Transcatheter aortic valve replacement (TAVR) has several alternative access routes when transfemoral access is unsuitable. This study compared perioperative and mid-term outcomes of transaxillary (TAx) TAVR with those of transapical (TA) and direct aortic (DA) approaches. Among 2,185 patients who underwent TAVR at our three centers between April 2015 and April 2024, 198 non-transfemoral cases were retrospectively analyzed. TAx-TAVR was classified as a non-thoracotomy approach, whereas TA/DA-TAVR were classified as thoracotomy approaches. Perioperative and mid-term outcomes were compared between the two groups. Of the 198 patients, 97 underwent the non-thoracotomy approach and 101 underwent thoracotomy (TA, n = 64; DA, n = 37). Most baseline characteristics were comparable, although dialysis-dependent patients were more common in the non-thoracotomy group. Operative time, transfusion requirement, and hospital stay were significantly greater in the thoracotomy group. Access-related complications included four events in the thoracotomy group (aortic injury or apical rupture) and five events in the non-thoracotomy group (aortic dissection or intimal injury). Postoperative ischemic stroke tended to occur more frequently in the non-thoracotomy group, though not significantly. One-year survival was significantly higher in the non-thoracotomy group, whereas mid-term mortality did not differ between groups. TAx-TAVR was associated with lower perioperative invasiveness and superior one-year survival compared with TA/DA-TAVR. However, the trend toward increased postoperative stroke underscores the importance of careful patient selection and thorough preoperative vascular assessment.

Objective: In acute type A aortic dissection, reports recommend total arch replacement with or without frozen elephant trunk over hemiarch replacement to avoid reoperation attributable to dilation of the residual dissected aorta. However, the residual dissected aorta can still enlarge. This study investigated the long-term factors contributing to enlargement in DeBakey type I aortic dissections. Methods: We analyzed 126 cases of central repair for false lumen–patent DeBakey type I aortic dissection. We compared preoperative computed tomography findings and characteristics, operative findings, and long-term outcomes between 51 cases experiencing aortic events (dilation of distal aorta >5 cm, new aortic dissections, distal aortic surgery, or distal aortic rupture) and 75 without events. Results: Patient characteristics and operative findings did not significantly differ between groups, with significantly more dissections involving the brachiocephalic artery or the iliac artery and cases undergoing hemiarch replacement in the event group. Univariable analyses showed that dissections involving the brachiocephalic artery, bilateral or unilateral iliac artery involvement, and hemiarch replacement were significantly associated with a greater risk of aortic events than in patients without these features. Multivariable analysis showed that dissections involving the brachiocephalic artery, unilateral iliac artery involvement, and hemiarch replacement were independent predictors of aortic events. Conclusions: Dissections involving the brachiocephalic artery or unilateral iliac artery on preoperative computed tomography were prognostic predictors of long-term aortic events. When dissection involves these vessels, large re-entry sites may form and contribute to late aortic events. Extensive aortic surgery and pre-emptive endovascular treatment may help suppress aortic events.

Background: The impact of cardiovascular surgery on balance function decline has not been well characterized. Objectives: This study investigated the frequency, associated factors, and prognostic significance of balance decline after cardiovascular surgery in older patients. Methods: This observational study included patients aged 65 years or older who underwent elective cardiovascular surgery. Balance function was assessed using the Functional Reach Test before surgery and at discharge. Balance decline was defined as a reduction of at least 8 cm, based on previously reported minimal detectable change. Logistic regression identified factors associated with balance decline, and Cox regression assessed its prognostic impact. Results: A total of 393 patients were analyzed (median age, 75 years). The prevalence of Functional Reach Test < 26.0 cm, indicating reduced mobility, increased significantly after surgery (preoperative 10.9% vs. postoperative 17.8%, p < 0.001). Balance decline occurred in 10.4% (n = 41). In multivariate analysis, higher N-terminal pro-brain natriuretic peptide, lower knee extensor strength, and longer operative time were significantly associated with balance decline (all p < 0.05). Patients with balance decline during hospitalization had a higher mortality rate than those without (p < 0.001). This association remained significant after adjusting for age, N-terminal pro-brain natriuretic peptide, and knee extensor strength at discharge (adjusted hazard ratio, 3.03; 95% confidence interval, 1.49-6.14; p = 0.002). Conclusion: Balance function decline after cardiovascular surgery was an independent predictor of poor prognosis in older patients. This decline was associated with preoperative cardiac dysfunction, reduced muscle strength, and longer operative time.

Background and aims Although whole-body phase angle (PhA) is a recognized prognostic marker in cardiovascular surgery, the clinical significance of segmental PhA and the impact of fluid overload on its interpretation remain insufficiently elucidated. This study investigated the associations between segmental PhA, physical function, and long-term prognosis in patients undergoing cardiovascular surgery. Methods This retrospective cohort study included consecutive patients who underwent elective cardiovascular surgery between October 2016 and March 2021 at Nagoya Heart Center, Japan. Preoperative whole-body, upper extremity, and lower extremity PhA were measured using bioelectrical impedance analysis. We analyzed correlations between PhA and physical functions. Additionally, the impact of fluid overload was assessed by stratifying patients based on an extracellular-to-total body water ratio (ECW/TBW) cut-off of 0.400. Long-term all-cause mortality was evaluated using multivariate Cox regression analyses adjusting for confounders including age, sex, cardiac and renal function. Results A total of 859 patients were included in the present analysis (mean age = 68.4 ± 11.9 years, 67.6% male). Segmental PhA significantly correlated with muscle mass, grip strength, and knee extension strength. However, in patients with fluid overload (ECW/TBW ≥ 0.400), the associations between PhA and physical function were attenuated, and the correlation with age lost statistical significance. Regarding prognosis, low PhA values across all segments were independent predictors of long-term all-cause mortality, even after adjusting for confounders. Conclusions Segmental PhA is a robust predictor of long-term mortality in cardiovascular surgery patients. However, because fluid overload confounds the relationship between PhA and physical function, clinicians must account for fluid status when interpreting PhA as a marker of muscle quality.

We report the case of a 52-year-old woman with severe tricuspid regurgitation due to Ebstein's anomaly. She underwent surgery through a 2.5 cm right minithoracotomy incision under three-dimensional endoscopic visualization. After identification of the atrialized right ventricle and the displaced attachments of the septal leaflet and part of the posterior leaflet within the atrialized segment, plication of the atrialized portion was performed to exclude it. The displaced leaflet attachment level within the atrialized right ventricle was regarded as the functional tricuspid annulus and served as the site for annuloplasty. Tricuspid annuloplasty was then performed using a semi-rigid partial ring, and leaflet coaptation was further improved by an edge-to-edge valvuloplasty. Postoperative echocardiography showed trace tricuspid regurgitation, and computed tomography demonstrated resolution of the atrialized right ventricle. She was discharged home in good condition.

Precise commissural height alignment is important for symmetric leaflet geometry during valve-sparing aortic root reimplantation. We describe a simple, reproducible “commissure-first planning” stepwise procedure. After placing subannular first-row sutures, the distance from each suture to the sinotubular junction level of commissural height is measured and transferred onto the graft from each planned commissural points on the same plane toward the graft base (sinotubular junction-to-base direction) and marked. Graft-side first-row sutures are then placed at these marks so that, when tied, the commissural heights within the graft are equalized. This procedure has yielded favorable early- to midterm results in 32 consecutive patients.

OBJECTIVES:The optimal choice of bioprosthetic valve for mitral valve replacement (MVR) remains controversial, with prior studies reporting inconsistent outcomes. This study aimed to compare mid-term clinical performance between bovine pericardial and porcine bioprostheses using a hierarchical composite end-point reflecting both durability and clinical relevance, including cardiac death, reoperation, and haemodynamic structural valve deterioration (SVD). METHODS:This retrospective study included 304 patients (152 per group) who underwent bioprosthetic MVR between 2007 and 2020, following 1:1 propensity score (PS) matching. The primary outcome was a hierarchical composite of cardiac death, reoperation for SVD, and echocardiographic diagnosis of haemodynamic SVD. Secondary outcomes included overall survival and perioperative complications. RESULTS:The median clinical follow-up durations were 7.3 years in the bovine group and 5.3 years in the porcine group. The win ratio was 1.49 (95% CI, 1.21-1.83; P < .001), indicating a statistically significant difference favouring the bovine group. While overall survival and freedom from cardiac death were comparable between groups, the cumulative incidence of reoperation for SVD and haemodynamic SVD diagnosis were significantly higher in the porcine group (Gray's P = .031 and 0.037, respectively). CONCLUSIONS:In this propensity-matched analysis, bovine pericardial valves showed a modest, consistent mid-term durability signal on SVD-related components, with similar overall survival. These findings are hypothesis-generating and should inform individualized prosthesis selection rather than dictate device choice; model-specific prospective studies, ideally randomized controlled trials, are needed for definitive guidance.

AIMS:This study aims to assess the association between the quadriceps rate of force development (RFD) and physical performance in older patients undergoing cardiovascular surgery. METHODS AND RESULTS:A cross-sectional study was conducted with hospitalized patients aged ≥65 years who underwent cardiovascular surgery. Physical performance was evaluated using a Short Physical Performance Battery (SPPB). The 4 m gait speed and time for five repeated chair stands were analysed as secondary outcomes. Ninety-four participants were enrolled (mean age, 75 years; men, 58.5%; median SPPB, 10 points; ≤9 points, 42.6%). Quadriceps isometric strength was measured, and RFD values at two time points (RFD100, 0-100 ms; RFD200, 0-200 ms) were calculated from the slope of the force-time curve. Maximal voluntary contraction (MVC) was also calculated. In all participants, the SPPB was significantly associated with RFD100, RFD200, and MVC. The 4 m gait speed was correlated with RFD100, RFD200, and MVC, and the chair stand test time was negatively correlated with RFD100, RFD200, and MVC. Although these significant associations persisted after adjusting for age, sex, and body mass index or skeletal muscle mass, the association between RFD and physical performance was not significant after adjusting for MVC. Subgroup analysis revealed that the correlation coefficients between RFD and physical performance measures were greater in patients with low muscle mass than in those with preserved muscle mass. Similar results were observed for the secondary outcomes. CONCLUSION:Rate of force development and physical performance were significantly correlated after cardiovascular surgery, especially in those with low muscle mass.

BackgroundValve-in-valve transcatheter aortic valve implantation (TAVI) has been confirmed as effective. Additionally, aortic annular enlargement has been advocated to avoid small valves at initial surgery, because they can cause patient-prosthesis mismatch, particularly after TAVI in surgical aortic valve replacement (SAVR). However, results remain unclear for TAVI with a small initial aortic valve in small body size patients. The purpose is to clarify the TAVI valve function after a small surgical valve in a small body population.MethodsWe retrospectively screened 52 cases of TAVI in SAVR performed from 2018 to 2024. Post-procedural TAVI valve function and post-procedural New York Heart Association (NYHA) functional class were examined.ResultsOf 52 TAVI in SAVR cases, 16 cases had a 19 mm initial surgical aortic valve, and 19 cases had 21 mm. The mean age of these 35 cases was 83.1 years old and 20% were male. Mean body surface area was 1.39 cm2. After TAVI in SAVR in 35 cases, the mean pressure gradient was 18.5 mmHg, and the effective orifice area (EOA) was 1.10 cm2. Even after 19-mm SAVR, the mean pressure gradient was 13.4 mmHg, and EOA was 1.13 cm2, excluding 3 cases of off-label use and 3 cases of balloon-expandable valves. At the time of last follow-up, 86.2% of survivors remained in NYHA I or II.ConclusionsSelf-expanding TAVI in a certain type of SAVR provided sufficient valve function in a population with small body size, even after small-sized initial surgical prostheses. Surgeons need to ensure that the proper type and size of surgical prosthesis are implanted.

BACKGROUND AND AIMS:Perioperative fluid management is a key component of care for patients undergoing cardiovascular surgery. The ratio of extracellular water to total body water (ECW/TBW) has been recognized as a valuable biomarker for perioperative assessment, as it integrates information regarding fluid retention, muscle wasting, and nutritional status. However, evidence regarding the clinical utility of ECW/TBW and its association with long-term postoperative outcomes in cardiovascular surgery remains limited. This study aimed to investigate the prognostic value of ECW/TBW for long-term mortality in patients undergoing cardiovascular surgery. METHODS:This retrospective cohort study included consecutive patients who underwent elective cardiovascular surgery between October 2016 and March 2021 at Nagoya Heart Center, Japan. ECW/TBW was assessed using bioelectrical impedance analysis before surgery and measured for the whole body, as well as each segment of the extremities. The association between ECW/TBW and all-cause mortality after discharge was assessed using Kaplan-Meier and multivariate Cox regression analyses. The cut-off value for all-cause mortality at each segmental ECW/TBW was calculated using the receiver operating characteristic curve. RESULTS:In total, 859 patients were included in this study (mean age = 68.4 ± 11.9 years, 67.6 % male). Whole-body ECW/TBW showed a significant positive correlation with log NT-proBNP (ρ = 0.51, p < 0.001) and age (ρ = 0.58, p < 0.001) and negative correlation with skeletal muscle mass index (ρ = -0.33, p < 0.001), body mass index (ρ = -0.22, p < 0.001), peak grip strength (ρ = -0.60, p < 0.001), knee extension isometric muscle strength (ρ = -0.51, p < 0.001), and Geriatric Nutritional Risk Index (ρ = -0.51, p < 0.001). The mean follow-up period was 907.6 ± 500.8 days, during which 46 patients (5.4 %) died. Kaplan-Meier survival curves based on ECW/TBW tertiles showed that higher ECW/TBW was associated with worse prognosis (log-rank test, p < 0.001). Cox regression analysis showed an independent association between ECW/TBW and mortality risk, even after adjusting for multiple confounding factors. The cut-off values for all-cause mortality, derived from the receiver operating characteristic curve, were 0.396 (area under the curve [AUC], 0.768) for whole-body ECW/TBW, 0.390 (AUC, 0.764) for upper-extremity ECW/TBW, and 0.398 (AUC, 0.764) for lower-extremity ECW/TBW. CONCLUSIONS:The segmental ECW/TBW is a useful predictor of long-term mortality in patients undergoing cardiovascular surgery. Although ECW/TBW strongly correlates with muscle mass and physical function, this correlation weakens at higher ECW/TBW levels, affecting measurement accuracy. Therefore, combining these measures may achieve more accurate postoperative risk stratification.

Background:In direct aortic transcatheter aortic valve implantation for patients with aortic stenosis, anterior right mini-thoracotomy presents challenges due to the limited visual field and raises concerns about significant bleeding. Furthermore, identifying the site closest to the ascending aorta while maintaining an adequate distance from the annulus is challenging. We report on the effectiveness of our preoperative simulation using virtual reality technology to ensure a safe and precise direct aortic transcatheter aortic valve implantation via anterior right mini-thoracotomy in two patients. Case summary:The patients were an 81-year-old man (Patient 1) and an 86-year-old woman (Patient 2) with aortic stenosis; their ascending aorta was closest to the third intercostal space. In Patient 1, virtual reality simulation revealed that, according to the distance and angulation from the annulus, the ideal puncture site was the second intercostal space. Accordingly, an anterior right mini-thoracotomy was performed at the second intercostal space, and a 23-mm SAPIEN 3 valve (Edwards Lifesciences Ltd.) was adequately implanted. Conversely, in Patient 2, the virtual reality assessment indicated that the third intercostal space was the appropriate site of entry. Therefore, anterior right mini-thoracotomy was performed at the third intercostal space, and a 23-mm SAPIEN 3 valve was successfully implanted, without difficulties. Discussion:The use of preoperative virtual reality simulation enabled the safe and precise execution of direct aortic transcatheter aortic valve implantation via anterior right mini-thoracotomy. Virtual reality technology is expected to have broader applications in cardiac surgery in the future.

BACKGROUND:Capecitabine, an oral prodrug of 5-fluorouracil, is widely used for gastrointestinal malignancies. While its coronary toxicity is well documented, large-vessel complications such as aortic dissection are rarely reported. CASE SUMMARY:We present a 65-year-old man with colorectal cancer who developed Stanford type A aortic dissection 3 days after initiating adjuvant capecitabine therapy. Imaging revealed extensive dissection from the ascending to the abdominal aorta. Emergency hemiarch replacement was successfully performed. DISCUSSION:The absence of prior cardiovascular disease, close temporal relationship, and known vasotoxicity of fluoropyrimidines suggest a likely association. Fluoropyrimidines may induce endothelial injury, vasospasm, and hypertension. A history of smoking in our patient may have contributed to vascular susceptibility. TAKE-HOME MESSAGES:Capecitabine, though well tolerated, may rarely cause life-threatening vascular complications such as aortic dissection. Clinicians should maintain a high index of suspicion for atypical vascular symptoms during therapy.

We report a case of a 77-year-old woman with an aneurysmal coronary-pulmonary artery fistula, which was incidentally identified on contrast-enhanced computed tomography. To prevent rupture and other potential complications, surgical repair was indicated. The procedure was performed via bilateral minithoracotomy, providing sufficient exposure while minimizing invasiveness. The aneurysmal segment was successfully excluded without intra-operative complications. Post-operative contrast-enhanced computed tomography confirmed complete exclusion of the lesion with no residual opacification. The patient's recovery was uneventful. This video tutorial demonstrates the step-by-step surgical technique used in this case, highlighting key considerations in exposure, fistula identification and closure. A bilateral minimally invasive approach may be a safe and effective option for selected patients with aneurysmal coronary-pulmonary artery fistulae, especially when conventional sternotomy is not desirable. This case adds to the limited literature on minimally invasive treatment of this rare condition and may assist surgeons in planning similar procedures.

Background and aims: Although the phase angle (PhA), a measure of frailty and sarcopenia, determined by bioelectrical impedance analysis has been reported as a prognostic factor after cardiovascular surgery, few studies have reported the trajectory of the PhA after discharge. In this study, we examined the trajectory of the PhA along with conventional physical function measures and explored the factors associated with recovery for 6 months after hospital discharge in patients who had undergone cardiovascular surgery. Methods: We included 116 patients who underwent elective cardiovascular surgery and cardiac rehabilitation after discharge. The PhA, physical function measures (grip strength, knee extension isometric muscle strength [KEIS], and usual gait speed), and Geriatric Nutritional Risk Index (GNRI) were assessed preoperatively, at discharge, and 3 and 6 months. Correlations between the PhA recovery rates and physical function and nutritional indices were assessed using Spearman's correlation analysis. Multivariate linear regression analysis was performed to examine the factors associated with recoveries of PhA and physical function indices (grip strength, KEIS, gait speed) after discharge. Results: Mean values of the PhA and physical function measurements and the GNRI score at discharge were lower than the preoperative values (PhA, -8.0 %; grip strength, -8.7 %; KEIS, -6.9 %; usual gait speed, -8.3 %; GNRI, -11 %). The grip strength, KEIS, and gait speed recovered to almost preoperative values 3 months after discharge. Values for the PhA and GNRI were still lower than preoperative values 3 months after discharge but had recovered to preoperative values at 6 months. The PhA was not significantly correlated with the recovery rates of the other indicators. Older age was negatively associated with PhA recovery rate, however, recovery rates decreased significantly with post-discharge physical activity. Conclusions: In patients undergoing cardiovascular surgery, the PhA takes longer to recover than muscle strength or gait speed, requiring up to 6 months to recover to preoperative levels. Post-discharge interventions to increase daily physical activity may be an important method of speeding PhA recovery. (c) 2024 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

The outcome of percutaneous coronary intervention (PCI) compared to coronary artery bypass grafting (CABG) is still controversial for patients with left main coronary artery (LMCA) disease. This multicenter cohort study aimed to evaluate the clinical outcomes of LMCA disease patients who underwent PCI or CABG. We reviewed 875 consecutive patients diagnosed with LMCA disease between January 2009 and December 2020 who underwent coronary revascularization by PCI (n = 404) or CABG (n = 471). A one-to-one propensity score matching was employed to control the potential biases. The primary outcome was any major adverse cardiac events (MACE), which were composed of all causes of death, myocardial infarction, or stroke. Before propensity score matching, both groups significantly differed in essential baseline characteristics. Patients undergoing PCI were significantly older (age 72.4 vs. 70.5 years). They had a better baseline left ventricular function (left ventricular ejection fraction (LVEF) 59.1

We report the case of a 15-year-old boy with severe mitral valve insufficiency due to an anomalous mitral arcade. Both papillary muscles were elongated and attached directly to the anterior leaflet, creating an arcade shape. He underwent an operation using a right minithoracotomy approach under three-dimensional endoscopic vision. Both papillary muscles were dissected off the anterior leaflet and trimmed. A muscle bar existed from the left ventricular wall to the right-side tip of the posterior papillary muscle and was also dissected off. Four loops were reconstructed from the papillary muscles and fixed to the free margin of the anterior leaflet in appropriate positions. After a 28-mm semi-rigid band was inserted, the posterior commissure was closed, and edge-to-edge stitches were applied from the posterior commissure to the P3 and the A3 segments to achieve better competence. His mitral valve was successfully repaired. The transoesophageal echocardiogram showed good opening of the mitral valve and trace regurgitation. The endoscope was useful for detailed observation and evaluation of the structure and abnormalities of the mitral valve and subvalvular apparatus.

BACKGROUND:Quadriceps strength assessment is widely used in rehabilitation; however, testing protocols often rely on empirical approaches. PURPOSE:To identify the optimal contraction time and number of attempts needed to reliably measure muscle strength (maximal voluntary contraction, MVC) and how quickly force is generated (rate of force development, RFD) in older adults with cardiovascular disease (CVD). METHODS:We included 28 older outpatients undergoing cardiac rehabilitation (median age: 77 years). Quadriceps MVC and RFD at 0-50 ms (RFD50) and 0-100 ms (RFD100) were measured using isometric contractions. The tests examined how results varied based on 1) mean or maximum values, 2) dominant or both legs, and 3) the number of repetitions. Intra- (ICC1,1) and inter-rater correlation coefficients (ICC2,1) were evaluated across these patterns. RESULTS:Mean to peak force was 1.73 seconds; only 2.4% required ≥3 seconds. A single trial with dominant leg yielded excellent reliability for MVC (ICC1,1 > 0.9; ICC2,1 > 0.9). For RFD50, moderate to good reliability was achieved with two repetitions of dominant leg or both sides (ICC1,1: 0.76-0.79; ICC2,1: 0.74-0.80), improving with three repetitions (ICC1,1: 0.75-0.86; ICC2,1: 0.79-0.84). For RFD100, two trials using dominant leg provided excellent reliability (ICC1,1: mean value 0.81, max value 0.89; ICC2,1: mean value 0.83, max value 0.85). Three repetitions provided consistently excellent reliability (ICC1,1: 0.88-0.93; ICC2,1: 0.86-0.92). CONCLUSION:Reliable MVC can be assessed with a single 3-second trial in older adults with CVD. For RFD, two repetitions, especially using the dominant leg and maximal value, provide excellent reliability.

Purpose: The safety and long-term durability of minimally invasive mitral valvuloplasty (MIMVP) remain controversial. This study aimed to compare the perioperative and long-term outcomes of minimally invasive mitral valve surgery (MIMVS) and conventional sternotomy.Methods: This study included 476 patients who underwent mitral valve surgeries at our institution between January 2011 and December 2023. Patients were classified according to whether they underwent sternotomy: the nonsternotomy (NS: 271 cases) and sternotomy (S: 205 cases) groups. Perioperative and long-term outcomes were compared between the two groups.Results: The NS group had a lower preoperative age and EuroScore II. In the S group, the left ventricular ejection fraction was lower, while the left ventricular end-systolic diameter and left atrial diameter were larger. Operative time, cardiopulmonary bypass time, and aortic cross-clamp time were longer in the NS group. Postoperative atrial fibrillation, more transfusion, and increased length of hospital stay were more frequent in the S group. The 10-year freedom from reoperation and 10-year survival rates in the NS and S groups were 98.1% vs. 93.6% (p = 0.07) and 94.8% vs. 86.9%, respectively (p = 0.08), with no significant differences.Conclusion: MIMVP demonstrates noninferior perioperative and long-term outcomes compared with conventional sternotomy.