Jae-Woong Choi

Early clinical outcomes of robot-assisted surgery for anterior mediastinal mass: its superiority over a conventional sternotomy approach evaluated by propensity score matching

OBJECTIVESnWe performed this study to assess early clinical outcomes of robot-assisted surgery for anterior mediastinal mass by comparing results of the robot group with those of the sternotomy group after propensity score matching.nnnMETHODSnBetween 2008 and 2012, 145 patients underwent resection of anterior mediastinal mass. Robot-assisted surgery was performed in 37 patients, and conventional surgery by sternotomy in 108 patients. Propensity score matching was done between two groups with variables of age, sex, size of the mass, myasthenia gravis, resection of other organ and pathological diagnosis. Thirty-four patients from the robot group and 34 from the open group were matched, fitting the model. The clinical outcomes of matched groups were compared.nnnRESULTSnIn the robot group, mediastinal cyst consisted of 47.1% (16 of 34), thymoma 32.4% (11 of 34), thymic carcinoma 8.8% (3 of 34), thymic hyperplasia 8.8% (3 of 34) and liposarcoma 2.9% (1 of 34). The mean duration of follow-up was 1.11 ± 0.21 and 1.85 ± 0.19 years for the robot and open groups, respectively. There were no mortality or recurrence in both groups during the follow-up. There were no significant differences in operation time, postoperative white blood cell and C-reactive protein increase, maximum visual analogue scale score for pain as well as postoperative intensive care unit care between the two groups. The robot group revealed a lesser number of drains (1.09 ± 0.1 vs 1.41 ± 0.1) and 24-h tube drainage (189.4 ± 20.5 vs 397.6 ± 52.6 ml), lower haemoglobin loss (0.54 ± 0.4 vs 1.35 ± 0.1 g/dl) and haematocrit decrease (1.92 ± 0.5 vs 3.85 ± 0.4%), shorter chest tube days (1.53 ± 0.2 vs 3.06 ± 0.2) and length of hospital stay (2.65 ± 0.2 vs 5.53 ± 0.8) after operation, which were all statistically significant. Although statistically insignificant, there were no postoperative complications in the robot group, but there were 5 (14.7%) in the open group (P = 0.063).nnnCONCLUSIONSnIn carefully selected patients with relatively smaller sized masses, robot-assisted surgery resulted in excellent early clinical outcomes with lesser tube drainage, lower blood loss, shorter tube days and length of hospital stay without any postoperative complications, compared with the matched open group. Further investigation for long-term clinical outcomes and oncological outcomes is required for a robotic approach. Particularly, long-term follow-up for the local recurrence rate according to the pathological diagnoses is required.

Paravalvular Leak After Mitral Valve Replacement: 20-Year Follow-Up.

BACKGROUNDnWe evaluated the incidence of paravalvular leak (PVL) after mitral valve replacement (MVR) and analyzed factors associated with early and late PVL during more than 20 years of follow-up.nnnMETHODSnWe studied 1,202 patients (50.4 ± 12.2 years; male/female, 456:746) who underwent MVR between 1992 and 2008. Follow-up duration was 134 months (range, 1 to 272 months). Incidence of early and late PVL was evaluated. The PVL was regarded as major if it caused hemolysis requiring multiple transfusions or regurgitant jet inducing heart failure symptoms.nnnRESULTSnIn-hospital mortality rate was 4.5%. Early mitral PVL was found in 23 patients (1.9%), including 7 patients with major PVL. Late mitral PVL without obvious infection occurred in 75 patients (major PVL in 55 patients). Median interval between the index operation and major PVL was 136 months (range, 6 to 250 months). Among 55 patients with major PVL, 50 patients underwent reoperations and 5 patients were treated medically. Ten- and 20-year late mitral PVL-free rates were 96.2% and 86.9%, respectively. Ten- and 20-year major mitral PVL-free rates were 98.0% and 89.3%, respectively. Cox proportional hazard analysis revealed that age (hazard ratio, 1.052; 95% confidence interval, 1.024 to 1.079), male sex (hazard ratio, 2.804; 95% confidence interval, 1.629 to 4.828), and redo MVR (hazard ratio, 5.193; 95% confidence interval, 2.930 to 9.112) were associated with major mitral PVL during the follow-up.nnnCONCLUSIONSnMajor PVL without obvious infection occurs even 20 years after MVR with 10- and 20-year major PVL-free rates of 96.2% and 86.9%, respectively. Occurrence of major PVL after MVR is more frequent in elderly, male patients and those who undergo redo MVR.

Histologic Characteristics and Mechanical Properties of Bovine Pericardium Treated with Decellularization and α-Galactosidase: A Comparative Study.

Background Bioprostheses for cardiovascular surgery have limitations in their use following as calicification. α-galactosidase epitope is known as a stimulant of immune response and then shows a progressing calcification. The objective of this study was to evaluate histologic characteristics and mechanical properties of decellularization and treated with α-galactosidase. Materials and Methods Bovine pericardial tissues were allocated into three groups: fixation only with glutaraldehyde, decellularization with sodium dodesyl sulfate and decellularization plus treatment with α-galactosidase. We confirmed immunohistological characteristics and mechanical properties as fatigue test, permeability test, compliance test, tensile strength (strain) test and thermal stability test. Results Decellularization and elimination of α-gal were confirmed through immunohistologic findings. Decellularization had decreased mechanical properties compared to fixation only group in permeability (before fatigue test p=0.02, after fatigue test p=0.034), compliance (after fatigue test p=0.041), and tensile strength test (p=0.00). The group of decellularization plus treatment with α-galactosidase had less desirable mechanical properties than the group of decellularization in concerns of permeability (before fatigue test p=0.043) and strain test (p=0.001). Conclusion Favorable decellularization and elimination of α-gal were obtained in this study through immunohistologic findings. However, those treatment including decellularization and elimination of α-gal implied the decreased mechanical properties in specific ways. We need more study to complete appropriate ioprosthesis with decellularization and elimination of α-gal including favorable mechanical properties too.

Changes in Right Ventricular Volume and Function After Tricuspid Valve Surgery – Tricuspid Annuloplasty vs. Tricuspid Valve Replacement –

BACKGROUNDnThere is a concern that clinical outcome of tricuspid valve replacement (TVR) is inferior compared with tricuspid annuloplasty (TAP). The aim of this study was therefore to compare changes in right ventricular (RV) volume and function following TAP with that following TVR on cardiac magnetic resonance imaging (CMR) in patients with severe functional tricuspid regurgitation (TR).nnnMETHODSANDRESULTSnForty patients who underwent surgery for severe functional TR and who underwent CMR preoperatively and on postoperative follow-up (24.8±13.3 months after surgery) were enrolled. Thirteen patients underwent TAP (TAP group) and 27 patients underwent TVR (TVR group). Both RV end-diastolic and end-systolic volume indices decreased significantly after surgery (from 178.9±53.9 to 116.3±26.7 ml/m(2), P<0.001, and from 95.7±36.1 to 67.3±28.0 ml/m(2), P<0.001, respectively), without intergroup differences. In the TAP group, RV ejection fraction (EF) was preserved following surgery (from 43.3±9.5 to 46.9±10.9%, P=0.312). In the TVR group, however, it decreased significantly following surgery (from 51.8±9.2 to 42.4±12.3%, P<0.001). In addition, postoperative RVEF was lower in the TVR than TAP group, with a marginal significance (mean difference, -6.967; 95% confidence interval: -14.529 to 0.595; P=0.070).nnnCONCLUSIONSnFor patients with severe functional TR, both TAP and TVR are beneficial for reduction of RV volume indices. TAP, however, might be superior to TVR, because RVEF is well preserved following surgery. (Circ J 2016; 80: 1142-1147).

Randomized trial comparing the efficacy between different types of paclitaxel-eluting stents: The comparison of Efficacy between COroflex PLEASe ANd Taxus stent (ECO-PLEASANT) randomized controlled trial

AIMSnPaclitaxel-eluting stents (PESs) have been shown to inhibit neointimal hyperplasia after percutaneous coronary intervention. Coroflex Please (B Braun, Melsungen, Germany) is a newly developed PES. We compared the clinical and angiographic efficacy of Coroflex Please with Taxus Liberte (Boston Scientific, Natick, MA) in a real-world practice.nnnMETHODS AND RESULTSnWe performed a prospective, open-label, randomized, controlled study that enrolled 945 patients undergoing percutaneous coronary interventions in 18 centers in Korea. The primary end point was clinically driven target vessel revascularization at 9 months. The baseline characteristics were mostly similar and comparable between 2 groups. At 9 months, the incidence of clinically driven target vessel revascularization was 14.6% for Coroflex and 6.4% for Taxus, which was significantly different (hazard ratio 2.43, 95% CI 1.50-3.94, noninferiority P value = 1.000). This is well corroborated by the difference of in-stent late loss between 2 stents (0.71 ± 0.64 mm vs 0.52 ± 0.50 mm, P < .001) by 9-month follow-up angiography (n = 415 vs 215). Among secondary clinical end points, stent thrombosis (definite and probable) for 1 year was 2.2% in Coroflex and 1.3% in Taxus (P = .317). Also, myocardial infarction for 9 months was higher in Coroflex group than that in Taxus (4.9% vs 1.6%, P = .012), which was partly contributed by the higher incidence of periprocedural myocardial infarction in Coroflex arm (2.2% vs 0.3%, P = .028).nnnCONCLUSIONSnCoroflex Please was inferior to Taxus Liberte with regard to clinical and angiographic efficacy.

Twenty-Year Experience of Heart Transplantation: Early and Long-Term Results.

Background We evaluated early and long-term results after heart transplantation (HTPL). Methods One hundred five consecutive patients (male:female=80:25) who underwent HTPL between 1994 and 2013 were enrolled. Based on the changes in immunosuppressive regimen, the study patients were divided into two groups. Early and long-term clinical outcomes were evaluated and compared between the patients who underwent HTPL before (group E, n=41) and after July 2009 (group L, n=64). The group L patients were older (p<0.001), had higher incidence of hypertension (p=0.001) and chronic kidney disease (p<0.001), and more frequently needed preoperative mechanical ventilation (p=0.027) and mechanical circulatory support (p=0.014) than the group E patients. Results Overall operative mortality was 3.8%, and postoperative morbidities included acute kidney injury (n=31), respiratory complications (n=16), reoperation for bleeding (n=15) and wound complications (n=10). There were no significant differences in early results except acute kidney injury between group E and group L patients. Overall survival rates at 1, 5, and 10 years were 83.8%, 67.7%, and 54.9%, respectively, with no significant difference between the two patient groups. Rejection-free rates at 1 and 5 years were 63.0% and 59.7%, respectively; rates were significantly higher in group L than in group E (p<0.001). Conclusion Despite increased preoperative comorbidities, group L patients showed similar early and long-term outcomes and significantly higher rejection-free rates when compared with group E patients.

Clinical Implication of Aortic Wall Biopsy in Aortic Valve Disease with Bicuspid Valve Pathology

Background Although unique aortic pathology related to bicuspid aortic valve (BAV) has been previously reported, clinical implications of BAV to aortopathy risk have yet to be investigated. We looked for potential differences in matrix protein expressions in the aortic wall in BAV patients. Methods Aorta specimens were obtained from 31 patients: BAV group (n=27), tricuspid aortic valve (TAV) group (n=4). The BAV group was categorized into three subgroups: left coronary sinus-right coronary sinus (R+L group; n=13, 42%), right coronary sinus-non-coronary sinus (R+N group; n=8, 26%), and anteroposterior (AP group; n=6, 19%). We analyzed the expression of endothelial nitric oxide synthase (eNOS), matrix metalloproteinase (MMP)-9, and tissue inhibitor of matrix metalloproteinase (TIMP)-2. Results Based on the mean value of the control group, BAV group showed decreased expression of eNOS in 72.7% of patients, increased MMP-9 in 82.3%, and decreased TIMP in 79.2%. There was a higher tendency for aortopathy in the BAV group: eNOS (BAV:TAV)= 53%±7%:57%±11%, MMP-9 (BAV:TAV)=48%±10%:38%±1%. The AP group showed lower expression of eNOS than the fusion (R+L, R+N) group did; 48%±5% vs. 55%±7% (p=0.081). Conclusion Not all patients with BAV had expression of aortopathy; however, for patients who had a suspicious form of bicuspid valve, aortic wall biopsy could be valuable to signify the presence of aortopathy.

Concomitant off-pump coronary artery bypass and non-cardiovascular surgery.

BACKGROUNDnReports on concomitant cardiac and non-cardiovascular surgeries have noted disadvantages in the use of extracorporeal circulation. We assessed the results of concomitant off-pump coronary artery bypass (OPCAB) and non-cardiovascular surgery, and compared them with isolated OPCAB results.nnnMETHODSnOf 2,439 patients who underwent OPCAB between 1999 and 2014, 115 patients underwent concomitant OPCAB and non-cardiovascular surgery. Combined non-cardiovascular diseases included 63 malignant and 52 benign diseases. Concomitant non-cardiovascular surgeries performed were general (n=62), thoracic (n=47), orthopedic (n=3), urologic (n=2) and otolaryngologic surgeries (n=1). Operative results were compared between the OPCAB patients who underwent concomitant non-cardiovascular surgeries (group 1, n=115) and isolated OPCAB patients (group 2, n=2,251). Because preoperative characteristics of the two groups were different, a 1:2 propensity score-matched analysis was performed and operative results of the two matched groups were compared.nnnRESULTSnOperative mortality rates were 0.9% (1/115) in group 1 and 1.0% (22/2,251) in group 2 (P=0.909). Although there were differences in preoperative patient characteristics, postoperative complications, including atrial fibrillation (36.5% vs. 28.8%), perioperative myocardial infarction (MI) (4.3% vs. 5.2%), acute renal failure (1.7% vs. 4.9%), mediastinitis (0.9% vs. 0.8%), bleeding reoperation (0.9% vs. 2.9%), and respiratory complications (2.6% vs. 2.1%), did not show significant differences between the two groups. After a 1:2 propensity score-matched analysis, there were no statistical differences in operative complications between the two groups.nnnCONCLUSIONSnConcomitant OPCAB and non-cardiovascular surgeries were not associated with increased mortality and postoperative morbidities when compared with isolated OPCAB.

Extra-Anatomic Ascending Aorta to Abdominal Aorta Bypass in Takayasu Arteritis Patients with Mid-Aortic Syndrome

Background We evaluated the operative outcomes of an extra-anatomic bypass from the ascending aorta to the abdominal aorta in patients with type II or III Takayasu arteritis (TA) with mid-aortic syndrome. Methods From 1988 to 2014, 8 patients with type II (n=2) or III (n=6) TA underwent an ascending aorta to abdominal aorta bypass. The mean patient age was 43.5±12.2 years and the mean peak pressure gradient between the upper and lower extremities was 54.8±39.0 mm Hg. The median follow-up duration was 54.4 months (range, 17.8 to 177.4 months). Results There were no cases of operative mortality. The mean peak pressure gradient significantly decreased to −2.4±32.3 mm Hg (p=0.017 compared to the preoperative value). Late death occurred in 2 patients. The symptoms of upper extremity hypertension and claudication improved in all patients. The bypass grafts were patent at 47.1±58.9 months in 7 patients who underwent follow-up imaging studies. Conclusion An extra-anatomic ascending aorta to abdominal aorta bypass could be an effective treatment option for severe aortic steno-occlusive disease in patients with type II or III TA, with favorable early and long-term outcomes.