OBJECTIVES:Despite the detrimental consequences associated with residual, progressive aortic regurgitation (AR) during LVAD support, correction of AR at LVAD implantation has rarely been shown to improve survival. METHODS:A retrospective study was conducted using the Japanese registry database, which included 300 continuous-flow LVAD recipients with pre-existing AR (mild or greater). Patients were divided into two groups: those who underwent concomitant surgery for AR during LVAD implantation (n = 77) and those who did not (n = 223). The groups were compared for significant AR development, all-cause mortality, and readmission for adverse events. A propensity score-matched cohort was also created to allow comparison of these outcomes to those of patients with similar baseline. RESULTS:The cumulative incidence of significant AR was lower after corrected AR than after uncorrected AR in both the pre-matched and matched analyses (p < 0.05). While mortality and readmission rates were similar between groups in the pre-matched cohort, mortality after uncorrected AR was higher in the matched cohort (p = 0.052). When the pre-matched cohort was divided by age, a trend towards improved survival (p = 0.099) was observed with correction compared to no correction in older patients (≥57 years), whereas the difference was negligible (p = 0.956) in younger patients (<57 years). These results were consistent in patients with mild AR at implantation, including the increased risk of significant AR for uncorrected AR (p = 0.058), as well as improved survival with AR correction in the older population (p = 0.054), but no survival difference in the younger population (p = 0.492). CONCLUSIONS:In older patients, correction of pre-existing AR, including mild AR, may improve long-term survival after LVAD implantation.

The Konno procedure is an effective option for performing aortic valve replacement in pediatric patients utilizing an aortoventriculoplasty patch with a right ventricular outflow patch. However, re-do procedures are technically demanding and carry a non-negligible risk of surgical complications when the prosthetic materials are infected. We report a case of a patient who successfully underwent a re-do Konno procedure and an aortic root replacement for prosthetic valve endocarditis involving an aortoventriculoplasty patch. A 21-year-old male patient had undergone multiple aortic valvular surgeries since childhood. The patient’s subsequent clinical course was complicated by prosthetic valve endocarditis caused by Propionibacterium acnes that occurred at the age of 19 years, which was treated with antibiotics. Due to the occurrence of a subdural hematoma associated with recurrent endocarditis and exacerbated residual paravalvular leak, the patient was referred to our hospital to receive the appropriate multidisciplinary care throughout the perioperative period. After managing the intracranial hemorrhage, aortic root replacement along with reconstruction of the Konno patch and right ventricular outflow tract was performed using a fresh autologous pericardium. Postoperative echocardiography revealed hemodynamic stability without residual paravalvular leakage. Computed tomography revealed the absence of pseudoaneurysms. The patient was discharged uneventfully after six weeks of antibiotic treatment. The re-do Konno procedure and aortic root replacement can be effective surgical options to resolve sustained infection with indwelling prosthetic materials.

Life expectancy in patients with hemophilia A has increased owing to advances in factor VIII replacement, and the prevalence of age-related comorbidities such as coronary artery disease (CAD) is rising. However, coronary revascularization in severe hemophilia A remains challenging because both antithrombotic therapy and surgery can precipitate serious bleeding. We report a case of minimally invasive coronary artery bypass grafting (MICS-CABG) in a patient with severe hemophilia A, focusing on perioperative factor VIII management. A 50-year-old man (height 167 cm, weight 81 kg) with severe hemophilia A (baseline factor VIII activity < 1

Background Durable left ventricular assist devices (LVADs) improve the outcomes of patients with advanced heart failure; however, recurrent hospitalization remains a major burden. The days alive and out of hospital (DAOH) is a patient‐centered metric that reflects both survival and hospitalization burden; however, data using this measure are limited. This study aimed to evaluate both short‐ and long‐term DAOH following durable LVAD implantation. Methods We analyzed patients who underwent durable LVAD implantation between 2010 and 2023 using the J‐MACS (Japanese Registry for Mechanically Assisted Circulatory Support) registry. DAOH and days lost due to death and hospitalization were evaluated across 3 postimplantation intervals: days 1 to 365 (n=1379), 366 to 730 (n=1136), and 731 to 1095 (n=895). Results The mean DAOHs were 216, 309, and 303 days during the first, second, and third years, respectively. During days 1 to 365, most days lost were attributable to the initial hospitalization for LVAD implantation, whereas in subsequent periods, other hospitalizations became the main contributors. Older age and impaired renal function were associated with shorter DAOH during the first 365 days. A lower INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profile and implantation in the earlier era were consistently associated with shorter DAOH among all 3 time intervals. Infection, particularly pump‐related infection, and neurological dysfunction were the major contributors to hospitalization‐related days lost after discharge from the initial hospitalization among all time intervals. Conclusions In this nationwide registry analysis, ≈15% of the days remained lost annually after the first year. These findings emphasize the need for improved chronic‐phase management and targeted prevention of key complications to optimize long‐term outcomes following durable LVAD implantation.

Background Aortic dissection and aneurysm rupture are leading causes of death in patients with Marfan syndrome. Due to the risk of such vascular complications, the indication for heart transplantation in this population remains controversial. Previous reports, however, have demonstrated that heart transplantation in patients with Marfan syndrome can result in good long-term survival comparable to that in patients without Marfan syndrome. Here, we present a case of successful orthotopic heart transplantation after total aortic replacement in a patient with Marfan syndrome. Case presentation A 41-year-old man with Marfan syndrome, who had been managed conservatively for type B aortic dissection, developed acute type A dissection involving both coronary arteries at age 30, resulting in myocardial infarction. He underwent aortic root replacement with a mechanical valve. Thereafter, he was repeatedly hospitalized for heart failure due to ischemic cardiomyopathy. Three years later, at age 33, he was referred to our institution for heart transplant registration because of progressively deteriorating cardiac function and frequent episodes of intractable lethal arrhythmias. He underwent replacement of the ascending aorta and aortic arch, along with bioprosthetic aortic valve replacement. His immediate postoperative course was complicated by hemodynamic decompensation, necessitating support with an extracorporeal left ventricular assist device. One year later, he underwent a thoracoabdominal aortic replacement and bridge-to-bridge implantation of a left ventricular assist device. Three years later, at age 37, he underwent replacement of the durable device because of a pump pocket infection. After 7 years on the transplantation list, he underwent successful orthotopic heart transplantation from a suitable donor at the age of 41. Conclusions This rare case report describes a patient with Marfan syndrome who underwent orthotopic heart transplantation after total aortic replacement, followed by multiple surgical procedures, including extracorporeal and durable left ventricular assist device implantations, over an extended period. Although total aortic replacement was challenging in the context of complex coexisting cardiovascular disease, this approach enabled subsequent heart transplantation after mitigating the potential risk of Marfan syndrome-associated cardiovascular events.

Background: Destination therapy (DT) was approved in Japan in May 2021. Use of Impella device as a bridge to left ventricular assist device (LVAD) implantation has been increasing. The difference of clinical outcomes between Impella-bridge (a conversion from Impella to durable left ventricular assist device [LVAD]), bridge-to-bridge (BTB) (a conversion from extracorporeal LVAD to durable LVAD), and primary LVAD remains unclear especially in Japanese. Methods: Patients who underwent durable LVAD implantation between October 2017 and March 2025 and were prospectively registered in the Japanese Registry for Mechanically Assisted Circulatory Support (J-MACS) were included. The baseline characteristics, cumulative mortality, and adverse events following durable LVAD implantation were retrospectively compared between 2 bridging strategies and primary LVAD cohort. Results: A total of 964 patients who received durable LVAD implantation (median age: 49 years; primary LVAD: 77.4%; Impella-bridge: 11.6%; BTB: 11.0%) were analyzed. The prevalence of Impella-bridge strategy increased especially after DT approval and the introduction of Impella 5.5. The cumulative mortality during durable LVAD support was lowest in Impella-bridge cohort and highest in BTB cohort during a median follow-up of 1053 days (8.0% vs 21.0%). Among the total cohort, an Impella-bridge strategy tended to be associated with a lower mortality following durable LVAD implantation with an adjusted hazard ratio of 0.316 (95% confidence interval 0.095-1.048, p = 0.060). Conclusions: Impella-bridge strategy increased after the introduction of Impella 5.5 in the era of DT and tended to be associated with a lower mortality following durable LVAD implantation. Further studies are warranted to validate the hypothesis.

BACKGROUND:A patent ductus arteriosus (PDA) can result in pulmonary arterial hypertension (PAH) due to a left-to-right shunt. Lung transplantation (LTx) is indicated when PAH becomes refractory to medical management. We report a case of bilateral LTx (BLTx) with simultaneous aortic replacement using a donor aorta in an adult patient with PAH complicated by PDA. CASE PRESENTATION:A 27-year-old woman was referred for an LTx evaluation. At 1-year-old, she was diagnosed with a PDA. At the time of diagnosis, PDA closure was not indicated due to severe PAH, with a pulmonary vascular resistance of 33.8 Wood units. Despite receiving maximal medical therapy, her condition progressively deteriorated. She was placed on the transplant waitlist at age 27. Since left ventricular function was preserved (ejection fraction 60%) and no complex congenital heart disease was present, bilateral lung transplantation was chosen instead of heart-lung transplantation. Preoperative computed tomography revealed a giant pulmonary artery aneurysm (PAA). At 31 years of age, she underwent BLTx with simultaneous replacement of the proximal descending thoracic aorta using a donor aortic graft under cardiopulmonary bypass to enable complete excision of the ductal tissue. The giant PAA was also repaired during the same procedure. Postoperatively, she required venoarterial extracorporeal membrane oxygenation and was successfully weaned off by postoperative day 4. After an extended rehabilitation period, the patient was discharged 153 days postoperatively and remained in good health for 16 months following transplantation. CONCLUSIONS:To our knowledge, this is the first reported case of LTx with aortic replacement using a donor aortic graft for the management of PDA. We believe this combined procedure may represent a feasible surgical strategy for adult patients with PAH complicated by PDA and warrants further investigation in future cases.

BACKGROUND:Frailty is a multidimensional syndrome associated with adverse outcomes in heart failure. However, its prognostic significance in patients with advanced heart failure receiving a durable left ventricular assist device (LVAD) remains unclear. This study aimed to investigate the association of frailty status with mortality and adverse events using a nationwide cohort of patients undergoing durable LVAD implantation. METHODS:We analyzed data from the Japanese Registry for Mechanically Assisted Circulatory Support, including patients who underwent durable LVAD implantation between June 2010 and December 2023. Frailty status was assessed at 3 months after LVAD implantation using the frailty index (FI), which is based on the Rockwood cumulative deficits approach. RESULTS:In total, 508 patients (34.8%) were classified as not frail (FI ≤ 0.210), 669 (45.9%) as more frail (FI = 0.211-0.310), and 281 (19.3%) as most frail (FI ≥ 0.311). During a median follow-up of 1237 days, 230 patients (15.8%) died. Compared with patients in the nonfrail group, those in the more frail or most frail groups had a higher risk of all-cause death (more frail: adjusted hazard ratio [HR] 2.04 [95% confidence interval (CI), 1.39-3.01]; most frail: 4.98 [95% CI, 3.34-7.43]). In addition, greater frailty was linked to an increased risk of hemocompatibility-related adverse events and right ventricular failure, but not driveline or pump infection, ventricular arrhythmia, or pump malfunction. CONCLUSIONS:Frailty after LVAD implantation is highly prevalent and is associated with long-term mortality and other clinically relevant outcomes. A comprehensive frailty assessment may help to stratify long-term risk after durable LVAD implantation.

Harvesting the left internal thoracic artery (LITA) during minimally invasive coronary artery bypass grafting (MICS-CABG) can be technically demanding, particularly in patients with a prominent osteophyte at the first costochondral joint. We report the use of an ultrasonic aspirator system, the SONOPET iQ (Stryker), to facilitate safe and effective LITA harvesting in such anatomically challenging cases. The SONOPET iQ was employed when proximal LITA exposure was hindered by the protrusion of the first rib at the costochondral junction. Operating at an ultrasonic frequency of 25 kHz, the device enabled precise bone sculpting with minimal heat generation and bleeding-an essential advantage within the constrained operative field of MICS-CABG. By allowing controlled thinning of the first rib, the SONOPET iQ enhanced visualization and access to the LITA without requiring extensive rib retraction or resection. This adjunctive technique improves surgical safety and exposure by enabling accurate bone modification while minimizing thermal injury and bleeding. The SONOPET iQ offers a simple, reproducible, and effective solution for overcoming anatomical obstacles during LITA harvesting in MICS-CABG.

BACKGROUND:The use of information and communication technology (ICT) as a strategy to improve the quality of emergency medical care is gaining attention. A survey was conducted to investigate the extent to which ICT is being used in cardiovascular emergencies. METHODS AND RESULTS:A web-based questionnaire survey targeting cardiovascular surgery, cardiology, and emergency medicine departments at 320 facilities was conducted. The survey questions focused primarily on the presence and effectiveness of image sharing between hospitals and information sharing with emergency technicians using ICT, challenges in the use of ICT, and barriers hindering ICT adoption. The adoption rates of ICT for image sharing in cardiovascular surgery and electrocardiogram transmission in cardiology were 24% and 28%, respectively. ICT implementation was evaluated as being highly useful not only for reducing time to treatment but also for improving collaboration between medical professionals both within and outside the hospital. In emergency medicine, ICT collaboration with emergency technicians was implemented at 38% of hospitals, with image sharing at the emergency scene being prevalent. In cardiovascular surgery, 29% of facilities reported that the number of non-urgent transfers decreased or decreased significantly due to ICT implementation. CONCLUSIONS:Although ICT utilization remains at 20-25%, expectations for its widespread adoption are extremely high. Conversely, concerns about the costs and differences in ICT platforms are common, and there is a desire to adopt compatible systems.

Background Unequal pulmonary blood flow in Fontan circulation is a known contributor to development of pulmonary arteriovenous fistula (PAVF). However, optimal revision strategies remain debated, especially in patients with a pedicled autologous pericardial conduit. Case presentation A 23-year-old woman with a history of pulmonary atresia and previous total cavopulmonary connection (TCPC) using a pedicled pericardial extracardiac lateral tunnel developed hemoptysis and cyanosis due to left-sided PAVF. Cardiac catheterization, 3-dimensional computed tomography and 4-dimensional flow magnetic resonance imaging demonstrated unequal inferior vena cava flow preferentially directed to the right pulmonary artery. Preoperative computational fluid dynamics (CFD) simulation was used to evaluate three reconstructive options to rectify the issue. A configuration created with a prosthetic vascular graft was selected for optimal flow balance with minimal energy loss and phrenic nerve preservation. The patient tolerated the procedure well, and has been in a satisfactory condition and free of hemoptysis with reduction of PAVF over a 5-year follow-up. Conclusion CFD simulation can serve as a useful adjunctive preoperative tool for comparing hemodynamic characteristics of different TCPC revision strategies, particularly in anatomically complex cases involving pedicled pericardial conduits.

BACKGROUND:Anticoagulant therapy with vitamin K antagonists is recommended in the current guidelines for 3 to 6 months following bioprosthetic valve replacement. However, in the era of direct oral anticoagulants, there is a paucity of evidence regarding the efficacy and safety of direct oral anticoagulants in this patient group.METHODS:The ENBALV trial (Edoxaban in Anticoagulant Therapy After Surgical Bioprosthetic Valve Replacement) was an investigator-initiated, phase 3, randomized, open-label, multicenter study that aimed to evaluate the efficacy and safety of edoxaban compared with warfarin within 3 months following bioprosthetic valve replacement at the aortic or mitral position or both. The primary outcome was stroke or systemic embolism. The secondary outcomes included major bleeding, intracardiac thrombus, and a composite of stroke, systemic embolism, or major bleeding. Given the limited study period and the low event rate of the primary outcome, this study assessed the difference in the point estimates of the event rate.RESULTS:Of the 410 enrolled patients, 389 were included in the final analysis (73 +/- 6 years, 56.8% male, 79.4% sinus rhythm; edoxaban group: n=195, warfarin group: n=194). The primary outcome occurred in 0.5% (n=1) in the edoxaban group, whereas in 1.5% (n=3) in the warfarin group (risk difference, -1.03% [95% CI, -4.34 to 1.95%]). Major bleeding occurred in 4.1% (n=8) in the edoxaban group and in 1.0% (n=2) in the warfarin group (risk difference, 3.07% [95% CI, -0.67 to 7.27%]). No fatal bleeding or intracranial hemorrhage was observed in patients treated with edoxaban, whereas 1 fatal intracranial hemorrhage occurred in the warfarin group. Intracardiac thrombus did not occur in any of the patients in the edoxaban group, but did occur in 1.0% (n=2) in the warfarin group.CONCLUSIONS:Edoxaban is a potential alternative anticoagulant therapy early after bioprosthetic valve replacement.REGISTRATION:URL: https://jrct.niph.go.jp/latest-detail/jRCT2051210209; Unique identifier: jRCT2051210209.

Objective Pneumonia is a common complication and a significant cause of mortality following cardiovascular surgery. This study aimed to investigate the incidence and risk factors for pneumonia after thoracic aortic surgery. Methods A retrospective review was conducted on the medical records of 380 patients who underwent thoracic aortic surgery between January 2016 and December 2019. Patients were classified into pneumonia and non-pneumonia groups based on postoperative outcomes. Pneumonia was further categorized as aspiration pneumonia, ventilation-associated pneumonia (VAP), or other types. Risk factors were identified through univariate and multivariate analyses. Results Postoperative pneumonia during hospitalization occurred in 30 patients (7.9 %), including 18 cases of aspiration pneumonia (4.7 %) and 9 cases of VAP (2.4 %). Risk factors identified included hoarseness before surgery, aortic arch replacement, longer anesthesia time, longer intubation duration, necessity for tracheostomy, cerebrovascular disease after surgery, and postoperative recurrent laryngeal nerve paralysis. Multivariate analysis suggested that hoarseness before surgery and the necessity for tracheostomy were independent risk factors for pneumonia during hospitalization. Conclusion This study identified key risk factors for postoperative pneumonia after thoracic aortic surgery. These findings may aid in identifying high-risk patients and implementing preventive strategies to reduce postoperative pneumonia.

Background and Objective:Congenitally corrected transposition of the great arteries (ccTGA) remains a rare congenital disorder with a wide range of manifestations. The management of heart failure (HF) of the systemic right ventricle (RV), arrhythmias, heart block, and acquired cardiac conditions require a complex and multi-faceted approach. The objective of this manuscript is to present the current evidence regarding diagnostic, treatment, and management strategies for HF in ccTGA, including ventricular assist device (VAD) therapy and heart transplantation. Methods:A systematic review of the literature was conducted using PubMed, covering the period between 2010 and 2024. The search terms included "heart failure", "ccTGA", "VAD", "heart transplantation", and "systemic RV failure". Two clinical cases were included for illustrative purposes. Key Content and Findings:HF is a common occurrence in the context of ccTGA, primarily driven by progressive pressure and volume overload of the systemic RV, regurgitation of the systemic atrio-ventricular (AV) valve, and the development of arrhythmias, including complete heart block and (supra-)ventricular tachycardia. The use of HF medication is indicated for symptomatic patients, however, data on the efficacy of standardized HF medication remains limited. Timing of AV-valve replacement is essential to prevent further progression of HF. Conclusions:In ccTGA, the timing of surgery and interventional treatment approaches, the effect of pharmacological treatment in the context of HF, as well as the timing of initiation of a mechanical circulatory support, VAD and heart transplantation, are based on individualised consensus-level decisions. Optimal management remains a topic of debate due to the scarcity of outcome data. Future investigations should focus on identifying surrogate parameters for guiding treatment.