Naoto Fukunaga

Late Results of Mitral Valve Repair With Glutaraldehyde-Treated Autologous Pericardium

BACKGROUND Mitral valve repair is an established surgical procedure for treating severe organic mitral regurgitation. The mechanisms of mitral regurgitation due to infective endocarditis include rheumatic disease and congenital diseases such as a lack of leaflet tissue, and thus additional material is required to create a functional coaptation surface. We review our experience with 139 patients who underwent mitral valve repair with glutaraldehyde-treated autologous pericardium to treat organic mitral regurgitation between March 1992 and November 2011. METHODS Mitral valve disease mainly consisted of infective endocarditis in 51 patients (active, n = 32; healed, n = 19) and rheumatic disease in 47. This procedure was also applied to 12 patients who required reoperation after mitral valve repair for degenerative, congenital, or rheumatic mitral regurgitation. The mean follow-up was 4.5 ± 4.3 years (maximum 19.1). RESULTS Actuarial survival at 10 years was 84% ± 5%. Eleven reoperations proceeded at a mean of 68 months after surgery. The causes of reoperation were rheumatic disease progression (n = 4), infection (n = 3), patch dehiscence (n = 2), progressive fibrosis of the remaining mitral valve tissue after infective endocarditis (n = 1), and patch tear (n = 1). Mitral valves were replaced in 8 patients and re-repaired in 3 patients. The autologous pericardium was not calcified at the time of reoperation. The rate of freedom from reoperation was 82% ± 7% at 10 years. CONCLUSIONS Mitral valves that might otherwise require replacement can be durably and predictably repaired using glutaraldehyde-treated autologous pericardium.

Clinical Outcomes of Redo Valvular Operations: A 20-Year Experience

BACKGROUND A higher operative mortality rate has been reported after redo valvular procedures than after the primary operation. METHODS Outcomes of 330 consecutive patients undergoing 433 redo valvular operations at our institute during a 20-year period (January 1990 to December 2010) were reviewed retrospectively. The mean follow-up was 6.4 years (range, 0.05 to 1.3 years). Logistic regression analysis was used to identify factors associated with hospital death. RESULTS The overall hospital mortality rate was 6.7% (29 of 433 procedures). Logistic regression analysis identified only advanced New York Heart Association (NYHA) class as an independent predictor of hospital death. Overall survival at 5, 10, and 15 years was 83.6%±2.2%, 70.7%±3.4%, and 61.5%±4.5%, respectively. The 5-, 10-, and 15-year survivals for the first redo vs more than second redo groups were 86.5%±2.4% vs 74.7%±5.5%, 71.8%±3.9% vs 66.8%±6.6%, and 60.2%±5.7% vs 63.1%±7.2%, respectively (log-rank P=0.505). The 5- and 10-year survivals for NYHA class I/II vs III/IV patients were 91.5%±2.1% vs 70.4%±4.5% and 77.8%±4.1% vs 58.5%±5.6%, respectively (log-rank p<0.005). CONCLUSIONS Redo valvular operation in NYHA class III/IV patients is associated with high hospital death and poor long-term survival. To achieve low hospital death and good long-term survival, redo operations, including more than third redo operations, should be performed in patients with lower NYHA class.

Successful Treatment for Infected Aortic Aneurysm Using Endovascular Aneurysm Repairs as a Bridge to Delayed Open Surgery

Management of infected aortic aneurysms, which can be life-threatening, remains challenging. Open surgical treatments, including debridement of the infected aorta and the surrounding tissue and either in situ reconstruction or extra-anatomic bypass covering with omentum or muscle flap, are the mainstay of therapy. However, increasing advances in technology have made endovascular treatment of infected aneurysms feasible. The present study describes the first clinical report of successful treatment of an infected aneurysm using endovascular techniques in the acute phase, followed by delayed open surgery.

Mitral Valve Stenosis Progression Due to Severe Calcification on Glutaraldehyde-Treated Autologous Pericardium: Word of Caution for an Attractive Repair Technique

A 42-year-old woman presented with a 6-month history of palpitations and progressive dyspnea on exertion. She had undergone aortic and mitral valve repair using glutaraldehyde-treated autologous pericardium for active infective endocarditis 5 years prior. Transthoracic echocardiography showed mitral valve stenosis with limited movement of the anterior leaflet. At redo surgery, severe calcification of the glutaraldehyde-treated pericardial patch on the anterior mitral leaflet was observed. Double valve replacement was performed with pulmonary vein isolation. Pathologic examination showed calcification of the glutaraldehyde-treated autologous pericardium. The patient was discharged on postoperative day 11 with oral anticoagulant therapy.

Late outcome of tricuspid annuloplasty using a flexible band/ring for functional tricuspid regurgitation.

BACKGROUND We assessed late outcome after tricuspid annuloplasty (TAP) using a flexible band or ring for functional tricuspid regurgitation (FTR). METHODS AND RESULTS We reviewed 220 consecutive patients (mean age, 65.4±11.4 years) who underwent TAP for FTR during mitral valve surgery between January 2000 and December 2010. Indications for TAP included the following: (1) TR grade greater than mild; (2) history of right heart failure; (3) atrial fibrillation; and (4) systolic pulmonary artery pressure (SPAP) ≥50 mmHg. The mean follow-up period was 4.4±2.6 years. Overall hospital mortality was 5.5% (12/220). The 5- and 10-year survival rates were 90.2±2.1% and 82.4±5.6%, respectively. Freedom from recurrent TR at 8 years was 78.0±6.6%. Twenty patients had a greater than mild TR grade at final follow-up. Elevated SPAP was a predictor of recurrent TR (hazard ratio, 1.091; P=0.0003), which was associated with advanced age, atrial fibrillation, rheumatic etiology and preoperative TR grade. There was a significant difference in freedom from valve-related events between residual TR greater than mild and less than moderate (log-rank test, P=0.0464). Factors affecting residual TR were preoperative TR grade (OR, 7.368; P=0.0267) and mitral valve replacement (OR, 4.369; P=0.0402). CONCLUSIONS Late outcome of TAP in the present series was acceptable. Late outcome can be improved by performing TAP before deterioration of TR.

The Impact of Preoperative and Postoperative Pulmonary Hypertension on Long-Term Surgical Outcome after Mitral Valve Repair for Degenerative Mitral Regurgitation

PURPOSE The aim of this study is to elucidate the impact of preoperative and postoperative pulmonary hypertension (PH) on long-term clinical outcomes after mitral valve repair for degenerative mitral regurgitation. METHODS A total of 654 patients who underwent mitral valve repair for degenerative mitral regurgitation between 1991 and 2010 were retrospectively reviewed. Patients were divided into PH(+) group (137 patients) and PH(-) group (517 patients). Follow-up was complete in 99.0%. The median follow-up duration was 7.5 years. RESULTS Patients in PH(+) group were older, more symptomatic and had higher tricuspid regurgitation grade. Thirty-day mortality was not different between 2 groups (p = 0.975). Long-term survival rate was lower in PH(+) group; 10-year survival rate after the operation was 85.2% ± 4.0% in PH(+) group and 89.7% ± 1.8% in PH(-) group (Log-rank, p = 0.019). The incidence of late cardiac events were not different between groups, however, the recurrence of PH was more frequent in PH(+) group. The recurrence of PH had an adverse impact on survival rate, late cardiac events and symptoms. Univariate analysis showed age and preoperative tricuspid regurgitation grade were the predictors of PH recurrence. CONCLUSION Early surgical indication should be advocated for degenerative mitral regurgitation before the progression of pulmonary hypertension and tricuspid regurgitation.

Long-Term Outcomes of Tricuspid Annuloplasty for Functional Tricuspid Regurgitation Associated with Degenerative Mitral Regurgitation: Suture Annuloplasty Versus Ring Annuloplasty Using a Flexible Band

PURPOSE We investigated the long-term outcomes of suture/ring tricuspid valve annuloplasty for functional tricuspid regurgitation associated with degenerative mitral regurgitation. METHODS We retrospectively reviewed patients who underwent flexible ring tricuspid valve annuloplasty (n = 120) or suture tricuspid valve annuloplasty (n = 42) for functional tricuspid regurgitation concomitant with surgery for degenerative mitral regurgitation (mean follow-up duration, 5.3 ± 5.1 years). RESULTS The mean age of patients was 62.5 ± 13.1 years. Thirty-day mortality was zero in the suture group, and 0.8% in the ring group. Tricuspid regurgitation grade at discharge was lower in the ring group ( p = 0.002). No difference was observed between survival and freedom from major cardiac/cerebrovascular adverse events between the groups. However, freedom from ≥moderate tricuspid regurgitation was higher in the ring group (Log-rank p = 0.003). From univariate analysis, the risk factors for ≥moderate TR were suture annuloplasty and preoperative tricuspid regurgitation grade. No reoperation for recurrent tricuspid regurgitation occurred in either group because symptoms experienced by patients with recurrent tricuspid regurgitation were relatively insignificant. CONCLUSION Concomitant tricuspid annuloplasty using flexible bands offered improved durability than suture annuloplasty for preventing postoperative tricuspid regurgitation progression.

Impact of tricuspid regurgitation after redo valvular surgery on survival in patients with previous mitral valve replacement

OBJECTIVE The impact on survival of tricuspid regurgitation (TR) after redo valvular surgery in patients with previous mitral valve replacement (MVR) is unclear. METHODS We retrospectively analyzed 118 consecutive patients undergoing redo valvular surgery after MVR over a 20-year period. We determined the impact of TR after redo valvular surgery on survival and clinical factors that were associated with TR of 2+ or higher. The mean follow-up period was 7.1±6.5 years. RESULTS Overall hospital mortality was 8.5% (10 of 118). Logistic regression analysis revealed that cardiopulmonary bypass duration (odds ratio, 1.025; P=.0270) was an independent risk factor for hospital death. There were 25 late deaths. Survival after 5, 10, and 15 years was 77.5%±4.2%, 68.5%±5.1%, and 58.8%±6.3%, respectively. Multivariate Cox regression analysis showed that TR less than 2+ at discharge was a predictor of late survival (hazard ratio, 0.043; P<.0382), whereas age, female sex, left ventricular end-diastolic dimension, and cardiopulmonary bypass duration were predictors of late death. Survival for patients with TR less than 2+ versus 2+ or higher after redo surgery were 91.4%±3.4% versus 59.5%±11.9% at 5 years and 81.1%±5.3% versus 52.1%±12.5% at 10 years, respectively (log-rank P=.0285). Logistic regression analysis indicated that preoperative TR (odds ratio, 3.718; P=.0044) and chronic obstructive pulmonary disease (odds ratio, 28.576; P=.0154) were independent risk factors for TR of 2+ or higher after redo surgery. CONCLUSIONS Survival in patients with TR of 2+ or higher after redo valvular surgery was poor. The results of this study suggest that it is important to maintain a postoperative TR less than 2+ to improve long-term survival.

Midterm Outcomes of Chordal Cutting in Combination with Downsized Ring Annuloplasty for Ischemic Mitral Regurgitation

PURPOSE We describe midterm outcomes after division of secondary chords (chordal cutting) combined with downsized ring annuloplasty for ischemic mitral regurgitation (IMR). METHODS We compared the clinical outcomes in patients who underwent chordal cutting with downsized ring annuloplasty (CC-group, n = 15) and those who underwent conventional ring annuloplasty only (Conventional-group, n = 35) for IMR. Follow-up was complete in all patients. The median follow-up time was 4.1 years. RESULTS Thirty-day mortality was 0% in CC-group and 20% in Conventional-group. The overall survival rate at 5-year was 80.8% ± 12.6% in CC-group and 61.7% ± 8.4% in Conventional-group (Log-rank, p = 0.145). The freedom rate from valve-related events at 5 year was 84.6% ± 10.0% in CC-group and 65.3% ± 10.1% in Conventional-group (Log-rank, p = 0.213). Recurrence of severe mitral regurgitation was revealed in 3 patients of CC-group. Preoperative tenting height was the significant predictor of mitral regurgitation recurrence. In CC-group, the mean left ventricular ejection fraction was 38.0% ± 14.0%, which was similar to the preoperative value of 40.0% ± 13.2% (p = 0.349). CONCLUSIONS Chordal cutting with downsized ring annuloplasty for IMR is a simple method and provides satisfactory early outcomes. However, it carries with high recurrence of MR especially for patients with high tenting height.

Prolonged Antegrade Cerebral Perfusion via Right Axillary Artery (≥60 min) Does Not Affect Early Outcomes in a Repair of Type A Acute Aortic Dissection

PURPOSE We aim to investigate whether the duration of antegrade cerebral perfusion (ACP) via right axillary artery with an 8-mm prosthetic graft affects early outcomes in a repair of type A acute aortic dissection (AAD). METHODS Over the 24 months from April 2010, a repair of AAD under ACP via the right axillary artery and mild hypothermic circulatory arrest (rectum temperature, 28-30°C) was performed in 34 patients. Mean age was 64.5 ± 13.7 years of age.Preoperative shock status was in three due to cardiac tamponade. Organ malperfusion occurred in 11 patients preoperatively. Mean follow-up period was 9.6 ± 8.4 months and follow-up rate was 100%. RESULTS Hospital mortality rate was 8.8%. No newly required hemodialysis and new onset of temporary or permanent neurologic deficits were present in survivors.There were no statistically significant differences of mortality rate, new onset of permanent or temporary neurologic deficits and distal organ dysfunction between ACP duration <60 min and ≥60 min. The 12-month survival was 84.4% ± 6.4%. And, freedom from aorta-related events at 12 and 18 months were 100% ± 0.0% and 88.9% ± 10.5%, respectively. CONCLUSIONS The duration of ACP via right axillary artery does not affect early outcomes following a repair of AAD.