Safety and efficacy of aortic valvuloplasty for de novo aortic insufficiency in patients with a left-ventricular assist device

OBJECTIVES

Progression of aortic insufficiency during left-ventricular assist device (LVAD) support is a crucial topic. One treatment option is aortic valvuloplasty (AVP); however, there is controversy regarding its safety and efficacy. We investigated the safety and efficacy of AVP using the coaptation stitch method (Park's stitch) performed for de novo aortic insufficiency.

METHODS

Between 2013 and 2020, 175 consecutive patients underwent LVAD implantation, of which 7 patients [men, 2 (28.6%); median age, 55 years] underwent late-stage AVP. Two patients underwent AVP within 2 weeks, and the remaining six patients underwent AVP 3, 19, 24, 28, 42, and 49 months, respectively, after LVAD implantation.

RESULTS

Preoperatively, the degree of aortic insufficiency was moderate in 6 (85.7%) patients and severe in 1 (14.3%) patient. AVP was technically successful in 6 (85.7%) patients, while one case of failed plasty was subsequently treated with bioprosthetic valve replacement. A 1-year post-AVP right heart catheterization study revealed a median pulmonary artery wedge pressure of 10.0 mmHg. No deaths or heart failure admissions occurred during the follow-up (median, 38.0 months). There was no aortic insufficiency in 2 (28.6%) patients; however, trivial AI was observed in 3 (42.8%) patients, and mild AI was observed in 1 (14.3%) patient 2 years postoperatively. However, at the 3-year follow-up, two patients developed an increase in AI grade from trivial to mild.

CONCLUSIONS

AVP using Park's stitch was safe. It is critical to carefully observe the aortic valve during AVP surgery to ensure that AVP is appropriate.

Predictors of late outcomes after concomitant tricuspid valve repair with left-sided valve surgery

BACKGROUND

Concomitant tricuspid valve (TV) repair is a safe and effective procedure to protect against late moderate or greater tricuspid regurgitation (TR) after left-sided valve surgery, but studies regarding its late outcomes and recurrent TR are limited. This study aimed to reveal the late outcomes and explore the predictors of mortality and recurrent TR among patients who underwent concomitant TV repair with left-sided valve surgery.

METHODS AND RESULTS

This study included 645 patients (mean age, 69.7 years; 44% male) who underwent concomitant TV repair with left-sided valve surgery (mitral valve surgery in 594 cases, aortic valve surgery in 172 cases) from 2006-2020. Preoperative TR was grade 4, 3, and less than 2 in 85, 235, and 325 patients, respectively. The median follow-up period was 4.6 (IQR 1.7-7.8) years. The in-hospital or 30-day mortality was 1.7% (n = 11). Regarding long-term outcomes after TV repair, 90.3% and 80.8% achieved 5- and 10-year survival, respectively, while 96.1% and 88.8% achieved 5- and 10-year freedom from recurrent TR, respectively. The following were independent predictors of overall mortality on multivariate analysis in patients with preoperative TR grade ≥ 3: prior pacemaker implantation, preoperative renal dysfunction, diabetes mellitus and NYHA class ≥ 3. Also, suture annuloplasty and ring type of ring annuloplasty were not independent risk factors for recurrent TR, classified as grade ≥ 3.

CONCLUSIONS

Concomitant TV repair with left-sided valve surgery had acceptable outcomes in terms of survival and TR durability. In patients with preoperative TR grade ≥ 3, preoperative patient status had negative impacts on prognosis.

Successful Implantation of Rapid Deployment Aortic Valve after TAVR Explantation

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has become widely used in recent years, However, there is also an increasing need for removal of TAVR valves due to prosthetic valve dysfunction (PVD) and the development of infective endocarditis. Surgical aortic valve replacement (AVR) for these patients is risky due to the original patient background and anatomic conditions. Intuity rapid deployment aortic valve (Edwards Lifesciences, Irvine, CA) replacement would be useful for such high risk patients to prevent longer cardiac arrest time and obtain good hemodynamic results. However, there are few reports which present Intuity valve replacement after TAVR explantation. Herein, We report two cases in which we have achieved good hemodynamics with shorter cardiac arrest times by using a rapid deployment valve after TAVR explantation.

CASE PRESENTATION

We present 2 cases of successful implantation of the Intuity rapid deployment valve after TAVR explantation. The 84- and 88-year-old female patients had previously received TAVR for severe aortic stenosis with SAPIEN XT (Edwards Lifesciences, Irvine, CA) and developed PVD during follow-up. The TAVR valve was removed carefully, then an Intuity valve was implanted with cardiac arrest times of 69 and 41 min. Both patients had good echocardiographic results with effective orifice area of 2.0 cm2 and 1.2 cm2 and mean trans-aortic plessure gradient of 9 mmHg and 15 mmHg respectively without aortic regurgitation. They were discharged without major complications.

CONCLUSIONS

Surgical AVR using a rapid deployment valve is a useful alternative to sutured AVR after TAVR valve explantation. It allows for shorter cardiac arrest times and better postoperative hemodynamics without major complication.

Management of aortic valve insufficiency in patients with continuous-flow left ventricular assist device: a republication of the review published in Japanese Journal of Artificial Organs

Since 2011, implantable ventricular assist devices have been a standard treatment for severe heart failure alongside heart transplantation in Japan. However, the limited availability of donors has led to a prolonged wait for transplants, now averaging 1719 days, intensifying the issue of aortic insufficiency in patients with continuous flow ventricular assist devices. These devices limit the opening of the aortic valve, leading to sustained closure and increased shear stress, which accelerates valve degradation. Risk factors for aortic insufficiency include having a smaller body surface area, being of advanced age, and the presence of mild aortic insufficiency prior to device implantation. In patients presenting with mild or moderate aortic regurgitation at the time of ventricular assist device implantation, interventions such as aortic valve repair or bioprosthetic valve replacement are performed with the aim of halting its progression. The choice of surgical procedure should be tailored to each patient's individual condition. The management of de novo aortic insufficiency in patients with continuous flow ventricular assist devices remains challenging, with no clear consensus on when to intervene. Interventions for significant aortic insufficiency typically consider the patient's symptoms and aortic insufficiency severity. De novo aortic insufficiency progression in continuous flow ventricular assist devices patients necessitates careful monitoring and intervention based on individual patient assessments and valve condition. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2023 (Vol. 52, No. 1, pp. 77-80), with some modifications.

Restrictive annuloplasty on remodeling and survival in patients with end-stage ischemic cardiomyopathy

OBJECTIVES

To elucidate the influence of concomitant restrictive mitral annuloplasty (RMA) on postoperative left ventricular (LV) reverse remodeling and survival in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG).

METHODS

This study comprised 157 patients with ischemic cardiomyopathy (LV ejection fraction ≤40%) who underwent CABG and completed echocardiographic examination at 1 year after surgery, with 84 (54%) undergoing concomitant RMA for clinically relevant ischemic mitral regurgitation. The primary end point was postoperative reduction in LV end-systolic volume index (LVESVI). The secondary end point was overall survival. Median follow-up was 5.1 years.

RESULTS

At baseline, patients who underwent CABG with RMA had a larger LVESVI (83 ± 23 vs 75 ± 24 mm; P = .046). One-year postoperatively, CABG with RMA reduced the LVESVI more than did CABG alone (37% vs 21% from baseline; P < .001), yielding nearly identical postoperative LVESVI (53 ± 27 vs 61 ± 26 mm; P = .065). In multivariable logistic regression analysis, concomitant RMA was associated with significant LV reverse remodeling (odds ratio, 2.79; 95% CI, 1.34-5.78; P = .006). The prevalence in moderate or severe mitral regurgitation was not different between the groups (7% vs 10%; P = .58). Survival rates were similar between the groups (5 years, 78% vs 83%; P = .35).

CONCLUSIONS

In patients with ischemic cardiomyopathy undergoing CABG, concomitant RMA was associated with significant reduction in LVESVI. The influence of LV reverse remodeling on survival remains undetermined.

The outcomes of a standardized protocol for extracorporeal mechanical circulatory support selection-left ventricular challenge protocol

There are no criteria for surgical mechanical circulatory system (MCS) selection for acute heart failure. Since 2021, we have utilized cardiopulmonary bypass system to assess patients' heart and lung condition to inform surgical MCS selection. we aimed to retrospectively analyze the outcomes of treatments administered using our protocol. We analyzed the data of 19 patients who underwent surgical MCS implantation. We compared patients' characteristics across the biventricular-assist device (BiVAD), central Y-Y extracorporeal membrane oxygenation (ECMO), central ECMO, and left VAD (LVAD) systems. Patients' diagnoses included fulminant myocarditis (47.4%), dilated cardiomyopathy (21.1%), acute myocardial infarction (15.8%), infarction from aortic dissection (5.3%), doxorubicin-related cardiomyopathy (5.3%), and tachycardia-induced myocarditis (5.3%). Eight patients (42.1%) underwent LVAD implantation, 1 (5.2%) underwent central ECMO, 4 (21.1%) underwent BiVAD implantation, and 6 (31.6%) underwent central Y-Y ECMO. 48 h after surgery, both the pulmonary arterial and right atrial pressures were effectively controlled, with median values being 19.0 mmHg and 9.0 mmHg, respectively. No patients transitioned from LVAD to BiVAD in the delayed period. Cerebrovascular events occurred in 21.1%. Successful weaning was achieved in 11 patients (57.9%), and 5 patients (26.3%) were converted to durable LVAD. Two-year cumulative survival was 84.2%. Our protocol showed good results for device selection in patients with heart failure, and device selection according to this protocol enabled good control of the pulmonary and systemic circulations.

Single-vessel access venoarterial extracorporeal membrane oxygenation and Impella technique for acute cardiogenic shock complicated by lung congestion

The combination of the Impella and peripheral venoarterial extracorporeal membrane oxygenation (Ecmella) is a promising treatment for critically ill patients. We report a single-access Ecmella approach using the brachiocephalic artery. A 65-year-old woman with acute myocardial infarction involving the left main coronary artery underwent intra-aortic balloon pump and peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) placement. Given the progression of pulmonary congestion and lower limb ischaemia, and an axillary artery diameter of 4.9 mm, we decided to perform a single Ecmella approach. A Y-shaped 9-mm Dacron woven graft was anastomosed to the brachiocephalic artery through a reverse T-shaped partial sternotomy. The Impella 5.5 and arterial cannula of VA-ECMO were introduced through each graft. Six days after, VA-ECMO was removed. Sixty-two days after the surgery, the patient received durable left ventricle assist device implantation. In conclusion, haemodynamic support using a single-access Ecmella through brachiocephalic artery allows for managing patients with narrow peripheral arteries.

Short- and Midterm outcomes of modified robotic tricuspid annuloplasty for secondary tricuspid regurgitation

BACKGROUND

Despite the growing popularity of robotically assisted mitral repair, robotically assisted tricuspid repair has not been widely adopted. We assessed the safety and feasibility of robotic tricuspid annuloplasty with continuous sutures for tricuspid regurgitation (TR).

METHODS AND RESULTS

We studied consecutive 68 patients (median age, 74 years) with secondary TR who underwent tricuspid annuloplasty using continuous sutures with (n = 61) and without mitral valve repair (n = 7) from 2018 to 2021. Robotic tricuspid annuloplasty consists of continuous sutures with flexible prosthetic band to the tricuspid annulus using two V-Loc barbed sutures (Medtronic Inc., Minneapolis, MN). Concomitant maze procedure was performed in 45 (66%) patients. Robotic tricuspid annuloplasty with continuous sutures was successfully performed. There was no in-hospital or 30-day mortality; 65 patients (96%) did not experience major surgery-related complications. Preoperatively, the TR grade was mild in 20 (29%) patients and mildly higher in 48 (71%). Postoperatively, the TR severity significantly improved, with TR grade mildly higher in 9% at hospital discharge and 7% at 1-year follow-up (p < 0.001). The 1-year and 2-year freedom rates from heart failure were 98% and 95%, respectively.

CONCLUSIONS

Robotic tricuspid annuloplasty with continuous sutures is safe and feasible alone or concomitant with mitral valve repair. It offered sustained improvement in TR severity and might prevent heart failure readmission.

Prognostic impact of lung computed tomography density in cardiogenic shock patients with veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Pulmonary complications often occur in patients receiving veno-arterial extracorporeal membrane oxygenation (VA ECMO). However, the prognostic impact of lung damage has not been fully elucidated.

METHODS

This single-center retrospective observational study targeted patients with cardiogenic shock who received VA ECMO between 2012 and 2021. This study included 65 patients who underwent chest computed tomography (CT) on VA ECMO, followed by escalation to central mechanical circulatory support (MCS) with left ventricular venting. The average density of lung CT images was measured using region-of-interest methods, and the primary endpoint was 180-day all-cause death after escalation to the central MCS.

RESULTS

Twenty-two patients (34%) developed 180-day all-cause death. According to the Cox regression analysis, age (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.03-1.14; p = 0.001), ischemic etiology (HR, 5.53; 95% CI, 2.09-14.62; p < 0.001), duration of VA ECMO support (HR, 1.19; 95% CI, 1.00-1.40; p = 0.045), and lung CT density (≥ -481 Hounsfield unit [HU]) (HR, 6.33; 95% CI, 2.26-17.72; p < 0.001) were independently associated with all-cause death. Receiver operating characteristic curve analysis determined that lung CT density ≥ -481 HU is an optimal cutoff value for predicting all-cause death (area under the curve [AUC], 0.72). The 180-day overall survival rate for patients with high lung CT density (≥ -481 HU) was significantly lower than that for those with low lung CT density (< -481 HU) (44.4% vs. 81.6%, respectively, p = 0.002).

CONCLUSIONS

Higher lung CT density could be a useful predictor of death in patients with VA ECMO requiring central MCS escalation.

Successful echocardiography-guided medical management of severe early post-implant right ventricular failure in a patient with left ventricular assist device support: a case report

BACKGROUND

Post-implant right heart failure (RHF) has been recognized as a crucial prognostic factor in patients receiving left ventricular assist devices (LVADs), and its management has long attracted attention from cardiologists and surgeons.

CASE PRESENTATION

This report described an 18-year-old female with acutely deteriorating heart failure due to dilated cardiomyopathy who underwent paracorporeal pulsatile-flow LVAD and developed early post-implant RHF. At postoperative day (POD) six, she was almost asymptomatic at rest on 2.5 mg/kg/min of dobutamine; however, the echocardiogram, performed as part of the daily postoperative care, revealed a severely enlarged right ventricle with a decompressed left ventricle, implying the development of post-implant RHF. Bolus infusion of saline and reduction of pump flow (6.0 L/min to 3.0 L/min) led to normalization of both ventricular shapes in 30 s, suggesting that RHF could be managed without surgical interventions. Milrinone was started on POD six, followed by sildenafil administration on POD seven. Fluid balance was strictly adjusted under the close observation of daily echocardiograms. Milrinone and dobutamine were discontinued on PODs 18 and 21, respectively. The patient was listed for a heart transplant on POD 40. Despite reduced right ventricular function (right ventricular stroke work index of 182.34 mmHg*ml/m- 2, body surface area 1.5 m2), she was successfully converted to implantable LVAD on POD 44 with no recurrence of post-implant RHF thereafter for four years.

CONCLUSIONS

In post-implant RHF management, early detection, together with proper and prompt medical management, is crucial to avoiding any surgical intervention. Close observation of daily echocardiograms might be helpful in detecting subclinical RHF and is useful for post-implant medical management.

Outcomes and residual gap analysis after the modified cryomaze procedure performed via right minithoracotomy versus sternotomy

Objectives

Developments in both technique and technology have enabled surgeons to perform the maze procedure via right minithoracotomy (RMT) to treat atrial fibrillation (AF). This study aimed to clarify the outcomes of the modified cryomaze procedure via the RMT approach compared with the sternotomy approach.

Methods

The study cohort comprised 803 consecutive patients who underwent a modified cryomaze procedure (130 via RMT and 673 via sternotomy) for paroxysmal AF and persistent AF from January 2001 to March 2022. The Gray test was applied to compare the incidence of recurrent atrial tachyarrhythmias. Additionally, residual electrical gaps were investigated in the patients who underwent additional catheter ablation for recurrent atrial tachyarrhythmias.

Results

The respective 1-, 2-, and 3-year cumulative incidences of recurrent atrial tachyarrhythmias were 13.1%, 19.5%, and 23.1% in the RMT group, and 9.3%, 10.9%, and 12.8% in the sternotomy group (Gray test P = .036). All 31 patients with recurrent atrial tachyarrhythmias underwent additional catheter ablation, comprising 14 (10.8%) in the RMT group and 17 (2.5%) in the sternotomy group. There was a significant intergroup difference in the site of residual electrical gaps; the RMT group more frequently had residual gaps in the tricuspid annulus than the sternotomy group (6.2% vs 0.4%; P < .001).

Conclusions

In the modified cryomaze procedure via the RMT approach, ablation failure is more likely to occur at the tricuspid annulus, where the surgical field of view is relatively poor compared with the sternotomy approach. Therefore, surgical ablation should be performed with caution when the RMT approach is used.

Impact of complete revascularization in coronary artery bypass grafting for ischemic cardiomyopathy

Objective

In patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting.

Methods

We retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors.

Results

The overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P = .05) than the incomplete revascularization group.

Conclusions

In patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible.

Efficacy of catheter cleaning methods using intravenous indwelling catheter, 10% silver nitrate solution and a monofilament nylon thread for deeply progressed superficial driveline infections: case series

Driveline infection (DLI) is treated by local irrigation via driveline exit site (DLES) and surgical debridement is considered in patients with deep DLI. We describe three cases of deeply progressed superficial DLI that were considered to require surgical debridement but could be treated with a unique catheter cleaning method using intravenous indwelling catheter, a cotton swab with 10% silver nitrate solution and a monofilament nylon thread. Case 1 was a 60-y-old man with ischemic cardiomyopathy with left ventricular assist device implantation 2 y before. Daily bedside debridement with 10% silver nitrate solution was performed via the DLES. Case 2 was a 43-y-old man with ischemic cardiomyopathy who had recurrent DLI with methicillin-resistant Staphylococcus aureus, and case 3 was a 49-y-old woman with hypertrophic cardiomyopathy, who also showed improvement in their DLI with Pseudomonas aeruginosa. These cleaning methods may be useful for the deeply progressed superficial DLI.

What Is the Optimal Mitral Valve Repair for Isolated Posterior Leaflet Prolapse to Achieve Long-Term Durability?

Background This study assessed risk factors for mitral regurgitation (MR) recurrence or functional mitral stenosis during long-term follow-up in patients undergoing mitral valve repair for isolated posterior mitral leaflet prolapse. Methods and Results We assessed a consecutive series of 511 patients who underwent primary mitral valve repair for isolated posterior leaflet prolapse between 2001 and 2021. Annuloplasty using a partial band was selected in 86.3%. The leaflet resection technique was used in 83.0%, whereas the chordal replacement without resection was used in 14.5%. Risk factors were analyzed for MR recurrence ≥grade 2 or functional mitral stenosis with mean transmitral pressure gradient ≥5 mm Hg using a multivariable Fine-Gray regression model. The 1-, 5-, and 10-year cumulative incidence of MR ≥grade 2 was 7.8%, 22.7%, and 30.1%, respectively, whereas that of mean transmitral pressure gradient ≥5 mm Hg was 8.1%, 20.6%, and 29.3%, respectively. Risk factors for MR ≥grade 2 included chordal replacement without resection (hazard ratio [HR], 2.50, P<0.001) and larger prosthesis size (HR, 1.13, P=0.023), whereas factors for functional mitral stenosis were use of a full ring (partial band versus full ring, HR, 0.53, P=0.013), smaller prosthesis size (HR, 0.74, P<0.001), and larger body surface area (HR, 3.03, P=0.045). Both MR ≥grade 2 and mean transmitral pressure gradient ≥5 mm Hg at 1 year post surgery were significantly associated with the long-term incidence of reoperation. Conclusions Leaflet resection with a large partial band may be an optimal strategy for isolated posterior mitral valve prolapse.

Does the residual aorta dilate after replacement of the bicuspid aortic valve and ascending aorta?

Background

Although a bicuspid aortic valve (BAV) is known to be associated with progressive ascending aortic dilatation, the fate of the residual aorta after aortic valve and ascending aorta surgery is unknown. We reviewed surgical outcomes and explored serial changes in the size of the sinus of Valsalva (SOV) and distal ascending aorta (DAAo) in 89 patients with a BAV undergoing aortic valve replacement (AVR) and graft replacement (GR) of the ascending aorta.

Methods

We retrospectively examined patients who underwent AVR and GR of the ascending aorta for BAV-and related disease and thoracic aortic dilatation at our institution between January 2009 and December 2018. Patients who underwent AVR alone or required intervention for the aortic root and aortic arch and patients with connective tissue diseases were excluded. Aortic diameters were examined using computed tomography (CT). Late CT more than 1 year after surgery was performed in 69 patients (78%) with a mean follow-up of 4.9±2.8 years.

Results

The surgical indication for aortic valve etiology was stenosis in 61 patients (69%), regurgitation in 10 (11%), and mixed in 18 (20%). Preoperative maximum short diameters of the ascending aorta, SOV, and DAAo were 47.3±4.7, 36.0±5.2, and 37.2±3.6 mm, respectively. The diameter of the SOV increased non-significantly by 0.08±0.45 mm per year [95% confidence interval (CI): -0.12 to 0.11, P=0.150], while that of the DAAo increased significantly by 0.11±0.40 mm per year (95% CI: 0.02-0.21, P=0.005). One patient required reoperation 6 years postoperatively due to a pseudo-aneurysm at the proximal anastomotic site. No patient required reoperation due to progressive dilatation of the residual aorta. According to the Kaplan-Meier analysis, the long-term survival rates were 98.9%, 98.9%, and 92.7% at 1, 5, and 10 years postoperatively, respectively.

Conclusions

Rapid dilatation of the residual aorta rarely occurred in patients with a BAV who underwent AVR and GR of the ascending aorta in the mid-term follow-up. For selected patients with a surgical indication for ascending aortic dilatation, simple AVR and GR of the ascending aorta may be sufficient surgical options.

Prognosis of Patients With Heart Failure Receiving Autologous Myoblast Patches ― Comparison of Single-Arm Trial Data to Registry Data ―

BACKGROUND

Clinical studies in regenerative medicine remain insufficient in Japan due to ethical concerns regarding the control group and a lack of statistical methodology to evaluate efficacy in a small treatment group. This study evaluated the efficacy of autologous myoblast patch (AMP) treatment for heart failure using restricted mean survival time (RMST) analysis by comparing data from a small single-arm trial to epidemiological data from a registry.Methods and Results: The clinical trial arm included 55 patients with advanced ischemic cardiomyopathy who received an AMP between 2010 and 2020. The registry-based control group comprised 937 participants with severely impaired left ventricular function who were hospitalized for heart failure during the study period. Due to the limited number of patients, RMST analysis was used to compare survival between the 2 groups. Cox regression analyses revealed non-significant differences in survival between the groups at 3, 3.5, and 4 years. In contrast, RMST analyses revealed significant differences in survival at 3 years (P=0.008) and 3.5 (P=0.024) years, but not at 4 years.

CONCLUSIONS

This small single-arm trial using RMST analyses was able to detect the efficacy of AMP transplantation for advanced heart failure (compared with a registry-based control group), with better survival until 3.5 years. This approach may be useful for efficacy analyses in regenerative medicine, where traditional clinical trials are difficult.

Ventricular Arrhythmias Following Coronary Artery Bypass Grafting for Ischemic Cardiomyopathy: When to insert an implanted cardiac defibrillator?

Objectives

The study objectives were to determine the incidence, predictors, and clinical impact of ventricular arrhythmias after coronary artery bypass grafting and to evaluate the impact of implantable cardioverter defibrillators on the survival of patients with ventricular arrhythmias.

Methods

We enrolled 498 patients with a left ventricular ejection fraction of 40% or less who underwent coronary artery bypass grafting between 1993 and 2015. Clinical follow-up was completed in 94.0% of patients, with a median follow-up of 58.4 months.

Results

Overall, 212 patients (43%) died, mainly of heart failure (n = 54, 10.8%) or sudden cardiac death (n = 40, 8.0%). The sudden cardiac death rate was highest during the first 6 months, with a monthly rate of 0.37%. Overall, 99 patients (20%) developed postoperative ventricular arrhythmias, and implantable cardioverter defibrillator was implanted in 55 patients. Previous ventricular arrhythmias (hazard ratio, 3.22; 95% confidence interval, 1.98-5.24; P < .001), left ventricular end-systolic dimension (hazard ratio, 1.07; 95% confidence interval, 1.04-1.10; P < .001), and myocardial infarction in the left anterior descending artery territory (hazard ratio, 1.73; 95% confidence interval, 1.10-2.73; P = .02) were independent predictors of postoperative ventricular arrhythmias. Notably, the 5-year survival of patients with ventricular arrhythmias who received an implantable cardioverter defibrillator was significantly higher than that of patients with ventricular arrhythmias who did not receive it (76.1% vs 22.7%, P < .001) and was comparable to that of patients without ventricular arrhythmias (76.1% vs 73.6%, P = .98).

Conclusions

Sudden cardiac death affects a significant proportion of patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, most frequently within 6 months postoperatively. To prevent sudden cardiac death, earlier implantable cardioverter defibrillator implantation should be indicated for high-risk patients with scars in the left anterior descending artery territory and excessive left ventricular remodeling.

Case report: Transplantation of human induced pluripotent stem cell-derived cardiomyocyte patches for ischemic cardiomyopathy

Despite major therapeutic advances, heart failure, as a non-communicable disease, remains a life-threatening disorder, with 26 million patients worldwide, causing more deaths than cancer. Therefore, novel strategies for the treatment of heart failure continue to be an important clinical need. Based on preclinical studies, allogenic human induced pluripotent stem cell-derived cardiomyocyte (hiPSC-CM) patches have been proposed as a potential therapeutic candidate for heart failure. We report the implantation of allogeneic hiPSC-CM patches in a patient with ischemic cardiomyopathy (ClinicalTrials.gov, #jRCT2053190081). The patches were produced under clinical-grade conditions and displayed cardiogenic phenotypes and safety in vivo (severe immunodeficient mice) without any genetic mutations in cancer-related genes. The patches were then implanted via thoracotomy into the left ventricle epicardium of the patient under immunosuppressive agents. Positron emission tomography and computed tomography confirmed the potential efficacy and did not detect tumorigenesis in either the heart or other organs. The clinical symptoms improved 6 months after surgery, without any major adverse events, suggesting that the patches were well-tolerated. Furthermore, changes in the wall motion in the transplanted site were recovered, suggesting a favorable prognosis and the potential tolerance to exercise. This study is the first report of a successful transplant of hiPSC-CMs for severe ischemic cardiomyopathy.

A unique cuff-sewing method to implant heartmate3 LVAD for arrhythmogenic right ventricular cardiomyopathy, facilitated by 3D-printing heart model

Implantation of left ventricular assist device (LVAD) for arrhythmogenic right ventricular (RV) cardiomyopathy is challenging associated with small LV cavity, laterally dislocated LV apex, thin and fragile RV free wall. A 43-year-old male with more than 10 years of medical treatment developed congestive heart failure related to biventricular failure. Durable LVAD was indicated to prevent further deterioration of the RV function, which would be exacerbated by progression of LV dysfunction. To simulate surgery, we printed-out a 3D heart model based on enhanced CT scanning study to identify the optimal coring position in the LV apex, by which the inflow directs the mitral valve. We then found that the mini-cuff of the HeartMate3 should be fixed in the paper-thin RV free wall by the usual cuff-sewing method. In the surgery, after the coring as planned, 5 pairs of interrupted sutures on the medial side were passed from the luminal side of the LV and then to the mini-cuff, and the lateral side of the mini-cuff was fixed with a continuous sutures, not to sew into the RV wall. The surgery was completed without complications with a good hemodynamics. The 3D heart model facilitated this unique method, indicating a usefulness of printed-out heart model for cases with unusual cardiac anatomy, which needs implantation of durable LVAD.

Mitral valve surgery for atrial functional mitral regurgitation: predicting recurrent mitral regurgitation and mid-term outcome

Objectives

This study aimed to elucidate the mid-term outcomes and risk factors for recurrent mitral regurgitation after mitral valve (MV) surgery for atrial functional mitral regurgitation (AFMR).

Methods and results

We retrospectively analyzed data of 50 consecutive patients (median age 74 years; 29 men) who underwent mitral valve surgery for AFMR between January 2001 and January 2019. Mean atrial fibrillation duration was 12 years. During the follow-up period of 4.6 ± 4.4 years, 5 cardiac-related deaths were identified. Five- and 10-year freedom from cardiac-related death rate for all patients was 88.4% and 78.6%. In total, 42 patients underwent MV repair with mitral annuloplasty and 8 underwent MV replacement. Five- and 10-year freedom from cardiac-related death rate in patients who underwent MV repair was 93.1% and 82.7%, which was better than MV replacement (log rank p = 0.04). During the follow-up period, MR recurrence rate was 16.8% at 5 and 10 years for the patients who underwent MV repair. Univariate analysis showed that partial band annuloplasty and preoperative elevated left ventricular end-systolic volume index were risk factors for recurrent MR after MV repair. Multivariate analysis identified partial band annuloplasty as the independent predictor for recurrent MR during long-term follow-up after MV repair for AFMR.

Conclusion

Patients who underwent MV repair for AFMR could have an acceptable mid-term outcome. However, MVR might not improve the mid-term outcome in patients with AFMR. The use of partial bands for mitral annuloplasty would not be recommended in terms of recurrent MR mid-term.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11748-022-01793-8.

[Beneficial Effects of the Modified Bicaval Anastomosis Technique for Orthotopic Heart Transplantation from a Size-Mismatched Donor:20-year Single Center Experience]

BACKGROUND

Size-mismatched heart transplantation( HTx) is associated with a risk of stenosis of the caval anastomosis site or low cardiac output syndrome. We developed a modified bicaval anastomosis technique( mBCAT) that achieved an adjustable caval anastomosis to compensate for the size mismatch. This study clarified clinical outcomes of HTx with mBCAT technique according to the degree of the size mismatch.

METHODS AND RESULTS

This study consisted of 130 adult patients who underwent HTx with the mBCAT during a 22-year period and were followed up for at least 1 year. The cohort was divided into three groups according to the donor-to-recipient body weight ratio:<0.8, undersized group (n=19);0.8 ~1.3, size-matched group( n=89);and >1.3, oversized group( n=22). The undersized, size-matched, and oversized groups showed no significant differences in the rate of mild or worse tricuspid regurgitation on echocardiography at 1 month [ 1( 5.3%), 8( 9.0%), and 1( 4.6%), respectively;p=0.683] or the survival rate at 10 years( 100%, 96%, and 95%, respectively;p=0.452). The right heart catheter study revealed no pressure gradient across the orifices of both cavae in any patient. Additionally, the cardiac index immediately post-HTx was low in the undersized group, but improved over time in all groups, achieving the comparable value at 6 and 12 months post-HTx.

CONCLUSIONS

The mBCAT prevented caval anastomosis-related complications in size-mismatched HTx and achieved excellent hemodynamics regardless of donor size.

Bridge from central extracorporeal life support is a risk factor of cerebrovascular accidents after durable left ventricular assist device implantation

A bridging strategy from extracorporeal life support (ECLS) is effective in salvage and a bridge to recovery or to a durable left ventricular assist device (LVAD) for acute refractory heart failure. However, the correlation of this strategy with adverse events after durable LVAD implantation has not been fully investigated. This study enrolled 158 consecutive patients who had either the HeartMate II or HeartMate 3 and were implanted for bridge-to-transplantation. These devices were implanted as the primary mechanical support device in 115 patients, whereas the remaining 43 underwent LVAD implantation as the bridge from central ECLS. The primary study endpoint was all-cause mortality and cerebrovascular accidents (CVAs) after durable LVAD implantation, and the secondary endpoints were adverse events. Overall survival was not significantly different between the two groups. In contrast, the probability of CVAs was significantly greater in the bridge group than in the primary group (probability of CVAs, P = 0.002; log-rank test). In Cox multivariate logistic regression analysis, a bridge from central ECLS was an independent predictive factor of CVAs (hazard ratio 4.27, 95% confidence interval 1.43-12.8; P = 0.0095). Patients who are bridged from central ECLS are more frequently complicated by CVAs compared with those who undergo primary implantation of a durable LVAD, but survival is not significantly different between the two groups. A bridge from central ECLS is an independent predictive factor of CVAs post-implantation of an LVAD.

Rare case of severe non-calcific aortic stenosis in an achondroplastic dwarf: surgical consideration

A 41-year-old patient with achondroplasia who had undergone surgery for congenital aortic stenosis >20 years ago presented with dyspnoea due to severe aortic stenosis. Computed tomography confirmed a small (16-mm) aortic annulus, thickened aortic valve leaflets without calcification and subaortic fibrous tissues. Intraoperatively, 3 non-calcific aortic leaflets were observed. Enlargement of the aortic root using a modified Manouguian technique for good exposure enabled the resection of subaortic tissues and replacement of the valve with a mechanical valve. The aortic root can be extremely small in patients with aortic stenosis and achondroplasia. The anatomy of the aortic root should be carefully assessed to enable appropriate surgical planning.

Acute Coronary Syndrome Requiring Coronary Artery Bypass Grafting in a Patient With Sotos Syndrome

Sotos syndrome, characterized by cerebral gigantism with neurologic disorders, is an overgrowth syndrome caused by mutations of the NSD1 gene, with an estimated prevalence of 1:10,000-1:50,000. We herein describe the first case of Sotos syndrome complicated by acute coronary syndrome, for which emergency coronary artery bypass grafting was performed. (Level of Difficulty: Intermediate.)

A hybrid approach for a case with a high risk of not only surgical but transcatheter aortic valve replacement

An 86-year-old woman with severe aortic stenosis was thought to be at a high risk for surgical aortic valve replacement and inoperability due to old age and porcelain aorta. Furthermore, transcatheter aortic valve replacement (TAVR) was considered difficult due to high risk of coronary obstruction secondary to the aortic root anatomy and poor vascular access associated with marked atherosclerotic lesions on the distal aortic arch with peripheral artery disease. We successfully treated her with TAVR via the brachiocephalic artery in combination with prophylactic off-pump coronary artery bypass grafting.

Clinical Outcomes Following Durable Mitral Valve Repair for Ischemic Mitral Regurgitation

BACKGROUND

This study aimed to clarify the incidence and determinants of postoperative adverse events in patients with ischemic cardiomyopathy who achieved long-term durable mitral valve repair.

METHODS

Between 1999 and 2015, 166 patients with chronic ischemic mitral regurgitation (MR) and left ventricular (LV) ejection fraction ≤40% underwent restrictive mitral annuloplasty. During follow-up (65±34 months), echocardiographic assessments were performed 809 times (mean, 4.9±2.4 times) and 20 patients who had developed postoperative recurrent MR (≥moderate) were excluded. Finally, 146 patients (68±9 years) whose MR was well controlled over time were included.

RESULTS

A total of 61 mortalities and/or 27 readmissions for heart failure were observed in 76 patients (52%). Among hospital survivors, age (adjusted hazard ratio: 1.05; P=0.001), and estimated glomerular filtration rate (adjusted hazard ratio: 0.61; P=0.001) were identified as independent predictors of long-term mortality and/or readmission for heart failure. The degree of LV function recovery after surgery was comparable between patients with and without adverse events. However, the former group showed greater values for systolic pulmonary artery pressure, tricuspid regurgitation severity, inferior vena cava dimension, and plasma brain natriuretic peptide level throughout the follow-up period (group effect p<0.05 for all).

CONCLUSIONS

Approximately 50% of patients died or were hospitalized for heart failure even in the absence of recurrent mitral regurgitation during the 5-year follow-up, indicating that durable mitral repair does not always lead to favorable clinical outcomes. The adverse events might be related to volume overload secondary to impaired renal function and less favorable pulmonary hemodynamics.

Multiple percutaneous coronary interventions worsen outcomes for subsequent surgical correction of chronic ischemic mitral regurgitation

Objective

We investigated whether or not a history of multiple percutaneous coronary interventions (PCIs) is associated with clinical outcomes after surgery for ischemic mitral regurgitation.

Methods

A total of 309 patients with chronic ischemic mitral regurgitation and left ventricular ejection fraction ≤40% who underwent restrictive mitral annuloplasty were classified as follows: patients with no or 1 previous PCI (nonmultiple PCI group [n = 211]) and patients with 2 or more previous PCIs (multiple PCIs group [n = 98]). Mean follow-up duration was 53 ± 40 months.

Results

Before surgery, there were no intergroup differences in patient demographic characteristics except for lower estimated glomerular filtration rate in patients with multiple PCIs. These patients underwent concomitant coronary artery bypass grafting less frequently with a lower number of distal anastomoses (P < .05 for both). The 30-day mortality was 3.3% and 2.0% in the nonmultiple and multiple PCIs group, respectively (P = .72). During follow-up, there were 157 deaths. Patients with multiple PCIs showed lower 5-year survival rate (44% vs 64%; P = .002). After adjustments with inverse-probability-of-treatment weighting, multiple PCIs history was an independent risk factor for mortality (adjusted hazard ratio, 1.4; 95% confidential interval, 1.1-1.7; P = .002). Patients with multiple PCIs showed less improvement in left ventricular ejection fraction (interaction effect P < .001).

Conclusions

In patients with ischemic mitral regurgitation, a history of previous multiple PCIs was associated with increased risk of long-term postoperative mortality, with less improvement in left ventricular ejection fraction.

Clinical Outcomes of Autologous Stem Cell-Patch Implantation for Patients With Heart Failure With Nonischemic Dilated Cardiomyopathy

Background

Clinical effectiveness of autologous skeletal cell‐patch implantation for nonischemic dilated cardiomyopathy has not been clearly elucidated in clinical settings. This clinical study aimed to determine the feasibility, safety, therapeutic efficacy, and the predictor of responders of this treatment in patients with nonischemic dilated cardiomyopathy.

Methods and Results

Twenty‐four nonischemic dilated cardiomyopathy patients with left ventricular ejection fraction <35% on optimal medical therapy were enrolled. Autologous cell patches were implanted over the surface of the left ventricle through left minithoracotomy without procedure‐related complications and lethal arrhythmia. We identified 13 responders and 11 nonresponders using the combined indicator of a major cardiac adverse event and incidence of heart failure event. In the responders, symptoms, exercise capacity, and cardiac performance were improved postoperatively (New York Heart Association class II 7 [54%] and III 6 [46%] to New York Heart Association class II 12 [92%] and I 1 [8%], P<0.05, 6‐minute walk test; 471 m [370–541 m] to 525 m [425–555 m], P<0.05, left ventricular stroke work index; 31.1 g·m²·beat [22.7–35.5 g·m²·beat] to 32.8 g·m²·beat [28–38.5 g·m²·beat], P=0.21). However, such improvement was not observed in the nonresponders. In responders, the actuarial survival rate was 90.9±8.7% at 5 years, which was superior to the estimated survival rate of 70.9±5.4% using the Seattle Heart Failure Model. However, they were similar in nonresponders (47.7±21.6% and 56.3±8.1%, respectively). Multivariate regression model with B‐type natriuretic peptide, pulmonary capillary wedge pressure, and expression of histone H3K4me3 (H3 lysine 4 trimethylation) strongly predicted the responder of this treatment (B‐type natriuretic peptide: odds ratio [OR], 0.96; pulmonary capillary wedge pressure: ​OR, 0.58; H3K4me3: OR, 1.35, receiver operating characteristic–area under the curve, 0.96, P<0.001).

Conclusions

This clinical trial demonstrated that autologous skeletal stem cell–patch implantation might promise functional recovery and good clinical outcome in selected patients with nonischemic dilated cardiomyopathy, in addition to safety and feasibility.

Registration

URL: http://www.umin.ac.jp/english/. Unique identifiers: UMIN000003273, UMIN0000012906 and UMIN000015892.

Left ventricle-mitral valve ring size mismatch following ring annuloplasty for nonischemic dilated cardiomyopathy

BACKGROUND

In patients with ischemic mitral regurgitation (MR) undergoing restrictive mitral annuloplasty (RMA), the ratio of left ventricular (LV) end-systolic dimension (LVESD) to mitral valve (MV) ring size (ie, LV-MV ring mismatch) is associated with postoperative recurrent MR. However, the impact of LV-MV ring mismatch on postoperative recurrent MR, LV function recovery, and long-term survival in patients with nonischemic dilated cardiomyopathy (DCM) remains unknown.

METHODS

Sixty-six patients with nonischemic DCM (mean LVESD, 62 mm) underwent RMA (mean ring size, 26 mm) between 2003 and 2014. Recurrent MR was defined as MR grade ≥2+ at a 6-month echocardiographic evaluation.

RESULTS

At the 6-month follow-up, 23 patients (35%) had developed recurrent MR. In univariable logistic regression analysis, larger LVESD (P = .012) and LVESD/ring size ratio (P = .008) were associated with recurrent MR. In multivariable models adjusted for age, sex, baseline LV ejection fraction, and severe MR, only LVESD/ring size ratio (odds ratio, 4.65; 95% confidence interval, 1.04-25.0; P = .048) remained significantly associated with MR recurrence. Receiver operating characteristic curve analysis demonstrated an optimal cutoff value for the LVESD/ring size ratio of 2.42. Patients with an LVESD/ring size ratio >2.42 (n = 30; mismatch) had a lower 5-year cumulative survival rate compared with those with an LVESD/ring size ratio ≤2.42 (n = 36; nonmismatch) (52% vs 71%; P = .045). Postoperatively, LV dimensions were significantly reduced in both groups; however, improvements in LVEF were only modest in the mismatched group (P = .091).

CONCLUSIONS

LV-MV ring size mismatch was associated with an increased risk of recurrent MR in our series. This finding may aid the formulation of surgical strategies for patients with nonischemic DCM.

Therapeutic efficacy of large aligned cardiac tissue derived from induced pluripotent stem cell in a porcine ischemic cardiomyopathy model

BACKGROUND

Although induced pluripotent stem (iPS) cell-derived cardiac constructs may have a potential in cardiomyogenesis of a distressed myocardium, obtaining polarity in cardiac constructs, such as via myocyte alignment, may be crucial to achieve a maximum contractile force for better clinical outcomes. We herein hypothesized that transplantation of an aligned cardiac tissue derived from iPS cells has therapeutic effects in a porcine ischemic cardiomyopathy model as a preclinical trial.

METHODS

Aligned cardiac tissues were developed by culturing high-purity iPS cell-derived cardiomyocytes in xeno-free conditions and transplanting them into infarct porcine hearts (iPS-CM group, n = 7; control, n = 6). Three months after treatment, therapeutic efficacy was evaluated functionally and histologically.

RESULTS

In vitro assessment revealed that the aligned cardiac tissue containing high purity cardiomyocytes contracted homogeneously and had excellent mechanical properties. In the in vivo study, the left ventricular ejection fraction of the iPS-CM group was significantly greater than that of the control group, 3 months after transplantation (37.8% ± 2.3% vs 28.3% ± 2.5%, p < 0.05). Pathologically, attenuated interstitial fibrosis, attenuation of hypertrophied cardiomyocytes, and an increased capillary density were also prominent in the iPS-CM group. A limited amount of engraftment of the transplanted tissue maintaining tissue alignment was observed at 2 weeks after transplantation.

CONCLUSIONS

The creation of large-scale functional aligned cardiac tissue was feasible, and the transplantation of the aligned tissue improved cardiac function with angiogenesis and antifibrotic effects in a porcine cardiomyopathy model.

Detrimental effects of elevated transpulmonary gradient on outcomes following restrictive mitral annuloplasty in patients with pre-existing pulmonary hypertension

Background

This study retrospectively examined the association between elevated trans-pulmonary gradient (TPG), which reflects pre-capillary contribution to pulmonary hypertension (PH), and postoperative pulmonary hemodynamics and outcomes following restrictive mitral annuloplasty (RMA) in patients with pre-existing PH.

Methods

Pre- and postoperative (1 month) cardiac catheterization was performed in 64 patients with severely impaired left ventricular function (i.e., ejection fraction ≤40%) and pre-existing PH (mean pulmonary artery pressure (PAP) ≥25 mmHg) who underwent RMA. Patients were segregated into two groups: low TPG (≤12 mmHg) and elevated TPG (>12 mmHg). The mean follow-up period was 54±27 months. The primary outcome seen was a change in pulmonary hemodynamics after RMA; secondary outcomes were composite adverse events, including all-cause mortality and readmission for heart failure.

Results

Compared to the low TPG group, patients in the elevated TPG group were more likely to show a postoperative mean PAP of ≥25 mmHg (84% vs. 38%), TPG of >12 mmHg (79% vs. 11%), and pulmonary vascular resistance of ≥240 dynes/sec/cm⁻⁵ (84% vs. 6.7%) (all P<0.001), although both groups showed comparable degrees of mitral regurgitation improvement. Serial echocardiography demonstrated that Doppler-derived systolic PAP, which once decreased in both groups, remained stable in the low group while steadily increasing in the elevated group (group effect P<0.001). Patients with elevated TPG had lower freedom from composite adverse events (5-year, 20% vs. 70%, P=0.003). After adjusting for baseline covariates, the elevated TPG was independently associated with increased risk of adverse events (adjusted hazard ratio 2.9, 95% CI: 1.2–6.9, P=0.017).

Conclusions

Elevated TPG negatively affects postoperative pulmonary hemodynamics and late outcomes in patients with advanced cardiomyopathy and pre-existing PH who have undergone RMA. These findings suggest that the assessment of TPG should be included in post-RMA risk stratification.

Impact of tricuspid regurgitation on late right ventricular failure in left ventricular assist device patients ~can prophylactic tricuspid annuloplasty prevent late right ventricular failure? ~

Background

In this study, we evaluated the prevalence of tricuspid regurgitation (TR) worsening in patients with left ventricular assist devices (LVADs) and its impact on late right ventricular (RV) failure.

Methods

We enrolled 147 patients of the 184 patients who underwent continuous-flow LVAD implantations from 2005 to March 2018. The prevalence of postoperative TR worsening and late RV failure were retrospectively evaluated.

Results

Concomitant tricuspid annuloplasty (TAP) was performed in 28 of 41 patients (68%) with preoperative TR greater than or equal to moderate (TR group) and in 23 of 106 patients (22%) with preoperative TR less than or equal to mild (non-TR group). Regarding the TR-free rates, despite receiving or not receiving concomitant TAP, there was no significant difference between the 2 groups (TR group: p = 0.37; non-TR group: p = 0.42). Of the 9 patients with postoperative TR greater than or equal to moderate, late RV failure developed in 3 patients, with TR worsening after RV failure in each case. During follow-up, 16 patients (11%) had late RV failure. As for the late RV failure-free rates, despite receiving or not receiving concomitant TAP, there was no significant difference between the 2 groups (TR group: p = 0.37; non-TR group: p = 0.96).

Conclusions

TR prognosis was preferable regardless of a patient receiving concomitant TAP; however, the presence of postoperative TR seemed to unrelated to late RV failure. Prophylactic TAP might not be necessary to prevent late RV failure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01492-0.

Cell barrier function of resident peritoneal macrophages in post-operative adhesions

Post-operative adhesions are a leading cause of abdominal surgery-associated morbidity. Exposed fibrin clots on the damaged peritoneum, in which the mesothelial barrier is disrupted, readily adhere to surrounding tissues, resulting in adhesion formation. Here we show that resident F4/80^HighCD206⁻ peritoneal macrophages promptly accumulate on the lesion and form a ‘macrophage barrier’ to shield fibrin clots in place of the lost mesothelium in mice. Depletion of this macrophage subset or blockage of CD11b impairs the macrophage barrier and exacerbates adhesions. The macrophage barrier is usually insufficient to fully preclude the adhesion formation; however, it could be augmented by IL-4-based treatment or adoptive transfer of this macrophage subset, resulting in robust prevention of adhesions. By contrast, monocyte-derived recruited peritoneal macrophages are not involved in the macrophage barrier. These results highlight a previously unidentified cell barrier function of a specific macrophage subset, also proposing an innovative approach to prevent post-operative adhesions.

Peritoneal adhesions are a major cause of complications after abdominal surgery. Here the authors use a post-operative abdominal adhesion model in mice to show that resident F4/80^HighCD206⁻ macrophages form a protective barrier that can be enhanced by IL-4 administration or adoptive transfer of these cells.

Four-quadrant visualization of systemic circulatory equilibrium: right ventricular failure after left ventricular assist device implantation

Right ventricular failure (RVF) is a serious adverse event after left ventricular assist device (LVAD) implantation but difficult to be characterized. This study aimed to visualize the dynamic circulatory equilibrium of acute RVF after LVAD implantation using a new four-quadrant diagram constructed by 1) cardiac function with central venous pressure (CVP) and cardiac index (CI) axes, 2) arterial vascular resistance with CI and mean blood pressure (mBP) axes, 3) pressure-diuretic function with mBP and net urinary sodium output (net U-Na) axes, and 4) venous compliance with net U-Na and CVP axes. Twenty LVAD patients were stratified into two groups, group S (≤10 days) and group L (>10 days), according to duration of postoperative inotropic support. The preoperative equilibrium loops were small in both groups. In the early postoperative phase, the loop in group S became dramatically enlarged to the left and upward, indicating increased CVP and CI by LVAD support. In group L, however, augmentation of CI was smaller despite similarly increased CVP, and net U-Na was decreased despite increased mBP. In the late postoperative phase, the equilibrium loop in group L recovered as similar to that seen in group S. Thus, acute RVF, as shown in group L, was characterized by the shape of the loop constructed by marked increased CVP, a relatively small increase in CI, and concomitant impairment of pressure natriuresis. In conclusion, the novel four-quadrant presentation of systemic circulatory equilibrium provides clear visualization of RVF after LVAD implantation, thus serving as a useful guide for prompt and optimal management.NEW & NOTEWORTHY Systemic circulatory dynamics are regulated by various negative feedback systems, including cardiac, arterial, venous, and renal functions, as well as autonomic nervous systems. The present novel four-quadrant presentation of their functions allows clear visualization of dynamic organ-to-organ interactions that can lead to a new circulatory equilibrium after therapeutic intervention. This new system physiological framework can serve as a useful guide for prompt and optimal management of circulatory malfunction.

Bilateral Internal Thoracic Artery Grafting Improves Survival for Severe Left Ventricular Dysfunction and Diabetes

BACKGROUND

In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.Methods and Results:Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024).

CONCLUSIONS

NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.

Incidence, determinants and clinical impact of left ventricular function recovery after surgical treatments for ischaemic cardiomyopathy

 

OBJECTIVES

This retrospective study aimed to clarify the incidence, determinants and clinical impact of left ventricular (LV) function non-recovery after coronary artery bypass grafting (CABG) in patients with ischaemic cardiomyopathy.

METHODS

A total of 490 patients with ischaemic cardiomyopathy (LV ejection fraction ≤ 40%) undergoing CABG were analysed. Follow-up echocardiography was performed at 1 month, 1 year, and annually thereafter. LV function recovery was defined as ejection fraction (EF) ≥40% at least once during follow-up. LV function non-recovery was defined as EF <40% at any follow-up. The primary and secondary end points were changes in LV function and all-cause mortality, respectively. Clinical follow-up was completed in 461 patients (94.1%; mean follow-up: 64.5 ± 45.5 months).

RESULTS

During follow-up, echocardiographic assessments were performed 1863 times (mean, 3.8 ± 2.4), and 193 patients (39.4%) exhibiting LV function non-recovery were identified. Overall survival was significantly higher in the recovery group (53.9%) than in the non-recovery group (31.4%) at 10 years (P < 0.001). Independent predictors of LV function non-recovery were preoperative LV end-systolic diameter [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.04-1.10; P < 0.001] and bilateral internal thoracic artery grafting (OR 0.61, 95% CI 0.39-0.95; P = 0.028). In a multivariable Cox proportional hazards model, LV function non-recovery was significantly associated with all-cause mortality (hazard ratio 2.14, 95% CI 1.60-2.86; P < 0.001).

CONCLUSIONS

Almost 40% of patients with ischaemic cardiomyopathy undergoing CABG did not achieve LV function recovery and were associated with poor prognosis. To achieve LV function recovery, CABG with bilateral internal thoracic artery may be recommended before excessive LV remodelling occurs.

CLINICAL TRIAL REGISTRATION NUMBER

Institutional review board of Osaka University Hospital, number 16105.

Sutureless patch repair with a novel adhesive for postinfarction ventricular septal rupture

Ventricular septal rupture after acute myocardial infarction is a fatal complication with a very high in-hospital mortality. Herein, we describe a new repair technique using a 1st patch for exclusion of the infarcted myocardium and a 2nd sutureless patch for rupture site closure with a novel tissue adhesive (Hydrofit®). Follow-up of over 2 years revealed a good clinical course and no residual interventricular shunt on echocardiography. This modified infarct exclusion technique with a 2nd sutureless patch has a benefit of avoiding stitches to the fragile infarcted myocardium and might be effective in preventing interventricular shunt recurrence after ventricular septal rupture.

Unusual Case of Giant Nonthrombosed Right Coronary Artery Pseudoaneurysm With Coronary Artery Fistula

Coronary artery aneurysm and pseudoaneurysm are rare and mainly result from atherosclerosis. We present a successfully treated case of a giant right coronary artery aneurysm and pseudoaneurysm with a coronary artery fistula, which might have developed after cardiac surgery for a right ventricular tumor 35 years earlier. (Level of Difficulty: Advanced.).