Impact of pericardial calcification on early postoperative outcomes after pericardiectomy: a retrospective observational study.

BACKGROUND: Owing to the lack of understanding of the clinical significance of pericardial calcification during pericardiectomy, whether pericardial calcification should be considered when determining the optimal timing for pericardiectomy is debatable. We aimed to investigate the effect of pericardial calcification on early postoperative outcomes in patients who underwent pericardiectomy for constrictive pericarditis. METHODS: Altogether, 44 patients who underwent pericardiectomy for constrictive pericarditis were enrolled. After excluding three patients who underwent concurrent surgeries, a total of 41 patients were categorized into two groups based on the presence of pericardial calcification as determined by preoperative computed tomography and pathological examination. Preoperative clinical and imaging characteristics, intraoperative data, and early postoperative outcomes were compared between the two groups. A multivariable analysis was performed to identify the factors associated with postoperative complications. RESULTS: The group with and without PC comprised 21 and 20 patients, respectively. No significant differences were observed in 30-day mortality (n = 1 [5%]) in the group with pericardial calcification and no mortality in the group without pericardial calcification (p > 0.999). Other early postoperative outcome variables did not demonstrate any significant differences between the two groups. However, the use of cardiopulmonary bypass was associated with postoperative complications (p < 0.009, odds ratio: 63.5, 95% confidence interval: 5.13-3400). CONCLUSIONS: Pericardial calcification did not significantly affect the postoperative outcomes after pericardiectomy. Further comprehensive studies, including those with larger sample sizes and longitudinal designs, are necessary to determine whether pericardial calcification can significantly influence the timing of surgical intervention.

Comparative analysis of del Nido cardioplegia versus blood cardioplegia in isolate coronary artery bypass grafting.

BACKGROUND: This study examined the efficacy of del Nido cardioplegia compared with traditional blood cardioplegia in adult cardiac surgery for isolated coronary artery bypass grafting by evaluating the early postoperative outcomes. METHODS: A total of 119 patients who underwent isolated conventional coronary artery bypass grafting were enrolled and divided into two groups (del Nido cardioplegia group [n = 36] and blood cardioplegia group [n = 50]) based on the type of cardioplegia used. This study compared the preoperative characteristics, intraoperative data, and early postoperative outcomes. Further subgroup analyses were conducted for high-risk patient groups. RESULTS: The 30-day mortality and morbidity rates were not significantly different between groups. The del Nido cardioplegia group exhibited advantageous myocardial protection outcomes, demonstrated by a significantly smaller rise in Troponin I levels post-surgery (2.8 [-0.4; 4.2] vs. 4.5 [2.9; 7.4] ng/mL, p = 0.004) and fewer defibrillation attempts during weaning off of cardiopulmonary bypass (0.0 ± 0.2 vs. 0.4 ± 1.1 times, p = 0.011) when compared to the blood cardioplegia group. Additionally, the del Nido group achieved a reduction in surgery duration, as evidenced by the reduced aortic cross-clamping time (64.0 [55.5; 75.5] vs. 77.5 [65.0; 91.0] min, p = 0.001) and total operative time (287.5 [270.0; 305.0] vs. 315.0 [285.0; 365.0] min, p = 0.008). Subgroup analyses consistently demonstrated that the del Nido cardioplegia group had a significantly smaller postoperative increase in Troponin I levels across all subgroups (p < 0.05). CONCLUSIONS: del Nido cardioplegia provided myocardial protection and favorable early postoperative outcomes compared to blood cardioplegia, making it a viable option for conventional coronary artery bypass grafting. Establishing a consensus on the protocol for Del Nido cardioplegia administration in adult surgeries is needed.

Features and outcomes of focal intimal disruption in acute type B intramural haematoma.

OBJECTIVES: A focal intimal disruption (FID) is a risk factor for adverse aorta-related events in patients with acute type B intramural haematoma. This study evaluated the impact of FIDs on overall survival with a selective intervention strategy for large or growing FIDs. Additionally, this study evaluated the risk factors associated with the growth of FIDs. METHODS: This retrospective study included all consecutive patients admitted for acute type B intramural haematomas between November 2004 and April 2021. The primary outcome was overall survival. The secondary outcome was the cumulative incidence of composite aortic events and the growth of FIDs. The latter was calculated on centreline-reconstructed computed tomography images. RESULTS: A total of 105 patients were included. A total of 106 FIDs were identified in 73 patients (73/105, 69.5%). The 1- and 5-year cumulative incidence rates of composite aortic events were 36.2% and 39.2%, respectively. The 1- and 5-year overall survival was 93.3% and 81.5%, respectively. Initial maximal aortic diameter and large FIDs during acute phase were significant risk factors for composite aortic events, but not risk factors for overall survival. The early appearance interval of an FID was a significant risk factor for growth of an FID. CONCLUSIONS: With a selective intervention strategy for large or growing FIDs, the presence of large FIDs during the acute phase does not affect overall survival. The early appearance interval was associated with the growth of FIDs.

Thrombocytopenia after Aortic Valve Replacement Using Sutureless Valves.

Background: Sutureless valves are widely used in aortic valve replacement surgery, with Perceval valves and Intuity valves being particularly prominent. However, concerns have been raised about postoperative thrombocytopenia with Perceval valves (Corcym, UK). We conducted a comparative analysis with the Intuity valve (Edwards Lifesciences, USA), and assessed how thrombocytopenia affected patient and transfusion outcomes. Methods: Among 595 patients who underwent aortic valve replacement from June 2016 to March 2023, sutureless valves were used in 53 (Perceval: n=23; Intuity: n=30). Platelet counts were monitored during hospitalization and outpatient visits. Daily platelet count changes were compared between groups, and the results from patients who underwent procedures using Carpentier Edwards Perimount Magna valves were used as a reference group. Results: Compared to the Intuity group, the Perceval group showed a significantly higher amount of platelet transfusion (5.48±1.64 packs vs. 0.60±0.44 packs, p=0.008). During the postoperative period, severe thrombocytopenia (<50,000/µL) was significantly more prevalent in the Perceval group (56.5%, n=13) than in the Intuity group (6.7%, n=2). After initial postoperative depletion, daily platelet counts increased, with significant differences observed in the extent of improvement between the Perceval and Intuity groups (p<0.001). However, there was no significant difference in early mortality or the incidence of neurological complications between the 2 groups. Conclusion: The severity of postoperative thrombocytopenia differed significantly between the Perceval and Intuity valves. The Perceval group showed a significantly higher prevalence of severe thrombocytopenia and higher platelet transfusion volumes. However, thrombocytopenia gradually recovered during the postoperative period in both groups, and the early outcomes were similar in both groups.

Influence of Preoperative COVID-19 Vaccination on Outcomes After Coronary Artery Bypass Grafting-A Propensity Score-Matched Analysis.

BACKGROUND: Reports of intravascular thrombosis and cardiac complications have raised concerns about the safety of COVID-19 vaccinations, particularly in patients with high cardiovascular risk. Herein, we aimed to analyze the impact of preoperative COVID-19 vaccination on outcomes after coronary artery bypass grafting (CABG). METHODS AND RESULTS: Among 520 patients who underwent isolated CABG from 2020 to 2022, 481 patients (mean±SD age: 67±11 years, 86 women) whose COVID-19 vaccination status could be confirmed were included. A total of 249 patients who had not received any COVID-19 vaccine before CABG (never vaccinated group) and 214 patients who had completed primary vaccination (fully vaccinated group) were subjected to 1:1 propensity score matching, and 156 pairs of patients were matched. There was no significant difference in early mortality between the 2 groups after matching. After matching, overall survival (P=0.930) and major adverse cardiovascular and cerebrovascular event-free survival (P=0.636) did not differ between the 2 groups. One-year graft patency also did not differ significantly between the 2 groups; all patent grafts in 85/104 patients (82%) and 62/73 patients (85%) in the never vaccinated and fully vaccinated groups, respectively (P=0.685). Subgroup analysis showed equivalent overall and major adverse cardiovascular and cerebrovascular event-free survival among AstraZeneca and Pfizer vaccine recipients and between those with ≤30 days versus >30 days from vaccination to CABG. CONCLUSIONS: Despite the very high cardiovascular risk for patients undergoing CABG, COVID-19 vaccination did not affect major outcomes after CABG. Therefore, there is no reason for patients with coronary artery disease requiring CABG to avoid preoperative COVID-19 vaccination.

Acute type A aortic dissection features and outcomes in octogenarians: a propensity score analysis.

OBJECTIVES: The clinical characteristics and early outcomes of surgical repair in octogenarians with acute type A aortic dissection were compared with those in nonoctogenarians. METHODS: All patients who underwent emergency surgical repair for acute type A aortic dissection in our institution between 2003 and 2022 were included in this study. The patients were divided into an octogenarian group and a nonoctogenarian group. The patients in the 2 groups were propensity score matched at a ratio of 1:1. Before matching, the baseline characteristics were compared between 2 groups. The major complication and 30-day mortality rates were compared in the matched population. RESULTS: A total of 495 patients were screened, and 471 were included in the analysis, with 48 in the octogenarian group and 423 in the nonoctogenarian group. Before matching, DeBakey type II dissection was significantly more prevalent in the octogenarians (42% vs 14% in the octogenarians and nonoctogenarians, respectively, P < 0.001). Additionally, intramural haematomas (39.6% vs 14.4%, P < 0.001) were more prevalent in the octogenarians. However, severe aortic regurgitation (4.2% vs 15.4%, P = 0.046) and root enlargement (0% vs 13.7%, P = 0.009) were less prevalent in the octogenarians. After matching (36 pairs), the incidence of postoperative delirium was higher in the octogenarians (56% vs 25%, P = 0.027). However, there were no significant differences in 30-day and in-hospital mortality rates, intensive care unit stay or major complications, including stroke, paraplegia, respiratory complications, mediastinitis and haemodialysis. CONCLUSIONS: The octogenarians with acute type A aortic dissection had higher incidences of DeBakey type II dissection and intramural haematomas and lower incidences of severe aortic regurgitation and aortic root enlargement than the nonoctogenarians. Being an octogenarian was not associated with an increased risk of early major complications or mortality after surgery for acute type A aortic dissection.

Improved clinical outcomes following introduction of an attending intensivist for patients admitted to the cardiac surgical intensive care unit after valvular heart surgery: a single-center experience.

Background: Although numerous studies have documented the improved clinical outcomes of patients undergoing cardiac surgery following introduction of attending intensivist, most of these studies included heterogeneous patient populations. We aimed to investigate the impact of an attending intensivist on the clinical outcomes of patients admitted to the cardiac surgical intensive care unit (CSICU) following valvular heart surgery. Methods: Patients who underwent valvular heart surgery between January 2007 and December 2012 (control group, n=337) were propensity matched (1:1) between January 2013 and June 2017 (intensivist group, n=407). Results: During the propensity score matching analysis, 285 patients were extracted from each group. Patients in the intensivist group underwent mechanical ventilation for a significantly shorter time than those in the control group (21.8±69.8 vs. 39.2±115.3 hours, P=0.021). More patients were extubated within 6 hours in the intensivist group than in the control group (53.7% vs. 42.8%, P=0.015). The incidence of ventilator-associated pneumonia (1.4% vs. 4.9%, P=0.031), cardiac arrest due to cardiac tamponade associated with post-cardiotomy bleeding (0.4% vs. 3.9%, P=0.002), and acute kidney injury (2.8% vs. 7.7%, P=0.011) in the intensivist group was significantly lower than that in the control group. The 30-day mortality rate of the intensivist group was significantly lower than that of the control group (2.1% vs. 6.7%, P=0.015). Conclusions: Critical care provided in the CSICU staffed by an attending intensivist is associated with a lower 30-day mortality rate and reduced incidence of postoperative complications.

Elevated troponin I is associated with a worse long-term prognosis in patients undergoing beating-heart coronary surgery.

OBJECTIVES: The impacts of elevated troponin I levels after coronary artery bypass grafting (CABG) on long-term outcomes were investigated. METHODS: A total of 996 patients who underwent elective isolated CABG for stable or unstable angina were enrolled. Patients were divided into higher and lower groups based on 80th percentile postoperative peak troponin I (ppTnI) levels. The relationship between ppTnI and long-term clinical outcomes was analysed. RESULTS: The median ppTnI was 1.55 (2.74) ng/ml and was significantly higher in the conventional CABG subgroup than in the beating-heart CABG subgroup: 4.04 (4.71) vs 1.24 (1.99) ng/ml, P < 0.001. The 80th percentile of ppTnI was 3.3 ng/ml in the beating-heart CABG subgroup and 8.9 ng/ml in the conventional CABG subgroup. In the conventional CABG subgroup (n = 150), 10-year overall survival showed no significant difference between the higher (≥8.9 ng/ml) and lower (<8.9 ng/ml) ppTnI groups: 71% (10%) vs 76% (5%), P = 0.316. However, the beating-heart CABG subgroup (n = 846) showed significantly worse 10-year overall survival in the higher ppTnI group (≥3.3 ng/ml) than in the lower ppTnI group (<3.3 ng/ml): 64% (6%) vs 73% (3%), P = 0.010. In the beating-heart CABG subgroup, multivariable analysis showed that ppTnI exceeding the 80th percentile was a risk factor for overall death (hazard ratio: 1.505, 95% confidence interval: 1.019-2.225, P = 0.040). CONCLUSIONS: Higher ppTnI over the 80th percentile was associated with worse long-term survival in beating-heart CABG, but not in conventional CABG.

Changes in aortic growth rate and factors influencing aneurysmal dilatation after uncomplicated acute type B aortic dissection.

OBJECTIVES: The aim of this study was to evaluate changes in aortic growth rate and factors influencing aneurysmal dilatation after uncomplicated acute type B aortic dissection (ABAD). METHODS: Medically treated patients with uncomplicated ABAD between September 2004 and January 2020 were retrospectively reviewed. Diameters of 6 different sites in the descending aorta were measured and aortic growth rate was calculated according to the time interval. Factors associated with aneurysmal changes were also investigated. RESULTS: This study enrolled a total of 105 patients who underwent >2 serial computed tomography with a mean follow-up duration of 35.4 (12.1-77.4) months. The mean overall growth rates of the proximal descending thoracic aorta (DTA), mid-DTA, distal DTA, proximal abdominal aorta, maximal DTA and maximal abdominal aorta were 0.6 (1.9), 2.9 (5.2), 2.1 (4.0), 1.2 (2.2), 3.3 (5.6) and 1.4 (2.5) mm/year, respectively. The growth rate was higher at the early stage. It decreased over time. Growth rates of proximal DTA, mid-DTA, distal DTA, proximal abdominal aorta, maximal DTA, and maximal abdominal aorta within 3 months after dissection were 1.3 (9.6), 12.6 (18.2), 7.6 (11.7), 5.9 (7.5), 16.7 (19.8) and 6.8 (8.9) mm/year, respectively. More than 2 years later, they were 0.2 (0.6), 1.6 (1.6), 1.2 (1.3), 0.9 (1.4), 1.7 (1.9) and 1.2 (1.7) mm/year, respectively. Factors associated with aneurysmal changes after uncomplicated ABAD included an elliptical true lumen (odds ratio = 3.16; 95% confidence interval: 1.19-8.41; P = 0.021) and a proximal entry >10 mm (odds ratio = 3.08; 95% confidence interval: 1.09-8.69; P = 0.034) on initial computed tomography imaging. CONCLUSIONS: The aortic growth rate was higher immediately after uncomplicated ABAD but declined eventually. Patients with an elliptical true lumen and a large proximal entry might be good candidates for early endovascular intervention after uncomplicated ABAD.

Coronary artery disease in aortic aneurysm and dissection.

Coexisting coronary artery disease is a significant risk factor of untoward outcomes after surgical and endovascular aortic repair. This article reviewed the data, consensus, and remaining controversy about the diagnosis and management of coexisting coronary artery disease in the patients who require intervention for aortic aneurysm and dissection. It can be summarized as follows: (1) the current guidelines generally recommend the same diagnostic algorithm, including indications of coronary artery angiography, as one for non-surgical patients; (2) they also recommend the same indications of coronary revascularization; and (3) there are minor, but important, remaining issues regarding the details of management and surgical techniques most of which are still at the discretion of individual surgeons and institutions. Because it is not likely to get large-scale investigational data about these issues, the collection of individual experiences should be promoted in future scientific meetings to build up the consensus.

Zone 2 hybrid thoracic endovascular aortic repair: Is it a good option for all types of thoracic aortic disease?

BACKGROUND: Zone 2 thoracic endovascular aortic repair (TEVAR) is performed for the treatment of various thoracic aortic diseases involving the left subclavian artery. This study aimed to analyze the late clinical outcomes of zone 2 hybrid TEVAR according to the various indications. METHODS: A total of 48 patients who underwent zone 2 TEVAR at our institution between December, 2010 and July, 2020 were enrolled. The indications were aortic aneurysm (AA, n = 15), acute type B aortic dissection (AD, n = 14), penetrating aortic ulcer (PAU, n = 8), traumatic aortic injury (TAI, n = 8), and others (n = 3). The clinical outcomes including early complications and mid-term aortic measurements were retrospectively reviewed. RESULTS: The technical success rate was 100% and in-hospital mortality occurred in one patient. The early postoperative complications included stroke (n = 1), transient spinal cord ischemia (n = 1), neck wound hematoma (n = 1), and left phrenic or vagus nerve injury (n = 9). In patients with AD, positive remodeling was observed in ten patients (76.9%) (false lumen regression in the entire or thoracic aorta [n = 9], false lumen thrombosis in the thoracic aorta [n = 1]). However, in patients with AA, increased aneurysm was found in six patients (40%). Persistent aneurysmal growth was found in patients with a maximal aortic diameter of > 60 mm on initial imaging (4/6, 50%). No aortic expansion was observed in those with TAI or PAU. Endoleak was noted in five patients (10.4%), and among them, aortic reintervention was required only in patients with large AAs. CONCLUSIONS: Zone 2 hybrid TEVAR was associated with an acceptable early complication rate and provided acceptable mid-term aortic results for patients with AD, PAU, and TAI. However, patients with large AAs were at increased risk of aortic reintervention. In cases of large AA, clinicians should carefully consider whether zone 2 hybrid TEVAR or open surgical repair will be more effective for the patient.

Fate of remaining dissected aorta after descending thoracic or thoracoabdominal aorta replacement for chronic dissection.

OBJECTIVES: After performing descending thoracic or thoraco-abdominal aorta replacement for chronic aortic dissection, the fate of the remaining dissected aorta, without significant enlargement, is not well known. This study aimed to investigate the changes in the remaining aorta and the risk factors for late composite aortic events. METHODS: In 98 patients with chronic type A or B aortic dissection who underwent descending thoracic or thoraco-abdominal aorta replacement, the immediate postoperative and last follow-up computed tomography scans were reviewed. Aortic area-derived diameter was measured using the centreline reconstruction method at the levels of the 10 zones of the aorta and iliac arteries. The incidence of and risk factors for late composite aortic events (aortic death, rupture, reoperation, last follow-up aortic area-derived diameter >60 mm) were analysed. RESULTS: The median follow-up and computed tomography follow-up durations were 88.5 and 63.7 months, respectively. Nine late deaths occurred. The median growth rate of the remaining aorta was the greatest in the dissected infrarenal abdominal aorta at 0.8 mm/year. Of 16 late composite aortic events, the majority (2 ruptures and 8 reoperations) occurred in the distal contiguous segment. The 5- and 10-year cumulative incidence of events in the distal contiguous segment were 4.9% and 16.1%, respectively. Young age and Marfan syndrome were significant risk factors. CONCLUSIONS: Late composite aortic events were not negligible, especially in the distal contiguous segment. In young or Marfan syndrome patients, a greater distal extent of replacement may have to be considered at experienced aortic centres.

Serial ultrastructural evaluation of myocardial ischemic injury after infusion of del Nido cardioplegia in the human heart.

OBJECTIVES: The safe ischemic time after a single-dose del Nido cardioplegia (DNC) infusion has not yet been established. This study evaluated the progression of myocardial ischemic injury to establish the safe ischemic time after a single-dose DNC infusion in the human heart using a transmission electron microscope. METHODS: Seven hearts extracted from heart transplant recipients after infusion of 1000 mL single-dose DNC were evaluated. Serial left ventricular myocardial tissue samples were collected every 30 minutes for 180 minutes. Ischemic injuries in the mitochondria and nuclei were scored from 0 to 3 (0 = normal, 0.5 = slight, 1 = moderate, 2 = severe, and 3 = irreversible). RESULTS: At the time of extraction, 83.5% of the mitochondria were normal. The proportion of mitochondria with moderate ischemic injury increased gradually from 1.4% at extraction to 52.5% at 180 minutes. From 90 minutes to 180 minutes, the proportion of mitochondria with severe and irreversible injury increased from 0.8% to 4.4% and 0.3% to 1.3%, respectively. A significant linear correlation was identified between the average ischemic injury score of mitochondria and ischemic time (P < .001). Most nuclei showed moderate to severe ischemic injury at every time point (61.0%-85.2%). A significant linear correlation was also found between the average ischemic injury score of nuclei and ischemic time (P < .001). CONCLUSIONS: Myocardial ischemic injury progresses gradually, and irreversible ischemic injury begins to occur 90 minutes after initial DNC infusion in the adult human heart. Therefore, redosing of DNC may be required after 90 minutes of aortic crossclamp time during adult cardiac surgery.

Diameter change in completely remodelled proximal descending aorta after acute type I dissection repair: implications for estimating the pre-dissection size.

OBJECTIVES: Pre-dissection diameter of the proximal descending thoracic aorta (p-DTA), if available, would be the reference for determining the size of the stent graft or elephant trunk. Acute type B dissection is known to increase p-DTA diameter by 23% (Rylski factor). This study aimed to investigate the accuracy of estimating post-remodelling diameter of the p-DTA based on the Rylski factor and other post-dissection morphological parameters in acute type I dissection, based on the assumption that the post-remodelling diameter is similar to the pre-dissection diameter. METHODS: In 60 patients with acute type I dissection showing complete remodelling of the p-DTA false lumen after surgical repair, preoperative and post-remodelling computed tomography scans were reviewed. Parameters, including maximal true lumen diameter (TLDmax) and aortic area-derived diameter divided by the Rylski factor (AoDRylski), were measured at the p-DTA. RESULTS: After complete remodelling, p-DTA diameter decreased by 4.1 mm (P < 0.001). The equivalent to the Rylski factor was 15%. Both TLDmax and AoDRylski frequently showed ≥2 mm discrepancy from post-remodelling aortic diameter (36.7% and 48.3%, respectively, P = 0.30). When 2 parameters coincided within 2 mm, two-third of their estimations were accurate. AoDRylski was more accurate than TLDmax in patients with a large extent of circumferential dissection, and vice versa with less circumferential dissection (P = 0.027). CONCLUSIONS: Prediction of post-remodelling aortic diameter relying on a single morphologic parameter carries a substantial risk of overestimation and underestimation. Evaluation based on the extent of circumferential dissection together with the 2 parameters may provide a more reliable estimation.

Clinical Outcomes of Surgical Treatment for Primary Chest Wall Soft Tissue Sarcoma.

BACKGROUND: This study investigated the clinical outcomes of surgical treatment of primary chest wall soft tissue sarcoma (CW-STS). METHODS: Thirty-one patients who underwent surgery for CW-STS between 2000 and 2015 were retrospectively reviewed. The disease-free and overall survival rates were estimated using the Kaplan-Meier method, and prognostic factors were analyzed using a Cox proportional hazards model. RESULTS: The median follow-up duration was 65.6 months. The most common histologic type of tumor was malignant fibrous histiocytoma (29%). The resection extended to the soft tissue in 14 patients, while it reached full thickness in 17 patients. Complete resection was achieved in 27 patients (87.1%). There were 5 cases of local recurrence, 3 cases of distant metastasis, and 5 cases of combined recurrence. The 5-year disease-free rate was 49%. Univariate analysis indicated that incomplete resection (p<0.001) and stage (p=0.062) were possible risk factors for recurrence. Multivariate analysis determined that incomplete resection (p=0.013) and stage (p=0.05) were significantly associated with recurrence. The overall 5- and 10-year survival rates were 86.8% and 64.3%, respectively. No prognostic factor for survival was identified. CONCLUSION: Long-term primary CW-STS surgery outcomes were found to be favorable. Incomplete microscopic resection and stage were risk factors for recurrence.

Meta-Analysis Comparing Mitral Valve Repair Versus Replacement for Degenerative Mitral Regurgitation Across All Ages.

Although current guidelines recommend mitral valve repair (MVr) over mitral valve replacement (MVR) for patients with mitral regurgitation (MR), it is unclear if it should be also recommended in elderly patients with limited life expectancy. This study was conducted to compare the results of MVr with those of MVR to determine the optimal treatment option for patients with degenerative MR, particularly according to the patient's age. A literature search of 5 electronic databases was performed. The primary outcome was all-cause mortality. The secondary outcomes included early mortality and freedom from reoperation. A metaregression analysis and subgroup analysis were performed according to the mean age of the study population. Twelve retrospective studies (2,950 and 1,252 patients in the MVr and MVR groups, respectively) were selected. Pooled analyses demonstrated that the risk of all-cause mortality was significantly higher in the MVR group than in the MVr group both in all studies and in studies presenting adjusted results (hazard ratio[95% confidence interval] = 1.57[1.39 to 1.77] and 1.53[1.34 to 1.74], respectively). This benefit was similar across all ages when the metaregression analysis and the subgroup analysis were performed (p = 0.879 and 0.123, respectively). Early mortality and risk of reoperation were also higher in the MVR group than in the MVr group (risk ratio[95% confidence interval] = 4.51[3.12 to 6.51] and hazard ratio[95% confidence interval] = 1.47[1.09 to 1.98], respectively). In conclusion, this study indicates that MVr is beneficial compared with MVR in patients with degenerative MR regardless of patients' age in terms of all-cause mortality.

Reoperation for coronary artery stenosis after arterial switch operation.

OBJECTIVES: Coronary artery stenosis after an arterial switch operation (ASO) leads to subsequent reoperation. Therefore, we investigated the indications for reoperation and the results of reoperation to suggest methods to improve our management protocol for coronary artery stenosis after an ASO. METHODS: Between September 2003 and December 2016, 86 consecutive patients who underwent an ASO were included in the study. The indications for reoperation, reoperation techniques and postoperative results were investigated. RESULTS: There were 4 in-hospital deaths (4.7%). One late death occurred during the median follow-up period of 59.6 months. The 5-year overall survival rate was 94.2%. Seven reoperations were performed in 5 patients due to coronary artery stenosis. The indications for reoperation were severe coronary artery stenosis confirmed by computed tomography (CT) angiography or coronary angiography with or without symptoms. Patients with a coronary artery between the great arteries or a high take-off coronary artery frequently required reoperation due to coronary artery stenosis. None of the patients who underwent unroofing or cut-back angioplasty experienced complications during the median follow-up period of 52.0 months. However, 2 patients who underwent ostioplasty required an additional reoperation due to coronary artery restenosis. CONCLUSIONS: A standardized follow-up protocol including CT angiography or coronary angiography after the ASO is required to address coronary artery stenosis. Good reoperation results were observed using the unroofing and cut-back angioplasty techniques.

Minimally Invasive Cardiac Surgery versus Conventional Median Sternotomy for Atrial Septal Defect Closure.

BACKGROUND: Median sternotomy is the standard approach for atrial septal defect (ASD) closure. However, minimally invasive cardiac surgery (MICS) has been introduced at many centers in adult/grown-up congenital heart patients. We retrospectively reviewed the results of right anterolateral thoracotomy compared with conventional median sternotomy (CMS) for ASD closure at Seoul National University Hospital. METHODS: We retrospectively analyzed 60 adult patients who underwent isolated ASD closure from January 2004 to December 2013 (42 in the CMS group, 18 in the MICS group). Preoperative, operative, and postoperative data were collected and compared between the 2 groups. RESULTS: The MICS group was younger (44.6 years vs. 32.4 years, p=0.002) and included more females (66.7% vs. 94.4%, p=0.025) than the CMS group. Operation time (188.4 minutes vs. 286.7 minutes, p<0.001), cardiopulmonary bypass time (72.7 minutes vs. 125.8 minutes, p<0.001), and aortic cross-clamp time (25.5 minutes vs. 45.6 minutes, p<0.001) were significantly longer in the MICS group. However, there were no significant differences in morbidity and mortality between groups. Only chest tube drainage in the first 24 hours (627.1 mL vs. 306.1 mL, p<0.001) exhibited a significant difference. CONCLUSION: MICS via right anterolateral thoracotomy is an alternative choice for ASD closure. The results demonstrated similar morbidity and mortality between groups, and favored MICS in chest tube drainage in the first 24 hours.

Minimally Invasive Surgical Repair for Congenital Bronchobiliary Fistula in an Adult.

Congenital bronchobiliary fistula (CBBF) is a very rare disease and usually requires surgical intervention at a young age. We report a case of CBBF in an adult who was treated successfully with a minimally invasive endoscopic operation.