Anti-adhesive effect and safety of a thermosensitive adhesion barrier (Mediclore) for thyroid surgery: a double-blinded randomized controlled trial

Purpose@#Postoperative adhesions after thyroidectomy adversely affect patients’ quality of life. This study assessed the anti-adhesive effect and safety of thermosensitive sol-gel agents for patients undergoing thyroidectomy. @*Methods@#A double-blind parallel-group randomized clinical trial involving patients aged 20–70 years undergoing thyroidectomy for thyroid nodules was conducted. From August 2017 to April 2020, 90 patients were randomly assigned to the experimental (n = 45, thermosensitive sol-gel agent applied to the surgical site) and control (n = 45, no treatment) groups in a 1:1 ratio. All patients were assessed using a questionnaire for swallowing difficulty, wrinkle problems, and inflammation at 2 weeks, 3 months, and 6 months after thyroid surgery. For reoperated patients, the degree of adhesion was evaluated according to the adhesion-evaluation score system (range, 0–4). @*Results@#During the follow-up period of 6.50 ± 1.38 months, the swallowing difficulty, wrinkle problem, and inflammation were improved in both groups. However, there was no statistically significant difference between the control and experimental groups related to swallowing difficulty, wrinkle problems, and inflammation. Two patients in the control group and 1 in the experimental group who underwent reoperation had an adhesion-evaluation score of 3 points. There were no adverse effects or allergic reactions. @*Conclusion@#A thermosensitive sol-gel agent can be safely used as an anti-adhesive barrier. However, this study did not reveal its efficacy for postoperative adhesions. A more objective and systematic study is required in the future.

Efficacy of Intraoperative Neuromonitoring in Reoperation for Recurrent Thyroid Cancer Patients

Background@#The use of intraoperative neuromonitoring (IONM) in thyroid surgery to preserve recurrent laryngeal nerve (RLN) function has been widely accepted. We aimed to evaluate the usefulness of IONM in reoperation for recurrent thyroid cancer patients to help identify the RLN and prevent vocal cord palsy (VCP). @*Methods@#We analyzed 121 consecutive patients (with IONM group, 48 patients; without IONM group, 73 patients) who underwent reoperation for recurrent thyroid cancer after total thyroidectomy from January 2009 to March 2019 in our institution without VCP due to previous operations. Data including age, sex, number of previous operations, histologic subtype of the malignancy at the initial operation, operation time, RLNs at risk, difficulty of RLN identification, surgical procedure, VCP, and other postoperative complications were reviewed. Vocal cord movement evaluations were performed preoperatively and at 2 weeks postoperatively to evaluate RLN function. In patients with VCP, additional evaluations were performed. VCP exceeding 12 months after surgery was considered permanent VCP. @*Results@#VCP was observed in six (12.5%) and 16 (21.9%) patients with and without IONM (P=0.189). Transient and permanent VCP were found in three (6.3%) and three (6.3%) patients with IONM (P=0.098 and P=0.982, respectively) versus in 12 (16.4%) and four (5.5%) patients without IONM. @*Conclusion@#The incidence of transient VCP seems to be lower in reoperations with IONM; however, there was no statistical significances. Further study will be needed to ascertain the efficacy of IONM in reoperation for recurrent thyroid cancer patients.

Efficacy of Intraoperative Neuromonitoring in Reoperation for Recurrent Thyroid Cancer Patients

Background@#The use of intraoperative neuromonitoring (IONM) in thyroid surgery to preserve recurrent laryngeal nerve (RLN) function has been widely accepted. We aimed to evaluate the usefulness of IONM in reoperation for recurrent thyroid cancer patients to help identify the RLN and prevent vocal cord palsy (VCP). @*Methods@#We analyzed 121 consecutive patients (with IONM group, 48 patients; without IONM group, 73 patients) who underwent reoperation for recurrent thyroid cancer after total thyroidectomy from January 2009 to March 2019 in our institution without VCP due to previous operations. Data including age, sex, number of previous operations, histologic subtype of the malignancy at the initial operation, operation time, RLNs at risk, difficulty of RLN identification, surgical procedure, VCP, and other postoperative complications were reviewed. Vocal cord movement evaluations were performed preoperatively and at 2 weeks postoperatively to evaluate RLN function. In patients with VCP, additional evaluations were performed. VCP exceeding 12 months after surgery was considered permanent VCP. @*Results@#VCP was observed in six (12.5%) and 16 (21.9%) patients with and without IONM (P=0.189). Transient and permanent VCP were found in three (6.3%) and three (6.3%) patients with IONM (P=0.098 and P=0.982, respectively) versus in 12 (16.4%) and four (5.5%) patients without IONM. @*Conclusion@#The incidence of transient VCP seems to be lower in reoperations with IONM; however, there was no statistical significances. Further study will be needed to ascertain the efficacy of IONM in reoperation for recurrent thyroid cancer patients.

Initial Experience of Endoscopic Thyroidectomy Using Bilateral Axillary Breast and Transoral Vestibular Approach in Georgia

Purpose@#Remote access thyroid surgery using a bilateral axillary breast approach (BABA) or a transoral endoscopic thyroidectomy vestibular approach (TOETVA) are increasingly performed worldwide. In the Caucasus, these methods were first applied in the Republic of Georgia. This study compares these two methods of endoscopic thyroid surgery performed on patients in a tertiary hospital in Tbilisi, Georgia. @*Methods@#Between December 2015 and January 2018, 41 patients underwent endoscopic thyroid surgery at the Aversi Clinic, including 32 who underwent BABA endoscopic thyroidectomy for benign nodules and nine who underwent TOETVA for thyroid cancers. Patients’ medical records were retrospectively reviewed. @*Results@#Tumors were significantly larger (2.38±0.38 cm versus 1.70±0.31 cm, p value <0.001), operation time was significantly longer (177.66±21.02 min versus 116.66±5.59 min, p value <0.001), and blood loss was significantly greater (149.07±28.10 ml versus 102.22±8.33 ml, p value <0.001) in patients who underwent BABA than TOETVA. There were no significant differences in postoperative complications between the two groups. @*Conclusion@#Remote access thyroid surgery, either BABA or TOETVA, was successfully started, without harmful complications, at the Aversi Clinic in Tbilisi, Georgia. BABA is suitable for large sized benign nodules and TOETVA for thyroid cancers with central lymph node dissection.

Long-Term Results of the Leaflet Extension Technique for Rheumatic Aortic Regurgitation: A 20-Year Follow-up

BACKGROUND@#Although aortic valve repair can reduce prosthesis-related complications, rheumatic aortic regurgitation (AR) caused by leaflet restriction is a significant risk factor for recurrent AR. In this study, we evaluated the long-term results of the leaflet extension technique for rheumatic AR.@*METHODS@#Between 1995 and 2016, 33 patients underwent aortic valve repair using the leaflet extension technique with autologous pericardium for rheumatic pure AR. Twenty patients had severe AR and 9 had combined moderate or greater mitral regurgitation. Their mean age was 32.2±13.9 years. The mean follow-up duration was 18.3±5.8 years.@*RESULTS@#There were no cases of operative mortality, but postoperative complications occurred in 5 patients. Overall survival at 10 and 20 years was 93.5% and 87.1%, respectively. There were no thromboembolic cerebrovascular events, but 4 late deaths occurred, as well as a bleeding event in 1 patient who was taking warfarin. Twelve patients underwent aortic valve reoperation. The mean interval to reoperation was 13.1±6.1 years. Freedom from reoperation at 10 and 20 years was 96.7% and 66.6%, respectively.@*CONCLUSION@#The long-term results of the leaflet extension technique showed acceptable durability and a low incidence of thromboembolic events and bleeding. The leaflet extension technique may be a good option for young patients with rheumatic AR.

Recurrent Ipsilateral Breast Sparganosis: A Case Report

Sparganosis is a rare parasitic infection that can infect the abdominal wall, extremities, urogenital system, and/or central nervous system. Because the incidence of sparganosis is less than 2% of all reported cases of sparganosis, early diagnosis of sparganosis is difficult. Breast sparganosis has characteristic radiologic findings. Complete surgical removal is the treatment of choice and has the benefit of producing a definite diagnosis. Herein, we would report a case of recurrent breast sparganosis that occurred two years after surgical excision of worms from the ipsilateral breast.

Long-Term Results of the Leaflet Extension Technique for Rheumatic Aortic Regurgitation: A 20-Year Follow-up / 대한흉부외과학회지

BACKGROUND: Although aortic valve repair can reduce prosthesis-related complications, rheumatic aortic regurgitation (AR) caused by leaflet restriction is a significant risk factor for recurrent AR. In this study, we evaluated the long-term results of the leaflet extension technique for rheumatic AR. METHODS: Between 1995 and 2016, 33 patients underwent aortic valve repair using the leaflet extension technique with autologous pericardium for rheumatic pure AR. Twenty patients had severe AR and 9 had combined moderate or greater mitral regurgitation. Their mean age was 32.2±13.9 years. The mean follow-up duration was 18.3±5.8 years. RESULTS: There were no cases of operative mortality, but postoperative complications occurred in 5 patients. Overall survival at 10 and 20 years was 93.5% and 87.1%, respectively. There were no thromboembolic cerebrovascular events, but 4 late deaths occurred, as well as a bleeding event in 1 patient who was taking warfarin. Twelve patients underwent aortic valve reoperation. The mean interval to reoperation was 13.1±6.1 years. Freedom from reoperation at 10 and 20 years was 96.7% and 66.6%, respectively. CONCLUSION: The long-term results of the leaflet extension technique showed acceptable durability and a low incidence of thromboembolic events and bleeding. The leaflet extension technique may be a good option for young patients with rheumatic AR.

Continuous Positive Airway Pressure Therapy Can Prevent Pulmonary Atelectasis after Laparoscopic Roux-en-Y Gastric Bypass Surgery in Obese Patients

PURPOSE: To compare the prophylactic effects of postoperative continuous positive airway pressure (CPAP) therapy plus conventional postoperatively pulmonary physiotherapy (CPP) and postoperative CPP alone on the development of pulmonary atelectasis after laparoscopic Roux-en-Y gastric bypass (LGBP) in obese patients. MATERIALS AND METHODS: Patients with BMIs>27.5 kg/m2 aged between 20 and 65 years were enrolled in the present study. All subjects received LGBP and were divided into 2 groups. Patients in the CPAP group received both CPAP and CPP therapy postoperatively, and patients in the conventional group received CPP alone. The primary outcome was the incidence of postoperative pulmonary atelectasis as determined by chest X-ray after LGBP, and the secondary outcome was duration of postoperative hospital stay (HS). RESULTS: Seventy-three patients were enrolled in this study. Fifty-seven patients received CPAP plus CPP, and 16 patients received CPP. The CPAP group had an atelectasis incidence of 40.4% (23/57) and the conventional group an incidence of 62.5% (10/16). Multivariate analysis showed the incidence of atelectasis after LGBP was significantly lower in the CPAP group (OR 0.198, 95% CI 0.045–0.874; P=0.033) and that HS was significantly correlated with the developments of atelectasis, pneumonia, and complications (partial correlation coefficients 0.271, 0.444 and 0.382; P-values 0.025, <0.05 and <0.05, respectively). CONCLUSION: Patients that received continuous positive airway pressure therapy plus conventional pulmonary physiotherapy postoperatively were at significantly less risk of developing pulmonary atelectasis after LGBP than patients that received conventional pulmonary physiotherapy postoperatively.

Extra-Anatomic Ascending Aorta to Abdominal Aorta Bypass in Takayasu Arteritis Patients with Mid-Aortic Syndrome

BACKGROUND: We evaluated the operative outcomes of an extra-anatomic bypass from the ascending aorta to the abdominal aorta in patients with type II or III Takayasu arteritis (TA) with mid-aortic syndrome. METHODS: From 1988 to 2014, 8 patients with type II (n=2) or III (n=6) TA underwent an ascending aorta to abdominal aorta bypass. The mean patient age was 43.5±12.2 years and the mean peak pressure gradient between the upper and lower extremities was 54.8±39.0 mm Hg. The median follow-up duration was 54.4 months (range, 17.8 to 177.4 months). RESULTS: There were no cases of operative mortality. The mean peak pressure gradient significantly decreased to −2.4±32.3 mm Hg (p=0.017 compared to the preoperative value). Late death occurred in 2 patients. The symptoms of upper extremity hypertension and claudication improved in all patients. The bypass grafts were patent at 47.1±58.9 months in 7 patients who underwent follow-up imaging studies. CONCLUSION: An extra-anatomic ascending aorta to abdominal aorta bypass could be an effective treatment option for severe aortic steno-occlusive disease in patients with type II or III TA, with favorable early and long-term outcomes.

Surgical Results of Third or More Cardiac Valve Operation

BACKGROUND: We evaluated operative outcomes after third or more cardiac operations for valvular heart disease, and analyzed whether pericardial coverage with artificial membrane is helpful for subsequent reoperation. METHODS: From 2000 to 2012, 149 patients (male:female=70:79; mean age at operation, 57.0+/-11.3 years) underwent their third to fifth operations for valvular heart disease. Early results were compared between patients who underwent their third operation (n=114) and those who underwent fourth or fifth operation (n=35). Outcomes were also compared between 71 patients who had their pericardium open during the previous operation and 27 patients who had artificial membrane coverage. RESULTS: Intraoperative adverse events occurred in 22 patients (14.8%). Right atrium (n=6) and innominate vein (n=5) were most frequently injured. In-hospital mortality rate was 9.4%. Total cardiopulmonary bypass time (225+/-77 minutes vs. 287+/-134 minutes, p=0.012) and the time required to prepare aortic cross clamp (209+/-57 minutes vs. 259+/-68 minutes, p<0.001) increased as reoperations were repeated. However, intraoperative event rate (13.2% vs. 20.0%), in-hospital mortality (9.6% vs. 8.6%) and postoperative complications were not statistically different according to the number of previous operations. Pericardial closure using artificial membrane at previous operation was not beneficial in reducing intraoperative events (25.9% vs. 18.3%) and shortening operation time preparing aortic cross clamp (248+/-64 minutes vs. 225+/-59 minutes) as compared to no-closure. CONCLUSION: Clinical outcomes of the third or more operations for valvular heart disease were acceptable in terms of intraoperative adverse events and in-hospital mortality rates. There were no differences in the incidence of intraoperative adverse events, early mortality and postoperative complications between third cardiac operation and fourth or more.

De Vega Annuloplasty for Functional Tricupsid Regurgitation: Concept of Tricuspid Valve Orifice Index to Optimize Tricuspid Valve Annular Reduction

We evaluated long-term results of De Vega annuloplasty measured by cylindrical sizers for functional tricuspid regurgitation (FTR) and analyzed the impact of measured annular size on the late recurrence of tricuspid valve regurgitation. Between 2001 and 2011, 177 patients (57.9+/-10.5 yr) underwent De Vega annuloplasty for FTR. Three cylindrical sizers (actual diameters of 29.5, 31.5, and 33.5 mm) were used to reproducibly reduce the tricuspid annulus. Long-term outcomes were evaluated and risk factor analyses for the recurrence of FTR > or =3+ were performed. Measured annular diameter indexed by patient's body surface area was included in the analyses as a possible risk factor. Operative mortality occurred in 8 patients (4.5%). Ten-year overall and cardiac death-free survivals were 80.5% and 90.8%, respectively. Five and 10-yr freedom rates from recurrent FTR were 96.5% and 93.1%, respectively. Cox proportional hazard model revealed that higher indexed annular size was the only risk factor for the recurrence of FTR (P=0.006). A minimal P value approach demonstrated that indexed annular diameter of 22.5 mm/m2 was a cut-off value predicting the recurrence of FTR. De Vega annuloplasty for FTR results in low rates of recurrent FTR in the long-term. Tricuspid annulus should be reduced appropriately considering patients' body size to prevent recurrent FTR.

The effect of duodenojejunal bypass for type 2 diabetes mellitus patients below body mass index 25 kg/m2: one year follow-up / 대한외과학회지

PURPOSE: The goals of this study are to evaluate the effect of duodenojejunal bypass (DJB) for type 2 diabetes mellitus (T2DM) patients below body mass index (BMI) 25 kg/m2 in one year follow-up, and to compare the results of 1 week which we have reported in 2011. METHODS: In this prospective observational study, there were 31 type 2 diabetic patients who underwent DJB at Inha University Hospital from July 2009 to January 2011. We did laboratories such as 75-g oral glucose tolerance test (OGTT), insulin level and hemoglobin A1c (HbA1c), etc. and compared their changes of preoperative, a week, 3 months, and 12 months. RESULTS: Mean BMI was 23.1 +/- 1.3 kg/m2, mean duration of T2DM was 8.3 +/- 4.7 and mean age was 46.6 +/- 7.7 years. There were a significant decrease of 75-g OGTT levels and increase of insulin secretion after 3 months. 13.3% showed diabetic remission (HbA1c < 6.0, medication cessation) and 26.7% showed diabetic improvement. The rates of remission and improvement much declined comparing with that of postoperative 1 week although those were determined by fasting and postprandial 2 hour level of glucose. CONCLUSION: This is the first study of metabolic surgery in Korean diabetes patients in the healthy weight range. DJB exerted positive influences on insulin resistance as well as beta cell function. Early effects on T2DM after DJB could be estimated as one of good modalities, although the effectiveness seems to be unacceptable. Further studies are mandatory for evaluation of the effectiveness of metabolic surgery and finding prognostic factors.

Clinical Outcomes of Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension: 12-Year Experience

BACKGROUND: We present our 12-year experience of pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension. MATERIALS AND METHODS: Between January 1999 and March 2011, 16 patients underwent pulmonary thromboendarterectomy. Eleven patients (69%) were classified as functional class III or IV based on the New York Heart Association (NYHA) classification. Seven patients had a history of inferior vena cava filter insertion, and 5 patients showed coagulation disorders. Pulmonary thromboendarterectomy was performed during total circulatory arrest with deep hypothermia in 14 patients. RESULTS: In-hospital mortality and late death occurred in 2 patients (12.5%) and 1 patient (6.3%), respectively. Extracorporeal membrane oxygenation support was required in 4 patients who developed severe hypoxemia after surgery. Thirteen of the 14 survivors have been followed up for 54 months (range, 2 to 141 months). The pulmonary arterial systolic pressure and cardiothoracic ratio on chest radiography was significantly decreased after surgery (76+/-26 mmHg vs. 41+/-17 mmHg, p=0.001; 55%+/-8% vs. 48%+/-3%, p=0.003). Tricuspid regurgitation was reduced from 2.1+/-1.1 to 0.7+/-0.6 (p=0.007), and the NYHA functional class was also improved to I or II in 13 patients (81%). These symptomatic and hemodynamic improvements maintained during the late follow-up period. CONCLUSION: Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension shows good clinical outcomes with acceptable early and long term mortality.

Successful treatment of type I endoleak of common iliac artery with balloon expandable stent (Palmaz XL stent) during endovascular aneurysm repair / 대한외과학회지

Type 1 endoleak of common iliac artery (type Ib endoleak) should be treated during endovascular aneurysm repair (EVAR). An 86-year-old female was diagnosed with abdominal aortic aneurysm measuring 6.6 cm in diameter and right internal iliac artery aneurysm measuring 4.0 cm in diameter. She underwent EVAR after right internal iliac artery embolization. There was type Ib endoleak, which was repaired by balloon-expandable stent, Palmaz XL stent (Cordis). We report successful treatment of type Ib endoleak with Palmaz XL stent, which may be considered as an alternative option for type Ib endoleak after EVAR.

Midterm Follow-up after Cryopreserved Homograft Replacement in the Aortic Position

BACKGROUND: The long-term results of homografts used in systemic circulation are controversial. We assessed the long-term results of using a cryopreserved homograft for an aortic root or aorta and its branch replacement. MATERIALS AND METHODS: From June 1995 to January 2010, 23 patients (male:female=15:8, 45.4+/-15.6 years) underwent a homograft replacement in the aortic position. The surgical techniques used were aortic root replacement in 15 patients and aortic graft interposition in 8 patients. Indications for the use of a homograft were systemic vasculitis (n=15) and complicated infection (n=8). The duration of clinical follow-up was 65+/-58 months. RESULTS: Early mortality occurred in 2 patients (8.7%). Perioperative complications included atrial arrhythmia (n=3), acute renal failure (n=3), and low cardiac output syndrome (n=2). Late mortality occurred in 6 patients (26.1%). The overall survival rates at 5 and 10 years were 66.3% and 59.6%, respectively. Six patients (28.6%) suffered from homograft-related complications. CONCLUSION: Early results of homograft replacement in aortic position were favorable. However, close long-term follow-up is required due to the high rate of homograft-related events.

Effectiveness of Endovascular Treatment of Acute Thrombosis of Arteriovenous Graft for Hemodialysis by Primary Endovascualr Treatment Strategy / 대한혈관외과학회지

PURPOSE: Acute thrombosis of arteriovenous graft (AVG) has been treated by surgical thrombectomy; however, endovascular treatment became an alternative treatment option recently. The purpose of this study is to evaluate the effectiveness of endovascular treatment for acute thrombosis of AVG (EndoAVG) by primary endovascular treatment strategy. METHODS: This is a retrospective study of patients who underwent EndoAVG from January 2003 to December 2010 in Inha University Hospital. The patients' clinical characteristics and EndoAVG procedures were reviewed by electronic charts and X-ray films. Clinical success was defined as the residual stenosis below 30% or success of hemodialysis. RESULTS: Thirty-eight patients were enrolled. The mean age was 64+/-15.4 years in the success group and 58+/-17.2 years in the failed group. The mean duration from AVG formation to endovascular thrombectomy was 19.2+/-29.5 months. The success rate of EndoAVG was 84.2% (32/38). There were three complications after EndoAVG: two brachial artery thromboses and one rupture of a vein at the ballooning site. Six months, twelve months and twenty-four months secondary patency rate were 77.5%, 65.5%, and 42.5%, respectively. CONCLUSION: The success rate of EndoAVG was 84.2%. Its result is compatible with open thrombectomy and can be a good alternative option for the treatment of acute thrombosis of AVG. Larger number of cases is required for stronger study.

Cardiac Myxoma Originating from the Anterior Mitral Valve Leaflet

Primary cardiac tumors are rare and myxoma is the most common tumor among them. Cardiac myxoma usually occurs in the left atrium. Myxoma originating from mitral valve is extremely rare. We report a case of mitral valve myxoma. The tumor originated from the anterior mitral valve leaflet. The tumor was completely removed and replacement of the mitral valve was not done.

Risk Factors of Drug Interaction between Warfarin and Nonsteroidal Anti-Inflammatory Drugs in Practical Setting

Nonsteroidal anti-inflammatory drugs (NSAIDs) are known to interact with the oral anticoagulant warfarin and can cause a serious bleeding complication. In this study, we evaluated the risk factors for international normalized ratio (INR) increase, which is a surrogate marker of bleeding, after addition of an NSAID in a total of 98 patients who used warfarin. Patient age, sex, body mass index, maintenance warfarin dose, baseline INR, coadministered medications, underlying diseases, and liver and kidney functions were evaluated for possible risk factors with INR increase > or =15.0% as the primary end-point. Of the 98 patients, 39 (39.8%) showed an INR elevation of > or =15.0% after adding a NSAID to warfarin therapy. Multivariate analysis showed that high maintenance dose (>40 mg/week) of warfarin (P=0.001), the presence of coadministered medications (P=0.024), the use of meloxicam (P=0.025) and low baseline INR value (P=0.03) were the risk factors for INR increase in respect to NSAID-warfarin interaction. In conclusion, special caution is required when an NSAID is administered to warfarin users if patients are taking warfarin >40 mg/week and other medications interacting with warfarin.

Characteristics of P wave in Patients with Sinus Rhythm after Maze Operation

Maze operation could alter P wave morphology in electrocardiogram (ECG), which might prevent exact diagnosis of the cardiac rhythm of patients. However, characteristics of P wave in patients with sinus rhythm after the operation have not been elucidated systematically. Consecutive patients who underwent the modified Cox Maze operation from January to December 2007 were enrolled. The standard 12-lead ECG and echocardiography were evaluated in patients who had sinus rhythm at 6 months after the operation. The average axis of P wave was 65+/-30 degrees. The average amplitude of P wave was less than 0.1 mV in all 12-leads, with highest amplitude in V1. The most common morphology of P wave was monophasic with positive polarity (49%), except aVR lead, which was different from those in patients with enlarged left atrium, characterized by large P-terminal force in the lead V1. There were no significant differences in P-wave characteristics and echocardiographic parameters between patients with LA activity (30.6%) versus without LA activity (69.4%) at 6 months after the operation. In conclusion, the morphology of P wave in patients after Maze operation shows loss of typical ECG pattern of P mitrale: P wave morphology is small in amplitude, monophasic and with positive polarity.

B-Type Natriuretic Peptide in Isolated Severe Tricuspid Regurgitation: Determinants and Impact on Outcome

BACKGROUND: The plasma B-type natriuretic peptide (BNP) level is a useful prognostic marker in heart failure and valvular heart disease. In patients with isolated severe tricuspid regurgitation (TR), little is known about the determinants of plasma BNP levels and the correlation with future outcome. The purpose of this study was to identify the determinants of plasma BNP levels in patients with isolated severe TR and the value of the BNP level in predicting postoperative outcomes after corrective surgery. METHODS: We prospectively enrolled 39 patients with isolated, severe TR undergoing corrective surgery. A plasma BNP assay and cardiac magnetic resonance (CMR) imaging were performed before surgery. The combined end-point was the occurrence of cardiac death or readmission due to heart failure. RESULTS: Linear regression analysis showed that the left ventricular ejection fraction and right ventricular end systolic volume were the most important determinants of the BNP levels (p = 0.002, R2 = 0.315). Based on the receiver operating characteristics (ROC) curve, we were able to derive an optimal cutoff value (200 pg/mL) to predict postoperative cardiac death with a sensitivity of 80% and a specificity of 85%. The one-year survival rate was 96% in patients with a BNP or = 200 pg/dL (p = 0.001). CONCLUSION: An elevation in the BNP level is determined by the functional status of the right and left ventricles in patients with isolated, severe TR. An elevated BNP predicts adverse events after corrective surgery. Therefore, the BNP level should be included in the clinical evaluation and risk stratification of patients with isolated TR.