Sung-Ho Jung

Comparison of radial artery patency according to proximal anastomosis site: Direct aorta to radial artery anastomosis is superior to radial artery composite grafting

OBJECTIVEnThe radial artery is frequently the second graft of choice after the left internal thoracic artery in coronary artery bypass graft surgery. However, the optimal radial artery proximal anastomosis site remains controversial. The aim of the present study was to compare the radial artery patency according to its use as either an aorta-radial artery graft or composite radial artery graft in coronary artery bypass grafting.nnnMETHODSnA total of 1735 patients received coronary artery bypass grafting using the radial artery between January 2001 and July 2007, of whom 893 received serial computed tomographic coronary angiographies; these patients formed the basis of the current study. The patients were divided into 2 groups: group I (direct radial artery to aortic anastomosis, n = 451 patients) and group II (radial artery composite grafting with the left internal thoracic artery, n = 442 patients). The number of distal radial artery anastomoses performed in group I was 657 and 749 in group II. Sequential bypassing was performed in 399 patients.nnnRESULTSnThe early patency rate was significantly higher in group I than in group II (98.3% vs 94.5%; P = .004). The 1-, 2-, and 5-year patency rates were also higher in group I than in group II (93.8% +/- 1.2%, 90.5% +/- 1.6%, and 74.3% +/- 6.1%, vs 90.5% +/- 1.4%, 85.3% +/- 1.9%, and 65.2% +/- 4.2%, respectively; P = .004). Multivariate analysis showed composite grafting (P = .02), the degree of target vessel stenosis <90% (P = .001), and the target revascularization site (P = .005) to be significant risk factors for occlusion.nnnCONCLUSIONnThe results of the current data showed superior early and late patency rates of coronary artery bypass grafting with radial artery to aorta anastomosis compared with left internal thoracic artery-radial artery composite grafting.

Ruptured sinus of Valsalva aneurysm: transaortic repair may cause sinus of Valsalva distortion and aortic regurgitation.

OBJECTIVESnRecurrent or newly developing aortic regurgitation is a critical problem after the repair of ruptured sinus of Valsalva aneurysm.nnnMETHODSnA retrospective review of 56 patients who underwent surgical repair of ruptured sinus of Valsalva aneurysm between June 1990 and August 2006 was performed. Rupture of the right coronary sinus into the right ventricle was the most common anatomic type (39/56, 69.6%). Preoperative aortic regurgitation equal to or greater than grade II (n = 8, 17.9%) was managed by repair (aortic valvuloplasty, n = 5) or replacement (n = 3). Ruptured sinus of Valsalva aneurysm was repaired primarily (n = 7) or by patching (n = 10) through an aortotomy in 17 patients (transaortic group). In the remaining patients (n = 39), ruptured sinus of Valsalva aneurysm was repaired primarily from the chamber into which the corresponding aortic sinus ruptured, and the aneurysmal sac was reinforced with a supporting patch (non-transaortic group).nnnRESULTSnMedian follow-up duration was 46 months (0.4-177 months). There were 2 late deaths. Excluding 3 patients with aortic valve replacement on aneurysm repair, 11 patients (11/53, 21%) had recurrent or new-onset significant aortic regurgitation (> or = II/IV) during the follow-up period. By multivariable analysis, aortic valvuloplasty at initial operation was the only significant risk factor for postoperative aortic regurgitation (P < .001). After adjustment, the non-transaortic approach appeared to be associated with a lower risk of postoperative aortic regurgitation, with marginal significance (hazard ratio 0.28; P = .058). Five-year freedom from significant aortic regurgitation in the transaortic and non-transaortic groups was 68% +/- 12% and 94% +/- 4%, respectively.nnnCONCLUSIONnTransaortic repair of ruptured sinus of Valsalva aneurysm may cause postoperative aortic regurgitation by progressive distortion of the aortic sinus geometry.

Long-term mortality in adult orthotopic heart transplant recipients.

Heart transplantation is now regarded as the treatment of choice for end-stage heart failure. To improve long-term results of the heart transplantation, we analyzed causes of death relative to time after transplantation. A total of 201 consecutive patients, 154 (76.6%) males, aged ≥ 17 yr underwent heart transplantation between November 1992 and December 2008. Mean ages of recipients and donors were 42.8 ± 12.4 and 29.8 ± 9.6 yr, respectively. The bicaval anastomosis technique was used since 1999. Mean follow up duration was 6.5 ± 4.4 yr. Two patients (1%) died in-hospital due to sepsis caused by infection. Late death occurred in 39 patients (19.4%) with the most common cause being sepsis due to infection. The 1-, 5-, and 10-yr survival rates in these patients were 95.5% ± 1.5%, 86.9% ± 2.6%, and 73.5% ± 4.1%, respectively. The surgical results of heart transplantation in adults were excellent, with late mortality due primarily to infection, malignancy, and rejection. Cardiac deaths related to cardiac allograft vasculopathy were very rare.

Pulmonary vascular compliance and pleural effusion duration after the Fontan procedure

BACKGROUNDnPreoperative risk analysis for Fontan candidates is still less than optimal in that patients with apparently low risks may have a poor outcome, such as prolonged pleural drainage, protein-losing enteropathy, pulmonary thromboembolism and death. We hypothesized that low pulmonary vascular compliance (PVC) is a risk factor for persistent pleural effusion after the Fontan operation.nnnMETHODSnA retrospective review of 85 patients who underwent the extracardiac Fontan procedures (median age: 3.87 years) was performed. Fontan risk score (FRS) was calculated from 12 categorized preoperative anatomical and physiological variables. PVC (mm(2)/m(2) x mmHg) was defined as pulmonary artery index (mm(2)/m(2)) divided by total pulmonary resistance (Wood Unit x m(2)) and pulmonary blood flow (L/min/m(2)), based on the electrical circuit analogy of the pulmonary circulation. Chest tube indwelling time was log-transformed (log indwelling time, LIT) to fit normal distribution, and the relationship between perioperative predictors and LIT was analyzed by multiple linear regression.nnnRESULTSnPreoperative PVC, chest tube indwelling time and LIT ranged from 6 to 94.8 mm(2)/mmHg/m(2) (median: 24.8), 3 to 268 days (median: 20 days), and 1.1 to 5.6 (mean: 2.9, standard deviation: 0.8), respectively. FRS, PVC, cardiopulmonary bypass time (CPB) and central venous pressure at postoperative 12 h were correlated with LIT by univariable analyses. By multiple linear regression, PVC (p=0.002) and CPB (p=0.003) independently predicted LIT, explaining 22% of the variation. The regression equation was LIT=2.744-0.016 PVC+0.007 CPB.nnnCONCLUSIONnLow pulmonary vascular compliance is an important risk factor for prolonged pleural effusion drainage after the extracardiac Fontan procedure.

Surgical results of active infective native mitral valve endocarditis: repair versus replacement

OBJECTIVEnThe current study compared clinical outcomes after mitral valve repair or replacement in patients with active infective endocarditis involving only the native mitral valve.nnnMETHODSnFrom January 1994 to December 2009, 102 patients were identified with active infective native mitral valve endocarditis. Mitral valve repair (MVP) was performed in 41 patients and mitral valve replacement (MVR) in 61 patients. The mean age was 34.4 ± 16.9 years in the MVP group and 43.1 ± 14.9 years in the MVR group (p=0.007). The composite end points of cardiac death and cardiac-related morbidities were compared in these two groups using the inverse-probability-of-treatment-weighted method. The median follow-up time was 4.7 years (range, 0.1-15.8) and follow-up was possible in 100 (98%) patients.nnnRESULTSnThere were three in-hospital deaths (2.9%), all in MVR patients (p=0.272). The mean cardiopulmonary bypass time and aortic cross-clamping time were 111.4 ± 34.7 min and 72.7 ± 23.7 min in the MVP group and 101.1 ± 42.9 min and 62.9 ± 26.9 min in the MVR group (p=0.204, p=0.062). The 1-, 5-, and 10-year survival rates were 97.5%, 97.5%, and 81.1%, respectively, in the MVP group and 90%, 85.8%, and 85.8%, respectively, in the MVR group (p=0.316). Actuarial event-free survival at 1, 5, and 10 years was 92.7%, 89.5%, and 72.2% in the MVP group, and 94.8%, 81.0%, and 77.3% in the MVR group (p=0.787), respectively.nnnCONCLUSIONSnThe present study showed that postoperative long-term survival and event-free survival in patients with active infective endocarditis of the native mitral valve were not statistically significantly different regardless of whether patients underwent MVP or MVR.

Mitral durability after robotic mitral valve repair: Analysis of 200 consecutive mitral regurgitation repairs

OBJECTIVESnThe study objective was to review a single-center experience on robotic mitral valve repair to treat mitral regurgitation, with a specific focus on midterm echocardiographic mitral durability. No data assessing the quality or durability of repaired mitral valves are currently available.nnnMETHODSnA total of 200 patients who underwent robotic mitral regurgitation repair using the da Vinci system (Intuitive Surgical, Inc, Sunnyvale, Calif) between August 2007 and December 2012 were evaluated. Serial echocardiographic results and operative and procedural times were analyzed.nnnRESULTSnMitral regurgitation repairs were successfully performed, and no or mild residual mitral regurgitation developed in 98.0% of patients, with no conversion to sternotomy. No in-hospital deaths occurred. Follow-up was completed in 96.5% of patients with a median of 31.4 months (interquartile range, 12.4-42.3 months). During follow-up, 4 late deaths, 2 strokes, 1 low cardiac output, 1 newly required dialysis, and 1 reoperation for mitral regurgitation occurred. Freedom from major adverse cardiac events at 5 years was 87.7% ± 5.1%. Regular echocardiographic follow-up (>6 months) was achieved in 187 patients (93.5%). At a median of 29.6 months (interquartile range, 14.9-45.8 months), 21 patients (10.5%) demonstrated moderate or greater mitral regurgitation. Freedom from moderate or greater mitral regurgitation at 5 years was 87.0% ± 2.6%. Mean cardiopulmonary bypass and crossclamping times were 182.9 ± 48.4 minutes and 110.9 ± 34.1 minutes, respectively, demonstrating a significant decrease in both times according to the chronologic date of surgery.nnnCONCLUSIONSnRobotic mitral regurgitation repair is technically feasible and efficacious, demonstrating favorable midterm mitral durability and improved procedural times as experience increases.

Surgical outcomes and post-operative changes in patients with significant aortic stenosis and severe left ventricle dysfunction.

Little is known regarding long-term survival and changes in systolic function following surgery after the occurrence of a severe left ventricular (LV) dysfunction in patients with severe aortic stenosis. Inclusion criteria were an aortic valve area less than 1 cm2 and an LV ejection fraction (EF) less than 35%. Between January 1990 and July 2007, 41 (male: 30) patients were identified. The pre-operative mean EF and mean aortic valve area were 26.7±6.1% and 0.54±0.2 cm2, respectively. Concomitant coronary artery bypass surgery was performed in 8 patients (19.6%). Immediate post-operative echocardiogram showed to be much improved in LV EF (27.2±5.5 vs. 37.4±11.3, P<0.001), LV mass index (244.2±75.3 vs. 217.5±71.6, P=0.006), and diastolic LV internal diameter (62.5±9.3 vs. 55.8±9.6, P<0.001). Post-operative LV changes were mostly complete by 6 months, and were maintained thereafter. There was one in-hospital mortality (2.4%) and 12 late deaths including one patient diagnosed with malignancy in whom LV function was normal. Multivariate analysis showed pre-operative atrial fibrillation and NYHA FC IV to be significant risk factors for cardiac-related death. Aortic valve replacement in patients with significant aortic stenosis and severe LV dysfunction showed acceptable surgical outcomes. Moreover, LV function improved significantly in many patients.

Multiple Coronary Arteriovenous Fistulas to the Coronary Sinus With an Unruptured Coronary Sinus Aneurysm and Restrictive Coronary Sinus Opening to the Right Atrium

A 37-year-old woman was transferred to our department for surgery. She had experienced intermittent chest discomfort or pain and palpitation during the last 4 years. Chest radiographs showed cardiomegaly (cardiothoracic ratio 0.63). A preoperative ECG showed normal sinus rhythm (Figure 1). Echocardiography showed marked dilatation of the coronary sinus with an intramural thrombus and flow acceleration at its opening (Figure 2). Cardiac catheterization showed no significant coronary artery stenosis but revealed coronary arteriovenous fistulas (CAVFs) from the distal right coronary artery, distal left anterior descending artery, and proximal left circumflex artery draining directly into the coronary sinus (Figure 3). A preoperative computed tomography scan showed a large aneurysm that contained thrombi with a maximal diameter of 73 mm at the outer side of the left ventricular inferior wall (Figure 4). The site of the aneurysm coincided with the coronary sinus and greater cardiac vein. The computed tomography scan was unable to reveal drainage of the thrombosed aneurysm into the right atrium (RA). Magnetic resonance imaging, however, showed a pinpoint opening from the coronary sinus aneurysm to the RA (Figure 5). The right coronary artery was diffusely dilated and was connected to the coronary sinus after forming a small coronary artery aneurysm. Distal collateral vessels from the left anterior descending artery and left circumflex artery were connected directly to the coronary sinus (Figure 6). On …

Performance of a Simplified Dichotomous Phenotypic Classification of Bicuspid Aortic Valve to Predict Type of Valvulopathy and Combined Aortopathy.

Background: A simplified classification of bicuspid aortic valve (BAV) morphology using only the orientation of fused cusps was recently proposed. The aim of this study was to test whether it is useful for showing an association with the type of valvulopathy or aortopathy. Methods: BAV phenotype was retrospectively classified in 681 patients (mean age, 59 ± 12 years; 424 men) who underwent aortic valve surgery. Each BAV was classified using both dichotomous (right and left coronary cusp fusion [CCF] vs mixed cusp fusion [MCF]) and conventional methods, and its association with the dominant valvulopathy (aortic stenosis [AS] vs regurgitation) and concomitant aortic surgery was analyzed. Four cardiologists individually reviewed transthoracic echocardiographic images of 100 randomly selected patients to compare the feasibility and accuracy of the two classification methods. Results: The frequencies of BAV CCF and MCF were 53% (n = 361) and 47% (n = 320), respectively. AS was the predominant cause of surgery (n = 546 [80%]), and concomitant aortic surgery was done in 31% (n = 214). Patients with BAV MCF showed a higher frequency of AS (89% vs 73%, P < .001) and aortic surgery (38% vs 26%, P < .001) than those with BAV CCF. There were independent associations between BAV MCF and AS (odds ratio, 3.32; 95% CI, 1.99–5.54; P < .001) as well as aortic surgery (odds ratio, 1.76; 95% CI, 1.26–2.45; P = .001). The feasibility of the classification methods did not differ, but dichotomous classification revealed higher accuracy than conventional (87% [95% CI, 84.1%–90.7%] vs 70% [95% CI, 65.0%–74.3%]) for all four examiners, with higher &kgr; coefficients representing interrater agreement (&kgr; = 0.73 ± 0.06 to 0.83 ± 0.06 [dichotomous method] vs 0.51 ± 0.06 to 0.73 ± 0.06 [conventional method]). Conclusions: The dichotomous classification method is useful for showing the association with the type of valvulopathy or aortopathy, with better diagnostic performance than the conventional method. HighlightsSimplified dichotomous BAV classification (BAV CCF vs BAV MCF) based on spatial orientation is useful for predicting patterns of valvulopathy and aortopathy.Using routine TTE images alone, this simplified method demonstrates better diagnostic performance compared to the conventional classification, which requires information regarding the individual cusps that are fused and the position of raphe.Simplified dichotomous BAV classification can be easily incorporated into the routine evaluation of BAV patients. Abbreviations: AR = Aortic regurgitation; AS = Aortic stenosis; AV = Aortic valve; BAV = Bicuspid aortic valve; CCF = Coronary cusp fusion; LCC = Left coronary cusp; LV = Left ventricular; MCF = Mixed cusp fusion; NCC = Noncoronary cusp; RCC = Right coronary cusp; TTE = Transthoracic echocardiographic.

DIAGNOSIS OF TUBERCULOUS PERICARDIAL EFFUSION BY T CELL-BASED ASSAYS ON PERIPHERAL BLOOD AND PERICARDIAL FLUID MONONUCLEAR CELLS

Results: ROC curve analyses showed that areas under curves for diagnosing TPE were 0.748 and 0.691 for Δ(ESAT-6 negative control (NC)) and Δ(CFP-10 NC) obtained from blood, while they were 0.946, 0.744, 0.854 and 0.838 for ADA, INT-, Δ(ESAT-6 NC) and Δ(CFP-10 NC) derived from the PE luid, respectively. Sensitivities and speciicities were 91% and 82% by ADA level (≥40 U/L), 62% and 100% by INT- (≥200 pg/L), 90% and 85% by Δ(ESAT-6 NC) (≥49), and 90% and 73% by Δ(CFP-10 NC) (≥4) from PE luid, respectively. For diagnosing deinite TPE, ROC curve analyses showed that areas under curves were 0.968, 0.946, 0.971, and 0.971 for ADA, INT-, Δ(ESAT-6 NC) and Δ(CFP-10 NC) from the PE luid, respectively. In all patients with deinite TPE, markedly increased number of sensitized T cells to both ESAT-6 and CFP-10 were presented in PE (Fig).