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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.

Purpose Ruptured abdominal aortic aneurysm (rAAA) is one of the most common aortic emergencies in vascular surgery and is associated with high operative mortality and morbidity rates despite recent treatment advances. We evaluated operative mortality risks for the outcomes of emergency endovascular aneurysm repair (eEVAR) vs. open repair in rAAA. Methods Twenty patients underwent eEVAR (n = 12) or open repair (n = 8) for rAAA between 2016 and 2020. We adopted the EVAR first strategy since 2018. Primary endpoints included in-hospital mortality and 1-year survival. The outcome variables were analyzed with Fisher exact, Mann-Whitney test, and linear by linear association. The Kaplan-Meier method was used to estimate survival. Results There were 13 males (65.0%) and the median age of the study cohort was 78.0 years (range, 49–88 years). In-hospital mortality occurred in 7 patients (35.0%); 5 (50.0%) in the early period and 2 (20.0%) in the later period of this series. According to the procedure type, 4 (50.0%) and 3 (25.0%) in-hospital mortalities occurred in the open repair and eEVAR patients, respectively. In 6 patients (50.0%), eEVAR was performed on unfavorable anatomy. The 1-year survival of eEVAR vs. open repair group was 75% ± 12.5% and 50% ± 17.7%, respectively. On univariate analysis, preoperative high-risk indices, postoperative acute renal failure requiring dialysis, pulmonary complications, and prolonged mechanical ventilation were associated with higher operative mortality. Conclusion The current data showed relatively superior outcomes with eEVAR vs. open repair for rAAA, even in some patients with unfavorable anatomy supporting the feasibility, efficacy, and safety of EVAR first strategy.

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.

Purpose Ruptured abdominal aortic aneurysm (rAAA) is one of the most common aortic emergencies in vascular surgery and is associated with high operative mortality and morbidity rates despite recent treatment advances. We evaluated operative mortality risks for the outcomes of emergency endovascular aneurysm repair (eEVAR) vs. open repair in rAAA. Methods Twenty patients underwent eEVAR (n = 12) or open repair (n = 8) for rAAA between 2016 and 2020. We adopted the EVAR first strategy since 2018. Primary endpoints included in-hospital mortality and 1-year survival. The outcome variables were analyzed with Fisher exact, Mann-Whitney test, and linear by linear association. The Kaplan-Meier method was used to estimate survival. Results There were 13 males (65.0%) and the median age of the study cohort was 78.0 years (range, 49-88 years). In-hospital mortality occurred in 7 patients (35.0%); 5 (50.0%) in the early period and 2 (20.0%) in the later period of this series. According to the procedure type, 4 (50.0%) and 3 (25.0%) in-hospital mortalities occurred in the open repair and eEVAR patients, respectively. In 6 patients (50.0%), eEVAR was performed on unfavorable anatomy. The 1-year survival of eEVAR vs. open repair group was 75% ± 12.5% and 50% ± 17.7%, respectively. On univariate analysis, preoperative high-risk indices, postoperative acute renal failure requiring dialysis, pulmonary complications, and prolonged mechanical ventilation were associated with higher operative mortality. Conclusion The current data showed relatively superior outcomes with eEVAR vs. open repair for rAAA, even in some patients with unfavorable anatomy supporting the feasibility, efficacy, and safety of EVAR first strategy.

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 CVE and in-hospital mortality between patients with and without warfarin use at admission, although warfarin-naïve patients were significantly more 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.

Background An enlarged left atrium (LA) is a major risk factor for atrial fibrillation (AF) recurrence after a maze operation. Methods Between 2000 and 2009, 35 patients underwent circumferential left atrium resection (CLAR), during mitral valve surgery. All patients had continuous AF. Results Hospital mortalities occurred in two patients (5.7%). Postoperative bleeding occurred in two patients (5.7%). The average follow-up was 64 months. The mean New York Heart Association (NYHA) functional class had significantly decreased to 1.16 ± 0.37 from 2.77 ± 0.65 (p

Indication for extracorporeal membrane oxygenation (ECMO) has been extended as the experience of ECMO in various clinical settings accumulates and the outcome after ECMO installation improves. We report two cases of successful mitral valve surgery for severe ischemic mitral regurgitation in patients on ECMO support for cardiogenic shock which developed upon coronary angiography.

This study evaluated the mid-term results of the modified maze procedure using cryoablation for treating atrial fibrillation associated with rheumatic mitral valve disease. Between March 2000 and February 2004, 177 consecutive patients underwent the modified maze procedure using cryoablation concomitant with mitral valve surgery, were divided into the modified Cox-Maze III (group CM, n=88), modified Kosakai-Maze (group KM, n=63) and left atrial maze (group LA, n=26) procedures. Postoperative and follow-up results were analyzed and compared between the groups, with a mean follow-up time of 22.4+/-15.1 months. There were three hospital deaths (1.7%). The operative time was significantly longer in the group CM than the KM or LA groups, respectively. One late death developed in the CM group. At last follow-up, 139 patients had sinus rhythm (79.9%), which was regained in 67 CM (77.9%), 50 KM (80.7%) and 22 (84.6%) LA group (P=0.743) patients. Freedom from stroke at 4 years was 84.6% in the CM, 95.0% in the KM, and 92.9% in the LA (P=0.916) groups. There were no significant differences in the sinus conversion or stroke rate between patients with the left atrial appendage preserved and those with it excised or obliterated. The modified maze procedure using cryoablation is safe and effective, with an acceptable sinus conversion rate and clinical improvement.

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.

The purpose of this study is to evaluate the long-term outcomes of the button Bentall procedure for the correction of aortic root disease.A total of 195 patients who underwent the button Bentall procedure between 1997 and 2010 were studied. The main pathology was annuloaortic ectasia. A mechanical valve was used in 163 patients (83.6%). The median duration of follow-up was 64 months (14133.0 patient-years).There were five operative deaths (2.6%). Late overall mortality was 7.9%. The actuarial overall survival rate was 95.8 ± 1.5% at 5 years, 89.6 ± 3.4% at 10 years, and 75.9 ± 7.3% at 15 years. Multivariate logistic regression analysis identified preoperative poor mobility, cardiopulmonary bypass time, deep hypothermic circulatory arrest (DHCA) use, embolism, and bleeding event as significant independent risk factors for the late overall mortality. At 5, 10, and 15 years, actuarial composite valve graft-related event-free survival was 85.8 ± 2.8%, 75.5 ± 4.4%, and 69.3 ± 7.3%, respectively. Hypertension and concomitant coronary artery bypass graft (CABG) were independent predictors of composite valve graft-related events. Age, concomitant CABG, and DHCA use were associated with bleeding.Valve-related morbidities, such as embolism and bleeding, determine the long-term overall mortality in aortic root replacement with button Bentall operation, similar to that in routine valve surgery.

An enlarged left atrium (LA) is a major risk factor for atrial fibrillation (AF) recurrence after a maze operation.Between 2000 and 2009, 35 patients underwent circumferential left atrium resection (CLAR), during mitral valve surgery. All patients had continuous AF.Hospital mortalities occurred in two patients (5.7%). Postoperative bleeding occurred in two patients (5.7%). The average follow-up was 64 months. The mean New York Heart Association (NYHA) functional class had significantly decreased to 1.16 ± 0.37 from 2.77 ± 0.65 (p 0.01). The mean LA dimension and the cardiothoracic ratio had significantly decreased to 52.8 ± 7.9 mm, and 0.55 ± 0.06 from 72.6 ± 11.0 mm, and 0.66 ± 0.11, respectively (p 0.01). The mean early postoperative LA volume had decreased to 178 ± 68 mL (102-343 mL) from 332 ± 133 mL (124-655 mL) (p 0.001). These LA volume reductions had been maintained until the last echocardiogram, which was done at an average of 29 months. In patients who underwent the maze procedure, the rate of sinus rhythm restoration was 82.1%, 81.5%, and 74% at three to six months, one year, and the last visit, respectively.CLAR significantly reduced the LA volume. CLAR had an additional beneficial effect with the maze procedure of a relative rate of sinus rhythm restoration. To clarify the role of CLAR in marked symptom improvements after mitral valve surgery in patients with a giant LA, well-designed comparative studies are required.

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-to-apical 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.

The purpose of this study was to examine the incidence of pulmonary embolism (PE) after a coronary artery bypass graft (CABG) using 64-slice multidetector CT (MDCT), and to determine the correlations between the occurrence of a PE and the clinical or surgical parameters. Three hundred and twenty-six consecutive patients, who underwent coronary CT angiography using 64-slice MDCT to assess the graft patency after CABG, were enrolled in this study. Additional axial CT images, which were reconstructed by adopting a large field of view and thinner image slices, were reviewed for the presence of PE. The relationship between the occurrence of a PE and the type of surgery (off-pump CABG versus conventional CABG), number of target vessels, use of a saphenous vein graft, and length of stay in the intensive care unit (ICU) were evaluated. PE was detected on the CT images of 33 patients (10.1%), which involved the lobar or more proximal arteries in seven patients and the segmental or subsegmental arteries in 26. PE occurred more frequently after off-pump CABG (16.5%, 14/85) than after conventional CABG (7.9%, 19/241) (P = 0.024). Patients with PE were older (67 years vs. 62.7 years) and had longer stays in the ICU (5.6 days vs. 3.8 days) than those without (P = 0.013 and P = 0.007, respectively). No significant difference was observed in the number of target vessels and use of a saphenous vein graft between patients with and without an embolism. In a multi-variable analysis, the age of the patient, surgical methods, and ICU stay were independent predictors for the occurrence of PE (P = 0.013, P = 0.017, and P = 0.005, respectively). MDCT helps detect PE in patients after CABG. It is encountered more frequently after off-pump CABG than after conventional CABG and in older patients with longer ICU stays.

Background: We evaluated the efficacy of a well-prepared left internal thoracic artery (LITA) auto Y graft for simultaneous left anterior descending artery (LAD) and diagonal artery (DA) re-vascularisation in selected patients for the reduction of the number of required grafts and improved graft patency, while limiting technical problems. Methods: Twenty well-controlled diabetic patients, mean age 62.8 8.3, 17 males and three females, underwent isolated elective off-pump coronary artery bypass grafting using the LITA auto Y graft from July 2003 to August 2004.Results:In-hospital data and angiographic results at 6 months after the surgery showed that there was no early mortality, early graft failure and major morbidity except for two cases of superficial wound infection. The 3-year follow-up results including angiographic findings (mean of 37 3.3-month follow-up) demonstrated that all patients are alive and have excellent graft patency in both the LAD and DA. Only two cases required right coronary artery (RCA) stenting during the follow-up period. Compared with our previous routine LITA composite Y graft technique, it is assumed that LITA auto Y graft technique may reduce the number of mobilised conduits or avoided sequential anastomosis. Conclusions:This small study showed that our technique is technically feasible and may be safely performed to the selective patients. The LITA auto Y graft might be an additional surgical option, in terms of not only preserving the other grafts and maintaining patency in the LAD area bypass, but also preventing the need for sequential anastomoses. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Radial arteries are gaining widespread acceptance as complementary arterial conduits for surgical myocardial revascularization, but there are limited reports about its angiographic patency compared with that of the internal thoracic artery or saphenous vein according to the degree of native coronary stenosis. Therefore, we tried to evaluate the mid-term angiographic results of the radial artery graft patency focusing on the native coronary stenotic status in a prospective manner.From March 2000 to September 2006, a total of 488 patients underwent coronary artery bypass grafting using radial artery graft at our institution. From this group, 123 patients (mean age of 59.02+/-8.9 years (range 34-73 years)) were enrolled in the present study, and underwent a postoperative angiography after surgery (mean 32 months). The angiograms were assessed visually and quantitatively.A total of 382 distal anastomoses were performed and 352 anastomosis remained patent (92.1%). Left internal thoracic artery showed the most excellent patency in all of the conduits (128/129, 99.2%). Overall the radial artery graft patency was 92% (160/174). In the univariate analysis, patency was significantly worse for targets of the right coronary system (left coronary system 129/135, 94.4% vs right coronary system 31/39, 79.4%. p0.05) and the radial artery graft showed a higher patency rate in the case of a severe stenotic lesion that preoperatively revealed more than 90% stenosis (defined as critical stenotic lesion) than in the case of a less severe lesion (50%stenosis90%) (100/102, 98% vs 60/72, 83.3%. p0.05). The methods used for proximal anastomosis failed to affect radial artery patency (p=0.123). Multivariate analysis revealed the target vessel stenotic degree (50%stenosis90%) was closely related to radial artery graft failure (p=0.002, Exp (B)=0.067, CI=0.012, -0.373).Regardless of the small study population, our data revealed that the radial artery conduit showed good midterm patency when it grafted to the critical stenotic lesion (over 90%). One might pay attention to the grafting strategy when the preoperative coronary angiogram reveals less than 90% of coronary stenosis, especially in the right coronary system but a larger and well-designed study should be warranted to confirm these findings.

Triple valve surgery is usually complex and carries a reported operative mortality of 13% and 10-yr survival of 61%. We examined surgical results based on our hospital's experience. A total of 160 consecutive patients underwent triple valve surgery from 1990 to 2006. The most common aortic and mitral valve disease was rheumatic disease (82%). The most common tricuspid valve disease was functional regurgitation (80%). Seventy-four percent of the patients were in New York Heart Association (NYHA) class III and IV. Univariate and multivariable analyses were performed to identify predictors of early and late survival. Operative mortality was 6.9% (n=11). Univariate factors associated with mortality included old age, preoperative renal failure, postoperative renal failure, pulmonary complications, and stroke. Of them, postoperative renal failure and stroke were associated with mortality on multivariable analysis. Otherwise, neither tricuspid valve replacement nor reoperation were statistically associated with late mortality. Survival at 5 and 10 yr was 87% and 84%, respectively. Ninety-two percent of the patients were in NYHA class I and II at their most recent follow-up. Ten-year freedom from prosthetic valve endocarditis was 97%; from anticoagulation-related hemorrhage, 82%; from thromboembolism, 89%; and from reoperation, 84%. Postoperative renal failure and stroke were significantly related with operative mortality. Triple valve surgery, regardless of reoperation and tricuspid valve replacement, results in acceptable long-term survival.