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Background: Hospitalization-associated disability (HAD) is associated with prolonged functional decline and increased mortality after discharge. Therefore, we examined the incidence and risk factors associated with HAD in elderly patients undergoing cardiac surgery in Japan. Methods and Results: We retrospectively examined 2,262 elderly patients who underwent elective cardiac surgery at Sakakibara Heart Institute. HAD was defined as a functional decline between time of admission and discharge measured by the Barthel Index. We analyzed clinical characteristics using machine learning algorithms to identify the risk factors associated with HAD. After excluding 203 patients, 2,059 patients remained, of whom 108 (5.2%) developed HAD after cardiac surgery. The risk factors identified were age, serum albumin concentration, estimated glomerular filtration rate, Revised Hasegawa’s Dementia Scale, N-terminal pro B-type natriuretic peptide, vital capacity, preoperative Short Physical Performance Battery (SPPB) score, operation times, cardiopulmonary bypass times, ventilator times, length of postoperative intensive care unit stay, and postoperative ambulation start day. The highest incidence of HAD was found in patients with an SPPB score ≤9 and in those who started ambulation >6 days after surgery (76.9%). Conclusions: Several risk factors for HAD are components of frailty, suggesting that preoperative rehabilitation to reduce the risk of HAD is feasible. Furthermore, the association between HAD and a delayed start of ambulation reaffirms the importance of early mobilization and rehabilitation.

BACKGROUND The purpose of this study was to investigate if the transcatheter aortic valve replacement (TAVR) risk score can independently predict outcomes following TAVR, and to evaluate its predictive performance.Methods and Results:This retrospective multicenter study comprised 682 patients with severe aortic stenosis who underwent TAVR. The primary endpoint was all-cause death following TAVR. The clinical model was established using variables identified as independent predictors in the multivariate analysis. Incremental values were assessed after adding atrial fibrillation, body mass index (BMI), and serum albumin to the TAVR risk score in receiver-operating characteristic analysis. The median TAVR risk score was 2.1% with a mean follow-up of 505 days. On Kaplan-Meier analysis, a TAVR risk score >4% had lowest survival rate, whereas TAVR risk score ≤2% had the highest survival rate at 3 years (log-rank P

Background To obtain a saphenous vein graft (SVG) for coronary artery bypass grafting (CABG), the benefit of using a no-touch (NT) technique in vascular function has not been fully investigated. Methods and Results: The pathological and physiological functions of human SVGs with a NT technique to preserve the perivascular adipose tissue (PVAT) and ones obtained by using a conventional (CON) technique removing PVAT, were examined. Immunohistochemistry of the section of SVGs showed that the phosphorylation of endothelial nitric oxide synthase in the endothelium of the NT group was more responsive to vascular endothelial growth factor. A myograph of SVGs showed greater contraction with phenylephrine in the NT group. However, the strong contraction was eliminated in SVGs taken by electrocautery. In the 10 patients whose SVGs were taken without electrocautery, endothelial-dependent relaxation with bradykinin was apparently increased in the CON group more than in the NT group. Smooth muscle relaxation with nitroprusside was higher in the CON group at the lower concentrations; however, the relaxation became greater in the NT group at the high concentrations. Therefore, the effect of neutralizing PVAT-released factors in the both groups was further examined. After medium of NT and CON were exchanged in half, relaxation of SVGs was immediately restored in the NT group. Conclusions The results suggest that the NT technique preserves the functions of vasoconstriction and relaxation. Also, the presence of PVAT-released vasoconstrictive factors was suspected.

Background Transcatheter aortic valve replacement (TAVR) has been an alternative less invasive therapy for high-surgical risk/inoperable patients with aortic valve stenosis (AS) in Japan. We report 5-year outcomes of the first pivotal clinical trial of TAVR in Japan (PREVAIL JAPAN).Methods and Results:A total of 64 patients with AS who were considered unsuitable candidates for surgery were enrolled at 3 centers in Japan (mean age: 84.3±6.1 years, female: 65.6%, STS score: 9.0±4.5%). Transfemoral approach (TF) and transapical approach (TA) was performed in 37 patients and 27 patients, respectively. At 5 years, freedom from all-cause death was 52.7% (TF: 51.3%, TA: 56.3%). Risk of all stroke at 5-year was 15.8% (TF: 8.9%, TA: 25.5%) and risk of major adverse cardiac and cerebrovascular events at 5 years was 58.0% (TF: 51.3%, TA: 69.2%). Mild or greater aortic regurgitation (AR) at 1 week was not associated with increased all-cause death at 5 years (69.1%) compared with none or trace AR (48.3%) (P=0.184). Patients with high STS score (>8) had higher mortality rate than those with low STS scores (≤8). Conclusions The 5-year data from PREVAIL JAPAN show the clinical benefit of TAVR and suggest that balloon-expandable TAVR is an effective treatment option for Japanese patients with severe AS who are not suitable for surgery. (Funded by Edwards Lifesciences Limited; ClinicalTrials.gov number, NCT01113983.).

BACKGROUND We conducted in vivo examinations of a newly designed stentless mitral valve (SMV), formed by suturing 2 leaflets with the "legs" serving as chorda tendinea, made from bovine pericardium, to a flexible ring. METHODS AND RESULTS: Seven pigs underwent implantation of the SMV constructed with a 23-mm (n=5) or 25-mm (n=2) Duran ring. Baseline echocardiography examinations were used to evaluate the annular anteroposterior diameter, and distance between the mitral annulus (MA) and papillary muscles (PMs) to determine SMV-leg length. After removing the native valve, the SMV-legs were fixed to the anterior and posterior PMs, followed by fixation of the ring to the native MA. Immediately after surgery, all animals presented none or trivial mitral regurgitation, with mean and peak trans-SMV pressure gradient values of 1.9±0.8 and 6.0±3.1 mmHg, respectively. The mean length of the SMV-leg was 19.4±3.9 mm, which correlated with the distance between anterior and posterior MA-PM (r=0.96 and 0.94, respectively, P

Background After reports of cardiac impairment caused by mitral annuloplasty with rigid rings, several prosthetic rings with semi-rigidity were introduced. The influence of semi-rigid rings on postoperative cardiac function remains unknown. This study compared postoperative cardiac function between patients receiving a semi-rigid prosthetic ring and those receiving a flexible ring or band. Methods and results Transthoracic echocardiographic data of 305 patients who underwent mitral valve repair for degenerative mitral regurgitation (227 patients receiving a semi-rigid ring and 78 receiving a flexible ring or band) were retrospectively reviewed. The imbalance in the preoperative characteristics between groups was adjusted with propensity score matching. Left ventricular ejection fraction, end-diastolic dimension, and end-systolic dimension were compared at 1 week, 6 months, and 1 year after surgery. Propensity score matching yielded 68 matched pairs of patients for whom there were few group differences in preoperative covariates. Between patients receiving a semi-rigid ring and those receiving a flexible ring or band in the propensity-matched cohorts, there were no significant differences in ejection fraction (P=0.322), end-diastolic dimension (P=0.576), or end-systolic dimension (P=0.567). Conclusions There was little difference in the influence on postoperative cardiac function between semi-rigid rings and flexible rings or bands.

With the development of techniques and technologies in the past decade, minimally invasive valve surgery (MIVS) has become a well-established surgical option for heart valve disease. Unlike emerging transcatheter valves, MIVS still requires cardiopulmonary bypass and cardiotomy. The only difference between minimally invasive and conventional valve operations is whether a full sternotomy is avoided or not. The minimally invasive approach has been shown to have some beneficial effects such as reduced blood transfusion and faster postoperative recovery. However, these could be limited and outweighed by the potential adverse effects of small access. Careful selection of patient, approach and perfusion strategy based on thorough preoperative assessment and each surgical team experience is necessary to perform MIVS safely.

BACKGROUND Patients with both cardiothoracic lesions and abdominal aortic aneurysm (AAA) are increasing in Japan. The objective of this study was to clarify the effect of 2-staged surgery on complication rates. METHODS AND RESULTS Three hundred and forty-six patients who underwent elective surgery for infrarenal AAA were entered. History of cardiac and thoracic aortic surgery within 1 year before AAA repair was recorded. A retrospective study regarding perioperative complications was performed. Operative mortality and complication rates were 0.6% and 10.7%, respectively. Seventy patients (20.2%) underwent prior cardiac and thoracic aortic surgery before AAA repair. There was no significant difference in preoperative characteristics between the group with prior cardiac and thoracic aortic surgery and the group without prior surgery. Significant risk factors for postoperative morbidity were: (1) prior cardiac and thoracic aortic surgery (odds ratio [OR] 2.5; 95%CI 1.1-5.1); (2) open aneurysm repair (OAR) (OR 2.7; 95%CI 1.3-5.1); and (3) VSG-CRI score ≥6 (OR 2.9; 95%CI 1.2-6.8). Subanalysis revealed that, although prior cardiac and thoracic aortic surgery was still a risk within patients undergoing OAR, it was not a risk factor for patients undergoing endovascular aneurysm repair (EVAR). CONCLUSIONS Prior cardiac and thoracic aortic surgery carries high risk for AAA repair. To lower complication rates, we propose to perform EVAR on these patients if they are anatomically suitable.

Background The maze procedure for the treatment of atrial fibrillation (AF) is a widely used adjunctive therapy. It is necessary to define the precise indications for the procedure based on preoperative factors, but definitive parameters in terms of atrial function have not been well determined. Methods and Results In the present study, 55 consecutive patients undergoing the maze procedure for persistent AF in combination with operations for organic heart diseases were evaluated. After dividing the patients into successful (n=41) and unsuccessful procedure (n=14) groups, based on the postoperative rhythm, the preoperative left atrial (LA) emptying fraction measured by transthoracic 2-dimensional echocardiogram was compared between groups. The LA emptying fraction was calculated as [(LA maximum volume - LA minimum volume)/LA maximum volume]×100. The preoperative LA emptying fraction was higher in the successful procedure group than in the unsuccessful procedure group (31.2±8.5 vs 21.4±10.9%, P=0.0011). Based on receiver-perating characteristic curve analyses, LA emptying fraction >26% predicted successful maze procedure with 70.7% sensitivity and 78.6% specificity. Conclusions LA emptying fraction should be considered in the precise indications of the maze procedure as adjunctive therapy. (Circ J 2009; 73: 269 - 273)