Impact of complete revascularization in coronary artery bypass grafting for ischemic cardiomyopathy.

Objective: In patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting. Methods: We retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors. Results: The overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P = .05) than the incomplete revascularization group. Conclusions: In patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible.

Protein quality control machinery supports primary ciliogenesis by eliminating GDP-bound Rab8-family GTPases.

The small GTPase Rab8 plays a vital role in the vesicular trafficking of cargo proteins from the trans-Golgi network to target membranes. Upon reaching its target destination, Rab8 is released from the vesicular membrane into the cytoplasm via guanosine triphosphate (GTP) hydrolysis. The fate of GDP-bound Rab8 released from the destination membranes, however, has not been investigated adequately. In this study, we found that GDP-bound Rab8 subfamily proteins are targeted for immediate degradation, and the pre-emptive quality control machinery is responsible for eliminating these proteins in a nucleotide-specific manner. We provide evidence that components of this quality control machinery have a critical role in vesicular trafficking events, including the formation of primary cilia, a process regulated by the Rab8 subfamily. These results suggest that the protein degradation machinery plays a critical role in the integrity of membrane trafficking by limiting the excessive accumulation of GDP-bound Rab8 subfamily proteins.

Cardiac calcified amorphous tumor with sustained ventricular tachycardia.

Cardiac calcified amorphous tumors are rare non-neoplastic intracavitary masses with unknown cause. A 60-year-old man presented with sustained ventricular tachycardia. Transthoracic echocardiography and contrast-enhanced angio-computed tomography demonstrated an expanding 73 × 40 mm sized calcified mass in the left ventricle. He underwent successful total removal of the mass and cryo-ablation at the normal myocardial border. Histopathological examination confirmed a diagnosis of cardiac calcified amorphous tumors. The postoperative course was uneventful, without ventricular tachycardia recurrence. To our knowledge, this is the first reported case of confirmed cardiac calcified amorphous tumors causing ventricular tachycardia and treated by surgical resection combined with cryo-ablation.

Bilateral Internal Thoracic Artery Grafting Improves Survival for Severe Left Ventricular Dysfunction and Diabetes.

BACKGROUND: In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.Methods and Results:Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024). CONCLUSIONS: NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.

Incidence, determinants and clinical impact of left ventricular function recovery after surgical treatments for ischaemic cardiomyopathy.

OBJECTIVES: This retrospective study aimed to clarify the incidence, determinants and clinical impact of left ventricular (LV) function non-recovery after coronary artery bypass grafting (CABG) in patients with ischaemic cardiomyopathy. METHODS: A total of 490 patients with ischaemic cardiomyopathy (LV ejection fraction ≤ 40%) undergoing CABG were analysed. Follow-up echocardiography was performed at 1 month, 1 year, and annually thereafter. LV function recovery was defined as ejection fraction (EF) ≥40% at least once during follow-up. LV function non-recovery was defined as EF <40% at any follow-up. The primary and secondary end points were changes in LV function and all-cause mortality, respectively. Clinical follow-up was completed in 461 patients (94.1%; mean follow-up: 64.5 ± 45.5 months). RESULTS: During follow-up, echocardiographic assessments were performed 1863 times (mean, 3.8 ± 2.4), and 193 patients (39.4%) exhibiting LV function non-recovery were identified. Overall survival was significantly higher in the recovery group (53.9%) than in the non-recovery group (31.4%) at 10 years (P < 0.001). Independent predictors of LV function non-recovery were preoperative LV end-systolic diameter [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.04-1.10; P < 0.001] and bilateral internal thoracic artery grafting (OR 0.61, 95% CI 0.39-0.95; P = 0.028). In a multivariable Cox proportional hazards model, LV function non-recovery was significantly associated with all-cause mortality (hazard ratio 2.14, 95% CI 1.60-2.86; P < 0.001). CONCLUSIONS: Almost 40% of patients with ischaemic cardiomyopathy undergoing CABG did not achieve LV function recovery and were associated with poor prognosis. To achieve LV function recovery, CABG with bilateral internal thoracic artery may be recommended before excessive LV remodelling occurs. CLINICAL TRIAL REGISTRATION NUMBER: Institutional review board of Osaka University Hospital, number 16105.

Surgical Ablation Concomitant With Nonmitral Valve Surgery for Persistent Atrial Fibrillation.

BACKGROUND: Consensus regarding an optimal atrial fibrillation (AF) ablation lesion set concomitant with aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) has not been established. METHODS: We enrolled 125 consecutive patients (89 men; 70 ± 8 years old) with persistent AF who underwent radiofrequency-based pulmonary vein isolation (PVI) (PVI group, n = 53) or a Cox-Maze procedure (Maze group, n = 72) with AVR and/or CABG. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent Cox-Maze with and those who underwent PVI, we established weighted Cox proportional-hazards regression models with inverse probability of treatment weighting. Mean follow-up was 63 ± 34 months (maximum, 154 months). RESULTS: There was 1 in-hospital death in each group. Patients who underwent Cox-Maze showed a higher freedom from AF at all follow-up examinations. After the operation, there were 32 deaths, 13 thromboembolisms, 8 hemorrhagic events, and 22 heart failure readmissions. The Maze group had higher rates for 5-year survival (88% vs 64%, P = .013) and freedom from composite events (74% vs 42%, P < .001). After adjustment with inverse probability of treatment weighting, the Cox-Maze procedure still showed a lower risk of overall mortality (adjusted hazard ratio, 0.38; 95% confidence interval, 0.21-0.66; P = .001) and composite adverse events (adjusted hazard ratio, 0.52; 95% confidence interval, 0.35-0.76; P = .001). CONCLUSIONS: In patients with persistent AF indicated for nonmitral valve surgery, a concomitant Cox-Maze procedure resulted in superior AF- and event-free survival compared with PVI, without increased risk of early mortality. These findings may assist decision making for surgical management of persistent AF concomitant with AVR and/or CABG.

A reproducible swine model of a surgically created saccular thoracic aortic aneurysm.

A reproducible swine thoracic aortic aneurysm (TAA) model is useful for investigating new therapeutic interventions. We report a surgical method for creating a reproducible swine saccular TAA model. We used eight female swine weighing 20-25 kg (LWD; ternary species). All procedures were performed under general anesthesia and involved left thoracotomy. Following aortic cross-clamping, the thoracic aorta was surgically dissected and the media and intima were resected, and the dissection plane was extended by spreading the outer layer for aneurysmal space. Subsequently, only the adventitial layer of the aorta was sutured. At 2 weeks after these procedures, angiography and computed tomography were performed. After follow-up imaging, the model animals were euthanized. Macroscopic, histological, and immunohistological examinations were performed. All model animals survived, and a saccular TAA was confirmed by follow-up imaging in all cases. The mean length of the shorter and the longer aortic diameter after the procedure were 14.01 ± 1.0 mm and 18.35 ± 1.4 mm, respectively (P<0.001). The rate of increase in the aortic diameter was 131.7 ± 13.8%, and the mean length of aneurysmal change at thoracic aorta was 22.4 ± 1.9 mm. Histological examination revealed intimal tears and defects of elastic fibers in the media. Immunostaining revealed MMP-2 and MMP-9 expressions at the aneurysm site. We report our surgical method for creating a swine saccular TAA model. Our model animal may be useful to investigate new therapeutic interventions for aortic disease.

Restrictive mitral annuloplasty with or without coronary artery bypass grafting in ischemic mitral regurgitation.

AIMS: In patients with ischaemic mitral regurgitation (MR), the impact of mitral valve surgery with concomitant coronary artery bypass grafting (CABG) on post-operative survival and left ventricular (LV) reverse remodelling remains unknown. Therefore, we investigated these outcomes following restrictive mitral annuloplasty (RMA) with and without CABG in those patients. METHODS AND RESULTS: This study included 309 patients with chronic MR and ischaemic cardiomyopathy for whom concomitant CABG was indicated (n = 225) or not indicated (n = 84) with RMA. The primary endpoint was all cause mortality during the follow-up, and the secondary endpoint was defined as the composite of mortality and re-admission for heart failure. Linear mixed model was used to analyse serial echocardiographic changes in LV function. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent RMA with and those who underwent it without CABG, we established weighted Cox proportional-hazards regression models with inverse-probability-of-treatment weighting. Pre-operatively, there were no intergroup differences in age (RMA with CABG, 67 ± 9 vs. RMA without CABG, 68 ± 11, P = 0.409) and logistic EuroSCORE II (16 ± 14 vs. 15 ± 15%, P = 0.496). The 30-day mortalities were 2.7% and 3.6%, respectively (P = 0.67). During follow-up with a mean duration of 72 ± 37 months (range, 5.6-179), there were 157 deaths and 105 re-admissions for heart failure. Overall 1-year and 5-year survival rates were 83 ± 2% and 58 ± 3%, respectively. Patients who did not receive CABG with RMA had a significantly lower 5-year survival rate (45% vs. 63%, P = 0.049) and freedom from adverse events defined as mortality and/or admission for heart failure (19% vs. 43%, P < 0.001) than those who did. After adjustments for clinical covariates with inverse-probability-of-treatment weighting, concomitant CABG was identified as an independent protective factor for adverse events (hazard ratio: 0.53; 95% confidence interval: 0.44-0.64; P < 0.001). Along with significant MR reduction, LV function parameters changed over time after surgery in both groups, with greater improvements in patients who underwent RMA with CABG (time effect, P < 0.001; and interaction effect, P = 0.002). CONCLUSIONS: RMA can be performed with an acceptable operative mortality, irrespective of indications for CABG. Patients with ischaemic MR for whom CABG is indicated with RMA are more likely to show better long-term and event-free survival and greater improvements in LV systolic function. The optimal revascularization strategy should be discussed with a heart team whenever indicated in patients with ischaemic MR; otherwise, they may miss the opportunity to benefit from concomitant CABG during subsequent RMA.

Aortic angioscopy assisted thoracic endovascular repair for chronic type B aortic dissection.

BACKGROUND: Non-obstructive general angioscopy is a powerful modality for detecting areas in the aorta with vulnerable plaque, which are difficult to visualize using conventional diagnostic tools such as computed tomography (CT). The aim of the present study was to clarify the efficacy and usefulness of aortic angioscopy in patients with chronic type B aortic dissection scheduled for thoracic endovascular repair (TEVAR). METHODS: Ten patients with chronic type B aortic dissection who underwent elective TEVAR were enrolled. Before starting the stent graft procedure, the aortic intima was observed by use of non-obstructive general angioscopy. Based on those findings, the range of the stent graft position was confirmed. RESULTS: In all patients, observations of the aortic intima with non-obstructive general angioscopy from a point just proximal of the descending aorta to the iliac artery were successful. At the proximal site, an entry site or ulcer-like projection was detected in all patients, while a small intimal tear or entry, or an irregular intima surface with a salmon-pink color were seen in some cases. In contrast, preoperative CT did not detect any such findings in the same locations. After confirming the position of the abnormal intima, we determined the position of the distal end of the stent graft. No complications considered to be related to aortic angioscopy were noted. CONCLUSIONS: Non-obstructive general angioscopy is useful for observing the condition of the aortic intima, revealing abnormal conditions, and confirming a normal aortic intima in patients with chronic type B aortic dissection. This modality may play an important role in determining the precise position of a stent graft for a TEVAR procedure.

Which Patients Are Candidates for Minimally Invasive Mitral Valve Surgery?　- Establishment of Risk Calculators Using National Clinical Database.

BACKGROUND: Although minimally invasive mitral valve surgery via a right minithoracotomy (MICS-mitral) is widely performed, no tool to evaluate its risk has been reported. We sought to establish MICS-mitral risk calculators using a national clinical database for selection of appropriate patients.Methods and Results:Between 2008 and 2015, 3,240 patients (mean age 59±14 years, males 1,950) underwent a MICS-mitral procedure in Japan and were registered in a national clinical database. We examined mortality and composite outcome (operative mortality, stroke, reoperation for bleeding) using multivariate analysis, then developed a risk calculator for each using stepwise analysis. Operative mortality was 1.1% and the composite outcome rate was 5%. In multivariate analysis, risk factors for operative mortality were shown to be age, respiratory dysfunction, thoracic aortic disease, myocardial infarction, body mass index >30, NYHA class IV, moderate or severe aortic regurgitation, mitral valve replacement, multiple valve surgery, and annual cases <10. ROC curve analysis of our prediction formulas for mortality and composite outcome revealed an area under the curve for operative mortality of 0.877 (95% confidence interval: 0.82-0.94, P<0.01) and for composite outcome of 0.665 (95% confidence interval: 0.62-0.71, P<0.01). CONCLUSIONS: We developed risk calculator formulas using risk factors associated with both operative mortality and composite outcome. The present risk calculator formula is useful for patient selection and may influence future applications for this procedure.

Surgery-first treatment improves clinical results in infective endocarditis complicated with disseminated intravascular coagulation†.

OBJECTIVES: Infective endocarditis (IE) is a critical infection with a high mortality rate, and it usually causes sepsis. Though disseminated intravascular coagulation (DIC) sometimes occurs in IE patients, no definitive treatment strategy for IE patients with DIC as a complication exists. Therefore, we evaluated the prevalence, surgical results and treatment strategy for IE complicated with DIC. METHODS: Between 2009 and 2017, a total of 585 patients undergoing valve surgery for active IE were enrolled at 14 institutions, of whom 116 (20%) had DIC as a complication. For further evaluation, we divided DIC patients into medical treatment-first (n = 45, group M) and valve surgery-first (n = 51, group S) groups after excluding 20 patients with intracranial haemorrhage. RESULTS: The overall survival rates at 1 and 5 years were 91% and 85% in the non-DIC group and 65% and 55% in the DIC group, respectively (P < 0.001). Recurrence-free survival rates at 1 and 5 years were 99% and 95% in the non-DIC group and 94% and 74% in the DIC group, respectively (P < 0.001). The overall survival rates at 1 and 5 years were 77% and 64% in group S and 51% and 46% in group M, respectively (P = 0.032). Multivariable analysis revealed that 'medical treatment first' was an exclusive independent risk factor [hazards ratio 2.26 (1.13-4.75), P = 0.024] for overall mortality. CONCLUSIONS: Mortality and IE recurrence were statistically significantly higher in DIC patients. Valve surgery should not be delayed because most patients proceeding with medical treatment eventually require emergency surgery and their clinical outcomes are worse than those of patients undergoing early surgery.

Equations Estimating the Predissected Diameter of the Ascending Aorta for Acute Type A Aortic Dissection.

BACKGROUND: A successful endovascular treatment for acute type A dissection has been recently reported. However, there has been no consensus regarding the appropriate stent graft size based on the estimated predissected aortic diameter for this pathology. METHODS: We developed new equations for estimating the predissected ascending aorta and aortic arch by investigating computed tomography images that had been scanned less than 3 years before dissection. From 684 patients with type A AAD, 28 were matched for the study. We measured the predissected whole circumference length (pre-wCL), postdissected whole circumference length (post-wCL), postdissected true lumen circumference length (post-tCL), postdissected major diameter (post-Dma), and postdissected minor diameter (post-Dmi) of the acutely dissected aorta. This was followed by the calculation of (post-tCL + post-wCL)/2 and (post-Dma + post-Dmi)/2. Six equations (linear function) and modified equations were derived from each of the abovementioned parameters. RESULTS: Four equations (post-wCL, post-Dma, [post-tCL + post-wCL]/2, and [post-Dma + post-Dmi]/2) had nearly the same bias and accuracy (<9.42 mm). For clinical use, we also developed one modified equation using the post-wCL (y = 0.9x) among four parameters because of its simplicity and decreased the possibility of measurement error. The biases of circumference length and accuracy were 5.5 ± 4.9 mm and 84.6%, respectively, and they improved to 4.4 ± 3.3 mm and 93.4% in cases with a ratio of post-tCL/post-wCL of 0.66 or more. CONCLUSIONS: Our newly developed equation can be used to calculate the predissected ascending aortic diameter and aortic arch diameter in cases of acute type A dissection.

Cytoplasmic control of Rab family small GTPases through BAG6.

Rab family small GTPases are master regulators of distinct steps of intracellular vesicle trafficking in eukaryotic cells. GDP-bound cytoplasmic forms of Rab proteins are prone to aggregation due to the exposure of hydrophobic groups but the machinery that determines the fate of Rab species in the cytosol has not been elucidated in detail. In this study, we find that BAG6 (BAT3/Scythe) predominantly recognizes a cryptic portion of GDP-associated Rab8a, while its major GTP-bound active form is not recognized. The hydrophobic residues of the Switch I region of Rab8a are essential for its interaction with BAG6 and the degradation of GDP-Rab8a via the ubiquitin-proteasome system. BAG6 prevents the excess accumulation of inactive Rab8a, whose accumulation impairs intracellular membrane trafficking. BAG6 binds not only Rab8a but also a functionally distinct set of Rab family proteins, and is also required for the correct distribution of Golgi and endosomal markers. From these observations, we suggest that Rab proteins represent a novel set of substrates for BAG6, and the BAG6-mediated pathway is associated with the regulation of membrane vesicle trafficking events in mammalian cells.

Single-Stage Total Arch Replacement With Open Stent Graft for Kommerell's Diverticulum With Right-Sided Aortic Arch.

We treated a 70-year-old patient with Kommerell's diverticulum associated with an aberrant left subclavian artery and right aortic arch using single-stage total arch replacement with a commercially available open stent graft through only a median sternotomy. A four-branched prosthetic graft was implanted after insertion of the open stent graft through the anastomotic site under moderate hypothermia and cardiopulmonary bypass with selective cerebral perfusion. The aberrant subclavian artery was occluded by coil embolization from the distal site and anatomically reconstructed from the prosthetic graft. This approach is safe and effective and allows avoidance of a right thoracotomy and second stage intervention.

Minimally invasive mitral valve repair via right mini-thoracotomy in patient with myelodysplastic syndrome.

BACKGROUND: Cardiac surgery for myelodysplastic syndrome (MDS) patients is challenging because anemia and neutropenia develop as a result of the syndrome, leading to infection and bleeding tendency during surgery. We report the case of minimally invasive mitral valve repair via a right mini-thoracotomy and perioperative use of granulocyte colony-stimulating factor (G-CSF) in a patient with MDS. CASE PRESENTATION: A 77-year-old man with myelodysplastic syndrome (MDS) was referred for surgical treatment for mitral valve regurgitation and underwent a minimally invasive mitral valve repair via a right mini-thoracotomy (MICS mitral procedure). On admission, laboratory results showed a leukocyte count of 1500/µL and neutrophils at 190/µL. Prior to surgery, a subcutaneous injection of granulocyte colony-stimulating factor (G-CSF) was given, based on a diagnosis of MDS by a hematologist. The MICS-mitral procedure using artificial chordae and an annular ring prosthesis was completed without requiring re-exploration for bleeding. Postoperatively, a G-CSF injection was administered and transfusion was required. There was no infection complication and the postoperative course was uneventful. CONCLUSION: A MICS-mitral procedure may be an effective option for MR patients with MDS who require a mitral valve repair to avoid postoperative infection and reduce the incidence of perioperative transfusion.

Successful surgical resection of giant arteriovenous malformation in supraclavicular fossa.

A 42-year-old woman with a large congenital giant arteriovenous malformation in the left supraclavicular fossa underwent surgical resection. Although endovascular treatment was initially planned, it was impossible to occlude the multiple feeding arteries (transverse cervical, clavicular branch of left internal mammary, thoracoacromial, anterior/posterior circumflex humeral), and the anatomy was difficult. After removal of the left clavicle, the arteriovenous malformation was exposed. Care was taken to not injure the brachial plexus, and each feeding artery was ligated, followed by division of the drainage veins. The postoperative course was uneventful, and no sign of recurrence has been seen.

[Postoperative Atrial Fibrillation in Patients who Underwent Thoracic Aortic Surgery].

PURPOSE: Postoperative atrial fibrillation (POAF) is a very common and important complication occurring after open heart surgery. Risk factors and prevention measure including ß blocker use have been reported mainly in regard to patients who underwent coronary artery bypass grafting, while little is known about POAF following thoracic aortic surgery. In the present study, we examined risk factors related to POAF and effective prevention of POAF in patients who underwent thoracic aortic surgery. PATIENTS AND METHODS: We evaluated 95 consecutive patients who underwent thoracic aortic surgery since 2010. We analyzed the relationship between perioperative factors and occurrence of POAF in the study cohort, as well as in 62 patients who had perioperative intravenous ß blocker (landiolol) administration. RESULTS: Following surgery, 21 (22%) of the patients had new onset POAF. The occurrence of POAF was related to that of stroke. Univariate analysis showed that age was a risk factor for POAF. In patients with landiolol, risk factors for POAF were age, arch aneurysm, and timing of landiolol administration. Six patients developed POAF during landiolol administration. However, of 56 patients who had not have POAF during landiolol administration, 8 developed POAF after stopping landiolol. CONCLUSION: Our findings show that the risk factor of POAF after thoracic aortic surgery is age, while perioperative administration of landiolol may reduce POAF incidence.

Recent Surgical Results for Active Endocarditis Complicated With Perivalvular Abscess.

BACKGROUND: Surgical treatment for endocarditis patients with a perivalvular abscess is still challenging.Methods and Results:From 2009 to 2016, 470 patients underwent surgery for active endocarditis at 11 hospitals. Of these, 226 patients underwent aortic valve surgery. We compared the clinical results of 162 patients without a perivalvular abscess, 37 patients who required patch reconstruction of the aortic annulus (PR group) and 27 who underwent aortic root replacement (ARR group). Patients with a perivalvular abscess had a greater number ofStaphylococcusspecies and prosthetic valve endocarditis, a greater level of inflammation at diagnosis and symptomatic heart failure before surgery, especially in the ARR group. Nevertheless, the duration between diagnosis and surgery was similar, because of a high prevalence of intracranial hemorrhage in the ARR group. Hospital death occurred in 13 (9%) patients without a perivalvular abscess, in 4 (12%) in the PR and in 7 (32%) in the ARR group. Postoperative inflammation and end-organ function were similar between the groups. Overall survival of patients without a perivalvular abscess and that of the PR group was similar, but was significantly worse in the ARR group (P=0.050, 0.026). Freedom from endocarditis recurrence was similar among all patients. CONCLUSIONS: Patients treated with patch reconstruction showed favorable clinical results. Early surgical intervention is necessary when a refractory invasive infection is suspected.

Atrial fibrillation following aortic valve replacement: impact of perioperative use of intravenous ß-blocker.

OBJECTIVES: Despite recent advances in perioperative management, postoperative atrial fibrillation/flutter (POAF) remains the most common complication after cardiac surgery. Therefore, it is important to determine related risk factors to establish effective management. However, most studies have focused on patients undergoing coronary artery bypass grafting and little is known about POAF in those who receive aortic valve replacement (AVR). We investigated the relationship of clinical predictors with POAF in patients undergoing AVR. METHODS: A total of 119 patients who underwent AVR were enrolled in this study, and the relationships between POAF incidence and perioperative (preoperative, operative, postoperative) factors were examined. RESULTS: POAF occurred in 47 patients (40%). In univariate analysis, older age was significantly associated with POAF occurrence, which was significantly related to prolonged intensive care unit (ICU) stay and postoperative stroke. It also showed patients with preoperative ß-blocker experienced POAF less frequently than those without ß-blocker. Multivariate analysis showed that preoperative ß-blocker usage was an independent predictor of POAF. In patients who received both preoperative oral and postoperative intravenous ß-blocker administrations, the incidence of POAF was reduced to 14% (3/22). CONCLUSIONS: POAF frequently occurred in patients undergoing AVR, and was significantly related to prolonged ICU stay and postoperative stroke. Our findings show that advanced age and absence of preoperative ß-blocker usage are risk factors for POAF. Furthermore, in patients undergoing AVR, perioperative intravenous ß-blocker administration may be useful for prevention.

Predictive factors for responders to tolvaptan in fluid management after cardiovascular surgery.

OBJECTIVE: To identify the predictive factors for responders to tolvaptan, a novel vasopressin type 2 receptor antagonist for fluid management after cardiovascular surgery. METHODS: Between January 2013 and May 2014, 113 patients were treated with tolvaptan for fluid management after cardiovascular surgery. As indicators for the effects of tolvaptan, change in bodyweight during the tolvaptan administration period and correlations with perioperative factors were assessed. Thirty-one patients were administered tolvaptan at the first day after surgery (early tolvaptan group). In this group, urine volume during the 6 h before the initial tolvaptan administration was compared with that at 6 h after administration. RESULTS: For all the patients, the change in bodyweight during the tolvaptan administration period significantly correlated with pre-operative serum creatinine (r = 0.19, p = 0.04) and albumin levels before tolvaptan administration (r = -0.29, p = 0.002). In the early tolvaptan group, the ratio of urine volume at 6 h before and 6 h after the initial tolvaptan administration significantly correlated with the pre-operative serum creatinine level (r = 0.43, p = 0.02), the serum albumin level before tolvaptan administration (r = -0.50, p = 0.004), and change in bodyweight (r = 0.38, p = 0.03). CONCLUSIONS: In patients undergoing cardiovascular surgery, deteriorating renal function, increased bodyweight, and hypoalbuminemia were found to be predictive factors for responders to tolvaptan for postoperative fluid management.