Postoperative outcomes of valve reoperation are associated with the number of previous cardiac operations.

OBJECTIVE: This study compared operative mortality and morbidity based on the number of previous cardiac operations to identify whether this was a risk factor for outcomes after valve reoperation. METHODS: Among valve surgery patients in the Japan Cardiovascular Surgery Database (2013‒2015), 4436 patients who underwent valve reoperation with a previous cardiac surgery were included. Patients were divided into three groups based on the number of previous cardiac operations (NPO1, NPO2, and NPO3+). Multivariable logistic regression analyses were conducted, adjusting for patient- and surgery-related factors to estimate the association of the NPO with the clinical outcomes of valve reoperation. RESULTS: Postoperative mortality was 8.6% in the NPO1, 11.2% in the NPO2, and 14.4% in the NPO3 + group, and the corresponding postoperative morbidity rates were 40.0, 46.2, and 59.2%, respectively. On multivariable logistic regression analysis, the odds of operative death were 1.36 (95% confidence interval [CI] 0.98‒1.87, p = 0.06) times higher for the NPO2 and 1.61 (95% CI 0.89‒2.90, p = 0.11) times higher for the NPO3+ group than for the NPO1 group. The odds ratios for postoperative complications were 1.31 (95% CI 1.08‒1.59, p < 0.01) for the NPO2 and 2.49 (95% CI 1.66‒3.74, p < 0.01) for the NPO3+ relative to the NPO1 group. CONCLUSION: The number of previous cardiac operations is associated with postoperative outcomes in patients undergoing valve reoperations. Considering the risk of repeat cardiac surgery, we recommend careful selection of operative procedures to avoid reoperation in patients requiring primary valve surgery.

Status of cardiovascular surgery in Japan between 2017 and 2018: A report based on the Japan Cardiovascular Surgery Database. 3. Valvular heart surgery.

OBJECTIVES: We aimed to present data regarding the current status and trends of valvular heart surgeries in Japan from the Japan Cardiovascular Surgery Database for the 2017-2018. METHODS: We extracted data on cardiac valve surgeries performed in 2017 and 2018 from the Japan Cardiovascular Surgery Database. We determined the trend in the number of aortic valve replacement procedures from 2013 to 2018. The operative mortality rates were calculated for representative valve procedures stratified by age group. Data regarding minimally invasive procedures and transcatheter aortic valve replacement in the Japan Cardiovascular Surgery Database are also presented. RESULTS: In conjunction with the dramatic increase in the number of transcatheter aortic valve replacements in 2017 and 2018, surgical aortic valve replacement also increased from 26,054 to 28,202. The operative mortality rate in first-time valve procedures was 1.8% in isolated aortic valve replacement, 0.9% in isolated mitral valve repair, and 8.2% and 4.6% in mitral valve replacement with biological prostheses and with mechanical prostheses, respectively. Regarding minimally invasive procedures, 30.8% of first-time isolated mitral valve plasty procedures were performed by a right thoracotomy. Although patients who underwent surgery by a right thoracotomy had better clinical outcomes, it was also apparent that patients who underwent surgery by a right thoracotomy had lower operative risk profiles. The overall mortality rates after transcatheter aortic valve replacement and surgical aortic valve replacement were 1.5% and 1.8%, respectively. CONCLUSION: We have reported benchmark data on heart valve surgery in 2017 and 2018 from the Japan Cardiovascular Surgery Database.

Evaluation of postoperative outcomes of valve reoperation: a retrospective study.

OBJECTIVES: The aim of this study was to compare the incidence of operative death and postoperative complications between primary and reoperation valve surgeries and to identify independent risk factors for these events among valve-reoperation patients. METHODS: Between 2013 and 2015, 54 269 patients who underwent valve surgery were retrospectively analyzed using the Japan Cardiovascular Surgery Database. They were divided into the primary (group P; n = 49 833) and reoperation (group R; n = 4436) surgery groups. Among the reoperation patients, we conducted multivariable logistic regression analyses to identify risk factors for the incidences of operative mortality and postoperative complications. Then, we also conducted propensity score matched analyses to compare the incidences of these 2 outcomes for primary versus reoperation procedures separately for patients with and without infective endocarditis (IE). RESULTS: Incidences of postoperative mortality (4.6% vs 9.1%; P < 0.001) and any complications (36.6% vs 41.4%; P < 0.001) were higher in the reoperation group. For patients undergoing reoperation, strong risk factors for operative mortality included urgency status, ejection fraction <30%, IE, dialysis, chronic kidney disease, New York Heart Association class 3/4, concomitant coronary artery bypass grafting and aorta procedure, tricuspid valve surgery only, multivalve surgery and age. In the propensity score matched cohort, the relative odds of operative mortality were 1.53 (95% confidence interval: 1.26-1.86, P < 0.001) among patients with IE and were 1.58 (95% confidence interval: 1.18-2.13, P < 0.002) among those without. CONCLUSIONS: Outcomes for reoperation were significantly worse than those for primary surgery. At the primary operation, the risk of reoperation should be considered and when considering the indications for reoperation, the preoperative state, surgical timing and intervention method should be considered.

High-Flow Nasal Cannula Therapy With Early Extubation for Subjects Undergoing Off-Pump Coronary Artery Bypass Graft Surgery.

BACKGROUND: The effects of high-flow nasal cannula (HFNC) therapy on postoperative atelectasis and duration of oxygen therapy after off-pump coronary artery bypass graft are unknown. The purpose of this study was to compare the effects of HFNC therapy for subjects who underwent off-pump coronary artery bypass graft with the effects of standard oxygen therapy in terms of oxygen requirement and atelectasis. METHODS: This prospective single-blinded randomized, controlled trial included 148 subjects who underwent off-pump coronary artery bypass graft between 2010 and 2015 with HFNC (n = 72) or without HFNC (standard O2, n = 76). The primary end point was the percentage difference in loss of lung volume between subjects with or without HFNC therapy. Secondary end points included the total amount of oxygen administered and duration of oxygen therapy with and without HFNC therapy. RESULTS: There were significant between-group differences in the percentage loss of lung volume (P < .001), total amount of oxygen administered (P < .001), duration of oxygen therapy (P < .001), and the need for postoperative diuretic therapy (P = .037). The amount (ρ = 0.569, P < .001) and duration (ρ = 0.678, P < .001) of oxygen administered were correlated with atelectasis volume. CONCLUSIONS: Using HFNC therapy after off-pump coronary artery bypass graft shortened the duration of oxygen therapy and reduced the percentage loss of lung volume and total amount of oxygen administered when compared with standard oxygen therapy.

Correction to: Current status of cardiovascular surgery in Japan, 2015 and 2016, a report based on the Japan Cardiovascular Surgery Database. 3-Valvular heart surgery.

In the original publication of this article, the title was published incorrectly. The correct article title is given in this correction.

Current status of cardiovascular surgery in Japan, 2015 and 2016, a report based on the Japan Cardiovascular Surgery Database. 3-Valvular heart surgery.

OBJECTIVES: Data related to valvular heart surgeries from the Japan Cardiovascular Surgery Database in 2015 and 2016 were analyzed to demonstrate the associated mortality and morbidity rates and choice of surgical procedures. METHODS: We used the Japan Cardiovascular Surgery Database to extract data related to cardiac valve replacement procedures performed in 2015 and 2016. The cases were further evaluated depending upon the type of procedure and prosthesis used at each site. The percentage of bio-prosthesis usage was calculated for each valve position and age group. The rates of operative mortality and morbidity were calculated for each valve position and type of procedure. RESULTS: Overall, 26,054 aortic valve replacements were performed in 2015 and 2016, showing a slightly larger number than the last report (2013-2014). A total of 3305 transcatheter aortic valve replacements, 5652 mitral valve replacements and 12,024 mitral valve repair procedures were performed. The percentage of bio-prosthesis usage in aortic valve replacement was 96.5, 92.7, and 63.5% for patients in their 80s, 70s, and 60s, respectively, demonstrating an increase in usage since 2013-2014. Mechanical valves were preferred in patients on chronic hemodialysis. The mortality rates of aortic valve replacement, mitral valve replacement, mitral valve repair, and tricuspid valve replacement procedures were 4.1, 7.1, 2.2, and 10.5%, respectively. CONCLUSION: We evaluated recent trends in valvular heart surgery in Japan with respect to the type of procedure and prosthesis preferred and the postoperative outcomes. We found that bio-prosthesis usage was becoming more common.

Correction to: Thoracic and cardiovascular surgery in Japan in 2016 : Annual report by The Japanese Association for Thoracic Surgery.

In the original publication of the article, the values of the row "Norwood procedure", under "(3) Main procedure" in Table 3 were published incorrectly. The corrected part of the table is given in this Correction.

[Prosthetic Valve].

In valvular disease treatment, it is extremely important to ensure good hemodynamics, to avoid thromboembolism and hemorrhagic complications, and to avoid reoperation. Due to the development of prosthetic valves, remarkable improvement in these results has been obtained. In recent years, the using rate of bioprosthetic valve has increased with the improvement of the durability of the bioprosthetic valve. Furthermore, a new bioprosthetic valve has also been developed, and it seems possible that the treatment strategy for valve disease such as valve selection of prosthetic valve and reoperation at the remote phase will change dramatically in the near future.

Current status of cardiovascular surgery in Japan, 2013 and 2014: A report based on the Japan Cardiovascular Surgery Database. 4. Valvular heart surgery.

Data from the Japan cardiovascular surgery database from 2013 to 2014 were analyzed to demonstrate the mortality rate and choice of surgical procedures, especially concerning the selection of valve prosthesis for each valve position and patient age group, and the effects of preoperative complications on mortality and prosthetic valve selection. The proportion of each surgical procedure was compared for each patient age in the aortic, mitral, and tricuspid positions. The proportion of mechanical valve prostheses was 23.1, 40.5, and 11.4% in the aortic, mitral, and tricuspid positions, respectively, and was higher in hemodialysis than in non-hemodialysis patients. The operative mortality rate was 4.3, 11.7, 15.8, and 5.6% in all cases, hemodialysis patients, patients with liver dysfunction, and patients with atrial fibrillation and flutter, respectively, after Aaortic valve replacement, and 4.0, 14.4, 11.2, and 4.1%, respectively, in each group listed above after mitral valve surgery. These results clarify the current status of cardiac valvular surgery in Japan.

Long-term outcome in a case of translocated mitral valve replacement for massive mitral annular calcification.

Few reports have described long-term outcomes after translocated mitral valve replacement. We describe tips, potential pitfalls, and long-term outcome associated with the construction of a new mitral annulus and reinforcement of prosthesis attachment using a mitral prosthetic valve with an equine pericardial collar in a woman with extensive mitral valve calcification.

Outcomes of prosthetic valve replacement in women of child-bearing age.

PURPOSE: The outcomes of pregnancy are more favorable for women with bioprostheses than for those with mechanical prostheses. However, bioprostheses are associated with a high reoperation rate in young women and it remains unclear whether these young women can give birth without any complications. We analyzed the outcomes of prosthetic valve replacement and investigated the effectiveness and problems associated with bioprostheses in women of child-bearing age in Japan. METHODS: The subjects of this study were six consecutive young adult women aged under 40 years, who underwent prosthetic valve replacement between January 2007 and April 2016. RESULTS: Bioprostheses were selected for four of these six women in consideration of their child-bearing age. Mechanical valves were selected for the other two women who underwent the Konno procedure and double valve replacement (AVR, MVR) in view of their high risk for reoperation. The cardiac operations, although without mortality or morbidity, were complex and some involved multi-time procedures. Three of the women with bioprostheses had uneventful term pregnancies. CONCLUSIONS: These young women with bioprostheses were able to give birth safely; however, as multiple operations are often required, and bioprostheses may not be ideal for young women. Prosthetic valve selection for young women of child-bearing age requires adequate pregnancy counseling and long-term planning.

Aortic valve replacement in a patient with MPO-ANCA-positive Goodpasture disease.

Goodpasture disease (GD) is a rare autoimmune disorder characterized by the development of pathologic autoantibodies against both glomerular and alveolar basal membranes. Approximately one third of the patients with GD are also positive for anti-neutrophil cytoplasmic antibody (ANCA). In this case report, a 74-year-old woman was diagnosed as having myeloperoxidase (MPO)-ANCA-positive GD with severe aortic valve stenosis (AS). She underwent immunosuppressive therapy and plasmapheresis that led to GD remission. Whether a cardiac surgery affects a MPO-ANCA-positive GD in remission is unknown. We reported the outcomes after aortic valve replacement for severe AS in a patient with MPO-ANCA-positive GD.

Use of a Stent Graft for Patent Ductus Arteriosus in an Octogenarian Eliminates Ductus Flow.

Closure of a patent ductus arteriosus (PDA) in the elderly is a high-risk procedure because of tissue fragility and many possible complications. The patient in our case was an 81-year-old woman with a window-type PDA caused by cardiac failure. Based on the anatomy of the PDA and aorta and to minimize invasion, we used a stent graft to close the PDA. This approach was successful; hemodynamics improved and ductus flow was eliminated during the follow-up period without intervention from the pulmonary artery side.

[Ascending-descending Aortic Bypass and Aortic Valve Replacement for Aortic Coarctation with Bicuspid Aortic Valve and an Aberrant Right Subclavian Artery;Report of a Case].

A 53-year-old woman was developed congestive heart failure. She was diagnosed as having aortic coarctation, incompetent bicuspid aortic valve and an aberrant right subclavian artery by using echocardiography and enhanced computed tomography. Ankle brachial pressure index(ABI)in the right was 0.71 and 0.69 in the left. Blood pressure of the right arm was 60 mmHg lower than that of the left arm. To avoid perioperative adverse cardiac events due to a 2-staged operation, we performed ascending-descending aortic bypass and aortic valve replacement simultaneously through a median sternotomy. The heart was retracted cranially, and a vascular prosthesis was anastomosed to the descending aorta just above the diaphragm in an end-to-side manner. Then the graft was placed curvilinearly around the right atrium and was anastomosed to the ascending aorta. After the operation, the right and left ABI increased to 0.90 and 0.98 respectively. There was no pressure difference between the arms. The postoperative course was uneventful.

Identification of Coronary Artery Orifice to Prevent Coronary Complications in Bioprosthetic and Transcatheter Aortic Valve Replacement.

BACKGROUND: The aim of this study was to identify anatomical variations in coronary artery orifices among high-risk patients with a small aortic root undergoing bioprosthetic aortic valve replacement (BAVR) and transcatheter aortic valve replacement (TAVR) in order to prevent coronary orifice obstruction perioperatively. METHODS AND RESULTS: Coronary orifice and root structure were identified in 400 patients using aortic multidetector-row computed tomography (MDCT). We measured the aortic root diameter; intercommissural distances; and distance from coronary orifice to valve annulus, commissure, and sinotubular junction. We examined positional relationships between the coronary orifice and stent post, or sewing cuff of the bioprosthetic valve and leaflet of the transcatheter aortic valve. Most left coronary artery orifices were distributed near the center of the non-left and left-right commissures; right ones were relatively distributed on the non-right commissural side. Thirty-four patients (8.5%) with BAVR (coronary orifice near the commissure: 31, 7.8%; low takeoff: 5, 1.3%; and both: 2) and 39 (9.8%) with TAVR were at risk for coronary orifice obstruction. During BAVR, one-stitch rotation of the stent and one-stitch rotation with intra-annular implantation were used in near-commissure and low takeoff cases, respectively. During TAVR, percutaneous coronary intervention may be required in the height of the coronary orifice was ≤10 mm from the base of the ventricle aortic junction. CONCLUSIONS: Potential coronary complications during BAVR and TAVR in high-risk patients for coronary obstruction were identified using preoperative aortic MDCT. Choice of appropriate surgical technique or valve is essential.

[The Use of Thromboelastometry and Tranexamic Acid Reduces Blood Loss and Transfusion Requirements in Cardiac Surgery under Cardiopulmonary Bypass].

BACKGROUND: We evaluated whether using thromboelastometry and tranexamic acid influenced blood loss and transfusion requirements in cardiac surgery requiring cardiopulmonary bypass. METHODS: We perfomed a retrospective analysis examining perioperative coagulation results, and the transfusion requirements of concentrated red cells (CRCs), fresh frozen plasma (FFP) and platelet administration between 12 months before and 10 months after thromboelastometry and tranexamic acid had been introduced in our institution. We also recorded patients' demographic details, the surgery performed and patient outcomes. RESULTS: After the introduction of thromboelastometry and tranexamic acid, fewer units of CRC were transfused during surgery, and fewer patients required postoperative CRC transfusion. Intra- and postoperative FFP requirements were also reduced. Intraoperative blood loss, blood loss in the first 24 hr after surgery, and length of hospital stay were also reduced. CONCLUSIONS: The use of ROTEM and tranexamic acid can potentially reduce blood loss and transfusion requirements in cardiac surgery.