Impact of left atrium plication on chronic heart failure with atrial functional mitral regurgitation.

Purpose: We hypothesized that a giant left atrium may oppress  the posterior left ventricle and aggravate diastolic dysfunction and heart failure. We evaluated the effect of left atrial plication (LAP) on atrial functional mitral regurgitation. Methods: We retrospectively reviewed patients who underwent LAP for atrial functional mitral regurgitation at our institution between January 2017 and December 2021. Early outcomes, follow-up echocardiography data, and heart failure indicators were compared. Results: Eighteen patients were divided into two groups: LAP + (n = 9) or LAP- (n = 9). There were no significant differences in patient characteristics and preoperative echocardiographic parameters, except for the preoperative New York Heart Association classification. Operative (505.7 [standard deviation: 100.0] minutes vs. 382.9 [standard deviation: 58.1] minutes, P = .0055) and cardiopulmonary bypass times (335.6 [standard deviation: 50.4] minutes vs. 246.9 [standard deviation: 62.7] minutes, P = .0044) were significantly longer in the LAP + group. No in-hospital mortalities were observed in both groups. The postoperative left atrial volume was significantly reduced in the LAP + group, and mitral regurgitation was controlled at less than mild levels in both groups. At follow-up, the left ventricular end-diastolic volume was reduced significantly in the LAP + group. Brain natriuretic peptide, cardiothoracic ratio, and the New York Heart Association classification were improved in the LAP + group. Conclusions: Additional left atrial plication contributes to the control of atrial functional mitral regurgitation and heart failure at a later stage. A careful long-term follow-up is needed as re-expansion of the left atrium is possible. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01569-6.

Long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation.

Purpose: To evaluate the early and long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation. Methods: Patients with ischemic mitral regurgitation who underwent left ventricular posterior wall plication via right-sided left atriotomy at our institution between 2010 and 2020 were retrospectively reviewed. Cases with normal cardiac function, left ventricular end-systolic diameter < 50 mm, and left ventriculotomy approach were excluded. Results: The mean follow-up period was 5.3 years [standard deviation (SD) = 3.5], with a maximum of 10 years. Among the 21 patients enrolled, 9 had New York Heart Association (NYHA) class ≥ III. Three patients required preoperative inotrope support, while two preoperative ventilator support. The mean left ventricular ejection fraction was 31.4% (SD: 8.6), and 16 patients had mitral regurgitation grade ≥ III. All patients underwent coronary artery bypass grafting and mitral annuloplasty. Concomitant surgeries included 11 chordae cutting and 3 tricuspid annuloplasties. One in-hospital death occurred due to sepsis. At the follow-up, echocardiographic data showed significant improvement in cardiac dilation and function and good control of mitral regurgitation. The serum brain natriuretic peptide level was significantly reduced, and 85% of patients improved to NYHA class I. Four deaths occurred later due to sudden, unknown causes. The 5- and 8-year survival rates were 60.2% and 46.8%, respectively, and the 5- and 8-year hospitalization rates due to heart failure were 14.9% and 21.3%, respectively. Conclusion: The long-term outcomes of left ventricular posterior wall plication were satisfactory for controlling heart failure and improving survival rate and patient prognosis. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01527-2.

Noncommunicating acute type A aortic dissection in elderly patients: Surgery versus medical management.

OBJECTIVES: Our goal was to evaluate the surgical and conservative outcomes of acute type A aortic dissection with a thrombosed false lumen of the ascending aorta in elderly patients. METHODS: Patients older than 75 years with acute type A aortic dissection admitted to our hospital from October 2011 to December 2020 were reviewed retrospectively, including those with the noncommunicating type without malperfusion and low physical capacity prehospitalization. RESULTS: Sixty-six patients were enrolled consecutively in the medical (M, n = 30) and surgical (S, n = 36) groups. The ascending aorta was the most replaced section in the S group (78%). Groups did not differ significantly in hospital deaths and in intensive care unit and hospital stays. Two patients (7%) underwent surgery and 3 (10%) underwent redissection in the M group. No significant difference existed between the groups in the decline of physical performance during hospitalization. Seven patients in the M group (24%) had aorta-related events in the late period as opposed to none in the S group (P=0.003). Survival rates after 4 years were 78.3% and 71.4% in the S and M groups, respectively (P=0.154). The cumulative incidence of overall reintervention due to an aortic event was significantly higher in the M group; however, the 2 groups did not differ significantly in overall aorta-related deaths. CONCLUSIONS: Surgical outcomes of noncommunicating acute type A aortic dissection in elderly patients were favorable. There was no significant difference in maintaining physical function at discharge, and the medical group had a significantly higher overall aortic event rate than the surgical group.

Mitral Valve Repair for Barlow's Disease with Mitral Annular and Subvalvular Calcification: A Case Report.

Barlow's disease with mitral annular calcification encompassing the subvalvular apparatus, including the valve leaflet and chordae, is extremely rare, and mitral valve repair in such cases is challenging. We report a case of a 60-year-old woman with mitral valve regurgitation that was successfully controlled by resecting the rough zone of P2 and calcifications on the excess leaflet regions and subvalvular apparatus, while retaining the calcification of P3 and implanting artificial chordae and an annuloplasty ring. Mitral valve repair for such cases requires an individualized and compounded surgical strategy for the technique to treat Barlow's disease and manage calcification to control mitral regurgitation.

Mitral valve repair using the daVinci surgical system after MitraClip failure.

Reports of mitral valve replacement after MitraClip removal have increased; however, surgical re-intervention is risky due to patients' frailty and comorbidities. We report a case of mitral valve repair after MitraClip failure using the daVinci surgical system for a 55-year-old man with many comorbidities and two previous cardiac surgeries. The daVinci surgical system allows detailed handling with high-resolution visualization and endowrist instruments that provide surgeons with clear three-dimensional images and stabilized handling. This procedure enables us to remove the MitraClip precisely while preserving the mitral valve leaflet.

[Successful Surgical Management for Ischemic Heart Failure with Fractional Flow Reserve Derived from Computed Tomography:Report of a Case].

A 71-year-old woman was referred to our hospital for mitral valve repair and coronary artery bypass grafting (CABG). Conventional coronary artery angiography showed stenosis in the right coronary artery (RCA) and two diagonal branches, whereas transthoracic echocardiography (TTE) showed diffuse hypokinesis and mild-to-moderate mitral valve regurgitation. Fractional flow reserve derived from computed tomography (FFRct) demonstrated two additional lesions in the coronary artery at the left anterior descending artery (LAD) and the high lateral (HL) branch. Thus, we decided to perform CABG to RCA, LAD, the second diagonal branch, and HL as well as mitral valve repair. TTE one year after surgery showed trivial mitral regurgitation and progressive improvements in the left ventricular wall motion and the ejection fraction. FFRct is a usuful non-invasive method to identify coronary lesions that cause ischemia.

Use of the Konno procedure in an 80-year-old woman with aortic stenosis, a narrow left ventricular outflow tract, and a small aortic annulus.

This report describes a technique for repairing an aortic stenosis in an elderly patient with a small aortic annulus and a narrow left ventricular outflow tract. Preoperative echocardiography in an 80-year-old woman showed severe aortic stenosis with a narrow outflow tract: the aortic valve area was 0.48 cm(2), the aortic annular diameter was 14 mm, and the left ventricular outflow tract diameter was 14 mm. The Konno procedure was used to enlarge both the small aortic annulus and the left ventricular outflow tract, and a 19-mm Carpentier-Edwards bioprosthetic valve was implanted. The patient's postoperative course was uneventful. The left ventricular mass decreased from a preoperative value of 236 g to 96 g, 3 years after surgery. Only a few reports have described the use of the Konno operation in adult patients. In the present case, the Konno operation was demonstrated to be a good option for aortic stenosis accompanied by a small aortic annulus and a narrow left ventricular outflow tract, even in an elderly patient.

Heart failure induced by the restrictive left ventricle due to hiatus hernia.

A 76-year-old woman presented with shortness of breath and dyspnea after the intake of meals. Chest X-ray showed pulmonary congestion and pleural effusion. Computed tomography disclosed a hiatus hernia. Echocardiography demonstrated that the motion of the posterior wall in the left ventricle (LV) was paradoxically by the hiatus hernia, although LV ejection fraction was preserved. The restriction of LV by hiatus hernia could cause heart failure and open surgical repair of the hiatus hernia was performed. Dyspnea after the intake of meals disappeared and no recurrence of heart failure was observed in the subsequent period of several years.

The value of angiogenic therapy with intramyocardial administration of basic fibroblast growth factor to treat severe coronary artery disease.

BACKGROUND: Basic fibroblast growth factor (bFGF) was administered intramyocardially together with CABG to induce myocardial neovascularizaton and collateral growth in patients with ungraftable coronary arteries. Coronary angiographic and myocardial scintigraphic findings revealed that the effects of CABG were potentially confounding. METHODS AND RESULTS: Patients in the bFGF group (n = 16) underwent angiogenic therapy using bFGF for ungraftable territory, and incomplete revascularization (IR) patients (n = 22) underwent only CABG. The magnitude of collateral development was assessed by the Rentrop score and collateral connection (CC) grade. Rentrop scores tended to increase among patients in the bFGF group (before vs. after surgery, 1.9 ± 1.2 vs. 2.3 ± 1.2, p = 0.05), but not in the IR group. The CC grade significantly increased among patients in the bFGF group (before vs. after surgery, 1.0 ± 0.9 vs. 1.4 ± 0.5, p <0.05), but not in the IR group. Myocardial perfusion in territories injected with bFGF improved in 13 patients (81%) of the bFGF group, and also in the nonbypassed territory in 4 IR patients (25%) (p <0.05). CONCLUSION: Angiogenic therapy with bFGF induced collateral development and improved myocardial perfusion in territories injected with bFGF.

Therapeutic angiogenesis with autologous hepatic tissue implantation and omental wrapping.

BACKGROUND: The liver produces various angiogenic and cytoprotective growth factors and the omentum has potent angiogenic properties that promote wound healing. The ability of hepatic tissue implantation plus omental wrapping to induce angiogenesis and restore cardiac function was investigated in a rat model of infarction. METHODS AND RESULTS: Myocardial infarction was induced in rats using coronary artery ligation. The omentum was wrapped (omentopexy group), hepatic tissue implantation was combined with omental wrapping (hepatic tissue implantation (H) group) or no other treatment was applied (control (C) group), and then ventricular function was evaluated by echocardiography 4 weeks later. Infarct size, ventricular remodeling, vascular density and collagen density were morphometrically and histologically evaluated. The expression of angiogenic growth factors in implanted tissues was examined using RT-PCR. The H group had thicker (p<0.05) and less expanded infarcts (p<0.001), as well as higher capillary (p<0.01) and arteriolar (p<0.05) density in the infarct border zone, than the C group. Hepatocyte growth factor was obviously expressed and the expression of both basic fibroblast growth factor and vascular endothelial growth factor was increased in the H group. CONCLUSIONS: Hepatic tissue implantation combined with omental wrapping stimulated angiogenesis, attenuated left ventricular remodeling and improved cardiac function.

Giant yolk sac tumor operated under percutaneous cardiopulmonary support (PCPS) and aspiration device.

We here report the case of an 18-year-old man with a giant yolk sac tumor that is resected under percutaneous cardiopulmonary support (PCPS). Because this patient had severe dyspea when he lay in a supine position, we resected the tumor. We used PCPS during the operation for the induction and maintenance of ventilation because his trachea and left main bronchus were collapsed by the tumor. Also, we used a vacuum aspiration device that is commonly used for facilitating difficult vaginal deliveries. We propose that several devices, such as a PCPS and vacuum aspiration device, are useful for the operation of a mediastinal tumor with dyspnea.

Protein kinase A-regulated nucleocytoplasmic shuttling of Id1 during angiogenesis.

Id1, an inhibitory partner of basic-helix-loop-helix transcriptional factors, has recently been recognized as a potent contributor to angiogenesis. However, the molecular mechanism underlying its role in angiogenesis remains essentially unknown. Herein we demonstrate the subcellular localization of Id1 to be altered depending on the cellular context of vascular endothelial cells. Id1 was localized in the nuclei of human umbilical vein endothelial cells (HUVECs) cultured on uncoated plates, whereas it was translocated to the cytoplasm in HUVECs on Matrigel along with the formation of capillary-like structures. Treatment with the nuclear export inhibitor leptomycin B and mutagenesis analysis using green fluorescent protein-fused Id1 revealed CRM1/exportin-dependent nuclear export of Id1 in HUVECs on Matrigel. This nuclear export of Id1 was inhibited by protein kinase A (PKA) activation by dibutyryl cyclic AMP and forskolin but was promoted by PKA inactivation by H-89 and MDL-12,330A. Mutagenesis analysis of Id1 showed the phosphorylation of Ser-5 to possibly mediate the effect of PKA. These results suggest the function of Id1 as a transcriptional factor to be controlled by nucleocytoplasmic shuttling during angiogenesis and that PKA might be involved in this process. This may serve as a novel mechanism regulating angiogenesis and as a possible target for therapeutic vascular regeneration.

Effects of intramyocardial administration of slow-release basic fibroblast growth factor on angiogenesis and ventricular remodeling in a rat infarct model.

BACKGROUND: Basic fibroblast growth factor (bFGF) stimulates neoangiogenesis. Incorporation into biodegradable gelatin hydrogels provides the sustained release of bFGF. The effects of intramyocardial injections of slow-release bFGF on neoangiogenesis in a rat model of infarction were investigated. METHODS AND RESULTS: Myocardial infarction was induced in rats using coronary artery ligation. A total of 124 rats received an intramyocardial injection of 20 microg of bFGF, the same amount of bFGF incorporated into gelatin hydrogel (bFGF + gel), gelatin hydrogel (gel) or saline. Ventricular function was evaluated by echocardiography 2 or 4 weeks later. Morphometric and histological analyses were used to evaluate infarct size, vascular density and myocardial apoptosis. Capillary density in the infarct border zone was higher in the bFGF and bFGF + gel groups than in the saline and gel groups at 4 weeks (p<0.001). Arteriolar density was higher in the bFGF + gel group than in the other 3 groups (p<0.05). The bFGF and bFGF + gel groups contained fewer apoptotic cardiomyocytes in the border zone than the saline and gel groups (p<0.01). The bFGF+gel group had thicker (p<0.05) and less expanded infarcts (p<0.01) compared with the saline group at 4 weeks. CONCLUSIONS: Incorporation of bFGF in gelatin hydrogels enhanced the effects of bFGF on arteriogenesis, ventricular remodeling and cardiac function.

Id1 gene transfer confers angiogenic property on fully differentiated endothelial cells and contributes to therapeutic angiogenesis.

BACKGROUND: Transplantation of endothelial progenitor cells has been proposed as a potential strategy for therapeutic revascularization. However, the limited endogenous cell pool and the related technical difficulties constitute clinically important disadvantages to autologous transplantation. In this study we investigated whether fully differentiated endothelial cells (ECs) modified with gene transfer of Id1, a helix-loop-helix transcription factor involved in angiogenesis, have the potential to contribute to therapeutic angiogenesis. METHODS AND RESULTS: The Id1 gene was transferred into human umbilical vein ECs (HUVECs) via a Sendai virus vector. Id1 stimulated migration, proliferation, and capillary-like tube/cord formation of HUVECs. In addition, Id1 reduced serum deprivation-induced HUVEC apoptosis, as shown by FACS analysis with annexin V and TUNEL staining. Transplantation of Id1-overexpressing HUVECs accelerated recovery of blood flow as evaluated by laser-Doppler perfusion imaging, increased capillary density, and improved the rate of limb salvage compared with the transplantation of control HUVECs. Histochemical analysis revealed that the regenerated vascular networks of limbs transplanted with Id1-overexpressing HUVECs contained numerous HUVECs, some of which were in a proliferative state. Untransfected HUVECs were also incorporated with Id1-transfected HUVECs, suggesting the noncell autonomous effect of Id1. Finally, angiopoietin-1 was upregulated in Id1-overexpressing HUVECs and functionally contributed to the in vitro angiogenic effect of Id1. CONCLUSIONS: Id1 gene transfer conferred HUVECs with an angiogenic property, contributing to neovascularization after transplantation into ischemic lesions. Transplantation of Id1-overexpressing mature ECs may serve as a novel and useful strategy for therapeutic angiogenesis.

Predictive factors for platelet number after cardiopulmonary bypass and postoperative blood loss.

We retrospectively searched for factors that can predict the circulating platelet count after cardiopulmonary bypass (CPB) and postoperative blood loss. Correlations between the circulating platelet count after CPB and several other perioperative variables were investigated in 42 patients who underwent cardiac surgery using the same type of oxygenator. Correlations between perioperative variables and 24 hour postoperative blood loss were also investigated. A multiple stepwise regression analysis showed that the preoperative platelet count, age, and intraoperative blood transfusion values were independent predictors of the circulating platelet count after CPB (R2 = 0.661, p < 0.0001). Gender, operation type, and priority (elective or urgent) were not associated with the platelet count after CPB or postoperative blood loss. Independent predictive factors for postoperative blood loss consisted of age and intraoperative blood loss (R2 = 0.231, p = 0.006). In addition to preoperative platelet count, age and amount of intraoperative blood transfusion are predictive factors for circulating platelet count after CPB. The association of postoperative blood loss with age and intraoperative blood loss may suggest friability of the tissues, including blood vessels, in elderly patients.