Takashi Murashita

Coronary artery bypass surgery is superior to percutaneous coronary intervention with drug-eluting stents for patients with chronic renal failure on hemodialysis.

BACKGROUND Improvements in the results of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) have been extending their use in patients with all forms of coronary artery disease. The purpose of this study was to compare the midterm clinical results of coronary artery bypass surgery (CABG) and PCI with DES in patients with chronic renal failure on hemodialysis. METHODS From January 2002 to December 2006, 29 patients underwent CABG, and 75 patients underwent PCI with DES. For CABG, 24 patients had off-pump surgery. The mean follow-up was 32.0 +/- 22.0 months for CABG and 23.5 +/- 14.8 months for PCI. Survival, cardiac death, major adverse cardiac events (cardiac death, myocardial infarction, revascularization), and target lesion revascularization were analyzed using the Kaplan-Meier method. RESULTS Preoperative characteristics and risk factors were compatible between the groups except for the European System for Cardiac Operative Risk Evaluation (7.3 +/- 2.7 for CABG and 5.0 +/- 2.4 for PCI, p < 0.0001) and the presence of a left main trunk lesion (53.3% for CABG and 18.7% for PCI). Thirty-day mortality was 3.3% for CABG and 4.0% for PCI. The 2-year survival rate was 84.0% for CABG and 67.6% for PCI (p = 0.0271). The cardiac death-free curve at 2 years was 100% for CABG and 84.1% for PCI (p = 0.0122). The major adverse cardiac events-free rate at 2 years was 75.8% for CABG and 31.5% for PCI (p < 0.0001). During the follow-up period, there were 6 late deaths in the CABG group and 27 late deaths (including 6 sudden deaths) in the PCI group. CONCLUSIONS Coronary artery bypass grafting was superior to PCI with DES in patients with chronic renal failure on hemodialysis in terms of long-term outcomes for cardiac death, major adverse cardiac events, and target lesion revascularization. The DES carried a higher risk for sudden death, which might be associated with stent thrombosis.

Less invasive surgical treatment for aortic arch aneurysms in high-risk patients: A comparative study of hybrid thoracic endovascular aortic repair and conventional total arch replacement

OBJECTIVE For aortic arch aneurysms, conventional total arch replacement has been the standard surgical option. In selected high-risk patients, we have attempted less invasive hybrid procedure involving supra-aortic bypass and endovascular stent-graft placement. We review the early and midterm outcomes to clarify the impact of the hybrid procedure. METHODS Between October 2007 and December 2010, 27 patients were treated with the hybrid procedure. During the same period, 191 patients underwent elective conventional total arch replacement. On retrospective analysis, the hybrid procedure was feasible in 103 patients (hybrid feasible) and not feasible in 88 patients (hybrid impossible). Patients undergoing the hybrid procedure attained significantly higher additive (11.6 ± 2.2 vs 9.5 ± 2.4, 10.3 ± 2.8, P < .001, P = .044) and logistic (31.1 ± 14.1 vs 18.8 ± 12.6, 23.7 ± 16.0, P < .001, P = .047) European System for Cardiac Operative Risk Evaluation scores than hybrid-feasible and hybrid-impossible groups. RESULTS Although the patients in the hybrid group had significantly higher risk, the early outcomes including mortality and morbidity were similar among the 3 groups, as were the 2-year survivals during the follow-up period: 85.9% for the hybrid group, 89.6% for the hybrid-feasible group, and 86.7% for the hybrid-impossible group (P = .510, .850, log-rank test). In the hybrid group, 2 patients required reintervention for type I endoleak. CONCLUSIONS The early and midterm outcomes of the hybrid procedure for aortic arch aneurysms were satisfactory. This procedure has the potential to be an alternative for conventional total arch replacement for high-risk patients.

Aortic Valve Replacement for Severe Aortic Valve Stenosis in the Nonagenarian Patient

BACKGROUND Outcome data are limited on aortic valve replacement (AVR) in nonagenarian patients. This study reports our experience in the treatment of this elderly population. METHODS A retrospective review was conducted of 59 patients 90 years of age or greater with severe aortic valve stenosis operated on with isolated AVR from January 1993 through August 2013. Valve replacement was surgical in 33 patients (55.9%) and transcatheter in 26 (44.1%). RESULTS Median age of the patients was 91 years (range, 90 to 97 years), sex was female in 38 (64.4%), and The Society of Thoracic Surgeons predicted risk of mortality was 10.1% (range, 4.7% to 27.9%). Operative complications occurred in 22 patients (37.3%) and included acute renal failure in 7 patients (11.9%) and stroke in 1 patient (1.7%). Vascular injury occurred only in patients treated with transfemoral SAPIEN transcatheter heart valve transcatheter AVR and included 6 patients (42.9%). Discharge to home occurred in 17 patients (34.7%), with no difference between the valve replacement groups (p=0.072). Operative mortality occurred in 2 patients (6.1%) in the surgical AVR group and 1 (3.9%) in the transcatheter AVR group (p=1.000). Kaplan-Meier survival estimate at 1 year was 81.3%±5.4% with no difference between the valve replacement groups (p=0.636) and age- and sex-matched control patients (p=0.415). CONCLUSIONS Aortic valve replacement for severe aortic valve stenosis can be done with less than predicted operative risk in nonagenarian patients. However, transfemoral SAPIEN transcatheter heart valve transcatheter AVR should be undertaken with caution because of increased risk of vascular injury. Aortic valve replacement should not be denied in select patients.

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.

Outcomes of mitral valve repair for bileaflet prolapse

OBJECTIVE Repair of bileaflet prolapse has been considered to be technically demanding and challenging. To assess the reliability and durability of mitral valve repair for bileaflet prolapse, the present study compared the outcomes of mitral valve repair for bileaflet prolapse with those for posterior prolapse. METHODS From January 1991 to April 2010, 191 consecutive patients with bileaflet prolapse (group B) underwent mitral valve repair using a combination procedure of expanded polytetrafluoroethylene chordal reconstruction for anterior prolapse, resection suture technique with/without sliding technique for posterior prolapse, and ring annuloplasty. During the same period, 323 patients with posterior prolapse (group P) underwent standard mitral valve repair. Serial echocardiograms were obtained at discharge and 1, 3, 5, and 10 years postoperatively. RESULTS The mean age in group B (54 ± 15 years) was significantly younger than that in group P (61 ± 12 years). Survival, including hospital death at 10 years, was superior in group B (group B, 90% ± 3%; group P, 83% ± 3%; P = .046). At 10 years, no significant differences were found between the groups in terms of freedom from recurrent mitral regurgitation of more than mild (group B, 89% ± 3%; group P, 90% ± 2%), freedom from reoperation (group B, 97% ± 2%; group P, 97% ± 1%), and event-free survival (group B, 79% ± 5%; group P, 83% ± 3%). CONCLUSIONS The reproducibility and reliability of mitral valve repair for bileaflet prolapse compares favorably with that of posterior leaflet prolapse. Early surgery might be recommended for patients with severe mitral regurgitation owing to bileaflet prolapse.

Long-Term Results of Mitral Valve Repair for Severe Mitral Regurgitation in Infants: Fate of Artificial Chordae

BACKGROUND The experience with mitral valve repair for severe mitral regurgitation in infants was retrospectively reviewed. METHODS From 1978 to 2009, 15 infant patients (4 boys, 7.2±3.2 months old) underwent mitral valve repair for severe mitral regurgitation. The etiology of mitral regurgitation according to Carpentier classification was type I in 1 patient, type II in 10 patients, and type III in 4 patients. Artificial chordal replacement was performed in 11 patients. The follow-up course was completed in all patients, with a median follow-up period of 10.2 years (range, 2.2 to 33.4 years). RESULTS There were no operative or in-hospital mortalities. The actuarial survival and freedom from reoperation rates at 10 years were 89% and 65%, respectively. Five patients required redo mitral valve surgery, including 4 patients needing mitral valve replacement. Three of 4 patients with type III mitral regurgitation, caused by congenital subvalvar structural abnormality, required redo mitral valve surgery. In 11 patients who underwent artificial chordal reconstruction, 2 (18%) required mitral valve replacement during the early postoperative period, whereas the remaining patients showed no recurrent mitral regurgitation during the entire study period. The latest echocardiography findings at 7.3 years after the operation showed that the left ventricular diastolic diameter, mitral valve diameter, and ejection fraction were 99.2%±5.0% of normal, 101.7%±13.3% of normal, and 0.741±0.058, respectively. CONCLUSIONS Long-term durability of mitral valve repair for severe mitral regurgitation in infants was satisfactory. Artificial chordal reconstruction is an effective procedure without an elevated risk of late reoperation.

Sapien XT Transcatheter Mitral Valve Replacement Under Direct Vision in the Setting of Significant Mitral Annular Calcification.

Mitral valve replacement carries a high risk in patients with extensive mitral annular calcification. We report the case of a 71-year-old woman with severely calcified mitral valve stenosis and extensive annular calcification. We approached the mitral valve through a left atriotomy using cardiopulmonary bypass and cardiac arrest. We successfully deployed a 29-mm Sapien XT valve under direct visualization with satisfactory positioning. We further balloon-expanded the device to diminish the likelihood of periprosthetic regurgitation. Open mitral valve replacement with a transcatheter valve can be performed without the need for decalcification of the mitral annulus and is a good alternative to conventional mitral valve replacement.

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.

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.