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Background The edge-to-edge technique (Alfieri stitch) has been widely adopted in mitral valve but not tricuspid valve (TV) repair. We evaluated long-term clinical and hemodynamic outcomes of tricuspid edge-to-edge repair. Methods We retrospectively reviewed 237 patients (mean age, 58.4 ± 13.9 years) who had undergone tricuspid edge-to-edge repair from January 2001 to March 2019 in our institution. Tricuspid annuloplasty was performed in 175 patients (73.8%) using ring (91 [38.4%]) or suture (84 [35.4%]) annuloplasty. Concomitant procedures were mitral valve replacement (133 [56.1%]), mitral valve repair (52 [21.9%]), aortic valve replacement (41 [17.3%]), and maze operation (138 [58.2%]). Results Postoperative echocardiography revealed mild or less tricuspid regurgitation (TR) in 220 patients (92.8%). Early mortality ( Conclusions Tricuspid edge-to-edge repair showed acceptable long-term clinical and hemodynamic results and is an effective and safe option in TV surgery.

The first aim of this study was to develop a prothrombin time international normalized ratio (PT INR) prediction model. The second aim was to develop a warfarin maintenance dose decision support system as a precise warfarin dosing platform. Data of 19,719 inpatients from three institutions was analyzed. The PT INR prediction algorithm included dense and recurrent neural networks, and was designed to predict the 5th-day PT INR from data of days 1–4. Data from patients in one hospital (n = 22,314) was used to train the algorithm which was tested with the datasets from the other two hospitals (n = 12,673). The performance of 5th-day PT INR prediction was compared with 2000 predictions made by 10 expert physicians. A generator of individualized warfarin dose-PT INR tables which simulated the repeated administration of varying doses of warfarin was developed based on the prediction model. The algorithm outperformed humans with accuracy terms of within ± 0.3 of the actual value (machine learning algorithm: 10,650/12,673 cases (84.0%), expert physicians: 1647/2000 cases (81.9%), P = 0.014). In the individualized warfarin dose-PT INR tables generated by the algorithm, the 8th-day PT INR predictions were within 0.3 of actual value in 450/842 cases (53.4%). An artificial intelligence-based warfarin dosing algorithm using a recurrent neural network outperformed expert physicians in predicting future PT INRs. An individualized warfarin dose-PT INR table generator which was constructed based on this algorithm was acceptable.

Surgical edge-to-edge repair has been suggested for tricuspid regurgitation (TR) with complex tricuspid valve (TV) pathologies. Nevertheless, the impact of concomitant TAP has not been well established. This study aimed to compare the outcomes of tricuspid edge-to-edge repair according to the implementation of concomitant TAP.A total of 264 patients who underwent tricuspid edge-to-edge repair between January 2001 and December 2020 were enrolled in the study, and 23 patients who had undergone previous TV repair were excluded. The remaining 241 patients were categorized into two groups: TAP (n = 190) and non-TAP (n = 51). Inverse probability of treatment weighting (IPTW) was used to adjust the baseline differences between the two groups.Early mortality and morbidity did not differ between the two groups. The mean follow-up duration was 111.5 ± 72.4 months. IPTW-adjusted survival analysis did not reveal a difference between the two groups in late significant tricuspid stenosis (trans-tricuspid pressure gradient ≥5 mmHg) and TV reoperations. However, freedom from overall mortality and late severe TR were significantly higher in the TAP group (p = 0.033 and 0.006, respectively). The sensitivity analysis, including propensity score matching, showed consistent results.The long-term outcomes of surgical tricuspid edge-to-edge repair were better when performed with concomitant TAP.

BACKGROUND: Left ventricular assist devices (LVADs) were not covered by the Korean national insurance until September 2018, and they were implanted at the patient’s own or a third party’s expense. However, there have been no reports on using an LVAD without insurance coverage or manufacturer support. METHODS: We reviewed 23 patients who underwent durable LVAD implantation at our institution from August 2012 to September 2018. Patients with temporary LVADs using extracorporeal or paracorporeal circulation were excluded. The available devices were the HeartMate II(TM) (HMII) and HeartWare(TM) Ventricular Assist Device (HVAD). The primary outcome was 30-day mortality. The secondary outcomes were postoperative complications and late mortality. RESULTS: The mean age of the patients was 68.7±9.9 years. The study sample comprised six female (26.1%) and 17 male (73.9%) patients. All patients had modifiable (bridge to candidacy) or unmodifiable absolute (destination therapy) contraindications for heart transplantation (HT). Among the patients in this study, 12 (52.2%) had ischemic cardiomyopathy and 11 (47.8%) had non-ischemic cardiomyopathy. Nine patients (39.1%) had temporary mechanical circulatory support such as extracorporeal membrane oxygenation or a temporary LVAD in place preoperatively. The average duration of LVAD support was 618.6±563.2 days (range, 59–2,285 days). There was no 30-day mortality. Four patients (17.4%) underwent HT. Six patients (26.1%) underwent re-exploration for postoperative bleeding, and one patient (4.3%) had a disabling stroke after discharge. The estimated survival rates at 12 and 24 months were 89.2% and 68.8%, respectively. CONCLUSIONS: All patients who received LVADs before insurance coverage had contraindications for HT. The overall outcomes were comparable with those reported in the international registry.

Little is known regarding the effects of early showers after cardiac surgery. We evaluated the influence of early showers on postoperative wound complications following cardiac surgery.This was a prospective observational study of 100 cardiac surgery patients (mean age, 63.0±13.5 years) who underwent early postoperative showers from September 2020 to March 2021 at our institution. Postoperative showers were initiated after the drain was removed. Postoperative wound complications were examined and patient satisfaction was evaluated using questionnaires.Surgery was performed through sternotomy in 48 patients (48.0%) and through minimally invasive approaches (right or left mini-thoracotomy) in 52 patients (52.0%). The mean time from surgery to shower was 6.0±1.4 days. No wound dehiscence, superficial wound infection, or deep wound infection was observed. Questionnaires showed that more than 50% of patients thought they were not allowed to shower until more than 2 weeks after the operation. Patient satisfaction score was 7.4±2.3 out of 10 for early showers after cardiac surgery.Our study suggests that postoperative early showers after cardiac surgery are not associated with an increased risk of wound complications. Patient satisfaction was also high. Early postoperative showering can be considered after cardiac surgery.

Background: Coronary artery bypass grafting (CABG) is being offered increasingly frequently to octogenarians. However, old age is known to be an independent risk factor in CABG. The aim of this study was to compare the outcomes of off-pump coronary artery bypass (OPCAB) between octogenarians and septuagenarians. Methods: We retrospectively reviewed the data of 1,289 consecutive patients aged ≥70 years who underwent OPCAB at a single institution between 2001 and 2016. We compared the outcomes of 115 octogenarians and 1,174 septuagenarians. Using propensity score matching, based on preoperative clinical characteristics, 114 octogenarians were matched with 338 septuagenarians. Results: Propensity score analysis revealed that the incidence of acute kidney injury (14.9% vs. 7.9%, p=0.028) and respiratory complications (8.8% vs. 4.2%, p=0.040) was significantly higher in octogenarians. The early mortality rate (2.6% vs. 1.0%, p=0.240) and 1-year survival rate (89.5% vs. 94.4%, p=0.097) were not statistically significant between the groups. However, the 5-year survival rate (67.3% vs. 79.9%, p＜0.001) was significantly lower in octogenarians. Previous myocardial infarction and a left ventricular ejection fraction ≤35% were associated with a poor 1-year survival rate. Conclusion: Early and 1-year outcomes of OPCAB in octogenarians were tolerable when compared with those in septuagenarians. OPCAB could be a suitable option for octogenarians.

Background Extracorporeal life support (ECLS) is used as a bridge to revascularization in high-risk patients with ischemic heart disease. We reviewed our experiences of coronary artery bypass grafting (CABG) after ECLS in patients with cardiac arrest or refractory cardiogenic shock. Methods We retrospectively reviewed 4,616 patients who underwent CABG at our institution between May 2006 and February 2017. We identified patients who underwent CABG following ECLS for cardiogenic shock or cardiac arrest. Twenty-three patients (0.5% of all CABG cases) were enrolled in the analysis. Their median age was 65 years (Q1-Q3, 58-77 years). Nine patients (39.1%) were diagnosed with ST-elevation myocardial infarction. Mechanical complications after acute myocardial infarction, including acute mitral regurgitation, left ventricular rupture, and ventricular septal defect, occurred in 9 patients (39.1%). Results The median time from cardiopulmonary resuscitation to ECLS initiation was 25 minutes (Q1-Q3, 18.5-28.5 minutes). Conventional CABG was performed in 10 patients (43.5%) who underwent concomitant intracardiac procedures. Postoperative ECLS was required in 16 patients (69.5%). The rate of successful ECLS weaning was 91.3% (n=21). There were 6 early mortalities (26.1%). Conclusion CABG after ECLS was very rare in real-world circumstances. Although the early mortality rate was high, the risk of mortality may be acceptable under such devastating circumstances.

Background The aim of this study was to evaluate the efficacy of early amiodarone-based pharmacological cardioversion for postoperative atrial fibrillation (POAF) following off-pump coronary bypass grafting (OPCAB). Methods A total of 507 patients who underwent OPCAB between 2015 and 2017 were categorized into POAF (n=94) and no-POAF (n=413) groups. Patients in the POAF group were treated according to the following institutional protocol: 150 mg loading dose of intravenous amiodarone, followed by oral administration with sequential maintenance doses at 600, 400, and 200 mg per day. If sinus rhythm was restored before discharge, patients were discharged without amiodarone or anticoagulants, except for dual antiplatelets. Results Before discharge at index hospitalization, 97.8% of POAF patients had restored sinus rhythm. Independent risk factors for POAF were age, unstable angina, prior percutaneous transluminal coronary angioplasty, and left atrial diameter. The mean follow-up duration was 41.1±12.8 months. Freedom from overall mortality and composite events, including mortality, major bleeding requiring admission and cerebrovascular events, were similar between the 2 groups. Results were consistent after propensity-score matching. Conclusions Amiodarone-based rapid pharmacological cardioversion of POAF resulted in a high sinus rhythm conversion rate (97.9%). Rate of late adverse cardiovascular events including stroke, were low even without anticoagulation. As optimal treatment and anticoagulation guidelines for POAF after OPCAB have not yet been established, amiodarone-based treatment protocols may be considered as a useful option.

Background Extracorporeal life support (ECLS) is widely used in refractory cardiac or pulmonary failure. Because complications of general thoracic surgery frequently involve the heart or lungs, ECLS can be a useful option. Therefore, we retrospectively reviewed our experience with ECLS after general thoracic surgery. Methods There were 17,185 adult general thoracic surgery procedures between 2005 and 2013 at our institution, including resection of the lung (n = 10,434; 60.7%), esophagus (n = 1,847; 0.7%), and other procedures (n = 4,904; 28.5%). Twenty-nine patients (0.2%) were supported by ECLS postoperatively. Results The median age was 64 years (range, 24 to 81). Primary operations were lobectomy (n = 13; 44.8%), pneumonectomy (n = 11; 37.9%), and bilobectomy (n = 5; 17.2%). The initial mode of ECLS was venovenous in 20 patients (69.0%) and venoarterial in 9 patients (31.0%). There were 10 patients (34.5%) who survived to decannulation and 7 patients (24.1%) who survived to discharge. Over the same period, the survival to decannulation rate and survival to discharge rate were 49.5% and 35.0%, respectively, among all ECLS patients (n = 759) at our institution. The hospital mortality of patients with surgery to ECLS time of longer than 2 days was 90.9%. Multivariate analysis revealed that a longer surgery to ECLS time was a risk factor for hospital mortality (odds ratio 1.720, 95% confidence interval: 1.039 to 2.849, p = 0.035). Conclusions ECLS after general thoracic surgery can be a viable rescue therapy option. Late presentation of complications or ECLS for late complications of general thoracic surgery may be predictors of death.

Background: Flowable hemostatic agents may be more advantageous than nonflowable hemostats, as they have capability to cover irregular wound surfaces, fill deep lesions, and easily remove excess materials with irrigation. In this study, we evaluated the hemostatic efficacy of the collagen hemostatic matrix (CHM) compared to FloSeal ® via incisions in the heart and cardiac vessels in a porcine model. Methods: In each of the two female pigs, a total of two incisions were made in seven locations: right atrium (RA), right ventricle (RV), and cardiac vessels, such as the innominate vein (IV), superior vena cava (SVC), pulmonary artery (PA), coronary artery (CA), and aorta. Hemostatic agents were applied directly to the bleeding wounds. In certain location, one incision was treated with the CHM and the other with FloSeal ® , and the time to hemostasis and the degree of bleeding of the two agents were assessed and compared. One week after surgery, the animals were sacrificed, and specimens were collected for histologic evaluation. Results: Bleeding from the vessels with relatively low pressure (the IV, SVC, and RA) was controlled within 1–2 minutes using both a CHM and FloSeal ® . Bleeding from the vessels with high blood pressure (the RV, PA, CA, and aorta) was controlled within 3–10 minutes with the CHM. However, hemostasis in the PA and CA was not achieved with FloSeal ® . Histological analysis revealed that the use of both the CHM and FloSeal ® resulted in foreign body reactions of similar severity. Conclusions: The hemostatic effect and safety of the CHM may be similar to that of FloSeal ® . Further clinical studies must be conducted to validate our results.

OBJECTIVESPatients on extracorporeal life support (ECLS), like other critically ill patients, are transported to other institutions for various reasons. However, little has been reported concerning the characteristics and clinical outcomes of transported patients compared with those of in-house patients.METHODSA total of 281 adult patients received ECLS between January 2014 and August 2016. Patients who underwent cannulation at another institution by our team were excluded. Patients were divided into 2 groups: transported group (N = 46) and in-house group (N = 235). All 46 patients were safely transported without serious adverse events. The mean travel distance was 206±140 km, with a mean travel time of 78 ± 57 min. Following propensity score matching, 44 transported patients were matched to 148 in-house patients.RESULTSIn the matched population, the mean age was 48 ± 13 years in the transported group and 49 ± 17 years in the in-house group (P = 0.70). The ECLS type (venoarterial/venovenous) comprised 35/9 (79.5/20.5%) in the transported group and 119/29 (80.4/19.6%) in the in-house group (P = 0.93). Seventeen (38.6%) extracorporeal cardiopulmonary resuscitations were performed in the transported group and 59 (39.9%) were performed in the in-house group (P = 0.91). The incidence of limb ischaemia and acute kidney injury was higher in the transported group (P = 0.007 and P = 0.001, respectively). However, the rate of survival to discharge did not differ between the groups (63.6% in the transported group vs 64.2% in the in-house group, P = 0.94) and there was no difference in overall mortality (P = 0.99).CONCLUSIONSAlthough transported patients had more complications than in-house ECLS patients, clinical outcomes were comparable in the matched population. Transporting ECLS patients to an experienced centre may be justified based on our experience.

Objective The aim of this study was to evaluate the long-term clinical and hemodynamic influences of prophylactic tricuspid annuloplasty (TAP) in patients with less-than-moderate tricuspid regurgitation (TR) who underwent mitral valve replacement (MVR). Methods Between November 1994 and December 2010, 293 patients with less-than-moderate TR who underwent primary mechanical MVR were categorized into 2 groups: TAP (n = 151) or no TAP (n = 142). The median age was 51 years (quartile (Q)1-Q3, 43-59 years). The cause of valve pathology was rheumatic in 92.5% of patients (n = 271). The prevalence of preoperative atrial fibrillation was in 73.0%. Using propensity score matching based on demographic information, 91 TAP patients could be matched to 91 no TAP patients. Median follow-up duration was 107 months (Q1-Q3, 76-162 months). Results There was no early mortality in either group. Early morbidities, including heart block were not different between groups. Although overall survival and freedom from cardiac-related mortality did not differ between groups ( P = .519 and P = .115, respectively), freedom from recurrence of moderate or higher TR grade were significantly higher in the TAP group ( P = .043). In subgroup analyses, these group differences of TAP were especially prominent in patients with sinus rhythm compared with patients with atrial fibrillation at discharge ( P = .047 vs P = .460). Conclusions Prophylactic TAP for patients with less-than-moderate TR grade who underwent mechanical MVR can prevent late TR progression without increasing early surgical risks. Longer-term follow-up is required to determine the clinical beneficial effect of prophylactic TAP.

Based on data reported for facilitated CO2 transport membranes, we analyzed the factors that would enhance their performance by utilizing an ionic liquid (IL)/Cu nanoparticle (NP) composite. The previously reported ILs were BMIM NO3, BMIM BF4, MOIM BF4, and HMIM NO3. Compared with neat ILs, the selectivity of the ILs/Cu increased with the enhancement of permeance. We investigated the effect of the percentage of free ions in ILs and the size of the Cu NPs on CO2 separation performance. In addition, we found that the viscosity and steric effect of ILs played an important role in enhancing separation performance. In this regard, CO2 easily dissolved in the low-viscosity ILs, and their low steric effect allowed the ILs to readily interact with the surface of the Cu NPs.

The study aimed to evaluate the late clinical outcomes of new-generation mechanical valves for severe aortic stenosis (AS) compared with old mechanical valves.We retrospectively reviewed data from 254 patients with severe AS, who underwent primary mechanical aortic valve replacement from 1995 to 2013. Patients were classified into two groups: old-valve group (n=65: 33 ATS standard, 32 Medtronic-Hall) and new-valve group (n=189: 113 St. Jude Regent, 46 On-X, 30 Sorin Overline). Median patient age was 58 years (Q1-Q3: 52-61). With propensity score matching based on demographic information, 56 patients in the old-valve group were matched with 177 patients in the new-valve group. The median follow-up duration was 91 months (Q1-Q3: 48-138).Cardiac-related mortality and hemorrhagic events were significantly lower in the new-valve group (P=0.047 and P=0.032, respectively). The median international normalized ratio (INR) at follow-up was significantly higher in the old-valve group [2.23, Q1-Q3: 2.14-2.35 (old-valve group); 2.08, Q1-Q3: 1.92-2.23 (new-valve group), P0.001]. The incidence of prosthesis-patient mismatch (PPM) was significantly higher in the old-valve group (P0.001). Multivariate analysis of the total population revealed that PPM was a significant risk factor for cardiac-related events [hazard ratio (HR) =5.279, 95% CI, 1.886-14.561, P=0.002] and showed higher trend of increasing mortality (HR =3.082, P=0.076).New mechanical prostheses showed a better hemodynamic performance and lower incidence of PPM. Anticoagulation strategy to lower the target INR in patients with new mechanical valves may improve late outcomes by reducing hemorrhagic events.

The early and late outcomes of valve-sparing root replacement (VSR) in type A aortic dissection (AAD) are unknown. The aim of this study was to review the outcomes of VSR in AAD. We also compared the outcomes of VSR with the Bentall operation, which served as a standard reference technique.We retrospectively reviewed 52 patients who underwent surgery for AAD and concomitant root replacement between 1998 and 2013 at Samsung Medical Center. Patients were divided into two groups: Bentall (n = 34) and VSR (n = 18). Two out of six surgeons performed VSR. The mean follow-up duration was 62.3 ± 46.5 months.Preoperative characteristics were similar between the two groups except age (Bentall, 48 ± 11 years; VSR, 37 ± 11 years, p = 0.011). The aortic cross-clamping time was longer in the VSR group (Bentall, 185.8 ± 63.8; VSR, 241.4 ± 44.3 min, p = 0.002). There was no early death in the VSR group, but there was one in the Bentall group (p = 1.000). Despite the higher reoperation rate for aortic valve in the VSR group (Three reoperations) than in the Bentall group (no reoperation), major valve-related events and overall mortality did not differ between the two groups(p = 0.876 and 0.119, respectively). In multivariable analysis, the root replacement technique was not a risk factor for major valve-related events.VSR seems to be equivalent to the Bentall procedure for AAD in terms of early and late outcomes. VSR can be considered as a viable option, particularly for young patients with favorable aortic valve leaflets undergoing surgery at an experienced center.

Background This study aimed to evaluate the clinical outcomes of aortic root replacement (ARR) surgery: Root reimplantation as valve-sparing root replacement (VSR) and the Bentall procedure. Methods We retrospectively reviewed 216 patients who underwent ARR between 1995 and 2013 at Samsung Medical Center. Patients were divided into two groups, depending on the procedure they underwent: Bentall (n = 134) or VSR (n = 82). The mean follow-up duration was 100.9 ± 56.4 months. Results There were 2 early deaths in the Bentall group and none in the VSR group (p = 0.53). Early morbidities were not different between the groups. Overall mortality was significantly lower in the VSR group (HR = 0.12, p = 0.04). Despite the higher reoperation rate in the VSR group (p = 0.03), major adverse valve-related events (MAVRE) did not differ between the groups (p = 0.28). Bleeding events were significantly higher in the Bentall group during follow-up (10 in Bentall group, 0 in VSR group, p = 0.04). There were 6 thromboembolic events only in the Bentall group (p = 0.11). We performed a propensity score matching analysis comparing the groups (134 Bentall versus 43 VSR). Matched analysis gave similar results, namely, HR = 0.17, p = 0.10 for overall mortality and HR = 1.01, p = 0.99 for MAVRE. Conclusions Although there was marginal significance in the propensity matched analysis, it is plausible to anticipate a survival benefit with VSR during long-term follow-up. Despite a higher reoperation for aortic valves, VSR can be a viable option in patients who decline life-long anticoagulation, especially the young or the patients in whom anticoagulation is contraindicated.

Background: Sternal wound complications could increase the hospital cost while decreasing the satisfaction of surgery. Furthermore, it can potentially also lead to life-threatening mediastinitis especially after coronary artery bypass grafting using bilateral internal thoracic artery (BITA). Skill levels of suture technique vary among surgeons and may contribute to an increased wound complication rate. Thus, standardization of surgical wound closure could potentially decrease the surgeon factor. The aim of the study is to compare the wound complication rate between non-invasive surgical skin closure devices (zip surgical skin closure device, Zipline Medical, Campbell, CA, USA) and conventional suture closure. Methods: Three hundred seventy-nine patients who underwent off-pump coronary artery bypass grafting (OPCAB) using BITAs at our institution between 2016 and 2018 were included in this study. Patients were divided into two groups; the Zipline group (zip-group, N=100), and conventional group (con-group, N=279). Following propensity score matching, 95 con-group patients were matched to 169 zip-group patients. Results: The average age and history of cancer were significantly higher in the zip-group (P=0.021 and P=0.023, respectively). However, after propensity score matching, no differences were observed in the demographic data between the groups. In total patients (unmatched), although there was no significant difference in the incidence of deep sternal wound infection (DSWI) between the two groups (zip vs . con, 0% vs . 1.1%, P=0.569), the incidence of post-operative superficial sternal wound infection (SSWI) or dehiscence was significantly higher in the con-group than in the zip-group (1.0% vs . 7.9%, P=0.013). The results were consistent in the matched patients. (DSWI: 0% vs . 0.6%, P>0.999; SSWI or dehiscence: 1.1% vs . 7.1%, P=0.036). Multivariable analysis revealed use of the zip surgical skin closure device showed a preventive effect against wound complications [odds ratio (OR): 0.128, 95% confidence interval (CI): 0.017–0.976, P=0.029]. Conclusions: Zip surgical skin closure devices could decrease superficial wound complication rates compared to conventional suture techniques in OPCAB using BITAs.

Congenital pericardial defects (CPDs) are infrequent anomalies that are usually asymptomatic and are discovered incidentally during unrelated interventions. Here we report the case of a CPD with herniation of an enlarged left atrial appendage identified during total thoracoscopic ablation (TTA) for persistent atrial fibrillation (AF). The persistent AF was successfully treated with a hybrid procedure, in which TTA was followed by an electrophysiological study.

Based on data reported for facilitated CO2 transport membranes, we analyzed the factors that would enhance their performance by utilizing an ionic liquid (IL)/Cu nanoparticle (NP) composite. The previously reported ILs were BMIM NO3, BMIM BF4, MOIM BF4, and HMIM NO3. Compared with neat ILs, the selectivity of the ILs/Cu increased with the enhancement of permeance. We investigated the effect of the percentage of free ions in ILs and the size of the Cu NPs on CO2 separation performance. In addition, we found that the viscosity and steric effect of ILs played an important role in enhancing separation performance. In this regard, CO2 easily dissolved in the low-viscosity ILs, and their low steric effect allowed the ILs to readily interact with the surface of the Cu NPs.

Unfractionated heparin (UFH) is currently the standard anticoagulant used in extracorporeal life support (ECLS). However, severe thrombocytopenia occurs frequently during ECLS use and it may be difficult to determine whether this represents heparin-induced thrombocytopenia (HIT) or not. In this case, UFH cannot be continued. Because a confirmatory laboratory test requires time, argatroban is empirically used if HIT is suspected. However, many patients are not found to have HIT. In non-HIT patients, the effectiveness and safety of argatroban are unclear. Thus, we investigated whether argatroban was safe and useful in patients who were suspected of having HIT and were started on argatroban, but were ultimately found to have non-HIT. We retrospectively reviewed all patients on ECLS who received the anticoagulant argatroban as an alternative to UFH between January 2014 and July 2015. The pretest clinical score (4Ts) was calculated, and a score greater than 4 was considered an indication for argatroban. The target-activated clotting time or activated partial thromboplastin time was 1.5 times the patient's upper normal value. Of 191 patients on ECLS during the study period, 10 (5.2%) were treated with argatroban infusion. No patients were found to have antiplatelet factor 4/heparin antibodies. The average maintenance dose of argatroban was 0.1 μg/kg/min. Platelet counts increased significantly following argatroban administration (P = .02). There were no anticoagulation-related complications such as bleeding or thrombosis. Our results suggest that argatroban is a safe alternative to UFH for patients with non-HIT on ECLS. Argatroban may have a more significant platelet-preserving effect than UFH, regardless of whether HIT is present.

Background Reconstruction of the aortic arch in patients with complex aortic coarctation or interruption continues to be a challenge because of early left main bronchial compression or recoarctation and late Gothic arch formation. We propose a modified arch reconstruction technique augmenting the lesser curvature with an autologous vascular patch, which can relieve tension on the anastomosis without a prosthetic material. Methods We retrospectively reviewed 33 patients with coarctation and arch hypoplasia (n = 31) or arch interruption (n = 2) who underwent arch reconstruction with an autologous vascular patch from 2007 to 2012. Median age at the operation was 17 days (range, 5 to 200 days). Median body weight was 3.7 kg (range, 2.3 to 7.0 kg). Cardiopulmonary bypass was used for all operations. Median antegrade selective cerebral perfusion time was 35 minutes (range, 23 to 59 minutes). Combined intracardiac anomalies in 29 patients (88%) were corrected simultaneously. The reconstructed arch was supplemented in the lesser curvature with an autologous vascular patch that was harvested from aortic isthmus (n = 25), pulmonary artery (n = 4), left subclavian artery (n = 2), aberrant right subclavian artery (n = 1), or distal arch (n = 1). Results One patient (3%) died of acute respiratory distress syndrome. All survivors were discharged at 15 days (range, 7 to 58 days) postoperatively without neurologic complications or bronchial obstructions. Median follow-up was 24.8 months (range, 0.2 to 48.5 months). No recoarctation was observed during follow-up, and no patient needed reoperation. Conclusions Augmenting the lesser curvature with an autologous vascular patch during arch reconstruction resulted in excellent midterm outcomes. Not only can a more natural shape of arch and less tension on the anastomosis be obtained, but complications, such as left main bronchial obstruction or recoarctation, can also be minimized. Long-term follow-up is needed to evaluate late development of recoarctation, hypertension, or aneurysm formation.

Irinotecan and cisplatin demonstrated promising outcomes in extensive-stage small-cell lung cancer. According to the dosage and schedule of irinotecan, efficacy and toxicity profiles showed subtle differences. This study was designed to evaluate efficacy and toxicity of 3-week schedule of irinotecan/cisplatin in patients with previously untreated extensive-stage small-cell lung cancer. The primary objective was to evaluate response rate and secondary objectives were overall survival and progression-free survival. Patients with previously untreated extensive-stage small-cell lung cancer were enrolled. Irinotecan 65 mg m-2 was administered on days 1 and 8 and cisplatin 60 mg m-2 on day 1. Treatment was repeated every 3 weeks. Seven out of 54 patients (13.0%) had complete response, and partial response was observed in 33 (61.1%). The overall response rate was 74.1% (95% CI; 62.0-82.2%). Stable disease was observed in eight (14.8%) and no progressive disease was observed. After a median follow-up duration of 28.7 months, the median overall survival and progressive-free survival were 13.6 and 6.5 months, respectively. Major grade 3/4 toxicities were neutropenia (50.0%), anorexia (42.6%), diarrhoea (29.6%), fatigue (29.6%) and vomiting (13.0%). There was one treatment-related death owing to pneumonia. Three-week schedule of irinotecan/cisplatin showed effective antitumour activity and moderate toxicities in patients with previously untreated extensive-stage small-cell lung cancer.

Background Extracorporeal life support (ECLS) is widely used in refractory heart or lung failure, and the demand for inter-facility transportation on ECLS is expanding. However, little is known about post-transportation outcomes, the clinical safety of such transportation, or the characteristics of the transported patients. Methods This was a retrospective review of a 3-year, single-institution experience with inter-facility ECLS transport, as well as a comparative analysis of clinical outcomes with those of in-house patients. We also analyzed the risk factors for hospital mortality in the entire ECLS population using univariate and multivariate analyses to investigate the effects of transport. Results All 44 patients were safely transported without adverse events. The average travel distance was 178.7 km, with an average travel time of 74.0 minutes. Early survival of the transported group seemed to be better than that of the in-house group, but the difference was not statistically significant (70.5% vs. 56.6%, p=0.096). The incidence of complications was similar between the 2 groups, except for critical limb ischemia, which was significantly more common in the transported group than in the in-house group (25.0% vs. 8.1%, p=0.017). After adjusting for confounders, being part of the transported group was not a predictor of early death (adjusted odds ratio, 0.689; p=0.397). Conclusion Transportation of patients on ECLS is relatively safe, and the clinical outcomes of transported patients are comparable to those of in-house ECLS patients. Although matched studies are required, our study demonstrates that transporting patients on ECLS did not increase their risk of hospital mortality after adjustment for other factors.