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Background: Analyses of the efficacy and safety of transcatheter aortic valve replacement (TAVR) in most countries have been based on outcomes obtained in accordance with national practice guidelines and monitoring protocols. The purpose of this study is to share our experience regarding the process for establishing guidelines and monitoring protocols for the use of TAVR in Korea, in the hopes that it may be helpful to others undergoing a similar process in their own country. Methods: The Korean guidelines for TAVR were established on June 1, 2015 in through a tri-party agreement involving the Department of Health and Welfare, the Korean Society of Thoracic and Cardiovascular Surgery and the Korean Society of Cardiology. We agreed to monitor the guidelines transparently and to exchange opinions regarding amendments or continuation of its contents after 3 years of monitoring. Results: The monitoring meetings were not held as regularly as agreed, and monitoring was also made difficult by insufficient and incomplete data. Nevertheless, during the meetings, measures to improve the monitoring process were discussed, and accordingly, an agreement was made to continue the monitoring process, with the aim of completing data collection by 2018. Conclusion: Compliance with guidelines is critical for assessing the efficacy and safety of TAVR. Moreover, the TAVR monitoring process must be properly conducted for an accurate evaluation to be made. Any country planning to introduce TAVR may encounter difficulties with regards to the optimal initiation strategy and subsequent monitoring. Nevertheless, continued efforts should be made to persuade the government and the corresponding medical societies to facilitate the optimal application of TAVR.

Stress-induced cardiomyopathy has become a more recognized and reported entity. It can be caused by emotional or physical stress, which causes excessive catecholamine release. Typically, the clinical course is benign with conservative treatment being effective. However, stress-induced cardiomyopathy can be fatal. A 41-year-old female presented with cardiogenic shock followed by sudden back pain. Initial echocardiographic finding showed severely decreased ejection fraction with akinesia at all mid-toapical walls with relatively preserved basal wall contractility. The coronary artery was intact on coronary angiography. Cardiac resuscitation and extra-corporeal membrane oxygenation was needed to manage the cardiogenic shock. Recovery was complete after 2 weeks. [ABSTRACT FROM AUTHOR]

Background Cerebrovascular complications (CVCs) frequently occur in patients with acute infective endocarditis (IE). The aim of this study is to describe the clinical findings of CVCs and to evaluate the impact of CVCs on long-term mortality in patients with IE. Methods We retrospectively analyzed 144 patients who fulfilled the modified Duke's criteria for definite left-sided IE. CVCs were classified into minor (silent cerebral embolism, TIA and stroke with an initial modified Rankin scale ⩽ 2) or major (an initial modified Rankin scale ⩾ 3) CVCs. Cox proportion hazard model was used for mortality analysis. Hazard ratio (HR) and 95% confidence interval (CI) were obtained. Results The mean age of the 144 patients (96 males and 48 females) was 49.1 years (range 6-85 years). A CVC was found in 37 (25.7%) patients. Of these, 25 were treated with surgical therapy. The patients who underwent early surgery within 2 weeks after stroke had a statistical trend toward a higher risk of postoperative brain hemorrhage (50% versus 4.8%, P = 0.057 by Fisher exact test). The minor CVC group had a similar risk of death as the no-CVC group (P = 0.803; HR 0.856; CI 0.253-2.894), whereas the major CVC group had a higher mortality (P = 0.013; HR 2.865; CI 1.254-6.548) than the no-CVC group. In the multivariate analysis, major CVC (P = 0.002; HR 3.893; CI 1.649-9.194) was a significant predictor of mortality in IE patients, together with advanced age (P = 0.005; HR 3.138; CI 1.421-6.930) and prosthetic valve IE (P = 0.008; HR 2.819; CI 1.315-6.044). Conclusions IE can give rise to various forms of CVC, most frequently, acute ischemic brain lesions. In our study, major CVC was associated with high risk of mortality although total CVC was not significantly related to the risk of death in patients with IE. [ABSTRACT FROM AUTHOR]

Background. The use of anticoagulant therapy (ACT) in patients with acute infective endocarditis (IE) remains a controversial issue. Our study attempts to estimate the impact of ACT on the occurrence of embolic complications and the usefulness of ACT in the prevention of embolism in IE patients. Methods. The present authors analyzed 150 patients with left-sided IE. Embolisms including cerebrovascular events (CVE) and the use of ACT were checked at the time of admission and during hospitalization. Results. 57 patients (38.0%) experienced an embolic event. There was no significant difference in the incidence of CVEand in-hospitalmortality between patientswith and without warfarin use at admission, although warfarin-naïve patientswere significantlymore likely to have large (>1 cm) and mobile vegetation. In addition, there was no significant difference in the incidence of postadmission embolism and in-hospital death between patients with and without in-hospital ACT. On multivariate logistic regression analysis, ACT at admission was not significantly associated with a lower risk of embolism in patients with IE. Conclusions. The role of ACT in the prevention of embolism was limited in IE patients undergoing antibiotic therapy, although it seems to reduce the embolic potential of septic vegetation before treatment. [ABSTRACT FROM AUTHOR]

Background: This study attempts to explore the clinical features, possible mechanisms and prognosis of the neurologic complications in patients with acute aortic dissection (AD). Methods: Medical records of 278 consecutive patients with AD (165 with type A and 113 with type B dissection) over 11.5 years were retrospectively analyzed for clinical history, CT findings, neurologic complications and outcome. Neurologic complications were classified into early-onset or delayed-onset complications. Independent t-test or Chi-square test (or Fisher exact test) was used for comparing the different groups. Multivariable logistic regression analysis was performed to determine the independent association between variables. Results: The mean age of the included patients (145 male and 133 female) was 59.4 years (range 19-91 years). 41 patients (14.7%) had a neurologic complication, which included 21 with early-onset complication and 23 with delayed-onset complication, including 3 with both. Advanced age and classic type of dissection were independently associated with the neurologic complication in patients with type A dissection. The most frequent manifestation was ischemic stroke (26 patients, 9.4%), followed by hypoxic encephalopathy (9, 3.2%), ischemic neuropathy (5, 1.8%), spinal cord ischemia (5, 1.8%), seizure (2, 0.7%), hoarseness (1, 0.4%) and septic encephalopathy (1, 0.4%). Overall in-hospital mortality was 10.1%, whereas the complicated group had a mortality rate of 43.9%. Renal impairment, pulse deficit, neurologic complication and nonsurgical treatment were independent variables for determining in-hospital mortality in patients with type A dissection. Conclusions: The dominance of neurologic symptom in the early stage of AD may make its early diagnosis difficult. Besides chest pain and widened mediastinum in chest x-ray, variable neurologic symptoms including left hemiparesis with asymmetric pulse and hypotension may suggest underlying AD. [ABSTRACT FROM AUTHOR]

Infected vascular lesion, including aortic graft infection, is one of the most challenging fields in vascular surgery. The primary treatment objectives are to remove the infected graft material and to re-establish vascular continuity with an extra-anatomic bypass or in situ graft replacement. Despite significant progress in perioperative care and antimicrobial therapy, mortality and morbidity remain high. The great saphenous veinsare gaining wide popularity as acceptable native vascular grafts, but in terms of flow capacity, their smallcaliber may be unsuitable for immediate replacement of arterial flow. Superficial femoral popliteal vein graftsare excellent conduits for infected aortic, peripheral arterial and central venous lesion, in terms of feasible harvesting, resistance to infection, serving immediate high postoperative flow and long-term durability. Surgery using the superficial femoral vein (SFV) graft is neither time-consuming nor dangerous. A delicate preoperative and intraoperative surgical plan is mandatory, and future studies regarding the long-term patency, appropriate clinical indication and safety issue of the SFV graft in peripheral vessel reconstruction are warranted. [ABSTRACT FROM AUTHOR]

Rupture of an aortic arch aneurysm is a life-threatening condition that requires emergency operation. For rupture of a distal arch aneurysm, we performed--with the patient under total circulatory arrest--an emergency total arch replacement with an elephant-trunk procedure, followed by one-stage antegrade stent-grafting. Prompt institution of cardiopulmonary bypass and total circulatory arrest has the advantage of lessening the risk of overt aortic rupture in this emergency situation. [ABSTRACT FROM AUTHOR]