the postprocedural PPI rates compared with the center marker-guided technique.

Background Heart failure might be an important determinant in choosing coronary revascularization modalities. There was no previous study evaluating the effect of heart failure on long‐term clinical outcomes after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG). Methods and Results Among 14 867 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013 in the CREDO‐Kyoto PCI/CABG registry Cohort‐3, we identified the current study population of 3380 patients with three‐vessel or left main coronary artery disease, and compared clinical outcomes between PCI and CABG stratified by the subgroup based on the status of heart failure. There were 827 patients with heart failure (PCI: N=511, and CABG: N=316), and 2553 patients without heart failure (PCI: N=1619, and CABG: N=934). In patients with heart failure, the PCI group compared with the CABG group more often had advanced age, severe frailty, acute and severe heart failure, and elevated inflammatory markers. During a median 5.9 years of follow‐up, there was a significant interaction between heart failure and the mortality risk of PCI relative to CABG (interaction P =0.009), with excess mortality risk of PCI relative to CABG in patients with heart failure (HR, 1.75; 95% CI, 1.28–2.42; P P =0.77). Conclusions There was a significant interaction between heart failure and the mortality risk of PCI relative to CABG with excess risk in patients with heart failure and neutral risk in patients without heart failure.

BACKGROUND In the current guidelines, indications for transcatheter aortic valve implantation (TAVI) are expanded to include several subgroups of asymptomatic patients with severe aortic stenosis (AS), and there is a paucity of data on the prognostic impact of New York Heart Association (NYHA) functional class in patients with severe AS undergoing TAVI. METHODS Among 2588 patients enrolled in the OCEAN-TAVI registry, patients were divided into 4 groups according to baseline NYHA class (class I in 95 patients, class II in 1172 patients, class III in 1126 patients, and class IV in 195 patients). RESULTS Median follow-up was 729 days. The cumulative 2-year incidence of all-cause death was significantly higher in patients with NYHA class IV and III than in those with NYHA class II and I. (30.0%, 21.3%, 13.4%, and 11.2%, respectively, P < 0.001). After adjusting confounders, NYHA class IV and III, but not NYHA class II were independently associated with higher mortality compared with NYHA class I (reference) (adjusted HR: 3.43, 95%CI: 1.83-7.15, P < 0.001; adjusted HR: 2.07, 95%CI: 1.15-4.19, P = 0.013; and adjusted HR: 1.50, 95%CI: 0.83-3.04, P = 0.19, respectively). With increasing NYHA class, there was an incremental increase of heart failure hospitalization in the effect size relative to the reference (NYHA class I). CONCLUSIONS The long-term outcomes of patients with NYHA class I were better than those with NYHA class IV or III in some selected patients undergoing TAVI.

A 66-year-old-man who had undergone partial aortic arch and descending aortic graft replacement for a dissecting aortic aneurysm presented to our hospital with pain and beating swelling of his left back shoulder. Enhanced computed tomography and aortic angiography revealed graft rupture caused by one of the claws of a rib fixation strut. Furthermore, another claw had invaded a lung. We performed emergency thoracic endovascular aortic repair, and removed all of the struts 3 weeks later. Claw-type rib fixation struts have the potential to injure other organs, including prosthetic grafts. Careful follow-up is mandatory after implantation of this type of strut.

ObjectivesTo evaluate patient characteristics and long-term outcomes in patients with non–ST-segment elevation acute coronary syndrome (NSTEACS) in the past two decades.DesignMulticenter retrospective study.SettingThe Coronary REvascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG) Registry Cohort-2 (2005–2007) and Cohort-3 (2011–2013).Participants3254 patients with NSTEACS who underwent first coronary revascularisation.Primary and secondary outcome measuresThe primary outcome was all-cause death. The secondary outcomes were cardiovascular death, cardiac death, sudden cardiac death, non-cardiovascular death, non-cardiac death, myocardial infarction, definite stent thrombosis, stroke, hospitalisation for heart failure, major bleeding, any coronary revascularisation and target vessel revascularisation.ResultsPatients in Cohort-3 were older and more often had heart failure at admission than those in Cohort-2. The prevalence of PCI, emergency procedure and guideline-directed medical therapy was higher in Cohort-3 than in Cohort-2. In patients who received PCI, the prevalence of transradial approach, drug-eluting stent use and intravascular ultrasound use was higher in Cohort-3 than in Cohort-2. There was no change in 3-year adjusted mortality risk from Cohort-2 to Cohort-3 (HR 1.00, 95% CI 0.83 to 1.22, p=0.97). Patients in Cohort-3 compared with those in Cohort-2 were associated with lower adjusted risks for stroke (HR 0.65, 95% CI 0.46 to 0.92, p=0.02) and any coronary revascularisation (HR 0.76, 95%CI 0.66 to 0.87, pConclusionsIn the past two decades, we did not find improvement for mortality in patients with NSTEACS. We observed a reduction in the risks for definite stent thrombosis, stroke and any coronary revascularisation, but an increase in the risk for major bleeding.

OBJECTIVES To determine the incidence of bioprosthetic structural valve deterioration in dialysis patients undergoing aortic valve replacement compared to that in patients without dialysis. METHODS This single-centre retrospective observational study included 1159 patients who underwent aortic valve replacement using bioprosthetic valves for aortic stenosis and/or regurgitation at our institution between 2007 and 2017 [patients with dialysis (group D, n = 134, 12%) or without dialysis (group N, n = 1025, 88%)]. To adjust for potential differences between groups in terms of initial preoperative characteristics or selection bias, a propensity score analysis was conducted. The final sample that was used in the comparison included 258 patients, as follows: 129 patients with dialysis (group D) and 129 patients without dialysis (group N). The cumulative incidences of all-cause death, cardiac death and moderate or severe structural valve deterioration were estimated using the Kaplan–Meier method. RESULTS Operative mortality was significantly higher in group D than group N (9% vs 0%, P = 0.001). Kaplan–Meier analysis revealed that in group D, the incidence was significantly higher for all-cause death (P CONCLUSIONS The incidence of structural valve deterioration in dialysis patients undergoing aortic valve replacement was higher than that in patients without dialysis. Bioprosthetic valves should be carefully selected in dialysis patients undergoing aortic valve replacement.

Chronic kidney disease (CKD) might be an important determinant in choosing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). However, there is a scarcity of studies evaluating the effect of CKD on long-term outcomes after PCI relative to CABG in the population including severe CKD. Among 30257 consecutive patients patients who underwent first coronary revascularization with PCI or isolated CABG in the CREDO-Kyoto PCI/CABG registry Cohort-2 (n = 15330) and Cohort-3 (n = 14,927), we identified the current study population of 12,878 patients with multivessel or left main disease, and compared long-term clinical outcomes between PCI and CABG stratified by the subgroups based on the stages of CKD (no CKD: eGFR >=60 ml/min/1.73m2, moderate CKD: 60> eGFR >=30 ml/min/1.73m2, and severe CKD: eGFR

Long-term safety of percutaneous coronary intervention (PCI) as compared with coronary artery bypass grafting (CABG) is still controversial in patients with unprotected left main coronary artery disease (ULMCAD), and there is a scarcity of real-world data on the comparative long-term clinical outcomes between PCI and CABG for ULMCAD in new-generation drug-eluting stents era. The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013, and we identified 855 patients with ULMCAD (PCI: N = 383 [45%], and CABG: N = 472 [55%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.5 (interquartile range: 3.9 to 6.6) years. The cumulative 5-year incidence of all-cause death was not significantly different between the PCI and CABG groups (21.9% vs 17.6%, Log-rank p = 0.13). After adjusting confounders, the excess risk of PCI relative to CABG remained insignificant for all-cause death (HR, 1.00; 95% CI, 0.68 to 1.47; p = 0.99). There were significant excess risks of PCI relative to CABG for myocardial infarction and any coronary revascularization (HR, 2.07; 95% CI, 1.30 to 3.37; p = 0.002, and HR, 2.96; 95% CI, 1.96 to 4.46; p0.001), whereas there was no significant excess risk of PCI relative to CABG for stroke (HR, 0.85; 95% CI, 0.50 to 1.41; p = 0.52). In conclusion, there was no excess long-term mortality risk of PCI relative to CABG, while the excess risks of PCI relative to CABG were significant for myocardial infarction and any coronary revascularization in the present study population reflecting real-world clinical practice in Japan.

An 81-year-old female developed dyspnea only upon assuming a sitting position. Trans-esophageal echocardiography demonstrated left-to-right shunt flow across the atrial septum when the patient was sitting, and right-to-left shunt flow when she was supine, along with severe aortic insufficiency. She was diagnosed as having platypnea-orthodeoxia syndrome and her symptoms were completely resolved following aortic valve replacement, closure of a patent foramen ovale, and shortening of an elongated ascending aorta.

Objective To investigate the influence of choice of prosthesis (bioprosthetic valves or mechanical valves) on intermediate-term outcomes in patients on hemodialysis undergoing aortic valve replacement (AVR). Methods A multi-institutional retrospective cohort study was conducted in 18 Japanese centers. All adult patients on chronic hemodialysis who underwent AVR from 2008 and 2015 were included (n = 491). The early and late results were compared between groups. The hazard ratios were calculated using Cox regression and Fine–Gray models with adjustment for propensity score based on 41 confounders. The mean follow-up period was 2.5 ± 2.1 years (up to 8.3 years) with 98% completeness. Results There were 323 patients who received a bioprosthetic valve (group B), and 168 patients who received a mechanical valve (group M). There was no significant difference for in-hospital death rate between groups (group B: 12.1%; group M: 8.9%; P = .29). The overall survival rate at 5 years after surgery was 39.3% in group B and 50.4% in group M (P = .42). Freedom from reoperation at 5 years was 97.1% in group B and 97.8% in group M (P = .88). On propensity-score adjusted analyses, there were no significant differences in overall survival between groups. Conclusions There were no significant differences in overall survival between bioprosthetic valves and mechanical valves in patients on hemodialysis undergoing AVR.

症例は34歳，女性．失神を契機に不整脈の精査目的に近医受診．経胸壁心エコー検査にて右房内に腫瘍を認めたため当院紹介となった．術前胸部CT検査にて右房内に約4×3cmの腫瘍を認め腫瘍摘出術を施行した．手術は人工心肺下に腫瘍摘出および心房中隔および左房壁欠損部の自己心膜による修復術を施行した．病理診断にて摘出された腫瘍は血管筋脂肪腫と診断された．血管筋脂肪腫は結節性硬化症に関連した腎臓に認められる良性腫瘍がよく知られているが，心臓原発の血管筋脂肪腫はこれまでにも数例の報告しかなく非常に稀な腫瘍であり報告する．なお，本症例では結節性硬化症との関連は認められなかった．

Objective Wound infection is a rare but life-threatening complication after coronary artery bypass grafting. Risk factors for wound infection after off-pump bypass grafting and the validity of using bilateral internal thoracic arteries harvested in a skeletonized fashion remain unclear, especially in patients with diabetes. Methods The data of 1500 consecutive patients having off-pump bypass grafting were prospectively collected from our database based on EuroSCORE. This cohort represents 95% of all patients undergoing coronary bypass during that period and 77% of patients undergoing off-pump bypass grafting who received bilateral internal thoracic artery grafts. Univariate and multivariate analyses were performed for patients with and without wound infection and in the diabetic subgroup. Results Ninety-eight patients had wound infections: 76, impaired wound healing; 7, superficial sternal wound infection; and 12, deep sternal wound infection. Patients with wound infections had a higher prevalence of female gender, atrial fibrillation, history of congestive heart failure, chronic renal failure, peripheral vascular disease, and diabetes. Patients with a wound infection more frequently had bilateral internal thoracic artery grafting, longer operation time, longer hospital stay, and a higher mortality rate. Blood transfusions were required in 43.9% of patients with wound infections and 28.1% of those without wound infections. On logistic regression analysis, female gender and history of congestive heart failure, chronic renal failure, and diabetes mellitus were independent risk factors for wound infection. In patients with diabetes, female gender, atherosclerosis obliterans, chronic renal failure, and use of bilateral internal thoracic artery grafts were independent risk factors for wound infection. Conclusions Risk factors for wound infection after off-pump coronary artery bypass grafting are comparable with those previously reported for conventional bypass grafting. In patients with diabetes, the use of bilateral internal thoracic arteries, even when harvested in a skeletonized fashion, is a risk factor. Thus, appropriate precautions should be taken in patients with diabetes.

Endoscopic saphenous vein harvesting (ESVH) requires a high degree of technical expertise. However, few studies have investigated the influence of SV caliber on the technical difficulty and outcome of ESVH. We analyzed 86 consecutive patients who underwent ESVH using a VirtuoSaph(trade mark) system. SV caliber was measured in the above-knee portion by ultrasound. Patients were then divided into two groups: group A (SV caliber

Recently we have developed new sustained release system of basic fibroblast growth factor (bFGF) using gelatin hydrogel as a carrier. Using this system, we examined the effect of topical sustained release of bFGF on angiogenesis and tissue blood perfusion in a rabbit model of hind limb ischemia. Thirty-two rabbits underwent excision of right femoral artery under general anesthesia. Two weeks later the rabbits were randomized into four groups (n = 8 each): no treatment, intramuscular injection of gelatin hydrogel alone, and intramuscular injection of gelatin hydrogel incorporating 30 microg and 100 microg of bFGF. Four weeks after each treatment, selective angiography, tissue blood flowmetry using laser Doppler perfusion imaging, and histological examination of thigh muscle were performed. In groups treated with bFGF incorporating gelatin hydrogel, tissue blood flow, number of arterioles, and vascular density were significantly increased in a dose-dependent manner 4 weeks after the treatment. Serum concentrations of bFGF and vascular endothelial growth factor were not elevated 4 weeks after the treatment. In conclusion, sustained release of bFGF using gelatin hydrogel augmented angiogenesis and improved tissue blood flow after excision of the femoral artery.

To evaluate the size adequacy of CarboMedics prosthetic heart valves, Doppler pressure gradients after aortic valve replacement were determined at rest and immediately after exercise in 83 patients, at a mean time of 18.8 days after aortic valve replacement with CarboMedics prosthetic heart valves (31 standard and 52 R-series). There were 54 males and 29 females, average age 55 years; 12 had pure aortic stenosis, 47 had aortic regurgitation, and 24 had combined lesions. Exercise significantly increased (p < 0.01) the peak velocity (from 2.50 to 2.88 m/sec), the peak pressure gradient (from 25.9 to 34.6 mm Hg), and the mean pressure gradient (from 13.9 to 18.4 mm Hg). Significant differences were observed even in patients with seemingly large valve sizes. Significant correlation (p < 0.0001) was observed between pressure gradients at rest and immediately after exercise, as well as between pressure gradients and theoretical performance index. A theoretical performance index larger than 1.0 cm2/m2 was needed to obtain a postexercise Doppler peak pressure gradient of less than 60 mm Hg early after aortic valve replacement using either the Carbomedics standard or R-series prosthetic heart valves.

We report a successful one-stage biventricular repair of truncus arteriosus communis with interrupted aortic arch in a neonate. This newborn girl was diagnosed with truncus arteriosus communis type III-B (Congenital Heart Surgeons Society classification) by the echocardiography and three-dimensional computed tomography. We present a new reconstructive approach for such heart defects, involving a modified Lecompte maneuver combined with arch reconstruction, by suturing the ascending aorta to the descending aorta in end-to-end fashion called the swing-back technique.

Coronary angiography (CAG) was performed in a 77-year-old woman who presented with chest discomfort. The CAG showed two diseased vessels. For treatment, the patient underwent angioplasty and stenting. During intravascular ultrasonography (IVUS) following stent deployment, the IVUS catheter became entrapped in the left anterior descending coronary artery, causing ischemic changes in the anterolateral wall, which were apparent on the electrocardiogram. The patient underwent emergency coronary artery bypass grafting and removal of the entrapped IVUS catheter.

OBJECTIVE Chymase, a serine protease, is released from mast cells, which is closely associated with adhesion formation. Chymase activates transforming growth factor-beta1 (TGF-beta1), which promotes tissue fibrosis. Recently we have found that chymase may play an important role in adhesion formation in hamsters. Accordingly, this study was designed to confirm that a chymase inhibitor prevents postoperative cardiac adhesions in large animals. METHODS In 14 dogs, the epicardium was abraded 200 times with gauze and the mid-portion of the left anterior descending coronary artery (LAD) was exposed with No. 15 blade. Either chymase inhibitor (CI group, n = 7) or placebo (P group, n = 7) was sprayed into the pericardial cavity, then the pericardium was closed. Cardiac chymase activity, the level of TGF-beta1 in the pericardial fluid, the density of epicardial mast cells, the adhesion area between the heart and the pericardium, and the presence of adhesion between the mid-LAD and the pericardium were evaluated 1 and 2 months after surgery. Five nonsurgical dogs were used as a control for cardiac chymase activity. RESULTS Cardiac chymase activity and TGF-beta1 level were lower in CI group than in P group (53.7 +/- 35.0 vs. 93.4 +/- 20.4 microU/mg protein, p = 0.01, 3.2 +/- 0.9 vs. 4.3 +/- 1.1 microg/mL, p = 0.06, respectively). In CI group, the density of mast cells (19 +/- 5 vs. 32 +/- 8 cells/cm, p < 0.01), the adhesion area (2.2 +/- 0.8 vs. 7.5 +/- 1.5 cm2, p < 0.01), and adhesions between the heart and the mid-LAD (0% vs. 57%) were all reduced. CONCLUSION Chymase inhibitor suppresses cardiac chymase activity and reduces the TGF-beta1 level, resulting in a reduction of cardiac adhesion in a large animal.

Undersized mitral annuloplasty (MAP) is effective in patients with dilated cardiomyopathy and functional mitral regurgitation (MR) since, as well as addressing the MR, the MAP may also reshape the dilated left ventricular (LV) base. However, the direct benefits of this possible reshaping on LV function in the absence of underlying MR remain incompletely understood. The study aim was to identify these benefits in a canine model of acute heart failure.Six dogs underwent MAP with a prosthetic band on the posterior mitral annulus, using four mattress sutures. The sutures were passed individually through four tourniquets and exteriorized untied via the left atriotomy. Sonomicrometry crystals were implanted around the mitral annulus and left ventricle to measure geometry and regional function. Acute heart failure was induced by propranolol and volume loading after weaning from cardiopulmonary bypass; an absence of MR was confirmed by echocardiography. MAP was accomplished by cinching the tourniquets. Data were acquired at baseline, after induction of acute heart failure, and after MAP.MAP decreased mitral annular dimensions in both commissure-commissure and septal-lateral directions. Concomitantly, the diastolic diameter of the LV base and LV sphericity decreased (i.e., improved) from 37.4 +/- 9.3 to 35.9 +/- 10 mm (p = 0.063), and from 67.9 +/- 18.6% to 65.3 +/- 18.9% (p = 0.016), respectively. Decreases were evident in both LV end-diastolic pressure (from 17 +/- 7 to 15 +/- 6 mmHg, p = 0.0480 and Tau (from 48 +/- 8 to 45 +/- 8 ms, p0.01), while fractional shortening at the LV base increased from 7.7 +/- 4.5% to 9.4 +/- 4.5% (p = 0.045). After MAP, increases were identified in both cardiac output (from 1.54 +/- 0.57 to 1.65 +/- 0.57 1/min) and Emax (from 1.86 +/- 0.9 to 2.41 +/- 1.31 mmHg/ml).The data acquired suggest that isolated MAP may have certain benefits on LV dimension/function in acute heart failure, even in the absence of MR. However, further investigations are warranted in a model of chronic heart failure.

Background We evaluated the effects of coronary artery bypass with off-pump skeletonized bilateral internal thoracic artery grafting in patients with insulin-dependent diabetes. Methods One hundred eighty-five consecutive patients with insulin-dependent diabetes who underwent isolated coronary artery bypass grafting with bilateral internal thoracic grafts were retrospectively compared according to surgical technique, ie, off-pump grafting with skeletonized internal thoracic artery (n = 162) or on-pump grafting with pedicled internal thoracic artery (n = 23). Results The on-pump group was younger (62.3 ± 9.2 versus 69.9 ± 8.5 years; p = 0.02) and had fewer distal anastomoses (3.5 ± 1.0 versus 4.0 ± 1.1; p = 0.02) than the off-pump group. No 30-day mortality occurred in either group. The incidence of deep sternal infection was significantly lower in the off-pump group than in the on-pump group (0.6% versus 13.0%; p = 0.01). The early angiographic results did not differ between the two groups. The median duration of follow-up was 3.4 years (range, 0.1 to 9.9 years). Rates of survival, freedom from cardiac mortality, and freedom from cardiac-related events (including cardiac-related death, myocardial infarction, percutaneous coronary intervention, repeat coronary artery bypass grafting, and congestive heart failure) did not differ between the two groups. Dialysis, peripheral vascular disease, ejection fraction less than 0.40, and age were independent risk factors of late death. Conclusions Overall, our results support the surgical management of coronary artery bypass grafting in insulin-dependent diabetics using off-pump skeletonized bilateral internal thoracic artery grafting.

Background We evaluated the perioperative and long-term results of bilateral internal thoracic artery grafting in dialysis patients. Methods One hundred one consecutive patients on chronic dialysis who underwent isolated coronary artery bypass grafting were retrospectively compared according to the surgical technique, bilateral internal thoracic artery (BITA) grafting (n = 76) or single internal thoracic artery (SITA) grafting (n = 25). Results Hospital mortality was 5.3% in the BITA group and 8.0% in the SITA group ( p = not significant). The incidence of mediastinitis was not different (7.9% in the BITA group and 8.0% in the SITA group). The median duration of follow-up was 3.1 years (range, 0.1 to 10.9). Survival and freedom from cardiac mortality were not different between the two groups, but the BITA group had a trend toward better results. Freedom from cardiac events (including cardiac-related death, myocardial infarction, pecutaneous coronary intervention, redo coronary artery bypass grafting, and congestive heart failure) was superior in the BITA group ( p = 0.03). Calcification of the ascending aorta, peripheral vascular disease, insulin-dependent diabetes mellitis, and age were the independent risk factors of late death. Conclusions Perioperative results of BITA grafting in dialysis patients were not different from the results of SITA grafting. However, the long-term results of BITA grafting in dialysis patients were better than the results of SITA grafting. Overall, our results support the continued use of BITA grafting in dialysis patients.

Objective: Recent reports have demonstrated that long-term patency of the gastroepiploic artery (GEA) in coronary artery bypass grafting (CABG) is less satisfactory compared with the internal thoracic artery (ITA). However, the reason has not been fully elucidated. Angiotensin II is known to play an important role in the development of intimal hyperplasia, we hypothesized that the GEA is different from the ITAwith respect to angiotensin II-forming ability. Accordingly, we measured activities of angiotensin II-forming enzymes, angiotensin-converting enzyme (ACE) and chymase, in human GEA and ITA. Methods: Remnant of the GEAs and ITAs were obtained from 24 patients who underwent CABG in which both conduits were used simultaneously. Activities of ACE and chymase were measured by using the extract form the GEA or ITA. Sections of the GEA or ITA were immunohistochemically stained with anti-human chymase antibody. Results: The ACE activity of the GEA (0.28 0.16 mU/mg protein) was greater than that of the ITA (0.18 0.11, p < 0.001). The chymase activity of the GEA (11.11 7.15 mU/mg protein) was also greater than that in the ITA (7.13 4.89, p < 0.001). The density of chymase-positive cells in the GEA (3.8 4.2 cells/mm 2 ) was greater than that in the ITA (1.1 1.2, p < 0.01). Conclusion: Activities of both ACE and chymase were significantly greater in the GEA compared with the ITA. The GEA may be different from the ITA with respect to potential ability of angiotensin II-formation.

As a pathologic entity this particular subtype may not constitute a distinct tumor from the other types of clear cell tumors, as suggested in the early 1980s. However, further clinicopathologic, immunohistochemical, and ultrastructural studies of subsequent case reports support CCC as a distinct subtype of large cell carcinoma with purely clear cell features or classified into squamous or adenomatous variants, depending on the type of cellular differentiation. In our case, no squamous or adenomatous differentiation was seen, and the tumor grew into and completely occluded the right main bronchus. This biologic behavior appears to be more benign than that seen in other types of non–small cell lung cancer.

Objective The purpose of this study was to investigate (1) the early and midterm patency rates in saphenous vein grafts that were anastomosed with the Symmetry Aortic Connector System (St Jude Medical, Inc, St Paul, Minn) and (2) risk factors for graft occlusion. Methods Thirty-one patients underwent off-pump coronary artery bypass grafting for proximal saphenous vein graft anastomoses with the aortic connector system. Intraoperative graft flow was studied with transit time flowmetry, and angiography was performed before discharge in 29 cases. Midterm (at least 1 year after the operation) saphenous vein graft patency was assessed by coronary angiography or 3-dimensional coronary computed tomography in 27 cases. Results Postoperative angiography demonstrated a 100% patency rate and no significant stenosis at the connector-anastomosed sites. The 1-year patency rate of the saphenous vein grafts with the aortic connector system was 92.6%, with 2 cases of saphenous vein graft occlusion. Both of these cases had low graft flow and poor left ventricular function documented during the operation. Conclusion Once surgical errors had been ruled out, the 1-year patency rate of proximal saphenous vein grafts anastomosed with the aortic connector system was favorable. Poor left ventricular function and low graft flow during the operation were risk factors for midterm graft occlusion. Selection of the target vessel and its runoff may also be an important determinant of long-term patency.

We describe a novel chordal-sparing technique of mitral valve replacement using minimum number of artificial chordae tendineae in patients with rheumatic mitral stenosis. Continuity between the papillary muscles and mitral annulus is restored by placing two 3-0 expanded polytetrafluoroethylene mattress sutures: one for the anterior papillary muscle at the 9-10 o'clock position (as defined by mid-anterior annulus to be 0 o'clock) on the mitral annulus, and the other for the posterior papillary muscle at the 5-6 o'clock position.

The Batista operation for dilated cardiomyopathy (DCM) has not, thus far, yielded satisfactory results. One of the explanations for disappointing results is the absence of a suitable animal model of dilated cardiomyopathy. Scientific research on volume reduction surgery needs to be carried out in an appropriate experimental model. This chapter reviews the few studies of volume reduction surgery using animal models of DCM published thus far, including our studies.

Chordal-sparing mitral valve replacement (CSMVR) has been proven to be beneficial for postoperative left ventricular (LV) function. In patients with mitral stenosis, however, diseased chordae tendineae (CT) often have to be replaced using artificial CT to achieve CSMVR. Previously, we reported that resusupension of artificial CT in an oblique direction enhances systolic LV function. Among 40 consecutive patients with mitral valve replacement (MVR), 17 (4 men and 13 women; mean age 66.5 years) with rheumatic mitral stenosis underwent CSMVR with oblique resuspension. Echocardiography was done before the operation, early (mean 25 days) after the operation, and at a late stage (mean 14 months). There was no mortality or major morbidity. LV ejection fraction late after the operation (68 +/- 8%) was better than that in the early period (61 +/- 8%, p < 0.01), and comparable to the preoperative level (65 +/- 9%). The oblique method may help to improve the results of MVR.

Background . The aim of this study was to report midterm valve replacement (VR) results with the CarboMedics valve (Sulzer Carbomedics, Austin, TX). Methods . From 1991 to 1999, 468 patients aged 13 to 76 years (mean 56 years) underwent VR with CarboMedics valve: 239 aortic (A), 167 mitral (M), and 62 A+M or double valve replacement (DVR). Mean follow-up time was 4.4 years; follow-up was 99.1% complete for 2,016 patient-years (PY). The anticoagulation level was targeted to an international normalized ratio of 1.47 to 2.8. Results . The hospital mortality rate was 1.2%. Actuarial analysis for the entire group at 7 years for survival was 87% ± 2.3%. Freedom from valve-related death was 94% ± 1.9%. Freedom from thromboembolic and bleeding events, respectively, were as follows: for AVR, 82% ± 4.9% (2.4%/PY) and 88% ± 2.9% (1.6%/PY); for MVR, 95% ± 2.1% (0.8%/PY) and 91% ± 3.1% (1.3%/PY); and for DVR, 96% ± 3.2% (0.7%/PY) and 85% ± 9.7% (1.0%/PY). Actuarial freedom from reoperation was 98% ± 1.4%. Conclusions . The CarboMedics valve can be implanted with satisfactory early mortality and a low incidence of valve-related events even under low-intensity anticoagulation, as shown in a Japanese population.

Objective(s): To report the early and mid-term results of surgical plasty of the left main coronary artery in 12 patients operated upon between 1993 and 1997.Methods: The anterior approach was used in all patients. Saphenous vein (n=4) or glutaraldehyde treated autologous pericardium (n=8) were used as patch material. Additional coronary artery bypass grafting was performed in 7 patients, the first 3 as a safety back up, and for coexisting stenosis of other coronary branches not revascularized by the plastic procedure in the remaining 4.Results: Pathologic specimens of the left main coronary artery in 5 revealed atheroma in 3 and myxomatous intimal thickening in 2. The left main coronary artery was widely patent angiographically in all patients prior to discharge. Six patients consented to angiographic restudy 5–40 months after the procedure and revealed excellent results in 5. One patient upon whom autologous pericardial patch had been used underwent percutaneous coronary angioplasty for restenosis of the left main coronary artery and a new lesion of the proximal left anterior descending branch 5 months after the operation. There were no late deaths nor other cardiac events. All patients were in CCS class 1 at their last follow-up.Conclusions: Surgical angioplasty of the left main coronary artery could be used to revascularize the left heart safely in patients with a discrete localized lesion of the left main coronary artery and is particularly useful in the face of unavailability of other conduits.