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.

Long-term outcome of isolated mitral valve repair versus replacement for degenerative mitral regurgitation in propensity-matched patients.

Objective: This study was performed to investigate the long-term outcomes in patients with degenerative mitral regurgitation (MR) undergoing mitral valve repair (MVr) versus mitral valve replacement (MVR) without concomitant surgeries. Methods: The study cohort comprised 1493 patients with degenerative MR who were treated with isolated mitral valve surgery between January 2000 and December 2017 in a large multicenter (5 hospitals) registry of the Province of British Columbia, Canada, including 991 with repair and 502 with replacement. A propensity-matched comparison and risk-adjusted model were used to analyze the outcomes. Results: After propensity matching (415 matched pairs), the 30-day mortalities were 2.4% and 3.6% in the MVr and MVR groups respectively (odds ratio [OR], 1.500; 95% confidence interval [CI], 0.674-3.339; P = .32). The MVR group had significantly greater rates of prolonged inotrope usage >24 hours (P = .024), prolonged ventilation (P = .039), and blood transfusion (P = .023). The respective 1-, 5-, 10-, and 15-year survival rates were 95.7%, 88.8%, 71.4%, and 53.3% in the MVr group, and 93.0%, 81.6%, 61.3%, and 46.0% in the MVR group (hazard ratio [HR], 1.355; 95% CI, 1.105-1.661; P = .004). A multivariable analysis revealed that MVR was an independent risk factor for 30-day mortality (OR, 2.270; 95% CI, 1.089-4.732; P = .029) and long-term mortality (HR, 1.417; 95% CI, 1.161-1.729; P < .001). The HR of MVR over MVr remained consistently greater than 1.0 across all ages. Conclusions: MVr is associated with lower postoperative morbidity and better long-term survival compared with MVR in patients undergoing isolated mitral valve surgery for degenerative MR. The benefit of MVr appears age-independent.

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.

Novel percutaneous intervention technique for obstructed coronary artery after valve-in-valve transcatheter aortic valve replacement.

Valve-in-valve transcatheter aortic valve replacement (valve-in-valve TAVR) increases the risk of coronary obstruction. Although the coronary protection strategy is widely used, the use of the bailout technique after coronary obstruction is limited. Hence, we report a simple bailout technique for coronary obstruction after valve-in-valve TAVR. An 82-year-old woman presented with structural valve deterioration. The left anterior descending coronary artery had 90% stenosis. After TAVR, the prosthetic valve shifted close to the ascending aorta wall, consequently impairing coronary flow. The wire crossed with the Judkins right guiding catheter (JR) reference to the en-face and perpendicular views. Using the guide-extension catheter, the JR contacted the contralateral ascending aorta as a backup catheter. After a balloon was dilated between the prosthetic valve and aorta, JR engaged into the coronary artery with excellent backup. This novel "Whisker pole guiding technique" is useful, even after valve-in-valve TAVR.

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.

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.

Transthyretin derived amyloid deposits in the atrium and the aortic valve: insights from multimodality evaluations and mid-term follow up.

BACKGROUND: Recent studies have reported atrial involvement and coexistence of aortic stenosis in transthyretin (ATTR) cardiac amyloidosis (CA). However, pathological reports of extraventricular ATTR amyloid deposits in atrial structures or heart valves are limited, and the clinical implications of ATTR amyloid deposits outside the ventricles are not fully elucidated. CASE PRESENTATION: We report 3 cases of extraventricular ATTR amyloid deposits confirmed in surgically resected aortic valves and left atrial structures, all of which were unlikely to have significant ATTR amyloidosis infiltrating the ventricles as determined by multimodality evaluation including 99mtechnetium-pyrophosphate scintigraphy, cardiac magnetic resonance, endomyocardial biopsy and their mid-term clinical course up to 5 years. These findings suggested that these were extraventricular ATTR amyloid deposits localized in the aortic valve and the left atrium. CONCLUSIONS: While long-term observation is required to fully clarify whether these extraventricular ATTR amyloid deposits are truly localized outside the ventricles or are early stages of ATTR-CA infiltrating the ventricles, our 3 cases with multimodality evaluations and mid-term follow up suggest the existence of extraventricular ATTR amyloid deposits localized in the aortic valve and left atrial structures.

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.

Incidence of and risk factors for pacemaker implantation after the modified Cryo-Maze procedure for atrial fibrillation.

OBJECTIVES: The Maze procedure is a well-established treatment for atrial fibrillation. However, it is sometimes associated with bradycardia requiring pacemaker implantation. We assessed the rates of in-hospital and late-onset pacemaker implantation after the modified Cryo-Maze procedure and explored the risk factors for pacemaker implantation. METHODS: This study enrolled a series of 751 patients who underwent the modified Cryo-Maze procedure at our institution between 2001 and 2020. Multivariable Fine-Gray regression was used to analyze the risk factors for late-onset pacemaker implantation. RESULTS: Twelve patients (1.6%) underwent in-hospital pacemaker implantation, and 55 patients (7.3%) underwent late-onset pacemaker implantation during a median follow-up of 4.5 years (interquartile range, 1.4-10.0). The most common primary indication for pacemaker implantation was sick sinus syndrome (56 patients [7.5%]), followed by complete atrioventricular block (11 patients [1.5%]). The cumulative incidence of late-onset pacemaker implantation with death as a competing risk was 2.8% at 1 year, 7.7% at 5 years, and 10.8% at 10 years. Risk factors for late-onset pacemaker implantation included a longer preoperative atrial fibrillation duration (hazard ratio, 1.14; P < .001) and an older age (hazard ratio, 1.05; P = .001). The mortality, cumulative incidence of cerebrovascular accidents, and rate of atrial fibrillation recurrence were not significantly different between patients with and without pacemaker implantation. CONCLUSIONS: Longer preoperative atrial fibrillation duration and older age are risk factors for late-onset pacemaker implantation after the modified Cryo-Maze procedure. However, the incidence of pacemaker implantation is not associated with increased morbidity or atrial fibrillation recurrence.

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.

15-year outcomes of the JOCRI study (JOCRIED study): a randomised comparison of off-pump and on-pump multiple arterial coronary revascularisation.

OBJECTIVE: The Japanese Off-Pump Coronary Revascularization Investigation (JOCRI) study reported a non-significant difference in early outcomes and graft patency between off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting in 2005. The JOCRIED study aimed to review the long-term outcomes of the JOCRI study participants. METHOD AND RESULTS: The JOCRIED study enrolled 123 of the JOCRI study participants completing the clinical follow-up between August 2018 and August 2020; 61 patients in the off-pump group and 62 patients in the on-pump group. The follow-up period was 13.8 ± 2.8 years. The groups were compared regarding mortality, the incidence of major adverse cardiac and cerebrovascular events and repeat revascularisation. The 15-year cumulative survival rate (off-pump vs on-pump, respectively; 77.7% vs 75.3%; p = 0.85), major adverse events-free survival rate (62.5% vs 55.6%; p = 0.27) and repeat revascularisation-free rate (84.8% vs 78.0%; p = 0.16) were not significantly different between the two groups. Revascularisation was the most common major adverse events in the JOCRIED participants. Although percutaneous coronary intervention was performed in 8 patients (13%) in the off-pump group and in 14 patients (23%) in the on-pump group (p = 0.23), no patients underwent redo coronary artery bypass grafting. CONCLUSIONS: Off-pump coronary artery bypass grafting provides comparable 15-year outcomes to on-pump coronary artery bypass grafting.

Short-Term Outcomes of Magnetically Levitated Left Ventricular Assist Device in Advanced Heart Failure　- The Japanese Cohort.

BACKGROUND: The superiority of a fully magnetically levitated centrifugal-flow left ventricular assist device (LVAD) in terms of overall survival, stroke events and pump thrombosis has been demonstrated in previous international analyses, so we evaluated a Japanese cohort for the same.Methods and Results: This retrospective observational study was conducted at Osaka University Medical Hospital and the National Cerebral and Cardiovascular Center in Japan. A total of 75 consecutive patients who underwent HeartMate3 (HM3) implantation were included. The primary endpoint was on-device survival, and the secondary endpoint was the incidence of LVAD-related complications at 2 years. All parameters were compared with those of the previously performed HeartMate II (HMII) implantation in 197 cases. The on-device survival rates were 94.7% and 92.3% in the HM3 and HMII groups, respectively, at the 2-year follow-up (P=0.62). The rehospitalization-free rate after implantation was 61.8% in the HM3 group, which was significantly higher than that in the HMII group (relative risk, 0.35; 95% confidence interval [CI], 0.23-0.55; P<0.0001). Event-free survival rates from cerebral cerebrovascular events and pump thrombosis in the HM3 group were significantly higher than those in the HMII group, at 97.2% and 100%, respectively (relative risk, 0.14; 95% CI 0.03-0.58); P=0.0015 and relative risk, not calculated; P=0.049, respectively). CONCLUSIONS: Satisfactory short-term outcomes were observed after HM3 implantation in a Japanese cohort.

Efficacy of Off-Pump Coronary Artery Bypass Grafting With Concomitant Transcatheter Aortic Valve Replacement.

AIM: This study aimed to evaluate the early and intermediate-term outcomes of patients who underwent concomitant off-pump coronary artery bypass grafting (CABG) and transcatheter aortic valve replacement (TAVR). METHOD: Between January 2014 and June 2021, 49 patients underwent concomitant off-pump CABG and TAVR via median sternotomy (TAVRCAB group) and 143 underwent concomitant on-pump CABG and surgical aortic replacement. Of the 143 patients who underwent on-pump surgery, 80 (SAVRCAB group) were eligible for comparison. The composite event included all-cause death, heart failure rehospitalisation, repeat revascularisation, brain infarction, and repeat aortic valve replacement. RESULTS: The Society of Thoracic Surgeons' predicted risk for mortality and age were higher in the TAVRCAB group than in the SAVRCAB group (7.1% vs 3.1% [p<0.001]; 81 yrs vs 75 years [p<0.001], respectively), while the surgical time was shorter (289 min vs 352 min; p<0.001). There was no conversion to on-pump surgery in the TAVRCAB group. The postoperative maximum creatinine kinase-MB value was lower in the TAVRCAB group. There was no deep sternal wound infection or repeat revascularisation in either group. Hospital death and brain infarction developed in one patient (1.3%) each in the SAVRCAB group, but in no patients in the TAVRCAB group. The rates of freedom from the composite event were similar between the two groups during the follow-up period. CONCLUSIONS: Concomitant off-pump CABG and TAVR would be a less-invasive alternative procedure for treating intermediate or high surgical risk patients with aortic stenosis and coronary artery disease unsuitable for percutaneous coronary intervention.

Early Atrial Tachyarrhythmia Recurrence Predicts Late Atrial Tachyarrhythmia Recurrence After the Cryo-Maze Procedure　- An Observational Study.

BACKGROUND: It is unknown whether early atrial tachyarrhythmia (ATA) recurrence occurring within 3 months after the Maze procedure predicts late ATA recurrence.Methods and Results: This study involved 610 patients who underwent the modified Cryo-Maze procedure in conjunction with other cardiac surgery. The primary outcomes were late ATA recurrence, defined as occurring ≥3 months after surgery. The effects of early ATA recurrence on late ATA recurrence were analyzed using a Cox proportional hazards model. The following 11 covariates were considered explanatory variables: early ATA recurrence, age, sex, body surface area, preoperative duration of atrial fibrillation, preoperative left atrial diameter, and concomitant surgery (mitral valve replacement, mitral valve repair, aortic valve replacement, tricuspid annuloplasty, and left atrial appendage closure). Statistical analyses were performed with a 2-sided 5% significance level. Early ATA recurrence occurred in 174 patients (28.5%). Late ATA recurrence occurred in 167 patients (27.5%), with 595 events identified in these patients. The Cox proportional hazards model showed that early ATA recurrence was an independent predictor of late ATA recurrence (hazard ratio, 4.14; 95% confidence interval, 3.00-5.70; P<0.001)Conclusions: Early ATA recurrence was an independent predictor of late ATA recurrence among patients undergoing the modified Cryo-Maze procedure. The blanking period might not be applied to patients undergoing the modified Cryo-Maze procedure.

Early Outcomes of Intuity Rapid Deployment Aortic Valve Replacement Compared With Conventional Biological Valves in Japanese Patients.

BACKGROUND: This study aimed to elucidate the short-term surgical outcomes and hemodynamics of the Intuity valve compared to the standard bioprosthesis in Japanese patients.Methods and Results: Among the 307 consecutive patients who underwent aortic valve replacement (AVR) between February 2019 and March 2021, the Intuity valve was implanted in 95 patients (Intuity group) and a conventional stented bioprosthesis was implanted in 193 patients (conventional group). After propensity score matching, there was no significant difference in in-hospital mortality between the Intuity (n=2, 3%) and conventional groups (n=0, P=0.490). Operation, cardiopulmonary bypass, and aortic cross-clamping times were significantly shorter in the Intuity group. Although the effective orifice area index, trans-prosthetic mean pressure gradient, and peak velocity were similar between the 2 groups at 1 week postoperatively, the Intuity group showed a better mean pressure gradient and peak velocity at 1 year postoperatively. Complete atrioventricular block requiring permanent pacemaker implantation developed in 2 patients (3%) in the Intuity group and none in the conventional group (P=0.476). Mild or greater paravalvular leakage was present in 8 patients (13%) in the Intuity group and 2 patients (3%) in the conventional group (P=0.095). CONCLUSIONS: AVR using the Intuity valve in Japanese patients is satisfactory, with a better valve performance and a low incidence of complete atrioventricular block at 1 year postoperatively.

U-shaped association between elapsed time after surgery and the intensity of chronic postsurgical pain following cardiac surgery via thoracotomy: an observational cohort study.

BACKGROUND: Chronic postsurgical pain (CPSP) is defined as chronic pain that develops or increases in intensity after a surgical procedure and persists beyond the healing process, defined as at least 3 months postoperatively. However, the rationale behind this time period is weak. METHODS: This prospective observational study included a total of 238 consecutive patients who underwent mitral valve repair via thoracotomy. A questionnaire consisting of a numerical rating scale (NRS) to assess the severity of postsurgical pain was mailed to each participant more than 3 months after the operation. The outcomes of interest were current pain, peak pain in the last 4 weeks, and average pain in the last 4 weeks, each assessed using the NRS. The nonlinear associations between the elapsed time after surgery and the intensity of CPSP were evaluated. All statistical analyses were performed with a two-sided significance level of 5%. RESULTS: Two-hundred and ten patients (88.2%) answered the questionnaire. There was a significant nonlinear association between the elapsed time after surgery and each NRS response (all, P < 0.05). The lowest adjusted log odds of current pain, peak pain in the past 4 weeks, and average pain in the past 4 weeks were - 1.49, - 1.13, and - 1.26 at 33, 33, and 33 months postoperatively, respectively. CONCLUSIONS: There was a significant U-shaped association between the elapsed time after surgery and intensity of CPSP. The adjusted log odds of each NRS response was lowest at 33 months after cardiac surgery via thoracotomy.

Immunocompetent cells in durable ventricular assist device-implanted non-ischaemic dilated cardiomyopathy.

OBJECTIVE: Because the presence of immunocompetent cells in the myocardium is associated with the pathological stage and/or myocardial viability, we explored relationships between functional recovery after left ventricular assist device implantation and the distribution of immunocompetent cells in non-ischaemic dilated cardiomyopathy patients. METHODS: We reviewed 50 consecutive dilated cardiomyopathy patients implanted with HeartMate II at our institute between April 2013 and December 2018 who were treated with optimal medical therapy during left ventricular assist device support. Patients were stratified by improvement of the left ventricular ejection fraction at 6 months after implantation: ≥ 10% increase (Gr ≥ 10%), 5-10% (Gr 5-10%), and ≤ 5% (Gr ≤ 5%). T cells and macrophages were evaluated in the apical myocardium after left ventricular assist device implantation. RESULTS: During left ventricular assist device support, 12 patients underwent heart transplantation and 2 patients died. Four patients with Gr ≤ 5% were readmitted because of congestive heart failure, but none with Gr ≥ 10%. Macrophages and T cells in the left ventricular myocardium with Gr ≥ 10% were significantly more present compared to those in other groups. CONCLUSIONS: The distribution of immunocompetent cells in the left ventricular myocardium might predict myocardial viability of this pathology after implantation.

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.