Takashi Kunihara

Valve Configuration Determines Long-Term Results After Repair of the Bicuspid Aortic Valve

Background— Reconstruction of the regurgitant bicuspid aortic valve has been performed for >10 years, but there is limited information on long-term results. We analyzed our results to determine the predictors of suboptimal outcome. Methods and Results— Between November 1995 and December 2008, 316 patients (age, 49±14 years; male, 268) underwent reconstruction of a regurgitant bicuspid aortic valve. Intraoperative assessment included extent of fusion, root dimensions, circumferential orientation of the 2 normal commissures (>160°, ≤160°), and effective height after repair. Cusp pathology was treated by central plication (n=277), triangular resection (n=138), or pericardial patch (n=94). Root dilatation was treated by subcommissural plication (n=100), root remodeling (n=122), or valve reimplantation (n=2). All patients were followed up echocardiographically (cumulative follow-up, 1253 years; mean, 4±3.1 years). Clinical and morphological parameters were analyzed for correlation with 10-year freedom from reoperation with the Cox proportional hazards model. Hospital mortality was 0.63%; survival was 92% at 10 years. Freedom from reoperation at 5 and 10 years was 88% and 81%; freedom from valve replacement, 95% and 84%. By univariable analysis, statistically significant predictors of reoperation were age (hazard ratio [HR]=0.97), aortoventricular diameter (HR=1.24), effective height (HR=0.76), commissural orientation (HR=0.95), use of a pericardial patch (HR=7.63), no root replacement (HR=3.80), subcommissural plication (HR=2.07), and preoperative aortic regurgitation grade 3 or greater. By multivariable analysis, statistically significant predictors for reoperation were age (HR=0.96), aortoventricular diameter (HR=1.30), effective height (HR=0.74), commissural orientation (HR=0.96), and use of a pericardial patch (HR=5.16). Conclusions— Reconstruction of bicuspid aortic valve can be performed reproducibly with good early results. Recurrence and progression of regurgitation, however, may occur, depending primarily on anatomic features of the valve.

Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair

OBJECTIVE Technical controversies exist in valve-preserving aortic root replacement. We sought to determine predictors of long-term stability of the aortic valve. METHODS A total of 430 patients (aged 57 ± 15 years, 323 male) underwent valve-preserving aortic root surgery (remodeling in 401, reimplantation in 29) between 1995 and 2009 and were followed echocardiographically. Factors influencing late recurrence of aortic valve regurgitation grade II or greater (n = 45) or need for reoperation on the aortic valve (n = 25) were analyzed. RESULTS Early mortality was 2.8% (1.9% for elective cases), and actuarial survival at 10 years was 83.5% ± 2.4%. Ten-year freedom from aortic valve regurgitation grade II or greater was 85.0% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm and postoperative effective height of the aortic cusp less than 9 mm were identified as significant predictors for late aortic valve regurgitation grade II or greater in multivariate analysis (both P < .001). Ten-year freedom from reoperation on the aortic valve was 89.3% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm (P < .001), use of pericardial patch (P = .022), and effective height of the aortic cusp less than 9 mm (P = .049) were identified as significant predictors for reoperation in multivariate analysis. Operative technique (remodeling, reimplantation), Marfan syndrome, bicuspid valve anatomy, concomitant central cusp plication, size of prosthesis used, and acute dissection were not associated with an increased risk of late aortic valve regurgitation grade II or greater or reoperation. In patients with preoperative aortoventricular junction diameter greater than 28 mm (n = 94), the addition of central cusp plication significantly improved freedom from aortic valve regurgitation grade II or greater (P = .006) regardless of root procedures (remodeling, P = .011; reimplantation, P = .053). CONCLUSIONS Long-term stability of valve-preserving aortic root replacement was influenced not by the technique of root repair but by the preoperative aortic root geometry and postoperative cusp configuration.

RING+STRING Successful Repair Technique for Ischemic Mitral Regurgitation With Severe Leaflet Tethering

Background— Residual/recurrent mitral valve regurgitation is observed in 30% after undersized ring annuloplasty (RING) for ischemic mitral regurgitation (IMR). RING addresses primarily annular dilatation but does not correct severe leaflet tethering attributable to papillary muscle (PM) displacement. We proposed adjunctive PM repositioning under transesophageal echocardiography (TEE) guidance in the loaded beating heart using a transventricular suture (STRING). Methods and Results— Patients with tenting height ≥10 mm were identified as high-risk patients for repair failure. In these patients (n=30, age 68±11 years, ejection fraction 37±14%), RING (partial, median 29 mm) was combined with the adjunctive STRING-technique. A Teflon-pledgeted 3-0-polytetrafluoroethylene-suture was anchored in the posterior PM via horizontal aortotomy, exteriorized through the aorto-mitral continuity, and tied in the loaded beating heart under TEE guidance. Tenting height (14±2 mm versus 6±1 mm, P<0.001) and tenting area (3.9±0.9 cm2 versus 1.0±0.2 cm2, P<0.001) decreased. The distance between pPM and aorto-mitral continuity decreased (44±4 mm versus 37±3 mm, P<0.001). Survival at 2 years was similar compared with a historical matched control-group (89% versus 73%, P=0.13), whereas freedom from MR>II was higher in the RING+STRING-group (94% versus 71%, P=0.01). End-diastolic (61.7±7.2 mm versus 54.8±9.2 mm, P<0.001) and end-systolic (48.5±8.5 mm versus 42.7±7.8 mm, P=0.002) ventricular diameters decreased in the RING+STRING-group but persisted in the control-group (60.4±7.8 mm versus 58.9±7.5 mm, P=0.38; 47.8±9.6 mm versus 48.3±9.5 mm, P=0.52). During follow-up (median 26 months) only 1 patient of the study-group required reoperation for degenerative MR, while 2 control-group patients underwent reoperation for recurrent functional MR. Conclusions— Our novel approach for IMR attenuates high risk of repair failure in patients with severe leaflet tethering and results in reverse remodeling.

Early results with annular support in reconstruction of the bicuspid aortic valve

OBJECTIVE Repair of the bicuspid aortic valve may be performed in aortic regurgitation and aneurysm. Dilatation of the atrioventricular junction has been identified as a risk factor for repair failure, and we have used suture annuloplasty to correct atrioventricular junction enlargement. The objective was to compare the early results of aortic repair with and without annuloplasty. METHODS Between November 1995 and January 12, a total of 559 patients were treated with bicuspid aortic valve repair for predominant regurgitation (n = 389), aortic aneurysm (n = 158), or acute dissection (n = 12). Isolated valve repair (aortic valve repair) was performed for aortic valve regurgitation with preserved aortic dimensions (n = 208) and sinotubular junction remodeling plus valve repair for aortic aneurysm and preserved root size (n = 116). Root remodeling was used for dilatation involving the root (n = 235). In 193 patients, dilatation of the atrioventricular junction (>27 mm) was corrected with suture annuloplasty. RESULTS Hospital mortality was 0.5% (n = 3); 2 patients required pacemaker implantation. Reoperation was necessary for recurrent regurgitation (n = 54) or stenosis (n = 2); 10-year freedom from reoperation was 82% but was inferior after isolated valve repair (70%, P = .007) compared with the 2 other techniques. Application of suture annuloplasty improved 3-year freedom from reoperation after isolated repair (84%) to 92% (P = .07). In all groups, the proportion of patients with no or trivial regurgitation was significantly higher with annuloplasty. CONCLUSIONS Preservation of the bicuspid aortic valve is feasible in many patients. Long-term stability of the repaired valves is good; the negative impact of a dilated atrioventricular junction can be reduced by suture annuloplasty.

Valve-preserving root replacement in bicuspid aortic valves

OBJECTIVE Bicuspid aortic valve anatomy is associated with aortic root aneurysm in a relevant proportion of patients. These patients require root replacement for prognostic reasons, and the valve may be preserved. The objective of this analysis is to analyze the early and late outcomes of root remodeling for bicuspid aortic valve. METHODS Between November 1995 and December 2009, 153 patients (133 male) were treated by root remodeling in the presence of a bicuspid aortic valve. Acute dissection was present in 6 individuals. In 137 instances, additional correction of cusp pathology was achieved by plication (n = 119), triangular resection (n = 59), and implantation of a pericardial patch (n = 27). Follow-up ranges from 3 months to 14.5 years (mean, 4.9 ± 3.8 years; cumulative, 757 years) and is complete in 99.3%. RESULTS One patient died of intracranial hemorrhage in the hospital (mortality 0.7%). Survival at 5 and 10 years was 99% and 91%, respectively. Seven patients required reoperation for stenosis (n = 1) or recurrent aortic insufficiency (n = 6) between 1 month and 11 years postoperatively. The aortic valve was re-repaired in 2 cases. Freedom from reoperation at 5 and 10 years was 95%; freedom from valve replacement was 97%. Freedom from valve-related complications was 91% at 5 and 10 years. CONCLUSIONS Root remodeling for aortic root aneurysm in the presence of a bicuspid aortic valve can be performed with a low morbidity and mortality. The long-term stability of the reconstructed aortic valve is excellent if normal valve configuration is achieved. The occurrence of late stenosis seems to be rare, and freedom from valve-related complications is high.

Repair versus replacement of the aortic valve in active infective endocarditis

OBJECTIVES Aortic valve repair has advantages over replacement in stable aortic regurgitation. It is unclear whether this is similar in active endocarditis. METHODS From January 2000 to July 2009, 100 patients (age 54.9±15.1 years) underwent surgery for aortic valve endocarditis. Thirty-three patients were treated by valve repair (I) and 67 underwent valve replacement (II: 51 biologic, 10 mechanical valves, 6 Ross operations). In Group I, cusp and root lesions were treated by autologous pericardial patches. A root abscess was present in 32 cases (I: 27%, II 34%; P=0.82). Concomitant procedures (n=49) were mitral repair (I: 10, II: 11; P=0.12) and coronary bypass (I: 4, II: 11; P=0.77). All patients were followed. Cumulative follow-up was 268 patient-years (mean 2.7±3.0 years). In a retrospective analysis, we analysed the outcome. RESULTS Hospital mortality was 15% (I: 9%, II: 18%; P=0.37). Survival at 5 years was significantly better after repair (I: 88%, II 65%; P=0.047). Ten patients were reoperated (I: 35%, II: 10%; P=0.021) between 1 month and 5 years postoperatively. Actuarial freedom from aortic regurgitation of grade II or higher was 80% at 5 years (I: 66%, II: 87%; P=0.066). In Group I, this was influenced by aorto-ventricular (AV) morphology (tricuspid 80%, bicuspid 50%; P=0.0045). Freedom from reoperation in reconstructed tricuspid valves (n=20) was 87% at 5 years, which was identical to Group II (P=0.40). At 5 years, freedom from thromboembolic events was 93% (I: 100%, II: 90%; P=0.087) and that from bleeding complications was 100%. CONCLUSIONS AV repair for active endocarditis seems to lead to better survival compared with replacement. The use of large patches in combination with bicuspid anatomy results in increased risk of late failure.

Predictors of postoperative outcome after pulmonary endarterectomy from a 14-year experience with 279 patients

OBJECTIVE Postoperative outcome after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is difficult to predict. We sought to analyze specific preoperative findings to predict mortality, shorter mechanical ventilation, and hemodynamic improvement after PEA. METHODS A total of 279 patients with CTEPH (57 ± 14 years old, 57% male), who underwent PEA between 1995 and 2009, were reviewed retrospectively. Preoperative pulmonary hemodynamic parameters, spirometry data, laboratory data, cardiac co-morbidities, clinical stage, and number of desobliterated segments were analyzed using a logistic regression model to identify independent predictors for early mortality, shorter duration of mechanical ventilation, and hemodynamic improvement. RESULTS There were 31 early deaths (11.1%, last three years: 6.7%). Among 16 significant predictors for early mortality, preoperative arterial oxygenation was the only significant predictor in multivariate analysis (P < 0.05). A total of 147 patients (52.7%) could be extubated within 48 h postoperatively. Out of 16 significant predictors in univariate analysis for mechanical ventilation less than 48 h, only higher forced expiratory volume in 1s FEV1.0 (P < 0.05) and higher preoperative cardiac index (P < 0.05) were significant in multivariate analysis. In 185 patients (66.3%), postoperative pulmonary vascular resistance (PVR) was reduced to lower than 400 dyn s(-1) cm(-5) at 48 h after PEA. Male gender (P < 0.05), lower preoperative mean pulmonary arterial pressure (PAP) (P < 0.05), and more intra-operative desobliterated segments (P < 0.01) were identified as significant predictors for this hemodynamic response with sensitivity of 77.5% and specificity of 67.9%. Using Pearsons correlation coefficient, PVR at 48 h after PEA could be estimated as PVR = 123.266+135.471 × creatinine-22.053 × desobliterated segments + 3.248 × systolic PAP (P < 0.01, R(2) = 0.401, 95% confidence interval = 0.464-0.830). CONCLUSIONS Preoperative factors can primarily predict postoperative outcome after PEA. Patients with underlying parenchymal lung disease will have increased risk for early mortality and prolonged mechanical ventilation. The extent of desobliterated segments as well as preoperative hemodynamic severity play a key role in predicting good hemodynamic responders.

Aortic valve reconstruction in myxomatous degeneration of aortic valves: Are fenestrations a risk factor for repair failure?

OBJECTIVE Aortic valve repair is a more recent approach for the treatment of aortic regurgitation. Limited data exist for reconstruction in specific pathologies with isolated cusp pathology. We analyzed the results of aortic valve repair in patients with aortic regurgitation caused by myxomatous cusp prolapse in the presence of tricuspid valve anatomy and normal root size. METHODS Over a 12-year period, 111 patients underwent aortic valve reconstruction for regurgitant tricuspid aortic valves without concomitant root dilatation. Cusp prolapse was caused by myxomatous degeneration in 72 subjects (group I) and associated with fenestrations in 39 subjects (group II). Prolapse was corrected by means of plication of the free margin in the presence of normal cusp tissue only (n = 62) or combined with triangular resection of cusp tissue (n = 10). It was treated with additional closure of the fenestration with autologous pericardium in 39 instances (group II). Follow-up was complete in 98.5% (cumulative 385 years). RESULTS Hospital mortality was 1.8%, and during follow-up, there was 1 thromboembolic event and no endocarditis. Freedom from reoperation at 5 and 8 years was 96%. CONCLUSIONS Isolated cusp prolapse is a relevant cause of aortic regurgitation in tricuspid aortic valves without concomitant root dilatation. In myxomatous stretching of cusp tissue, plication of the free margin suffices to restore cusp geometry and aortic valve function. In the presence of fenestrations, reconstruction of normal cusp configuration can be achieved by means of closure of the fenestration with a pericardial patch. The midterm stability of both approaches is good.

Mid-term results after sinutubular junction remodelling with aortic cusp repair

OBJECTIVES An ascending aortic aneurysm with aortic valve regurgitation (AR) may be treated by sinutubular junction remodelling (STJR) with aortic cusp repair if the root diameter is preserved. We analysed the outcome of STJR with cusp repair. METHODS Between 1995 and 2010, 1094 patients underwent valve-preserving surgery. Of these, 560 individuals with root replacement, 128 patients with acute aortic dissection and 262 patients with preoperative AR ≤ II were excluded. The remaining 144 patients (mean age 56.0 ± 17.0 years, 103 males) underwent STJR ± cusp repair for ascending aortic aneurysm and AR ≥ III. In all, sinus dimensions were preserved according to the following criteria: maximum diameter ≤42 mm in bicuspid aortic valve (BAV, n = 59) and unicuspid aortic valve (UAV, n = 27), and ≤45 mm in tricuspid aortic valves (TAV, n = 58). In BAV, right-left (n = 52) and right-non-coronary (n = 7) cusp fusions were seen. To evaluate the influence of valve morphology, patients were divided into two groups: TAV and non-TAV. The patients with non-TAV were younger (P < 0.01) and had less concomitant cardiac surgery (P < 0.01). The mean follow-up was 25.9 ± 22.0 months. RESULTS Early mortality was 2.1% (n = 3). The causes of death were cardiac (n = 1), respiratory (n = 1) and mesenteric ischaemia (n = 1). Higher age was the predictor of early mortality by multivariate analysis (P = 0.04, hazard ratio 13.2). Overall 5-year survival was 93.9 ± 2.9% (TAV, 82.8 ± 10.2%; non-TAV, 98.5 ± 1.5%; P = 0.02). Causes of late death were cardiac (n = 1), respiratory (n = 1) and carcinoma (n = 1). Freedom from recurrent AR ≥ III at 5 years was 80.1 ± 7.7% (TAV, 97.0 ± 3.0%; non-TAV, 73.4 ± 8.7%; P = 0.02). By multivariate analysis, only aortoventricular junction (AVJ) > 28 mm (P < 0.01, hazard ratio 9.7) was a predictor of recurrent AR. Freedom from reoperation at 5 years was 81.9 ± 7.8% (TAV, 97.0 ± 3.0%; non-TAV, 76.6 ± 8.8%; P < 0.05). The causes of reoperation (five re-aortic valve repairs and four valve replacements) were dehiscence of pericardial patch (n = 7) and recurrent cusp prolapse (n = 2). By multivariate analysis, only AVJ > 28 mm was a significant predictor for reoperation (P < 0.01, hazard ratio 11.6). CONCLUSIONS STJR with cusp repair is a useful technique in patients with an ascending aortic aneurysm and relevant AR. Although the dilated AVJ is a risk of recurrent AR and reoperation, concomitant cusp repair is associated with an acceptable mid-term outcome.

Association between smoking habits and the first-time appearance of atrial fibrillation in Japanese patients: Evidence from the Shinken Database

BACKGROUND We previously reported a cross-sectional analysis regarding the relationship between smoking and atrial fibrillation (AF) in a single hospital-based cohort with Japanese patients, but the effect of cessation of smoking and/or total tobacco consumption were unclear. METHODS AND RESULTS We used data from the Shinken Database 2004-2011 (men/women, n=10,714/6803, respectively), which included all new patients attending the Cardiovascular Institute between June 2004 and March 2012. After excluding those previously diagnosed with AF (n=2296), 15,221 patients (men/women, n=9016/6205) were analyzed. During the follow-up period of 2.0±2.1 years (range 0.0-8.1), the incidence rates of new AF in smokers and non-smokers were 9.0 and 5.0 per 1000 patient-years, respectively. In adjusted models with Cox regression analysis, smokers were independently associated with new AF [hazard ratio (HR) 1.47, 95% confidence interval (CI) 1.09-2.00]. Also, current smokers (HR 1.81, 95% CI 1.17-2.79) and smokers with Brinkman index ≥800 (HR 1.69, 95% CI 1.05-2.70) were independently associated with new AF. However, in current smokers, the HRs were not different by Brinkman index (Brinkman index <800/≥800; HR 1.81/1.82, 95% CI 1.07-3.05/0.94-3.51, respectively). CONCLUSIONS Smoking was independently associated with the first-appearance of AF in patients in sinus rhythm, especially when the patients continued their smoking habit. However, in patients who continued smoking, difference by total tobacco consumption was not observed, suggesting the significance of cessation of smoking for preventing AF. Our data are limited because of a single hospital-based nature and a relatively short observation period.