Nobuyuki Furukawa

Ministernotomy versus conventional sternotomy for aortic valve replacement: matched propensity score analysis of 808 patients

OBJECTIVES The proportion of minimally invasive approaches is rising in cardiac surgery, in part driven by increasing patient demand. This study aimed to perform a risk-adjusted comparison of mortality, rate of stroke and perioperative morbidity of aortic valve replacement (AVR) conducted through either partial mini-sternotomy or conventional sternotomy. METHODS Between July 2009 and July 2012, data from 984 consecutive patients undergoing isolated AVR were prospectively recorded. In 44.3% (n = 436), the less invasive partial mini-sternotomy was used. Propensity score matching was performed based on 15 preoperative risk factors to correct for selection bias. In-hospital mortality, stroke rate as well as other major complications in the minimally invasive group and conventional sternotomy group were compared in 404 matched patient pairs (total 808). RESULTS In-hospital mortality and rate of postoperative intra-aortic balloon pump use were identical for propensity-matched patients, 1.0% (4 in each group). The rate of stroke [OR (95% confidence interval (CI)): 0.80 (0.22-2.98)], perioperative myocardial infarction [OR (95% CI): 2.00 (0.18-22.06)], low-output syndrome [OR (95% CI): 0.90 (0.37-2.22)], new onset of dialysis [OR (95% CI): 1.25 (0.49-3.17)] and re-exploration for bleeding [OR (95% CI): 0.88 (0.50-1.56)] were similar. Likewise, resource utilization (operation time, duration of stay in the intensive care unit and in-hospital stay) and valve selection (type and size) was not affected by the surgical approach either. CONCLUSIONS AVR can be safely conducted through a partial mini-sternotomy. This approach is not associated with an increased rate of complications. However, wide CIs reflect the still prevailing statistical uncertainty in estimates, not excluding patient-relevant differences between approaches. Large trials, which also address end points, such as postoperative pain, duration of postoperative recovery and quality of life, are needed to clarify the role of minimally invasive AVR.

A silent gigantic solitary fibrous tumor of the pleura: case report

Solitary fibrous tumor of the pleura is a rare mesenchymal tumor, representing less than 5% of all neoplasms associated with the pleura. A 57-year-old man had general malaise without chest symptoms for 1 month. A chest roentgenogram and computed tomography showed a giant mass in the left thorax. Although the tumor compressed the descending aorta and other mediastinal structures strongly, thereby shifting them to the right side, the patient had no symptoms except malaise. The tumor was successfully resected via two separate thoracotomies. The tumor was measured (20 cm × 19 cm × 15 cm) and weighed (2150 g). The tumor was histologically and immunohistochemically diagnosed as benign. Although SFT is benign, a long follow-up period is essential as even patients with complete resection are at risk of recurrence many years after surgery.

Complete resection of undifferentiated cardiac sarcoma and reconstruction of the atria and the superior vena cava: case report

Primary cardiac tumors are rare with an incidence ranging from 0.001% to 0.03% in autopsy series. The prognosis of cardiac sarcomas remains poor because it proliferates rapidly and distant metastases are often found at diagnosis. A 47-year-old male complained of persistent cough. The chest roentgenogram was normal. Subsequent computed tomography revealed a mass in the right atrium. Echocardiography and magnetic resonance imaging confirmed also a right atrial mass (34 x 35 mm) infiltrating the atrial septum. The tumor was completely resected en bloc, including the anterior and lateral right atrial walls, the left atrial dome, and a large segment of the superior vena cava, and reconstructed the atria and superior vena cava with bovine pericardium. The tumor was histologically and immunohistochemically diagnosed as undifferentiated pleomorphic sarcoma. This type of cardiac sarcoma is very rare and usually found in the left atrium. Twenty-seven months after surgery, the patient is doing well without metastasis or local tumor recurrence.

Minimally invasive versus transapical versus transfemoral aortic valve implantation: A one-to-one-to-one propensity score–matched analysis

Objectives Although transcatheter aortic valve implantation was the treatment of choice in inoperable and high‐risk patients, the effect of transcatheter aortic valve implantation relative to conventional aortic valve replacement via ministernotomy in patients with moderate surgical risk remains unclear. Methods We consecutively enrolled patients who underwent minimally invasive aortic valve replacements via ministernotomy (n = 1929), transapical (n = 607), and transfemoral (n = 1273) aortic valve implantations from a single center during the period from July 2009 to July 2017. Of those, we conducted a 1:1:1 propensity score matching according to 23 preoperative risk factors. Results We were able to find 177 triplets (n = 531). The median European System for Cardiac Operative Risk Evaluation II was 3.0% versus 3.4% versus 2.9%, and Society of Thoracic Surgeons Predicted Risk of Mortality was 3.2% versus 3.6% versus 3.4%, respectively. According to the Valve Academic Research Consortium 2 criteria, there were no significant periprocedural differences regarding 30‐day mortality (2.3% minimally invasive aortic valve replacement vs 4.5% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .34), stroke (1.1% minimally invasive aortic valve replacement vs 0.6% transapical transcatheter aortic valve implantation vs 1.7% transfemoral transcatheter aortic valve implantation, P = .84), or myocardial infarction (0.6% minimally invasive aortic valve replacement vs 0.0% transapical transcatheter aortic valve implantation vs 0.0% transfemoral transcatheter aortic valve implantation, P = .83). Both intensive care and hospitalization times were significantly longer in the transapical group. Regarding midterm survival, transapical transcatheter aortic valve implantation was associated with a tendency toward a less favorable outcome (hazard ratio, 1.48; 95% confidence interval, 0.95‐2.31; P = .17) compared with minimally invasive aortic valve replacement. Conclusions In this real‐world propensity score–matched minimally invasive aortic valve replacement, transapical transcatheter aortic valve implantation, transfemoral transcatheter aortic valve implantation cohort of intermediate‐risk patients, early mortality was not significantly different, whereas the rates of periprocedural complications were different depending on the approach. During follow‐up, there was a tendency in the transapical transcatheter aortic valve implantation group toward a less favorable survival outcome, although there was no significant difference among the 3 groups.

Mitral Regurgitation Caused by an Isolated Mitral Leaflet Cleft

An isolated cleft of the mitral valve leaflet is rare cause of mitral regurgitation in adults. We report a successful minimally invasive mitral valve repair for severe mitral regurgitation caused by an isolated cleft of the anterior mitral leaflet. During the operation, we found a large cleft measuring 5×8 mm in the center of the anterior mitral leaflet. We closed the cleft directly and performed annuloplasty with a 30-mm Carpenter-Edwards Physio Ring (Edwards Lifesciences, Irvine, CA). The mitral valve is very well visualized with the video-assisted minimally invasive approach through the right chest.

Posterior papillary muscle rupture after transapical transcatheter aortic valve implantation

Transapical transcatheter aortic valve implantation is a well-established alternative in patients at a high risk for conventional aortic valve replacement. We performed transapical transcatheter aortic valve implantation on an 83-year-old woman with symptomatic severe aortic stenosis. Intraoperative transoesophageal echocardiography (TOE) after transcatheter aortic valve implantation showed mild mitral regurgitation without intracardiac structural injury. In the intensive care unit, the patient gradually had haemodynamic instability; TOE revealed severe mitral regurgitation with A2 and A3 prolapse due to rupture of the posterior papillary muscle. To repair the mitral regurgitation, mitral valve replacement was performed. Preoperative TOE revealed posterior displacement of the left ventricle due to right ventricular dilatation. Computed tomography showed the insertion angle of the guidewire from the left ventricular apex to the aortic valve as 95.6° and a relatively sharp angle of guidewire through the aortic valve. In such a case, it is necessary to carefully perform the catheter procedures to prevent intracardiac structure injury; posterior papillary muscle is particularly crucial.

Outflow graft abrasion due to bend relief detachment in a HeartMate II device

A 68-year old male with ischaemic cardiomyopathy who underwent HeartMate II implantation complained of chest discomfort 4 months after the operation. Computed tomography images clearly demonstrated a disconnected outflow graft bend relief (Fig. 1). During reoperation, the bend relief was indeed found to be disconnected and the outflow graft was severely abraded by the sharp metal end of the bend relief (Fig. 2).

Fulminant Fungal Infection of a Biventricular Assist Device

(J Card Surg 2012;27:646)