Minimally Invasive Approach versus Sternotomy for Cardiac Surgery in Jehovah's Witness Patients.

OBJECTIVE: To evaluate the outcomes of minimally invasive cardiac surgery (MICS) compared with the sternotomy approach for Jehovah's Witness (JW) patients who cannot receive blood transfusions DESIGN: This was a retrospective observational study. SETTING: The study was conducted at a specialized cardiovascular intervention and surgery institute. PARTICIPANTS: The study cohort comprised JW patients undergoing cardiac surgery between September 2016 and July 2022. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Patients (n = 63) were divided into MICS (n = 19) and sternotomy (n = 44) groups, and clinical outcomes were analyzed. There was no difference in types of operation except coronary bypass grafting (n = 1 [5.3%] in the MICS group v n = 20 [45.5%] in the sternotomy group; p = 0.005). There were no between-group differences in early mortality and morbidities. Overall survival did not differ significantly during the follow-up period (mean, 43.9 ± 24.4 months). The amount of chest tube drainage was significantly lower in the MICS group on the first postoperative day (mean, 224.0 ± 122.7 mL v 334.0 ± 187.0 mL in the sternotomy group; p = 0.022). The mean hemoglobin level was significantly higher in the MICS group on the day of operation (11.7 ± 1.3 mg/dL v 10.6 ± 2.0 mg/dL in the sternotomy group; p = 0.042) and the first postoperative day (12.3 ± 1.8 mg/dL v 11.2 ± 1.9 mg/dL; p = 0.032). CONCLUSIONS: MICS for JW patients showed favorable early outcomes and mid-term survival compared to conventional sternotomy. MICS may be a viable option for JW patients who decline blood transfusions.

Tricuspid Edge-to-Edge Repair Versus Tricuspid Valve Replacement for Severe Tricuspid Regurgitation.

BACKGROUND AND OBJECTIVES: Tricuspid valve (TV) repair techniques other than annuloplasty remain challenging and frequently end in tricuspid valve replacement (TVR) in complicated cases. However, the results of TVR are suboptimal compared with TV repair. This study aimed to evaluate the clinical effectiveness of TV edge-to-edge repair (E2E) compared to TVR for severe tricuspid regurgitation (TR). METHODS: We retrospectively reviewed 230 patients with severe TR who underwent E2E (n=139) or TVR (n=91) from 2001 to 2020. Clinical and echocardiographic results were analyzed using inverse probability of treatment weighting analysis and propensity score matching. RESULTS: The two groups showed no significant differences in early mortality and morbidities. During the mean follow-up of 106.2±68.8 months, late severe TR and TV reoperation rates were not significantly different between groups. E2E group, however, showed better outcomes in overall survival (p=0.023), freedom from significant tricuspid stenosis (TS) (trans-tricuspid pressure gradient ≥5 mmHg, p=0.021), and freedom from TV-related events (p<0.001). Matched analysis showed consistent results. CONCLUSIONS: E2E for severe TR presented more favorable clinical outcomes than TVR. Our study supports that E2E might be a valuable option in severe TR surgery, avoiding TVR.

Midterm outcomes of isolated tricuspid valve surgery with a mini-thoracotomy and beating heart strategy.

Background: Isolated tricuspid valve (TV) operation is considered high-risk surgery; thus, early surgical referral is frequently discouraged. Our study aims to evaluate the outcomes of isolated TV surgery with a mini-thoracotomy and beating heart strategy. Methods: We retrospectively reviewed 25 patients [median age, 65.0 years (Q1-Q3, 59.0-72.0 years)] who had undergone mini-thoracotomy beating heart isolated TV surgery from January 2017 to May 2021. TV repair was performed in 16 patients (64.0%), and TV replacement in 9 patients (36.0%). Among them, 18 patients (72.0%) had previous cardiac surgery, including TV replacement (n=4, 16.0%) and TV repair (n=4, 16.0%). Results: The median cardiopulmonary bypass time was 75.0 minutes (Q1-Q3, 61.0-98.0 minutes). There was 1 early mortality (4.0%) due to low cardiac output syndrome. Acute kidney injury requiring dialysis occurred in 3 patients (12.0%), and a permanent pacemaker was required in 1 patient (4.0%). The median lengths of stay in the intensive care unit and hospital were 1.0 day (Q1-Q3, 1.0-2.0) and 9.0 days (Q1-Q3, 6.0-18.0), respectively. The median follow-up duration was 30.3 months (Q1-Q3, 19.2-43.8). Freedoms from overall mortality, severe tricuspid regurgitation (TR), and significant tricuspid stenosis [i.e., trans-tricuspid pressure gradient (TTPG) ≥5 mmHg] at 4 years were 89.1%, 94.4%, and 83.3%, respectively. There was no TV reoperation. Conclusions: Mini-thoracotomy beating heart strategy for isolated TV surgery showed favorable early and midterm outcomes. This strategy may be a valuable option for isolated TV operations.

Surgical edge-to-edge repair for tricuspid regurgitation: Impact of the concomitant annuloplasty.

BACKGROUND: Surgical edge-to-edge repair has been suggested for tricuspid regurgitation (TR) with complex tricuspid valve (TV) pathologies. Nevertheless, the impact of concomitant TAP has not been well established. This study aimed to compare the outcomes of tricuspid edge-to-edge repair according to the implementation of concomitant TAP. METHODS: A total of 264 patients who underwent tricuspid edge-to-edge repair between January 2001 and December 2020 were enrolled in the study, and 23 patients who had undergone previous TV repair were excluded. The remaining 241 patients were categorized into two groups: TAP (n = 190) and non-TAP (n = 51). Inverse probability of treatment weighting (IPTW) was used to adjust the baseline differences between the two groups. RESULTS: Early mortality and morbidity did not differ between the two groups. The mean follow-up duration was 111.5 ± 72.4 months. IPTW-adjusted survival analysis did not reveal a difference between the two groups in late significant tricuspid stenosis (trans-tricuspid pressure gradient ≥5 mmHg) and TV reoperations. However, freedom from overall mortality and late severe TR were significantly higher in the TAP group (p = 0.033 and 0.006, respectively). The sensitivity analysis, including propensity score matching, showed consistent results. CONCLUSION: The long-term outcomes of surgical tricuspid edge-to-edge repair were better when performed with concomitant TAP.

Trends in Heart Valve Surgery in Korea: A Report from the Heart Valve Surgery Registry Database.

Background: In this study, we present recent trends in heart valve surgery in Korea through analyses of data from the Korea Heart Valve Surgery Registry (KHVSR). Methods: We enrolled 8,981 patients who were registered in the KHVSR from 2017 to 2020. Yearly trends in patients' baseline characteristics, surgical profiles, and early mortality rates were explored. The observed/expected mortality ratio (O/E ratio), calculated from the actual mortality in the KHVSR and the predicted mortality estimated using the EuroSCORE II, was also analyzed. Results: The proportion of aortic valve surgery significantly increased from 56.8% in 2017 to 60.3% in 2020. The proportion of all combined procedures and minimally invasive surgery significantly increased over the 4-year study period. The operative mortality rate was 2.9% in the entire cohort, while mitral valve repair showed the lowest mortality risk (0.9%). The mortality rates of isolated aortic valve replacement (AVR) significantly decreased from 2.1% in 2017 to 0.8% in 2020 (p=0.016). Overall, the O/E ratio was 0.784 (95% confidence interval [CI], 0.677-0.902) demonstrating significantly lower actual mortality risks than expected based on the EuroSCORE II. In particular, the O/E ratios were as low as 0.364 (95% CI, 0.208-0.591) for isolated AVR. Conclusion: The recent data from the KHVSR showed increasing trends for complex procedures and minimally invasive surgery in heart valve surgery in Korea, and demonstrated remarkably low risks of operative mortality.

Effects of early postoperative shower after cardiac surgery.

BACKGROUND: Little is known regarding the effects of early showers after cardiac surgery. We evaluated the influence of early showers on postoperative wound complications following cardiac surgery. METHODS: This was a prospective observational study of 100 cardiac surgery patients (mean age, 63.0±13.5 years) who underwent early postoperative showers from September 2020 to March 2021 at our institution. Postoperative showers were initiated after the drain was removed. Postoperative wound complications were examined and patient satisfaction was evaluated using questionnaires. RESULTS: Surgery was performed through sternotomy in 48 patients (48.0%) and through minimally invasive approaches (right or left mini-thoracotomy) in 52 patients (52.0%). The mean time from surgery to shower was 6.0±1.4 days. No wound dehiscence, superficial wound infection, or deep wound infection was observed. Questionnaires showed that more than 50% of patients thought they were not allowed to shower until more than 2 weeks after the operation. Patient satisfaction score was 7.4±2.3 out of 10 for early showers after cardiac surgery. CONCLUSIONS: Our study suggests that postoperative early showers after cardiac surgery are not associated with an increased risk of wound complications. Patient satisfaction was also high. Early postoperative showering can be considered after cardiac surgery.

Early pharmacologic conversion of atrial fibrillation after off-pump coronary artery bypass grafting.

BACKGROUND: The aim of this study was to evaluate the efficacy of early amiodarone-based pharmacological cardioversion for postoperative atrial fibrillation (POAF) following off-pump coronary bypass grafting (OPCAB). METHODS: A total of 507 patients who underwent OPCAB between 2015 and 2017 were categorized into POAF (n=94) and no-POAF (n=413) groups. Patients in the POAF group were treated according to the following institutional protocol: 150 mg loading dose of intravenous amiodarone, followed by oral administration with sequential maintenance doses at 600, 400, and 200 mg per day. If sinus rhythm was restored before discharge, patients were discharged without amiodarone or anticoagulants, except for dual antiplatelets. RESULTS: Before discharge at index hospitalization, 97.8% of POAF patients had restored sinus rhythm. Independent risk factors for POAF were age, unstable angina, prior percutaneous transluminal coronary angioplasty, and left atrial diameter. The mean follow-up duration was 41.1±12.8 months. Freedom from overall mortality and composite events, including mortality, major bleeding requiring admission and cerebrovascular events, were similar between the 2 groups. Results were consistent after propensity-score matching. CONCLUSIONS: Amiodarone-based rapid pharmacological cardioversion of POAF resulted in a high sinus rhythm conversion rate (97.9%). Rate of late adverse cardiovascular events including stroke, were low even without anticoagulation. As optimal treatment and anticoagulation guidelines for POAF after OPCAB have not yet been established, amiodarone-based treatment protocols may be considered as a useful option.

Development of a system to support warfarin dose decisions using deep neural networks.

The first aim of this study was to develop a prothrombin time international normalized ratio (PT INR) prediction model. The second aim was to develop a warfarin maintenance dose decision support system as a precise warfarin dosing platform. Data of 19,719 inpatients from three institutions was analyzed. The PT INR prediction algorithm included dense and recurrent neural networks, and was designed to predict the 5th-day PT INR from data of days 1-4. Data from patients in one hospital (n = 22,314) was used to train the algorithm which was tested with the datasets from the other two hospitals (n = 12,673). The performance of 5th-day PT INR prediction was compared with 2000 predictions made by 10 expert physicians. A generator of individualized warfarin dose-PT INR tables which simulated the repeated administration of varying doses of warfarin was developed based on the prediction model. The algorithm outperformed humans with accuracy terms of within ± 0.3 of the actual value (machine learning algorithm: 10,650/12,673 cases (84.0%), expert physicians: 1647/2000 cases (81.9%), P = 0.014). In the individualized warfarin dose-PT INR tables generated by the algorithm, the 8th-day PT INR predictions were within 0.3 of actual value in 450/842 cases (53.4%). An artificial intelligence-based warfarin dosing algorithm using a recurrent neural network outperformed expert physicians in predicting future PT INRs. An individualized warfarin dose-PT INR table generator which was constructed based on this algorithm was acceptable.

Is Prophylactic Tricuspid Annuloplasty Beneficial for Degenerative Mitral Valve Repair?

BACKGROUND: This study aimed to evaluate the long-term clinical impacts of prophylactic tricuspid annuloplasty (TAP) in patients with mild tricuspid regurgitation (TR) who underwent mitral valve repair. METHODS: One hundred fifty-one patients with mild TR who underwent mitral valve repair for degenerative mitral regurgitation between 1997 and 2013 were categorized into the TAP (n = 85) or no TAP (n = 66) groups. The indications for TAP were atrial fibrillation and tricuspid annular dilatation. The mean follow-up duration was 115.5 ± 48.6 months. Inverse probability of treatment weighting analysis and propensity score matching with 53 patients in each group were used to adjust for the baseline differences between the 2 groups. RESULTS: There were no early mortalities in either group, and early morbidities, including heart block, were not different between the groups. Inverse probability of treatment weighting-adjusted survival analysis did not reveal any difference in overall survival (P = .862), freedom from cardiac-related mortality (P = .535), or major adverse valve-related events (P = .972) between the groups. There was no difference in late TR progression (moderate or greater) between the groups (P = .316). These results were consistent in the matched analysis. CONCLUSIONS: Prophylactic TAP in mild TR may not have a beneficial effect on TR progress in degenerative mitral regurgitation. Further large studies are necessary to define the role of prophylactic TAP in mild TR.

Long-term Clinical and Hemodynamic Outcomes of Edge-to-Edge Repair for Tricuspid Regurgitation.

BACKGROUND: The edge-to-edge technique (Alfieri stitch) has been widely adopted in mitral valve but not tricuspid valve (TV) repair. We evaluated long-term clinical and hemodynamic outcomes of tricuspid edge-to-edge repair. METHODS: We retrospectively reviewed 237 patients (mean age, 58.4 ± 13.9 years) who had undergone tricuspid edge-to-edge repair from January 2001 to March 2019 in our institution. Tricuspid annuloplasty was performed in 175 patients (73.8%) using ring (91 [38.4%]) or suture (84 [35.4%]) annuloplasty. Concomitant procedures were mitral valve replacement (133 [56.1%]), mitral valve repair (52 [21.9%]), aortic valve replacement (41 [17.3%]), and maze operation (138 [58.2%]). RESULTS: Postoperative echocardiography revealed mild or less tricuspid regurgitation (TR) in 220 patients (92.8%). Early mortality (<30 days) occurred in 9 patients (3.8%), reoperation for bleeding in 16 (6.8%), and low cardiac output syndrome in 15 (6.4%). Freedom from all-cause mortality was 87.2% at 5 years and 80.6% at 10 years. Freedom from moderate or severe TR was 97.1% at 5 years and 84.9% at 10 years. Transtricuspid pressure gradient was 3.8 ± 4.2 mm Hg at discharge and 3.2 ± 5.6 mm Hg at the last follow-up (P = .60). Freedom from significant tricuspid stenosis (transtricuspid pressure gradient ≥5 mm Hg) was 96.4% and 88.4% at 5 and 10 years, respectively. There was 1 early TV reoperation for severe TR on postoperative day 3 (0.4%). Freedom from TV reoperation was 99.1% at 10 years. CONCLUSIONS: Tricuspid edge-to-edge repair showed acceptable long-term clinical and hemodynamic results and is an effective and safe option in TV surgery.

Use of durable left ventricular assist devices for high-risk patients: Korean experience before insurance coverage.

BACKGROUND: Left ventricular assist devices (LVADs) were not covered by the Korean national insurance until September 2018, and they were implanted at the patient's own or a third party's expense. However, there have been no reports on using an LVAD without insurance coverage or manufacturer support. METHODS: We reviewed 23 patients who underwent durable LVAD implantation at our institution from August 2012 to September 2018. Patients with temporary LVADs using extracorporeal or paracorporeal circulation were excluded. The available devices were the HeartMate IITM (HMII) and HeartWareTM Ventricular Assist Device (HVAD). The primary outcome was 30-day mortality. The secondary outcomes were postoperative complications and late mortality. RESULTS: The mean age of the patients was 68.7±9.9 years. The study sample comprised six female (26.1%) and 17 male (73.9%) patients. All patients had modifiable (bridge to candidacy) or unmodifiable absolute (destination therapy) contraindications for heart transplantation (HT). Among the patients in this study, 12 (52.2%) had ischemic cardiomyopathy and 11 (47.8%) had non-ischemic cardiomyopathy. Nine patients (39.1%) had temporary mechanical circulatory support such as extracorporeal membrane oxygenation or a temporary LVAD in place preoperatively. The average duration of LVAD support was 618.6±563.2 days (range, 59-2,285 days). There was no 30-day mortality. Four patients (17.4%) underwent HT. Six patients (26.1%) underwent re-exploration for postoperative bleeding, and one patient (4.3%) had a disabling stroke after discharge. The estimated survival rates at 12 and 24 months were 89.2% and 68.8%, respectively. CONCLUSIONS: All patients who received LVADs before insurance coverage had contraindications for HT. The overall outcomes were comparable with those reported in the international registry.

Outcomes of transported and in-house patients on extracorporeal life support: a propensity score-matching study.

OBJECTIVES: Patients on extracorporeal life support (ECLS), like other critically ill patients, are transported to other institutions for various reasons. However, little has been reported concerning the characteristics and clinical outcomes of transported patients compared with those of in-house patients. METHODS: A total of 281 adult patients received ECLS between January 2014 and August 2016. Patients who underwent cannulation at another institution by our team were excluded. Patients were divided into 2 groups: transported group (N = 46) and in-house group (N = 235). All 46 patients were safely transported without serious adverse events. The mean travel distance was 206±140 km, with a mean travel time of 78 ± 57 min. Following propensity score matching, 44 transported patients were matched to 148 in-house patients. RESULTS: In the matched population, the mean age was 48 ± 13 years in the transported group and 49 ± 17 years in the in-house group (P = 0.70). The ECLS type (venoarterial/venovenous) comprised 35/9 (79.5/20.5%) in the transported group and 119/29 (80.4/19.6%) in the in-house group (P = 0.93). Seventeen (38.6%) extracorporeal cardiopulmonary resuscitations were performed in the transported group and 59 (39.9%) were performed in the in-house group (P = 0.91). The incidence of limb ischaemia and acute kidney injury was higher in the transported group (P = 0.007 and P = 0.001, respectively). However, the rate of survival to discharge did not differ between the groups (63.6% in the transported group vs 64.2% in the in-house group, P = 0.94) and there was no difference in overall mortality (P = 0.99). CONCLUSIONS: Although transported patients had more complications than in-house ECLS patients, clinical outcomes were comparable in the matched population. Transporting ECLS patients to an experienced centre may be justified based on our experience.

Comparison between noninvasive and conventional skin closure methods in off-pump coronary artery bypass grafting using bilateral internal thoracic artery.

BACKGROUND: Sternal wound complications could increase the hospital cost while decreasing the satisfaction of surgery. Furthermore, it can potentially also lead to life-threatening mediastinitis especially after coronary artery bypass grafting using bilateral internal thoracic artery (BITA). Skill levels of suture technique vary among surgeons and may contribute to an increased wound complication rate. Thus, standardization of surgical wound closure could potentially decrease the surgeon factor. The aim of the study is to compare the wound complication rate between non-invasive surgical skin closure devices (zip surgical skin closure device, Zipline Medical, Campbell, CA, USA) and conventional suture closure. METHODS: Three hundred seventy-nine patients who underwent off-pump coronary artery bypass grafting (OPCAB) using BITAs at our institution between 2016 and 2018 were included in this study. Patients were divided into two groups; the Zipline group (zip-group, N=100), and conventional group (con-group, N=279). Following propensity score matching, 95 con-group patients were matched to 169 zip-group patients. RESULTS: The average age and history of cancer were significantly higher in the zip-group (P=0.021 and P=0.023, respectively). However, after propensity score matching, no differences were observed in the demographic data between the groups. In total patients (unmatched), although there was no significant difference in the incidence of deep sternal wound infection (DSWI) between the two groups (zip vs. con, 0% vs. 1.1%, P=0.569), the incidence of post-operative superficial sternal wound infection (SSWI) or dehiscence was significantly higher in the con-group than in the zip-group (1.0% vs. 7.9%, P=0.013). The results were consistent in the matched patients. (DSWI: 0% vs. 0.6%, P>0.999; SSWI or dehiscence: 1.1% vs. 7.1%, P=0.036). Multivariable analysis revealed use of the zip surgical skin closure device showed a preventive effect against wound complications [odds ratio (OR): 0.128, 95% confidence interval (CI): 0.017-0.976, P=0.029]. CONCLUSIONS: Zip surgical skin closure devices could decrease superficial wound complication rates compared to conventional suture techniques in OPCAB using BITAs.

Evaluation of a novel collagen hemostatic matrix in a porcine heart and cardiac vessel injury model.

BACKGROUND: Flowable hemostatic agents may be more advantageous than nonflowable hemostats, as they have capability to cover irregular wound surfaces, fill deep lesions, and easily remove excess materials with irrigation. In this study, we evaluated the hemostatic efficacy of the collagen hemostatic matrix (CHM) compared to FloSeal® via incisions in the heart and cardiac vessels in a porcine model. METHODS: In each of the two female pigs, a total of two incisions were made in seven locations: right atrium (RA), right ventricle (RV), and cardiac vessels, such as the innominate vein (IV), superior vena cava (SVC), pulmonary artery (PA), coronary artery (CA), and aorta. Hemostatic agents were applied directly to the bleeding wounds. In certain location, one incision was treated with the CHM and the other with FloSeal®, and the time to hemostasis and the degree of bleeding of the two agents were assessed and compared. One week after surgery, the animals were sacrificed, and specimens were collected for histologic evaluation. RESULTS: Bleeding from the vessels with relatively low pressure (the IV, SVC, and RA) was controlled within 1-2 minutes using both a CHM and FloSeal®. Bleeding from the vessels with high blood pressure (the RV, PA, CA, and aorta) was controlled within 3-10 minutes with the CHM. However, hemostasis in the PA and CA was not achieved with FloSeal®. Histological analysis revealed that the use of both the CHM and FloSeal® resulted in foreign body reactions of similar severity. CONCLUSIONS: The hemostatic effect and safety of the CHM may be similar to that of FloSeal®. Further clinical studies must be conducted to validate our results.

Comparison of Off-Pump Coronary Artery Bypass between Octogenarians and Septuagenarians: A Propensity Score Analysis.

BACKGROUND: Coronary artery bypass grafting (CABG) is being offered increasingly frequently to octogenarians. However, old age is known to be an independent risk factor in CABG. The aim of this study was to compare the outcomes of off-pump coronary artery bypass (OPCAB) between octogenarians and septuagenarians. METHODS: We retrospectively reviewed the data of 1,289 consecutive patients aged ≥70 years who underwent OPCAB at a single institution between 2001 and 2016. We compared the outcomes of 115 octogenarians and 1,174 septuagenarians. Using propensity score matching, based on preoperative clinical characteristics, 114 octogenarians were matched with 338 septuagenarians. RESULTS: Propensity score analysis revealed that the incidence of acute kidney injury (14.9% vs. 7.9%, p=0.028) and respiratory complications (8.8% vs. 4.2%, p=0.040) was significantly higher in octogenarians. The early mortality rate (2.6% vs. 1.0%, p=0.240) and 1-year survival rate (89.5% vs. 94.4%, p=0.097) were not statistically significant between the groups. However, the 5-year survival rate (67.3% vs. 79.9%, p<0.001) was significantly lower in octogenarians. Previous myocardial infarction and a left ventricular ejection fraction ≤35% were associated with a poor 1-year survival rate. CONCLUSION: Early and 1-year outcomes of OPCAB in octogenarians were tolerable when compared with those in septuagenarians. OPCAB could be a suitable option for octogenarians.

Outcomes of Coronary Artery Bypass Grafting after Extracorporeal Life Support in Patients with Cardiac Arrest or Cardiogenic Shock.

BACKGROUND: Extracorporeal life support (ECLS) is used as a bridge to revascularization in high-risk patients with ischemic heart disease. We reviewed our experiences of coronary artery bypass grafting (CABG) after ECLS in patients with cardiac arrest or refractory cardiogenic shock. METHODS: We retrospectively reviewed 4,616 patients who underwent CABG at our institution between May 2006 and February 2017. We identified patients who underwent CABG following ECLS for cardiogenic shock or cardiac arrest. Twenty-three patients (0.5% of all CABG cases) were enrolled in the analysis. Their median age was 65 years (Q1-Q3, 58-77 years). Nine patients (39.1%) were diagnosed with ST-elevation myocardial infarction. Mechanical complications after acute myocardial infarction, including acute mitral regurgitation, left ventricular rupture, and ventricular septal defect, occurred in 9 patients (39.1%). RESULTS: The median time from cardiopulmonary resuscitation to ECLS initiation was 25 minutes (Q1-Q3, 18.5-28.5 minutes). Conventional CABG was performed in 10 patients (43.5%) who underwent concomitant intracardiac procedures. Postoperative ECLS was required in 16 patients (69.5%). The rate of successful ECLS weaning was 91.3% (n=21). There were 6 early mortalities (26.1%). CONCLUSION: CABG after ECLS was very rare in real-world circumstances. Although the early mortality rate was high, the risk of mortality may be acceptable under such devastating circumstances.

Use of argatroban for extracorporeal life support in patients with nonheparin-induced thrombocytopenia: Analysis of 10 consecutive patients.

Unfractionated heparin (UFH) is currently the standard anticoagulant used in extracorporeal life support (ECLS). However, severe thrombocytopenia occurs frequently during ECLS use and it may be difficult to determine whether this represents heparin-induced thrombocytopenia (HIT) or not. In this case, UFH cannot be continued. Because a confirmatory laboratory test requires time, argatroban is empirically used if HIT is suspected. However, many patients are not found to have HIT. In non-HIT patients, the effectiveness and safety of argatroban are unclear. Thus, we investigated whether argatroban was safe and useful in patients who were suspected of having HIT and were started on argatroban, but were ultimately found to have non-HIT.We retrospectively reviewed all patients on ECLS who received the anticoagulant argatroban as an alternative to UFH between January 2014 and July 2015. The pretest clinical score (4Ts) was calculated, and a score greater than 4 was considered an indication for argatroban. The target-activated clotting time or activated partial thromboplastin time was 1.5 times the patient's upper normal value. Of 191 patients on ECLS during the study period, 10 (5.2%) were treated with argatroban infusion.No patients were found to have antiplatelet factor 4/heparin antibodies. The average maintenance dose of argatroban was 0.1 µg/kg/min. Platelet counts increased significantly following argatroban administration (P = .02). There were no anticoagulation-related complications such as bleeding or thrombosis.Our results suggest that argatroban is a safe alternative to UFH for patients with non-HIT on ECLS. Argatroban may have a more significant platelet-preserving effect than UFH, regardless of whether HIT is present.

Late clinical outcomes after mechanical aortic valve replacement for aortic stenosis: old versus new prostheses.

BACKGROUND: The study aimed to evaluate the late clinical outcomes of new-generation mechanical valves for severe aortic stenosis (AS) compared with old mechanical valves. METHODS: We retrospectively reviewed data from 254 patients with severe AS, who underwent primary mechanical aortic valve replacement from 1995 to 2013. Patients were classified into two groups: old-valve group (n=65: 33 ATS standard, 32 Medtronic-Hall) and new-valve group (n=189: 113 St. Jude Regent, 46 On-X, 30 Sorin Overline). Median patient age was 58 years (Q1-Q3: 52-61). With propensity score matching based on demographic information, 56 patients in the old-valve group were matched with 177 patients in the new-valve group. The median follow-up duration was 91 months (Q1-Q3: 48-138). RESULTS: Cardiac-related mortality and hemorrhagic events were significantly lower in the new-valve group (P=0.047 and P=0.032, respectively). The median international normalized ratio (INR) at follow-up was significantly higher in the old-valve group [2.23, Q1-Q3: 2.14-2.35 (old-valve group); 2.08, Q1-Q3: 1.92-2.23 (new-valve group), P<0.001]. The incidence of prosthesis-patient mismatch (PPM) was significantly higher in the old-valve group (P<0.001). Multivariate analysis of the total population revealed that PPM was a significant risk factor for cardiac-related events [hazard ratio (HR) =5.279, 95% CI, 1.886-14.561, P=0.002] and showed higher trend of increasing mortality (HR =3.082, P=0.076). CONCLUSIONS: New mechanical prostheses showed a better hemodynamic performance and lower incidence of PPM. Anticoagulation strategy to lower the target INR in patients with new mechanical valves may improve late outcomes by reducing hemorrhagic events.

Life-Threatening Acute on Chronic Pulmonary Thromboembolism Requiring Extracorporeal Membrane Oxygenation.

A 71-year-old female patient was admitted to the emergency department with sudden aggravation of chest pain and severe dyspnea. Computed tomography showed extensive pulmonary thromboembolism. Venoarterial extracorporeal membrane oxygenation (ECMO) was instituted due to sudden bradycardia and hypotension. An emergency operation was performed. However, chronic pulmonary thromboembolism combined with an acute pulmonary embolism was detected in the operating room. Embolectomy and endarterectomy were performed. ECMO was then discontinued. The patient was discharged on postoperative day 13 with warfarin for anticoagulation. The patient was followed up for 46 months as an outpatient without further thromboembolic events.