Heart Transplantation in a Patient With Rheumatic Heart Disease and Severe Left Atrial Calcification.

A 62-year-old woman who had undergone mitral valve replacement 24 years ago was admitted to the hospital with congestive heart failure. She needed heart transplantation for stage D heart failure. Preoperative cardiac computed tomographic scans showed a severely calcified left atrium and a large right atrium. Given that the left atrium's calcification was too severe to suture, the calcified left atrial wall was broadly resected, and the resected left atrial wall was reconstructed with a bovine pericardial patch for anastomosis with the donor's left atrial wall. The operation was completed without heavy bleeding, and the patient was discharged from the hospital with no complications.

Comparison of Conventional Methods with Pump-Controlled Retrograde Trial off for Weaning Adults with Cardiogenic Shock from Veno-Arterial Extracorporeal Membrane Oxygenation.

Background: Pump-controlled retrograde trial off (PCRTO) is a safe, simple, and reversible method for weaning patients from veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, few studies have compared PCRTO to conventional weaning methods. This retrospective study aimed to compare PCRTO to non-PCRTO methods. Methods: This study included patients who were weaned from VA-ECMO from January 2016 to December 2022 at our medical center. Demographic data, ECMO management, ECMO complications, survival to discharge, and cardiogenic shock after VA-ECMO weaning were compared between the 2 groups. Results: Seventy patients who were weaned from VA-ECMO using PCRTO and 85 patients who were weaned with conventional methods were compared. Patient characteristics were not significantly different between the 2 groups. The rate of survival to discharge was significantly higher in the PCRTO group than in the non-PCRTO group (90% vs. 72%, p=0.01). The rates of freedom from all-cause mortality at 10, 30, and 50 days after weaning from ECMO were 75%, 55%, and 35% in the non-PCRTO group and 62%, 60%, and 58% in the PCRTO group, respectively (p=0.1). The incidence of cardiogenic shock after weaning from VA-ECMO was significantly higher in the non-PCRTO group (16% vs. 5%, p=0.04). In logistic regression analysis, PCRTO was a significant factor for survival to discharge (odds ratio, 2.42; 95% confidence interval, 1.29-5.28; p=0.02). Conclusion: Compared to conventional methods, PCRTO is a feasible and reversible method, and it serves as a useful predictor of successful VA-ECMO weaning through a preload stress test.

Outcomes of Concomitant Maze Procedure in Tricuspid Repair for Severe Tricuspid Regurgitation.

BACKGROUND: We aimed to analyze the impact of concomitant Maze procedure on the clinical and rhythm outcomes, and echocardiographic parameters in tricuspid repair for patients with severe tricuspid regurgitation (TR) and persistent atrial fibrillation (AF). METHODS: Patients who had severe TR and persistent AF and underwent tricuspid valve (TV) repair were included in the study. Both primary TR and secondary TR were included in the current study. The study population was stratified according to Maze procedure. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE) at 15 years post-surgery. Propensity-score matching analyses was performed to adjust baseline differences. RESULTS: Three hundred seventy-one patients who underwent tricuspid repair for severe TR and persistent AF from 1994 to 2021 were included, and 198 patients (53.4%) underwent concomitant Maze procedure. The maze group showed 10-year sinus rhythm (SR) restoration rate of 55%. In the matched cohort, the maze group showed a lower cumulative incidence of cardiac death (4.6% vs. 14.4%, P = 0.131), readmission for heart failure (8.1% vs. 22.2%, P = 0.073), and MACCE (21.1% vs. 42.1%, P = 0.029) at 15 years compared to the non-maze group. Left atrial (LA) diameter significantly decreased in the maze group at 5 years (53.3 vs. 59.6 mm, P < 0.001) after surgery compared to preoperative level, and there was a significant difference in the change of LA diameter over time between the two groups (P = 0.013). CONCLUSION: The Maze procedure during TV repair in patients with severe TR and persistent AF showed acceptable SR rates and lower MACCE rates compared to those without the procedure, while also promoting LA reverse remodeling.

Total arch replacement versus hybrid operation for aortic arch aneurysm in elderly patients: a retrospective cohort analysis.

Background: There is not sufficient evidence of the superiority of hybrid procedures over total arch replacement (TAR) for the aortic arch aneurysm of an elderly patients. This retrospective study aimed to compare total arch replacement and hybrid procedures for treatment of aortic arch aneurysms in patients aged ≥75. Methods: This study was a multicenter retrospective investigation of peri-operative outcomes of patients undergoing aortic arch aneurysm repair using either TAR or hybrid procedures between January 2012 and May 2021. Risk factors for mortality were evaluated using multivariate analyses. Results: This study included 90 patients, of which 28 underwent hybrid procedures (hybrid group: frozen elephant trunk =9, zone 0 =6, zone 1 =1, zone 2 =12), and 62 underwent TAR (TAR group), and the mean duration of follow-up was 27.0±28.8 months. In patient characteristics, the incidence of chronic obstructive lung disease and chronic kidney disease in the TAR group was significantly higher than in the hybrid group, and other operative risk factors were not significantly different in both groups. No significant differences in the incidence of post-operative complications and mortality on hospitalization. Survival rates of both groups were not significantly different (P=0.31). However, re-intervention rates after aortic arch aneurysm repair were significantly higher in the hybrid group compared to the TAR group (freedom from re-intervention rates at 1, 3, 5 years: 100%, 93%, 93% in the TAR group, and 90%, 80%, 80% in the hybrid group, P=0.04). Conclusions: There was no definitive evidence of the superiority of hybrid procedures over TAR, although the risk of re-intervention was higher in the former group. The surgical strategy for aortic arch aneurysms should be selected based on the patient's demographic and anatomical characteristics.

Is It Safe to Preserve Left Atrial Appendage During Maze Procedure?

BACKGROUND AND OBJECTIVES: The left atrial appendage (LAA) can contribute significantly to LA mechanical contraction. Nevertheless, the preventive effect of LAA occlusion during the maze procedure against cerebral infarction remains controversial. In this study, we compared the surgical, cardiac hemodynamic, and neurologic outcomes between LAA preservation and occlusion performed during the maze procedure. METHODS: Between January 2015 and August 2021, 252 patients underwent the maze procedure using cryoablation at our medical center. After excluding patients according to our exclusion criteria (i.e., mechanical prosthesis implantation, preexisting LAA thrombus), LAA was preserved in 113 patients (non-occlusion group) and occluded in 75 patients (occlusion group). Outcomes were compared using propensity score matching (PSM). RESULTS: PSM did not reveal significant intergroup differences in baseline characteristics between the non-occlusion (n=53) and occlusion (n=53) groups. During a median follow-up of 44 months, 2 patients in the non-occlusion group (3.8%) experienced ischemic strokes. There was no significant difference in the rate of freedom from stroke (p=0.19) and major adverse cardiac events (p=0.43) between the 2 groups. Through echocardiography at 1-year follow-up, a statistically significant difference in LA mechanical contraction was observed between the non-occlusion group and occlusion group (24 of 33 [72.7%] vs. 18 of 37 [48.6%], respectively; p=0.04). CONCLUSIONS: In this study, preservation of the LAA during the maze procedure resulted in better LA function than LAA occlusion, with similar rates of stroke.

Surgical Results of the Superior Vena Cava Intimal Layer-Only Suture Technique in Heart Transplantation.

Background: Superior vena cava (SVC) stenosis during follow-up is a major concern after heart transplantation, and many technical modifications have been introduced. We analyzed the surgical results of the SVC intima layer-only suture technique in heart transplantation. Methods: We performed SVC anastomosis with sutures placed only in the intima during heart transplantation. We measured the area of the SVC at 3 different points (above the anastomosis, at the anastomosis, and below the anastomosis) in an axial view by freely drawing regions of interest, and then evaluated the degree of stenosis. Patients who underwent cardiac computed tomography (CT) at 2 years postoperatively between June 2017 and May 2020 were included in this study. Results: We performed heart transplantation in 41 patients. Among them, 24 patients (16 males and 8 females) underwent follow-up cardiac CT at 2 years postoperatively. The mean age at operation was 49.4±4.9 years. The diagnoses at time of operation were dilated cardiomyopathy (n=12), ischemic heart disease (n=8), valvular heart disease (n=2), hypertrophic cardiomyopathy (n=1), and congenital heart disease (n=1). No cases of postoperative bleeding requiring intervention occurred. The mean CT follow-up duration was 1.9±0.7 years. At follow-up, the mean areas at the 3 key points were 2.7±0.8 cm2, 2.7±0.8 cm2, and 2.7±1.0 cm2 (p=0.996). There were no SVC stenosis-related symptoms during follow-up. Conclusion: The suture technique using only the SVC intimal layer is a safe and effective method for use in heart transplantation.

Surgical results of only antegrade del Nido cardioplegia infusion in conventional coronary artery bypass grafting: a retrospective study.

BACKGROUND: Additional retrograde cardioplegia infusion in conventional coronary artery bypass grafting (CABG) was introduced to address the concern of inappropriate cardioplegia delivery through the stenotic coronary artery. However, this method is complex and requires repeated infusions. Therefore, we investigated the surgical outcomes of only antegrade cardioplegia infusion in conventional CABG. METHODS: We included 224 patients who underwent isolated CABG between 2017 and 2019. The patients were divided into two groups according to the cardioplegia infusion method: antegrade cardioplegia infusion with del Nido solution (n=111, group I) and antegrade+retrograde cardioplegia infusion with blood cardioplegia solution (n=113, group II). RESULTS: The sinus recovery time after release of the aorta cross-clamp was shorter in group I (3.8±7.1 minutes, n=98) than in group II (5.8±4.1 minutes, n=73) (p=0.033). The total cardioplegia infusion volume was lower in group I (1,998.6±668.6 mL) than in group II (7,321.0±2,865.3 mL) (p<0.001). Creatine kinase-MB levels were significantly lower in group I than in group II (p=0.039). Newly developed regional wall motion abnormalities on follow-up echocardiography were detected in two patients (1.8%) in group I and five patients (4.4%) in group II (p=0.233). There was no significant difference in ejection fraction improvement between the two groups (3.3%±9.3% in group I and 3.3%±8.7% in group II, p=0.990). CONCLUSION: The only antegrade cardioplegia infusion strategy in conventional CABG is safe and has no harmful effects.

Safety of low-dose anticoagulation in extracorporeal membrane oxygenation using the Permanent Life Support System: a retrospective observational study.

BACKGROUND: Bleeding and thrombosis are major complications associated with high mortality in extracorporeal membrane oxygenation (ECMO) management. Anticoagulant therapy should be adequate to reduce thrombosis. However, related studies are limited. METHODS: We retrospectively reviewed all patients supported with ECMO at a single institution between January 2014 and July 2022 and included those on all types of ECMO using the Permanent Life Support System. Patients were classified into two groups according to their measured mean activated partial thromboplastin time (aPTT) during ECMO management: a high-anticoagulation (AC) group (aPTT, ≥55 seconds; n=52) and a low-AC group (aPTT, <55 seconds; n=79). The primary outcome was thrombotic or bleeding events during ECMO. RESULTS: We identified 10 patients with bleeding; significantly more of these patients were in the high-AC group (n=8) than in the low-AC group (15.4% vs. 2.5%, p=0.01). However, thrombus events and oxygenator change-free times were not significantly different between the two groups. Four patients in the high-AC group died of bleeding complications (brain hemorrhage, two; hemopericardium, one; and gastrointestinal bleeding, one). One patient in the low-AC group developed a thrombus and died of ECMO dysfunction due to circuit thrombosis. CONCLUSION: Heparin did not significantly improve thrombotic outcomes. However, maintaining an aPTT of ≥55 seconds was a significant risk factor for bleeding events, especially those associated with mortality.

Optimal Position of a Femorojugular Cannulation for Venovenous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome.

BACKGROUND: This study aimed to determine the optimal position of venovenous extracorporeal membrane oxygenation (V-V ECMO) draining cannulas for refractory respiratory failure based on short-term clinical results. METHODS: In total, 278 patients underwent V-V ECMO at our hospital between 2012 and 2020. Those who underwent V-V ECMO with a femorojugular configuration were included. In the final cohort, 96 patients were divided into groups based on the draining cannula tip site: an inferior vena cava (IVC) group (n = 35) and a right atrium (RA) group (n = 61). The primary outcome was the change in fluid balance and ratio of awake ECMO 72 hours after V-V ECMO initiation. RESULTS: The only significant difference in baseline characteristics before V-V ECMO between the groups was a higher PaO2/FiO2 ratio in the RA group than in the IVC group (79.1 ± 26.21 vs 64.7 ± 14, P = .001). The degree of recirculation and arterial oxygenation, 90-day mortality, and clinical outcomes were similar between the groups. However, more patients achieved negative intake and output fluid balances (57.4% vs 31.4%, P = .01) and reductions in body weight (68.9% vs 40%, P = .006) in the RA group. At 72 hours after Vfemoral-Vjugular ECMO initiation, more patients in the RA group than in the IVC group were managed under awake ECMO (42.6% vs 22.9%, P =.047). CONCLUSIONS: Placement of a V-V ECMO draining cannula in the RA rather than the IVC is more effective for restricted fluid management and awake ECMO without significant recirculation.

Surgical correction of total anomalous pulmonary venous return in an adult patient.

BACKGROUND: Total anomalous pulmonary venous return (TAPVR) is rare congenital heart disease. Most TAPVRs require surgical corrections in the neonatal period and survival to adulthood without surgical correction is extremely rare. Most untreated patients with large atrial septal defects and no pulmonary venous obstruction have pulmonary vascular damage from pulmonary over circulation. CASE PRESENTATION: 44-year-old TAPVR patient admitted to our medical center. A snowman-shaped heart, including cardiomegaly and an increase in pulmonary blood flow, was seen in the chest X-ray. A large-sized (around 3 cm) atrial septal defect with dilated right atrium, right ventricle, and pulmonary artery was detected on echocardiography. Heart computed tomography was performed for further evaluation, and supra-cardiac type TAPVR without any obstructive lesion was identified. CONCLUSIONS: TAPVR in an adult patient is extremely rare, and this patient was treated successfully with surgical correction and is doing well. A sinus rhythm and mild mitral valve regurgitation have remained during 2.5 years of outpatient follow-up.

Docosahexaenoic acid suppresses breast cancer cell metastasis by targeting matrix-metalloproteinases.

Breast cancer is one of the most prevalent cancers in women, and nearly half of breast cancer patients develop distant metastatic disease after therapy. Despite the significant advances that have been achieved in understanding breast cancer metastasis in the past decades, metastatic cancer is still hard to cure. Here, we demonstrated an anti-cancer mechanism of docosahexaenoic acid (DHA) that suppressed lung metastasis in breast cancer. DHA could inhibit proliferation and invasion of breast cancer cells in vitro, and this was mainly through blocking Cox-2-PGE2-NF-κB-MMPs cascades. DHA treatment significantly decreased Cox-2 and NF-κB expression as well as nuclear translocation of NF-κB in MDA-MB-231 cells. In addition, DHA also reduced NF-κB binding to DNA which may lead to inactivation of MMPs. Moreover, in vivo studies using Fat-1 transgenic mice showed remarkable decrease of tumor growth and metastasis to EO771 cells to lung in DHA-rich environment. In conclusion, DHA attenuated breast cancer progression and lung metastasis in part through suppressing MMPs, and these findings suggest chemoprevention and potential therapeutic strategy to overcome malignant breast cancer.

Lumbar Lordosis of Spinal Stenosis Patients during Intraoperative Prone Positioning.

BACKGROUND: To evaluate the effect of spondylolisthesis on lumbar lordosis on the OSI (Jackson; Orthopaedic Systems Inc.) frame. Restoration of lumbar lordosis is important for maintaining sagittal balance. Physiologic lumbar lordosis has to be gained by intraoperative prone positioning with a hip extension and posterior instrumentation technique. There are some debates about changing lumbar lordosis on the OSI frame after an intraoperative prone position. We evaluated the effect of spondylolisthesis on lumbar lordosis after an intraoperative prone position. METHODS: Sixty-seven patients, who underwent spinal fusion at the Department of Orthopaedic Surgery of Gwangmyeong Sungae Hospital between May 2007 and February 2012, were included in this study. The study compared lumbar lordosis on preoperative upright, intraoperative prone and postoperative upright lateral X-rays between the simple stenosis (SS) group and spondylolisthesis group. The average age of patients was 67.86 years old. The average preoperative lordosis was 43.5° (± 14.9°), average intraoperative lordosis was 48.8° (± 13.2°), average postoperative lordosis was 46.5° (± 16.1°) and the average change on the frame was 5.3° (± 10.6°). RESULTS: Among all patients, 24 patients were diagnosed with simple spinal stenosis, 43 patients with spondylolisthesis (29 degenerative spondylolisthesis and 14 isthmic spondylolisthesis). Between the SS group and spondylolisthesis group, preoperative lordosis, intraoperative lordosis and postoperative lordosis were significantly larger in the spondylolisthesis group. The ratio of patients with increased lordosis on the OSI frame compared to preoperative lordosis was significantly higher in the spondylolisthesis group. The risk of increased lordosis on frame was significantly higher in the spondylolisthesis group (odds ratio, 3.325; 95% confidence interval, 1.101 to 10.039; p = 0.033). CONCLUSIONS: Intraoperative lumbar lordosis on the OSI frame with a prone position was larger in the SS patients than the spondylolisthesis patients, which also produced a larger postoperative lordosis angle after posterior spinal fusion surgery. An increase in lumbar lordosis on the OSI frame should be considered during posterior spinal fusion surgery, especially in spondylolisthesis patients.

The Use of T1 Sagittal Angle in Predicting Cervical Disc Degeneration.

STUDY DESIGN: Retrospective evaluation. PURPOSE: To analyze the effect of T1 slope on degree of degeneration in patients with cervical disc degeneration. OVERVIEW OF LITERATURE: The T1 slope is well known parameter that may be very useful in evaluating sagittal balance. There are no reports on the analysis of the relationship between T1 slope and cervical disc degeneration. We hypothesized that T1 slope has an effect on the degree of cervical degeneration. METHODS: Sixty patients who had cervical spine magnetic resonance imaging (MRI) in our orthopedic clinic were enrolled. Patients were divided into two groups according to T1 slope. Radiologic parameters obtained from radiography and cervical spine MRI were compared between low T1 slope group (≤25) and high T1 slope group (>25). RESULTS: Among low T1 slope group, average degeneration grade of each cervical segment was 2.65 in C2-3, 2.50 in C3-4, 2.62 in C4-5, 3.23 in C5-6, and 2.81 in C6-7. And that of high T1 group was 2.35 in C2-3, 2.32 in C3-4, 2.59 in C4-5, 2.79 in C5-6, and 2.32 in C6-7. Grade of degeneration of low T1 group was significantly higher, as compared with high T1 group in C5-6 (p=0.028) and C6-7 (p=0.009). Percentage of high grade degeneration of more than grand III was 65.4% in low T1 group and 32.4% in high T1 group (p=0.018). Risk of high grade degeneration of C6-7 was significantly higher in low T1 group (odds ratio, 5.63; 95% confidence interval, 1.665-19.057; p=0.005). CONCLUSIONS: Patients with low T1 slope had higher grade of degeneration regardless of age and gender. Low T1 slope is a potential risk factor of cervical spondylosis especially in the C6-7 cervical segment.