Prosthesis–Patient Mismatch in Patients Undergoing Transcatheter Aortic Valve Replacement
http://www.onlinejacc.org/content/72/22/2701
On the basis of the discharge echocardiographic effective valve area indexed to body surface area, PPM was classified as severe (<0 .65="" 0.85="" cm2="" m2="" moderate="" none="" or="" to="">0.85 cm2/m2).
Severe and moderate PPM were present following TAVR in 12% and 25% of patients, respectively.
Severe PPM after TAVR was present in 12% of patients and was associated with higher mortality and HF rehospitalization at 1 year.
Generally, PPM after SAVR doesn't matter. Moreover, PPM might be thought as old fashion in new prosthetic aortic valve (Crown and Trifecta) era.
It seems that severe PPM after SAVR and TAVI is quite different.
It might be reason why the incidence of severe PPM after TAVI is generally less than SAVR.
2018年12月31日月曜日
2018年12月28日金曜日
Functional Mitral Regurgitation: Therapeutic Strategies for a Ventricular Disease
Functional Mitral Regurgitation: Therapeutic Strategies for a Ventricular Disease
J Cardiac Fail 2014;20:252 -267
ABSTRACT
Functional mitral regurgitation is a highly prevalent condition among patients with ischemic and dilated cardiomyopathies. Arising from remodeling of both the mitral valve annulus and the left ventricle, it is associated with high mortality and morbidity. In selected patients, cardiac resynchronization therapy helps to reduce functional mitral regurgitation, but surgical intervention remains the mainstay of therapy when medical therapy for left ventricular dysfunction has been inadequate. It is, however, associated with significant perioperative risks and does not alter long-term mortality. Percutaneous devices, and more recently the Mitraclip in particular, represent a promising alternative that can improve symptoms and ventricular remodeling with significantly lower periprocedural risk.
It remains unclear whether fMR repair is beneficial to this ventricular-valvular disease paradigm.
Current ACC/AHA and ESC guidelines do not make a distinction in recommended diagnostic modalities or in classification schema for severity, between fMR and
other etiologies of MR.
Medical therapy is limited in its ability to fully correct fMR.
CRT specifically targets myocardial dyssynchrony, which can be especially pronounced in those patients with segmental wall motion abnormalities and contributes to fMR.
MV surgery significantly reduces or eliminates fMR, reduces LV dimensions, and improves symptoms, but it is also associated with periprocedural complications,
such as mortality, bleeding, stroke, and renal dysfunction, and provides no clear long-term mortality benefit. There have been no randomized trials to compare the effectiveness of different surgical repair techniques.
Although there have been no prospective studies comparing the effects of MV surgery alone with the combination procedure of valve surgery and SVR, the combination procedure allowed for more consistent reduction in fMR but not
mortality, and they are accompanied by high perioperative risk.
Edge-to-Edge Repair (Mitraclip) corrects fMR with significantly lower periprocedural risk.
J Cardiac Fail 2014;20:252 -267
ABSTRACT
Functional mitral regurgitation is a highly prevalent condition among patients with ischemic and dilated cardiomyopathies. Arising from remodeling of both the mitral valve annulus and the left ventricle, it is associated with high mortality and morbidity. In selected patients, cardiac resynchronization therapy helps to reduce functional mitral regurgitation, but surgical intervention remains the mainstay of therapy when medical therapy for left ventricular dysfunction has been inadequate. It is, however, associated with significant perioperative risks and does not alter long-term mortality. Percutaneous devices, and more recently the Mitraclip in particular, represent a promising alternative that can improve symptoms and ventricular remodeling with significantly lower periprocedural risk.
It remains unclear whether fMR repair is beneficial to this ventricular-valvular disease paradigm.
Current ACC/AHA and ESC guidelines do not make a distinction in recommended diagnostic modalities or in classification schema for severity, between fMR and
other etiologies of MR.
Medical therapy is limited in its ability to fully correct fMR.
CRT specifically targets myocardial dyssynchrony, which can be especially pronounced in those patients with segmental wall motion abnormalities and contributes to fMR.
MV surgery significantly reduces or eliminates fMR, reduces LV dimensions, and improves symptoms, but it is also associated with periprocedural complications,
such as mortality, bleeding, stroke, and renal dysfunction, and provides no clear long-term mortality benefit. There have been no randomized trials to compare the effectiveness of different surgical repair techniques.
Although there have been no prospective studies comparing the effects of MV surgery alone with the combination procedure of valve surgery and SVR, the combination procedure allowed for more consistent reduction in fMR but not
mortality, and they are accompanied by high perioperative risk.
Edge-to-Edge Repair (Mitraclip) corrects fMR with significantly lower periprocedural risk.
2018年12月27日木曜日
Pulmonary Hypertension
Pulmonary Hypertension
Two blood flow patterns of PH with different prognoses have been reported in patients with heart failure. In the most common, called post-capillary PH (IpcPH), PH is solely caused by increased left-sided filling pressures. However, 10-15% of patients have both pre- and post-capillary PH (CpcPH), characterized by high filling pressures and a pulmonary vascular component.
This form of PH has similarities with pulmonary arterial hypertension, and is defined by a combined elevation of mean pulmonary artery wedge pressure (mPAWP), a measure of pressure in the upper left heart chamber, or atrium; pulmonary vascular resistance (PVR), reflecting changes in arteries that supply blood to the lungs; and/or diastolic pressure gradient (DPG), which is the difference between pulmonary artery diastolic pressure and mean pulmonary capillary wedge pressure.
Old
Transpulmonary pressure gradient（TPG：mean PAP － mean PAWP)
12< CpcPH, 12> IpcPH
New
Diastolic pressure gradient (DPG : diastolic PAP - mean PAWP)
7< CpcPH, 7> IpcPH
PVR ＞ 3.0 Wood CpcPH, PVR ≦ 3.0 Wood IpcPH
Prognosis
CpcPH BAD
IpcPH better
Two blood flow patterns of PH with different prognoses have been reported in patients with heart failure. In the most common, called post-capillary PH (IpcPH), PH is solely caused by increased left-sided filling pressures. However, 10-15% of patients have both pre- and post-capillary PH (CpcPH), characterized by high filling pressures and a pulmonary vascular component.
This form of PH has similarities with pulmonary arterial hypertension, and is defined by a combined elevation of mean pulmonary artery wedge pressure (mPAWP), a measure of pressure in the upper left heart chamber, or atrium; pulmonary vascular resistance (PVR), reflecting changes in arteries that supply blood to the lungs; and/or diastolic pressure gradient (DPG), which is the difference between pulmonary artery diastolic pressure and mean pulmonary capillary wedge pressure.
Old
Transpulmonary pressure gradient（TPG：mean PAP － mean PAWP)
12< CpcPH, 12> IpcPH
New
Diastolic pressure gradient (DPG : diastolic PAP - mean PAWP)
7< CpcPH, 7> IpcPH
PVR ＞ 3.0 Wood CpcPH, PVR ≦ 3.0 Wood IpcPH
Prognosis
CpcPH BAD
IpcPH better
2018年12月24日月曜日
Cost-Effectiveness of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis at Intermediate Risk: Results From the PARTNER 2 Trial
https://www.ctsnet.org/jans/cost-effectiveness-transcatheter-versus-surgical-aortic-valve-replacement-patients-severe?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F21%2F2018
Cost-effective analysis of TAVR versus SAVR in 3110 intermediate-risk aortic stenosis patients from the PARTNER-2 trial
Costs were ~$20,000 higher with TAVR than SAVR.
Total cost differences for the index hospitalization were
only $2888 higher with XT-TAVR (p=0.014) and
$4155 lower with S3-TAVR (p<0 .001="" nbsp="" p="">owing to reductions in length of stay with TAVR.
Follow-up costs were significantly lower with XT-TAVR (△-$9304; p<0 .001="" and="" compared="" nbsp="" p="" s3-tavr="" savr.="" with="">
Over a lifetime horizon, TAVR was projected to lower total costs by $8000-$10,000 and to increase quality-adjusted survival by 0.15-0.27 years.
XT-TAVR and S3-TAVR were found to be economically dominant compared with SAVR in 84% and 97% of bootstrap replicates, respectively.
Q
TAVR Durability is same as SAVR? We'll see.
If the durability of TAVR is inferior, the results might be changed.
https://www.ctsnet.org/jans/cost-effectiveness-transcatheter-versus-surgical-aortic-valve-replacement-patients-severe?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F21%2F2018
Cost-effective analysis of TAVR versus SAVR in 3110 intermediate-risk aortic stenosis patients from the PARTNER-2 trial
Costs were ~$20,000 higher with TAVR than SAVR.
Total cost differences for the index hospitalization were
only $2888 higher with XT-TAVR (p=0.014) and
$4155 lower with S3-TAVR (p<0 .001="" nbsp="" p="">owing to reductions in length of stay with TAVR.
Follow-up costs were significantly lower with XT-TAVR (△-$9304; p<0 .001="" and="" compared="" nbsp="" p="" s3-tavr="" savr.="" with="">
Over a lifetime horizon, TAVR was projected to lower total costs by $8000-$10,000 and to increase quality-adjusted survival by 0.15-0.27 years.
XT-TAVR and S3-TAVR were found to be economically dominant compared with SAVR in 84% and 97% of bootstrap replicates, respectively.
Q
TAVR Durability is same as SAVR? We'll see.
If the durability of TAVR is inferior, the results might be changed.
2018年12月21日金曜日
“Respect When You Can, Resect When You Should”: A Realistic Approach to Posterior Leaflet Mitral Valve Repair
“Respect When You Can, Resect When You Should”: A Realistic Approach to Posterior Leaflet Mitral Valve Repair
https://www.ctsnet.org/jans/%E2%80%9Crespect-when-you-can-resect-when-you-should%E2%80%9D-realistic-approach-posterior-leaflet-mitral-valve?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
J Thorac Cardiovasc Surg 2018;156:1856-66
“respect when you can, resect when you should” concept
Resection was performed only if an excess tissue in height or width was present. The excess tissue in height was treated if P2, after a complete unfolding, was twice as high than P1 or P3. In such cases, a transverse resection of P2 was performed to bring it to approximately the same height as P1 and P3 (P2 being slightly higher than P1 and P3 in a normal valve).
This usually removes the rough area that was thickened. During this
operative step, great care was taken to individualize the secondary, and
even marginal, chordae that were at the adequate length (when compared
with the reference point) to resuspend the new free edge of P2. As far as
the excess in width is concerned, it was treated and carried out each time
there was an obvious and natural transverse folding of the leaflet. The
most objective way to evaluate such an excess of tissue in width was to
lay P2 on the posterior ventricular wall and to see if there was any natural
folding. When this happened, a small triangular resection was performed,
the base of the triangle being at the level of the free edge and the apex at the
annulus. A small resection was often effective in eliminating the excess
transverse tissue without putting the posterior leaflet (PL) under tension
2005 - 2015
701 consecutive severe mitral regurgitation
441 degenerative: 376 posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments)
aged 65.8 ± 13 years, and 70.5% were male.
Median follow-up was 61.1 months.
There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%).
After 1, 5, and 10 years,
overall survival was 97.8%, 93.6%, and 86.7%
recurrent/residual >2+ mitral regurgitation was 0.7%, 1.9%, and 5.9%
New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%.
https://www.ctsnet.org/jans/%E2%80%9Crespect-when-you-can-resect-when-you-should%E2%80%9D-realistic-approach-posterior-leaflet-mitral-valve?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
J Thorac Cardiovasc Surg 2018;156:1856-66
“respect when you can, resect when you should” concept
Resection was performed only if an excess tissue in height or width was present. The excess tissue in height was treated if P2, after a complete unfolding, was twice as high than P1 or P3. In such cases, a transverse resection of P2 was performed to bring it to approximately the same height as P1 and P3 (P2 being slightly higher than P1 and P3 in a normal valve).
This usually removes the rough area that was thickened. During this
operative step, great care was taken to individualize the secondary, and
even marginal, chordae that were at the adequate length (when compared
with the reference point) to resuspend the new free edge of P2. As far as
the excess in width is concerned, it was treated and carried out each time
there was an obvious and natural transverse folding of the leaflet. The
most objective way to evaluate such an excess of tissue in width was to
lay P2 on the posterior ventricular wall and to see if there was any natural
folding. When this happened, a small triangular resection was performed,
the base of the triangle being at the level of the free edge and the apex at the
annulus. A small resection was often effective in eliminating the excess
transverse tissue without putting the posterior leaflet (PL) under tension
2005 - 2015
701 consecutive severe mitral regurgitation
441 degenerative: 376 posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments)
aged 65.8 ± 13 years, and 70.5% were male.
Median follow-up was 61.1 months.
There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%).
After 1, 5, and 10 years,
overall survival was 97.8%, 93.6%, and 86.7%
recurrent/residual >2+ mitral regurgitation was 0.7%, 1.9%, and 5.9%
New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%.
2018年12月20日木曜日
Outcomes Following Surgical Revascularization With Single Versus Bilateral Internal Thoracic Arterial Grafts in Patients With Left Main Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting: Insights From the EXCEL Trial
Outcomes Following Surgical Revascularization With Single Versus Bilateral Internal Thoracic Arterial Grafts in Patients With Left Main Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting: Insights From the EXCEL Trial
Eur J Cardiothorac Surg. 2018 Aug 27. doi: 10.1093/ejcts/ezy291.
https://www.ctsnet.org/jans/outcomes-following-surgical-revascularization-single-versus-bilateral-internal-thoracic?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG.
Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA.
The unadjusted 3-year composite primary endpoint of
death, stroke or myocardial infarction (MI) 15.6% of SITA = 11.6% of BITA
all-cause death 6.7% = 3.3%
Sternal wound dehiscence within 30 days 1.8% = 2.2% !!!
CONCLUSIONS:
In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
Eur J Cardiothorac Surg. 2018 Aug 27. doi: 10.1093/ejcts/ezy291.
https://www.ctsnet.org/jans/outcomes-following-surgical-revascularization-single-versus-bilateral-internal-thoracic?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG.
Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA.
The unadjusted 3-year composite primary endpoint of
death, stroke or myocardial infarction (MI) 15.6% of SITA = 11.6% of BITA
all-cause death 6.7% = 3.3%
Sternal wound dehiscence within 30 days 1.8% = 2.2% !!!
CONCLUSIONS:
In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
2018年12月9日日曜日
Outcomes Following Surgical Revascularization With Single Versus Bilateral Internal Thoracic Arterial Grafts in Patients With Left Main Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting: Insights From the EXCEL Trial
https://www.ctsnet.org/jans/outcomes-following-surgical-revascularization-single-versus-bilateral-internal-thoracic?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
SITA vs. BITA
The EXCEL trial randomized 1905 patients with LMT coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG.
Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA.
The BITA group
younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P = 0.020)
less likely female (24.3% vs 14.3%, P = 0.002)
diabetic (28.8% vs 15.2%, P < 0.001)
a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P = 0.040).
The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P = 0.17).
The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P = 0.070).
Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups.
After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71–1.78; P = 0.62] nor mortality (HR 1.36, 95% CI 0.60–3.12; P = 0.46) was significantly higher with SITA.
The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P = 0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93–1.74; P = 0.13).
Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P > 0.99).
CONCLUSIONS
In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
The selection of SITA or BITA was not randamized.
So probably SITA group had more likely complicated pts and worse results.
It seems to me that no differences and more comfortable with BITA due to less anastomosis.
https://www.ctsnet.org/jans/outcomes-following-surgical-revascularization-single-versus-bilateral-internal-thoracic?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018
SITA vs. BITA
The EXCEL trial randomized 1905 patients with LMT coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG.
Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA.
The BITA group
younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P = 0.020)
less likely female (24.3% vs 14.3%, P = 0.002)
diabetic (28.8% vs 15.2%, P < 0.001)
a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P = 0.040).
The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P = 0.17).
The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P = 0.070).
Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups.
After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71–1.78; P = 0.62] nor mortality (HR 1.36, 95% CI 0.60–3.12; P = 0.46) was significantly higher with SITA.
The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P = 0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93–1.74; P = 0.13).
Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P > 0.99).
CONCLUSIONS
In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.
The selection of SITA or BITA was not randamized.
So probably SITA group had more likely complicated pts and worse results.
It seems to me that no differences and more comfortable with BITA due to less anastomosis.
2018年9月30日日曜日
Transcatheter Mitral-Valve Repair in Patients With Heart Failure
Transcatheter Mitral-Valve Repair in Patients With Heart Failure
https://www.ctsnet.org/jans/transcatheter-mitral-valve-repair-patients-heart-failure?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+9%2F28%2F2018
This multicenter RCT study evaluated the efficacy of medical therapy plus transcatheter valve repair (MitraClip) to medical therapy alone for heart failure accompanied by secondary moderate to severe mitral regurgitation.
The device group experienced significantly fewer hospitalizations and lower mortality at 24 months follow-up.
Neither surgical repair nor surgical replacement of the mitral valve has been shown to lower the rate of hospitalization or death associated with secondary mitral regurgitation, and both procedures confer a substantial risk of complications.
Why are there the difference between surgery and MitraClip?
If surgery is too invasive, the mortality of surgical survivor must be improved.
According to MR improvement, MVR must be better than MVP and Mitraclip. But there were no differences between MVR and MVP.
I doubt some limitations affect the results.
1. Abbot's trial It might cause COI.
2. F/U doctors know who are MitraClip patients due to XP.
https://www.ctsnet.org/jans/transcatheter-mitral-valve-repair-patients-heart-failure?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+9%2F28%2F2018
This multicenter RCT study evaluated the efficacy of medical therapy plus transcatheter valve repair (MitraClip) to medical therapy alone for heart failure accompanied by secondary moderate to severe mitral regurgitation.
The device group experienced significantly fewer hospitalizations and lower mortality at 24 months follow-up.
Neither surgical repair nor surgical replacement of the mitral valve has been shown to lower the rate of hospitalization or death associated with secondary mitral regurgitation, and both procedures confer a substantial risk of complications.
Why are there the difference between surgery and MitraClip?
If surgery is too invasive, the mortality of surgical survivor must be improved.
According to MR improvement, MVR must be better than MVP and Mitraclip. But there were no differences between MVR and MVP.
I doubt some limitations affect the results.
1. Abbot's trial It might cause COI.
2. F/U doctors know who are MitraClip patients due to XP.
2018年9月26日水曜日
Combined Transaortic and Transapical Approach to Septal Myectomy for Complex Long-Segment Hypertrophy
Combined Transaortic and Transapical Approach to Septal Myectomy for Complex Long-Segment Hypertrophy
https://www.ctsnet.org/article/combined-transaortic-and-transapical-approach-septal-myectomy-complex-long-segment?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=Pulse+9%2F25%2F2018
Standard Morrow's myectomy + myectomy through LV apex 5cm incision
https://www.ctsnet.org/article/combined-transaortic-and-transapical-approach-septal-myectomy-complex-long-segment?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=Pulse+9%2F25%2F2018
Standard Morrow's myectomy + myectomy through LV apex 5cm incision
Aortic Valve Replacement With Right Anterior Thoracotomy, Sutureless Valves, and Ultrafast-Track Anesthesia: A Truly Minimally Invasive Approach in Ancona
Aortic Valve Replacement With Right Anterior Thoracotomy, Sutureless Valves, and Ultrafast-Track Anesthesia: A Truly Minimally Invasive Approach in Ancona
https://www.ctsnet.org/article/aortic-valve-replacement-right-anterior-thoracotomy-sutureless-valves-and-ultrafast-track?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=Pulse+9%2F25%2F2018MICS-AVR
Need the disrtance between Aortomy and aortic valve over 7cm
Standard antegrade CP x1
Sutureless valve Perceval (crimp)
Every Nadia 1 suture
2018年3月7日水曜日
Right Coronary Aneurysm With Coronary Arteriovenous Fistula to Right Atrium
https://www.ctsnet.org/article/right-coronary-aneurysm-coronary-arteriovenous-fistula-right-atrium
The fistula between the proximal of RCA and SVC
They had some choices
1 Open the fistula, and close the entry and exit through the fistula ( or through the SVC). No need bypass.
2 Close the proximal RCA and the exit through the fistula ( or through the SVC). need bypass.
They chose 2. Why? I am afraid that SVG long term patancy. maybe too close.
The fistula between the proximal of RCA and SVC
They had some choices
1 Open the fistula, and close the entry and exit through the fistula ( or through the SVC). No need bypass.
2 Close the proximal RCA and the exit through the fistula ( or through the SVC). need bypass.
They chose 2. Why? I am afraid that SVG long term patancy. maybe too close.
2018年1月31日水曜日
Minimally Invasive Aortic Valve Replacement by Thoracotomy: Step-by-Step Guide
https://www.youtube.com/watch?time_continue=3&v=nIRL52PpM-E
Preop
Assessment of incision level: CT Coronal view, Aortic cross clamp above PA
4-0 prolene sutures on FA and FV.
FV cannulation: Valsalva manuever
FA cannulation: 15Fr (BSA<1 .6="" 17fr="" 19fr="">2.1)
Remove excess pericardial fat to visualize
Preop
Assessment of incision level: CT Coronal view, Aortic cross clamp above PA
4-0 prolene sutures on FA and FV.
FV cannulation: Valsalva manuever
FA cannulation: 15Fr (BSA<1 .6="" 17fr="" 19fr="">2.1)
Remove excess pericardial fat to visualize
Right Anterior Minithoracotomy AVR Intuity Valve for Bicuspid Aortic Stenosis
https://www.youtube.com/watch?time_continue=1&v=ckiAlZc0A_4
Intuity Valve (Suture-less valve)
Very small incision 6cm?
Difficult even for valve sizers to enter thoracic space.
Use tourniquets for three valve sutures.
Intuity Valve (Suture-less valve)
Very small incision 6cm?
Difficult even for valve sizers to enter thoracic space.
Use tourniquets for three valve sutures.
2018年1月15日月曜日
The use of preoperative aspirin in cardiac surgery: A systematic review and meta-analysis
http://onlinelibrary.wiley.com/doi/10.1111/jocs.13250/abstract
Aspirin is of benefit to patients following CABG.
Continuation or administration of preoperative aspirin before CABG or any cardiac surgical procedure remains controversial.
12 randomized controlled trials and 28 observational studies
Result
1
The use of preoperative aspirin in patients undergoing CABG at any dose is associated with reduced early mortality as well as a reduced incidence of postoperative acute kidney injury.
2
Low-dose aspirin (≤160 mg/d) is associated with a decreased incidence of perioperative myocardial infarction (MI).
3
Administration of preoperative aspirin at any dose in patients undergoing cardiac surgery increases postoperative bleeding. It did not increase the rates of surgical re-exploration due to excessive postoperative bleeding nor did it increase the rates of packed red blood cell transfusions (PRBC).
Bayaspirin １T = 100mg
Aspirin is of benefit to patients following CABG.
Continuation or administration of preoperative aspirin before CABG or any cardiac surgical procedure remains controversial.
12 randomized controlled trials and 28 observational studies
Result
1
The use of preoperative aspirin in patients undergoing CABG at any dose is associated with reduced early mortality as well as a reduced incidence of postoperative acute kidney injury.
2
Low-dose aspirin (≤160 mg/d) is associated with a decreased incidence of perioperative myocardial infarction (MI).
3
Administration of preoperative aspirin at any dose in patients undergoing cardiac surgery increases postoperative bleeding. It did not increase the rates of surgical re-exploration due to excessive postoperative bleeding nor did it increase the rates of packed red blood cell transfusions (PRBC).
Bayaspirin １T = 100mg
2018年1月12日金曜日
MitraClip : Minimally Invasive Mitral Valve Repair
https://www.youtube.com/watch?v=wgHiI-lSi1M&list=PLC9uVfWun4-QcEPD2CJKbW4imsaZ9LLYz&index=5&t=142s
エコーによる評価が非常に重要。
88F NYHA3 MR4
スタンダードは外科的僧帽弁形成術。
リスクが高い症例が良い適応。
中隔穿刺は僧帽弁に近づきすぎないことが大切。
術中左房圧を測定する。平均左房圧、V波が下がる。
エコーによる評価が非常に重要。
88F NYHA3 MR4
スタンダードは外科的僧帽弁形成術。
リスクが高い症例が良い適応。
中隔穿刺は僧帽弁に近づきすぎないことが大切。
術中左房圧を測定する。平均左房圧、V波が下がる。
2018年1月10日水曜日
Echo Assessment for MitraClip
https://www.youtube.com/watch?v=peVD1ch3S8E&list=PLC9uVfWun4-QcEPD2CJKbW4imsaZ9LLYz&index=7&t=35s
経食道エコー、3Dイメージングで、逆流量をかなり正確に測定できるようになった。
MitraClip後の僧帽弁狭窄の評価は心拍数を60前後にコントロールしてする。
僧帽弁狭窄になった場合はクリップをより真ん中に打ち直す。
心臓MRIでPISA使用で、かなり逆流量を測定できる。
経食道エコー、3Dイメージングで、逆流量をかなり正確に測定できるようになった。
MitraClip後の僧帽弁狭窄の評価は心拍数を60前後にコントロールしてする。
僧帽弁狭窄になった場合はクリップをより真ん中に打ち直す。
心臓MRIでPISA使用で、かなり逆流量を測定できる。
2018年1月9日火曜日
Contemporary Trends in the Use and Outcomes of Surgical Treatment of Tricuspid Regurgitation
http://jaha.ahajournals.org/content/6/12/e007597
アメリカ、ウエストバージニア大
三尖弁の経皮的修復術の実現を見据えての現時点での状況を研究
アメリカ全体のデータベースを使用 三尖弁手術症例 N=45 477 !!!
2003-2014 12years!
（1）TRに対する手術はまれ。 ほとんどの三尖弁手術は他の心臓手術との合併組み合わせて行われる 。
（2）単独三尖弁手術患者は合併症例に比較してもともとリスクが高い。
（3）単独三尖弁手術後の院内死亡率は 過去10年間で大きく変化しなかった。
（4）単独三尖弁手術は、 術後合併症、長期入院、 コストが高い。単独三尖弁置換は永久ペースメーカ移植の割合が高い。
三尖弁手術。先天性やIE手術に比べてかなり増加している。
単独TVR N=795, 単独TVP N=569 （日本2014年 78/175なので年間数としては同じ。アメリカのほうが手術件数自体はかなり多いので全体に対する割合ではかなり低い)
死亡率が高い。10.9(TVR)/8.1%(TVP)!!!（日本2014年6.4/2.9%)
アメリカ、ウエストバージニア大
三尖弁の経皮的修復術の実現を見据えての現時点での状況を研究
アメリカ全体のデータベースを使用 三尖弁手術症例 N=45 477 !!!
2003-2014 12years!
（1）TRに対する手術はまれ。 ほとんどの三尖弁手術は他の心臓手術との合併組み合わせて行われる 。
（2）単独三尖弁手術患者は合併症例に比較してもともとリスクが高い。
（3）単独三尖弁手術後の院内死亡率は 過去10年間で大きく変化しなかった。
（4）単独三尖弁手術は、 術後合併症、長期入院、 コストが高い。単独三尖弁置換は永久ペースメーカ移植の割合が高い。
三尖弁手術。先天性やIE手術に比べてかなり増加している。
単独TVR N=795, 単独TVP N=569 （日本2014年 78/175なので年間数としては同じ。アメリカのほうが手術件数自体はかなり多いので全体に対する割合ではかなり低い)
死亡率が高い。10.9(TVR)/8.1%(TVP)!!!（日本2014年6.4/2.9%)
これは手術割合が低い（手術に消極的）からかもしれない。
手術症例が少なくて成績もそんなに良くないことから、経皮的修復術(MitraClip)の余地が十分という主張かな。
そもそも論として、日本やヨーロッパのように三尖弁手術を積極的にやってどうかが気になるところ。
2018年1月8日月曜日
Management of the Small Aortic Root Using the Floating Valve Technique
https://www.youtube.com/watch?v=V4vsKh2j5wA
バルサルバグラフト内に機械弁を入れる。
もともとは17mm機械弁。26mmバルサルバグラフト。23mm機械弁を使用。
バルサルバグラフト内に機械弁を入れる。
もともとは17mm機械弁。26mmバルサルバグラフト。23mm機械弁を使用。
2018年1月5日金曜日
The Hunt for the Best Second Conduit
https://www.ctsnet.org/article/hunt-best-second-conduit
RIMA > RA> SVG
SVG patency may improve with new interventions.
BIMA avoid obese diabetes and skeltnize.
RIMA > RA> SVG
SVG patency may improve with new interventions.
BIMA avoid obese diabetes and skeltnize.
2018年1月4日木曜日
Coronary Endarterectomy of the Left Anterior Descending Artery
https://www.youtube.com/watch?time_continue=2&v=4A9C5fnaRho
LADを損傷しないのか非常に気になる。もし起こればかなりcritical。
小切開で石灰化内膜を外している。奥の癒着を1mmゾンデを使用して剥がす。大丈夫？
高梨先生のやり方のほうが安全に思える。
心停止下手術なので出血の回収が可能。
LADを損傷しないのか非常に気になる。もし起こればかなりcritical。
小切開で石灰化内膜を外している。奥の癒着を1mmゾンデを使用して剥がす。大丈夫？
高梨先生のやり方のほうが安全に思える。
心停止下手術なので出血の回収が可能。
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