Purpose: The aims of the present study were to examine sternal and saphenous vein (SV) harvest site wound complication rates, and to assess the strategies to minimize the sternal and leg wound complications after coronary artery bypass grafting using a no-touch (NT) SV.

Methods: Patients who underwent coronary artery bypass grafting (CABG) using internal thoracic artery (ITA) and/or NT SV grafts from March 2021 to June 2023 (N = 166) at a newly opened cardiac surgical program were included. We obeyed the current guidelines for the prevention of sternal wound infection. In addition, unilateral ITA was used in most of the patients and the sternal wound was meticulously closed using multiple sternal wires (≥7) and ZipFix. For the NT SV harvesting, the LigaSure device was used to minimize thermal injury, and the wound was meticulously closed.

Results: Sternal wound infections developed in 3/166 (1.8%) patients; all three patients showed superficial sternal wound infections. Leg wound complications were present in 2/153 (1.3%) patients, who recovered after secondary intention healing.

Conclusion: Sternal wound complications after CABG could be minimized by the unilateral ITA usage, meticulous closure of the sternal wound in addition to compliance with the current guidelines. Wound complications after NT SV harvest may also be minimized by preoperative evaluation, careful harvesting, and meticulous wound closure.

Purpose: Coronary anastomosis is the most key factor to accomplish coronary artery bypass grafting, which is one of the largest areas in cardiovascular surgery. Although we have organized on-site simulator training courses of coronary anastomosis using BEAT YOUCAN, it became difficult to continue it because of COVID-19. Therefore, we established a real-time evaluation sheet instead of an Objective Structured Assessment of Technical Skills (OSATS) evaluation sheet. The purposes of this study was to develop the real-time assessment system and to prove the correlation between the score obtained by the OSATS and the score obtained by the real-time evaluation system.

Subjects and Methods: A total of 22 videos from the qualifying round of real-time coronary anastomosis competition evaluated by both the modified OSATS and the real-time evaluation system were utilized in this study. The global rating score of OSATS was compared with the global rating score of real-time evaluation system.

Results: When examined the relationship between the OSATS total score and the real-time total score, there was a significant correlation (R = 0.752, p <0.001). The OSATS general definition score and the real-time total score also showed a strong correlation (R = 0.733, p <0.001).

Conclusions: We developed a real-time assessment sheet to evaluate coronary anastomosis. This assessment sheet had a good correlation with the OSATS evaluation sheet.

Purpose: Reimplanting the radial artery in the left internal thoracic artery as a composite graft allows total arterial revascularization (TAR) without aortic manipulation. The limitation of this strategy is the length of the radial artery required to reach distal right coronary artery (RCA) branches. Our analysis focuses on the feasibility of this strategy.

Methods: A total of 169 patients underwent TAR using the radial artery in a composite grafting configuration. Length of the radial artery, number of sequential anastomoses, heart size, target location, length of the arm, patient height, body surface area, and flow in the composite graft were prospectively collected.

Results: The mean length of the radial artery was 18.02 cm. Patients with a mean length of the radial artery of 15.9 cm needed an extension of the radial artery with another conduit to reach the RCA distal branches. When T-configuration is used, the length of the radial artery should be 0.53 cm per sequential anastomosis to reach the RCA distal branches.

Conclusions: Our study shows that an average length of 18.02 cm of radial artery is needed to reach targets on the RCA distal branches in composite grafting. In T-configuration, we need 0.53 cm more length per anastomosis to achieve TAR.

Purpose: Saphenous vein grafts (SVGs) sometimes occur as vein graft stenosis or failure in coronary artery bypass grafting. The purpose of this study was to detect the factors affecting vein graft atherosclerosis.

Methods: We performed two analysis. In the first analysis, we enrolled 120 grafts using conventionally harvested saphenous vein graft (C-SVG) and followed-up with multiple coronary computed tomography angiography (CCTA). We examined the factors that contribute to the graft atherosclerosis defined by graft failure at subsequent CCTA or substantial progression of graft stenosis (a decrease of ≥0.6 mm in diameter). In the second analysis, 66 grafts using no-touch harvested saphenous vein graft (N-SVG) were compared with those in the first analysis using C-SVG, focusing on the differences in intraoperative factors using propensity score-matched analysis.

Results: In the first analysis, graft atherosclerosis+ group comprised 27 grafts, which had a larger SVG diameter, lower graft velocity, and higher graft/native ratio in diameter than the graft atherosclerosis– group. In the multivariable analysis, slow graft velocity and graft/native ≥2 in diameter were independently associated with the graft atherosclerosis. In the second analysis, the N-SVG group had a much greater graft velocity than the C-SVG group.

Conclusion: Lower graft velocity and higher graft/native ratio in diameter were associated with the graft atherosclerosis. The N-SVG group had increased graft velocity, which may contribute to prevent the graft atherosclerosis.

(Trial registration: UMIN Clinical Trial Registry no. UMIN000050482. Registered 3 March 2023, retrospectively registered.)

Purpose: Little is known about the outcomes of patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) who undergo coronary artery bypass grafting (CABG) in the current percutaneous coronary intervention (PCI) era.

Methods: We analyzed 25120 acute myocardial infarction (AMI) patients hospitalized between January 2011 and December 2016. In-hospital outcomes were compared between patients who underwent CABG during hospitalization and those who did not undergo CABG in the STEMI group (n = 19428) and NSTEMI group (n = 5692).

Results: Overall, CABG was performed in 2.3% of patients, while 90.0% of registered patients underwent primary PCI. In both the STEMI and NSTEMI groups, patients who underwent CABG were more likely to have heart failure, cardiogenic shock, diabetes, left main trunk lesion, and multivessel disease than those who did not undergo CABG. In multivariable analysis, CABG was associated with lower all-cause mortality in both the STEMI group (adjusted odds ratio [OR] = 0.43, 95% confidence interval [CI] 0.26–0.72) and NSTEMI group (adjusted OR = 0.34, 95% CI 0.14–0.84).

Conclusion: AMI patients undergoing CABG were more likely to have high-risk characteristics than those who did not undergo CABG. However, after adjusting for baseline differences, CABG was associated with lower in-hospital mortality in both the STEMI and NSTEMI groups.

The excellent long-term patency of no-touch (NT) saphenous vein grafts (SVGs) makes the grafts very attractive for coronary artery bypass grafting; however, NT-SVG harvesting has a greater incidence of wound complications than conventional methods. Since 2009, we have performed endoscopic vein harvesting (EVH) in our department with very few major wound complications. Because NT-SVG harvesting is expected to provide long-term patency, if performed with EVH, the incidence of wound complications will be reduced. Thus, we began performing endoscopic pedicle SVG harvesting (Pedicle-EVH) in March 2019. Herein, we report the early results obtained using our current Pedicle-EVH procedure. No major wound complications were reported, and the early results, including patency, were satisfactory. To harvest the pedicle SVG, however, we used a different method than the NT-SVG procedure, so careful monitoring will be needed to assess long-term outcomes.

Purpose: We retrospectively evaluated the postoperative efficacy of an orexin receptor antagonist for patients who underwent off-pump coronary artery bypass grafting (OPCAB).

Materials and Methods: We invested 108 patients who underwent cardiovascular surgery at our hospital. Patients were categorized as those received orexin receptor antagonist after surgery (S group, n = 64) or without orexin receptor antagonist (N group, n = 44), and the following data were analyzed between both groups.

Results: The incidence of postoperative delirium (POD) was significantly less in the S group than in the N group (N vs. S = 36.4 vs. 6.3%, p <0.001). Postoperative new atrial fibrillation (POAF) was significantly less in the S group compared with the N group (N vs. S = 36.4% vs. 12.5%, p = 0.003). Intensive care unit stay (N vs. S = 5.0 ± 1.5 vs. 3.8 ± 0.9 days, p <0.001) and hospitalization (N vs. S = 20.5 ± 9.2 vs. 17.1 ± 7.2 days, p = 0.037) were significantly shorter in the S group compared with the N group.

Conclusion: Orexin receptor antagonists might reduce POD and POAF, and this effect could introduce the shortness of intensive care unit stay and hospitalization. Orexin receptor antagonist could be useful for patients who undergo OPCAB.

Purpose: To analyse the outcome of coronary artery bypass grafting (CABG) in octogenarians with coronary multivessel disease and the impact of different graft strategies and other factors.

Methods: Out of 1654 patients with multivessel disease who underwent CABG at our institution between January 2014 and March 2020, we investigated 225 consecutive patients with a median age of 82.1 years for survival prediction and need for coronary reintervention; a detailed outcome analysis was performed.

Results: At mean follow-up of 3.3 years, the overall survival was 76.4%. An indication for emergency operation (p = 0.002), age (p <0.001), chronic pulmonary disease (p = 0.024), and reduced renal or ventricular function (p <0.001) had the highest impact on limited survival. The combination outcome of survival and coronary reintervention was 1.7-fold improved (p = 0.024) after use of the bilateral internal thoracic artery (BITA) (66.2%). Off-pump CABG (12%) revealed no impact on survival. Smokers showed a poorer outcome (p = 0.004). The logistic European System for Cardiac Operative Risk Evaluation was highly effective for evaluating long-term outcomes (p <0.001).

Conclusions: BITA grafting normalizes survival and reveals a better outcome in octogenarians with multivessel disease. However, patients at risk of poorer survival were operated under emergency conditions and those with pulmonary disease and reduced ventricular or renal function.

Purpose: Continuous annual reporting on coronary artery bypass grafting (CABG) surgical practice is key for quality control and improvement of clinical results. In this report, Japanese nationwide features and trends in the extent of coronary artery disease and the characteristics of those undergoing CABG procedures in 2019 are presented. Clinical results of related ischemic heart disease are also presented.

Methods and Results: The Japanese Cardiovascular Surgery Database (JCVSD) is a nationwide surgical case registry system. Data regarding CABG cases in the year 2019 (1 January–31 December) were captured with questionnaires regularly administered by the Japanese Association for Coronary Artery Surgery (JACAS). We analyzed trends in the number and types of grafts selected according to the number of diseased vessels in patients undergoing CABG. We also analyzed descriptive clinical results of those undergoing surgery for acute myocardial infarction or ischemic mitral regurgitation.

Conclusions: This is the second publication summarizing the results following the JACAS annual report based on JCVSD Registry data from the year 2019. Clinical outcomes and surgical strategy trends were relatively stable. Further accumulation of information with a similar data collection system is expected.

Purpose: Cardiovascular surgery entails considerable risk because of its complexity and the frequency of perioperative complications. The right ventricular Tei index (RV-TI) provides an integrated measure of ventricular performance, encompassing systolic and diastolic function. Although not widely applied in this setting, its role as a predictor of outcomes is promising. This study evaluated the utility of RV-TI in predicting postoperative complications in patients undergoing diverse cardiovascular surgeries, emphasizing its value for surgical risk stratification and patient management.

Methods: A single-center, cross-sectional study was conducted at the National Institute of Cardiology Ignacio Chávez, Mexico City, including 195 adults who underwent cardiac surgery between June 2022 and April 2023. RV-TI was obtained by transthoracic tissue Doppler, using 0.53 as the abnormal cutoff. One hundred and forty-nine patients had normal RV-TI values, while 46 were classified as abnormal.

Results: Abnormal RV-TI correlated with diabetes mellitus, advanced age, and vasoplegic syndrome. These patients experienced higher in-hospital mortality and more severe complications, including the need for renal replacement therapy, pneumonia, delirium, and greater transfusion requirements.

Conclusion: RV-TI appears to be a valuable adjunct in preoperative risk assessment for cardiac surgery. Its incorporation into clinical practice could improve patient selection and decision-making, contributing to better surgical outcomes.

Purpose: The superior septal approach offers improved mitral valve exposure compared to the right-sided left atriotomy or transseptal approach. However, the risk of postoperative sinus node dysfunction remains controversial, with limited data in the context of right mini-thoracotomy.

Methods: This retrospective study included 155 patients (64 women; mean age, 60.8 ± 13.4 years) who underwent mitral valve surgery via right mini-thoracotomy between November 2016 and August 2023. Indications included degenerative mitral regurgitation (94.8%) and mitral stenosis (5.2%). Patients were divided into 2 groups: the conventional minimally invasive mitral valve surgery (CM) group (n = 47), using the right-sided left atriotomy, and the drawer-case technique (DCT) group (n = 108), using the superior septal approach. Demographic, intraoperative, and outcome data were analyzed.

Results: Baseline characteristics were similar between groups. There were no significant differences in valve repair techniques or postoperative echocardiographic findings. Postoperative junctional rhythm occurred in 6 patients (CM group) and 21 patients (DCT group); all patients with preoperative sinus rhythm returned to sinus rhythm postoperatively.

Conclusion: The superior septal approach does not increase the risk of persistent junctional rhythm in right mini-thoracotomy and is a safe and effective option for mitral valve surgery.

Purpose: This study evaluated the midterm outcomes, including adverse aortic events (AAEs), of the “graft insertion technique” (GIT) for left ventricular outflow tract (LVOT) and aortic root reconstruction.

Methods: From August 2014 to March 2024, 14 consecutive patients underwent GIT for LVOT and aortic root reconstruction. The indications for surgery were prosthetic valve endocarditis in 9 cases and noninfectious pseudoaneurysm in 5 cases. Among these patients, seven (50.0%) underwent aortic root surgery, while the other seven (50.0%) underwent aortic valve replacement alone or in combination with other procedures without aortic root surgery. Their mean EuroSCORE II was 28.8 ± 17.6.

Results: The mean total operation time was 504 ± 87 min. The mean cardiopulmonary bypass and aortic cross-clamp times were 311 ± 41 and 240 ± 45 min, respectively. Operative mortality occurred in one case (7.1%), and five patients (35.7%) died during the first year of follow-up. No surviving patients experienced recurrent endocarditis. No patients died from cardiovascular events or infections after the second year of follow-up. Furthermore, no AAEs were observed on computed tomography during the follow-up period after hospital discharge.

Conclusion: GIT is a feasible alternative for high-risk cases of redo aortic root surgery.

Purpose: Pericardial effusion (PE), tamponade, and atrial fibrillation are challenging complications after cardiac surgeries. This prospective randomized study was conducted to evaluate the impact of posterior pericardiotomy (PP) in the prevention of PE and cardiac tamponed after adult cardiac surgery.

Methods: This single-center, prospective, randomized controlled trial included 330 patients undergoing open-heart surgery. They were randomly assigned to either a PP group or a control group.

Results: Of 703 screened patients, 330 were enrolled from January 2022 to June 2024 (mean age: 50.2 ± 14.7 years, 64.2% males). Compared to controls, the PP group had significantly lower early and late PE (19.4% vs. 44.8%, and 4.2% vs. 17%, respectively), tamponade (2.4% vs. 11.5%), and postoperative atrial fibrillation (10.3% vs. 19.4%). PP also significantly reduced the need for surgical re-exploration, duration of mechanical ventilation, and both intensive care unit and overall hospital stays (all P <0.05). Adjusted multivariate analysis confirmed the benefits of PP after correcting for baseline imbalances in left ventricular ejection fraction and operative time. No adverse events directly attributable to PP were noted.

Conclusions: PP is a simple, safe, and effective technique for reducing postoperative PE, and cardiac tamponade after cardiac surgery.

The scarcity of leaflet tissue and restricted systolic motion remain challenges in mitral valve repair. In addition to functional or secondary mitral regurgitation, atrial functional mitral regurgitation, characterized by chronic atrial fibrillation, preserved left ventricular function, and atriogenic leaflet tethering, exacerbates leaflet scarcity, complicating mitral valve repair. To address this, we introduce the “elbow patch repair,” a novel technique using an autologous pericardium overlay patch to reinforce the posterior mitral valve leaflet. A 65-year-old male patient with chronic atrial fibrillation and severe mitral regurgitation consistent with atrial functional mitral regurgitation underwent the “elbow patch repair” combined with annuloplasty and neochordae placement. This approach effectively managed posterior mitral valve leaflet deficiency and restored the coaptation surface. The “elbow patch repair” offers a straightforward and effective solution for leaflet shortage in atrial functional mitral regurgitation and select cases of Carpentier Class IIIb. Further studies are needed to assess its long-term durability.

Purpose: This study aimed to summarize 8-year clinical outcomes for patients who underwent transcatheter aortic valve replacement (TAVR) with the J-Valve system and evaluate the long-term durability and hemodynamic performance of the valve.

Methods: Between July 2014 and June 2015, 21 patients underwent transapical TAVR with the J-Valve system. Systematic clinical and echocardiographic follow-up was conducted on 18 patients for up to 8 years.

Results: Eight years post-TAVR with the J-Valve system, the all-cause mortality rate was 16.7%, with no prosthesis failures or thrombosis. Moderate to severe valve deterioration was observed in 50% of patients with aortic stenosis (AS), whereas no such deterioration was noted in patients with pure aortic regurgitation (PAR). At 8 years following TAVR, the effective orifice area measured 2.27 ± 0.50 cm² in patients with PAR and 1.35 ± 0.38 cm² in those with AS. Additionally, patients with AS exhibited a mean pressure gradient of 17.90 ± 10.61 mmHg. Over 8 years, PAR patients experienced a significant reduction in left ventricular end-diastolic diameter from 61.50 ± 2.08 mm to 48.67 ± 7.23 mm (p < 0.001), whereas AS patients showed no significant change.

Conclusion: The J-Valve system demonstrates favorable long-term outcomes in TAVR, with excellent durability and hemodynamic performance in PAR patients.

Mitral annular calcifications have been known to increase complexity during mitral valve replacement (MVR). Standard procedure requires decalcification followed by reconstruction of the mitral annulus prior to placing the prosthesis. While this is the ideal technique, it is not feasible in every patient due to the associated risks. The mere attempt at valve replacement without proper annular decalcification has been associated with a high incidence of periprosthetic leak which complicates the postoperative course and has been associated with increased morbidity and mortality. With the advances in transcatheter therapy, postoperative periprosthetic regurgitation can be managed with devices and primary transcatheter valve implantation could be alternative to standard valve replacement; however, these alternate strategies are not without its own limitations and drawbacks. In the current report, we present a novel strategy to be used in a select group of patients with severe but non-circumferential annular calcifications to prevent/minimize periprosthetic regurgitation during MVR. This involves placing a patch over the posteriorly located calcium bar, thus minimizing tension on the posterior suture line and contain any periprosthetic regurgitation if to develop. This modification has been performed in a total of nine cases with acceptable early results.

This preclinical study in a porcine model of recurrent regurgitation following tricuspid valvuloplasty aims to confirm the feasibility and safety of a novel transjugular tricuspid valve (TV) replacement device and to optimize the implantation procedure prior to first-in-human study. The novel device was implanted via a transjugular approach in a large white pig model (n = 2). No perivalvular leakage (PVL) or central tricuspid regurgitation (TR) was observed on post-operative echocardiography. The mean transvalvular gradient at 3 months follow-up was 1.69 ± 0.7 mmHg with mild central TR but no PVL. There was no right ventricular outflow tract obstruction, III atrioventricular block, device malposition, pericardial effusion, coronary artery compression, or myocardial infarction. This technique may be a promising option for patients after TV valvuloplasty and is ideal for high-risk patients undergoing open-heart surgery.

Purpose: This study aimed to compare the clinical outcomes of isolated surgical aortic valve replacement (SAVR) and transfemoral (TF)-transcatheter aortic valve replacement (TAVR) in low-risk aortic stenosis (AS) patients.

Methods: A total of 696 low-risk (Society of Thoracic Surgeons score <4%) AS patients underwent isolated SAVR or TF-TAVR at five centers. After 1:1 propensity score matching, 159 pairs were identified. Early and follow-up events, including cardiac mortality and major adverse cardiac and cerebrovascular events (MACCE: all-cause mortality, heart failure admission, reoperation, prosthetic valve endocarditis, and stroke), were compared.

Results: Baseline characteristics are similar between the matched groups. There were no 30-day cardiac mortalities in either group. All-cause mortality and MACCE at 30 days did not differ. During 5-year follow-up (median 3.1 [range 0–7.2] years), the incidence of cardiac mortality (1.3% vs. 18.9%; adjusted hazard ratio [aHR], 8.89; 95% confidence interval [CI], 2.68–29.53; P <0.001), all-cause mortality (4.2% vs. 33.9%; aHR, 8.56; 95% CI, 3.41–21.45; P <0.001), and MACCE (25.1% vs. 47.0%; aHR, 2.36; 95% CI, 1.54–3.63; P <0.001) were lower in the SAVR group than in the TAVR group.

Conclusions: Isolated SAVR demonstrated better outcomes in low-risk AS patients. TAVR in this subset should be chosen carefully.

Purpose: Aortic valve neocuspidization (AVNeo) is a relatively recent advancement in surgical AV replacement. Data on its performance beyond the short term are limited. We assessed the mid-term outcomes in patients undergoing AVNeo, focusing on feasibility, perioperative details, and its role in AV pathology treatment.

Methods: Sixty-five consecutive patients underwent AVNeo between December 2016 and February 2018. Clinical data were prospectively collected and retrospectively analyzed. Tricuspid reconstruction with autologous pericardium was performed in all cases. Echocardiographic follow-up was conducted post-discharge, at 6 and 12 months, and annually thereafter.

Results: The mean age was 62.6 ± 18.7 years. AVNeo was feasible in all cases. Concomitant procedures were performed in 43 (66.2%) patients. Mean bypass and cross-clamp times were 119.2 ± 30.3 and 87.1 ± 22.9 minutes, respectively. Postoperative transvalvular hemodynamics was excellent. There was one (1.5%) in-hospital death. Follow-up (mean 66.72 ± 12.77 months) was complete in 58 patients (89.2%). There were no detected valve-related or thromboembolic events. Transvalvular hemodynamic parameters were stable during the observation period: peak pressure gradient at discharge and follow-up was 15.3 ± 4.6 mmHg and 15.01 ± 6.3 mmHg, respectively (ρ = 0.346).

Conclusions: AVNeo demonstrated the feasibility and favorable mid-term outcomes. Studies with longer-term observation are warranted to evaluate its durability.

Purpose: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are both well-established treatments for carotid artery stenosis. We analyzed real-world data from the Korean National Health Insurance Service (NHIS) database to compare the clinical outcomes.

Methods: This retrospective cohort study included patients with carotid artery stenosis registered in the NHIS from 2008 to 2018. Patients who underwent either treatment were divided into CEA or CAS groups and subjected to 1:4 propensity score matching.

Results: The study cohort included 1521 CEA and 6768 CAS patients. In symptomatic patients, the stroke rate within 1 month was lower in the CAS group (hazard ratio [HR], 0.61). However, the incidence of cardiovascular disease (CVD) death was higher in the CAS group at 1 month, 1 year, and during the total follow-up (HRs, 4.18, 2.43, and 1.50). There were no significant differences in outcomes between asymptomatic patients in the 2 groups.

Conclusion: The periprocedural stroke risk was higher in symptomatic carotid stenosis patients who underwent CEA, but mortality was higher in those who received CAS, both in the short and long term. In asymptomatic patients, however, the incidence of major adverse cardiovascular events and mortality was similar between the 2 groups.