Adult Cardiovascular Surgery Research Articles

Surgical Repair of Post-Infarction Ventricular Septal Defect - Findings From a Japanese National Database.

Ventricular septal defect (VSD) after myocardial infarction (MI) is a rare but fatal complication. We report patients' characteristics and operative outcomes after surgical repair of post-MI VSD using a national database of Japan.Methods and Results:This was a retrospective review of the Japan Adult Cardiovascular Surgery Database (JCVSD) to identify adults (age ≥18 years) who underwent surgical repair of post-MI VSD between 2008 and 2014. The primary outcome was operative death. We identified 1,397 patients (671 male [48%], 74.1±9.3 years old) undergoing surgical repair of post-MI VSD among 288,736 patients undergoing cardiac surgery enrolled in the JCVSD during the same period. Of these, 1,075 (77.0%) were supported preoperatively with an intra-aortic balloon pump. Surgical status was urgent in 391 (28.0%) and emergency/salvage in 731 (52.3%). Concomitant coronary artery bypass grafting was performed in 475 (34.0%). Overall 30-day and operative mortalities were 24.3% and 33.0%, respectively. Operative mortality varied according to surgical status: 15.6% in elective, 30.9% in urgent, and 40.6% in emergency/salvage cases. Multivariable analysis identified advanced age and emergency/salvage status as being strongly associated with increased odds of operative death. Post-MI VSD remains a devastating complication in Japan as well as in the USA and Europe.

Procedure- and Hospital-Level Variation of Deep Sternal Wound Infection From All-Japan Registry

The outcome of cardiovascular surgery has been improving over time, but the treatment of postoperative complications such as deep sternal wound infection (DSWI) still needs critical attention. A nationwide surgical registry was analyzed for procedural details and hospital factors related to DSWI. The study used the Japan Adult Cardiovascular Surgery Database, which captured data from 82% of all the hospitals performing cardiac surgery in Japan. A total of 109,717 surgical cases (34,980 coronary artery bypass grafting, 43,602 valve operations, 31,135 thoracic aortic operations) were included in the study. The overall incidence of DSWI was 1738 (1.6%). The 30-day mortality and operative mortality were 3311 (3.0%) and 5155 (4.7%), respectively. Across the 3 procedures, thoracic aortic operation showed the highest odds ratio (2.61; 95% confidence interval [CI], 2.32 to 2.94) for operative mortality but the lowest (0.91; 95% CI:,0.73 to 1.13) for DSWI incidence. Conversely, coronary artery bypass grafting showed the lowest odds ratio (1.36; 95% CI, 1.24 to 1.49) for operative mortality but the highest (1.52; 95% CI, 1.32 to 1.76) for DSWI. There was also hospital-level variation: Correlation was statistically significant between the observed-to-expected ratio of DSWI incidence and the observed-to-expected mortality ratio of cardiovascular procedures across the hospitals, but the coefficient was small (r= .24, P < .001). Hospitals that have a lower risk-adjusted mortality rate of cardiovascular procedures do not always have a lower risk-adjusted DSWI occurrence rate. In addition, the incidence of DSWI varies across hospitals. We need to consider DSWI independently of surgical mortality, whereas for treatment we should consider both the specific hospital environment and the multidisciplinary care.

Risk Factors for Mortality and Morbidity of Surgical Aortic Valve Replacement for Aortic Stenosis - Risk Model From a Japan Cardiovascular Surgery Database.

Background: The aim of this study was to determine adequate indication for transcatheter aortic valve replacement (TAVR). We analyzed risk factors of surgical aortic valve replacement (SAVR) not only for mortality, but also for morbidity, including long hospital stay (≥90 days) and patient activity at discharge, in patients who underwent SAVR for aortic stenosis (AS). Methods and Results: Using the Japan Adult Cardiovascular Surgery Database (JCVSD), 13,961 patients with or without coronary artery bypass grafting who underwent elective SAVR for AS were identified from January 2008 to December 2012. The hospital mortality rate was 3.1%. The percentage of patients who had long hospital stay (≥90 days) and who had moderately or severely decompressed activity at discharge (modified Rankin scale ≥4) was 2.9% and 6.5%, respectively. Eleven and 20 preoperative predictors of hospital mortality and morbidity, respectively, including long hospital stay and compromised status at discharge, were identified. Based on these risk factors, the risk model predicted hospital mortality (area under the curve [AUC], 0.732) and morbidity (AUC, 0.694). Conclusions: Using JCVSD, a risk model of SAVR was developed for AS. This model can identify patients at high risk not only for mortality, but also for mortality and morbidity, including long hospital stay and status at discharge.

Outcomes of Thoracic Aortic Surgery in Patients With Coronary Artery Disease - Based on the Japan Adult Cardiovascular Surgery Database.

Coronary artery disease (CAD) is associated with increased morbidity and mortality after open repair of thoracic aorta. Nevertheless, the efficacy of preoperative coronary angiography (CAG) and revascularization is controversial. The aim of this study was to clarify the effect of preoperative CAD on surgical outcome by reviewing the Japan Adult Cardiovascular Database. Methods and Results: This study involved 4,596 patients who underwent open surgery for true thoracic aortic aneurysm between 2004 and 2009. After excluding patients with concomitant cardiac operation, except coronary artery bypass grafting (CABG), the remaining 1,904 patients with coronary artery stenosis included 995 cases of simultaneous CABG. The prevalence of CAD was significantly higher in patients with diabetes, renal dysfunction, hyperlipidemia, cerebrovascular disorders, peripheral artery lesions, old myocardial infarction (MI), and coronary intervention. Patients with simultaneous CABG had severe CAD compared with those without, with no other major differences in patient background noted. Thirty-day postoperative and in-hospital mortalities were higher in CAD patients. Incidence of perioperative MI was higher in patients who underwent open aortic repair with simultaneous CABG, but simultaneous CABG did not affect operative mortality. In patients with surgically treated true aortic aneurysm, CAD was frequently observed, suggesting that aggressive preoperative coronary evaluation is needed.

Deep sternal wound infection after bilateral internal thoracic artery grafting: Insights from a Japanese national database

ObjectivesDespite its survival benefits, bilateral internal thoracic artery (BITA) grafting is not commonly utilized due to concerns over deep sternal wound infection (DSWI). The present study investigated the early outcome of BITA grafting and analyzed the risk of DSWI using a Japanese national database (the Japan Adult Cardiovascular Surgery Database). MethodsData from 560 hospitals were used. Between April 2012 and December 2015, BITA was harvested in 14,249 patients, corresponding to 32.6% of isolated coronary artery bypass cases. DSWI was defined as a wound infection requiring surgical intervention and/or the administration of antibiotics. Multiple logistic regression analysis was employed to model the risk of DSWI. ResultsThe mean age was 67.1 years. The prevalence of diabetes, renal failure, hemodialysis, and liver dysfunction was 51.8%, 21.2%, 7.8%, and 1.2%, respectively. The incidence of DSWI and operative mortality was 1.6 (234 patients) and 1.6% (226 patients), respectively. The operative mortality rate in patients with DSWI was 13.7% (32 patients). The off-pump technique was used in 72.8%, with a conversion rate of 2.5%. Female sex, diabetes mellitus, chronic lung disease, renal failure, liver dysfunction, ejection fraction ≤60%, shock status, reoperation, preoperative intra-aortic balloon pump use, and an increased operative time were independent risk factors for DSWI after BITA grafting. The off-pump technique did not reduce the risk of DSWI. ConclusionsThe present study showed that early outcomes of BITA grafting were satisfactory regarding DSWI and operative mortality. The current data are informative to predict the risk of DSWI when performing BITA grafting.

Fibrinogen Concentrate in Cardiovascular Surgery: A Meta-analysis of Randomized Controlled Trials.

Postoperative bleeding remains a frequent complication after cardiovascular surgery and may contribute to serious morbidity and mortality. Observational studies have suggested a relationship between low endogenous plasma fibrinogen concentration and increased risk of postoperative blood loss in cardiac surgery. Although the transfusion of fibrinogen concentrate has been increasing, potential benefits and risks associated with perioperative fibrinogen supplementation in cardiovascular surgery are not fully understood. PubMed, Cochrane Library, Ovid MEDLINE, Embase, Web of Science, and China National Knowledge Infrastructure were searched on January 15, 2017, with automated updates searched until February 15, 2018, to identify all randomized controlled trials (RCTs) of fibrinogen concentrate, whether for prophylaxis or treatment of bleeding, in adults undergoing cardiovascular surgery. All RCTs comparing fibrinogen infusion versus any other comparator (placebo/standard of care or another active comparator) in adult cardiovascular surgery and reporting at least 1 predefined clinical outcome were included. The random-effects model was used to calculate risk ratios and weighted mean differences (95% confidence interval [CI]) for dichotomous and continuous variables, respectively. Subgroup analyses by fibrinogen dose and by baseline risk for bleeding were preplanned. A total of 8 RCTs of fibrinogen concentrate in adults (n = 597) of mixed risk or high risk undergoing cardiovascular surgery were included. Compared to placebo or inactive control, perioperative fibrinogen concentrate did not significantly impact risk of all-cause mortality (risk ratio, 0.41; 95% CI, 0.12-1.38; I = 10%; P = .15). Fibrinogen significantly reduced incidence of allogeneic red blood cell transfusion (risk ratio, 0.64; 95% CI, 0.49-0.83; I = 0%; P = .001). No significant differences were found for other clinical outcomes. Subgroup analyses were unremarkable when analyzed according to fibrinogen dose, time of infusion initiation, mean cardiopulmonary bypass time, and rotational thromboelastometry/fibrinogen temogram use (all P values for subgroup interaction were nonsignificant). Current evidence remains insufficient to support or refute routine perioperative administration of fibrinogen concentrate in patients undergoing cardiovascular surgery. Fibrinogen concentrate may reduce the need for additional allogeneic blood product transfusion in cardiovascular surgery patients at high risk or with evidence of bleeding. However, no definitive advantage was found for reduction in risk of mortality or other clinically relevant outcomes. The small number of clinical events within existing randomized trials suggests that further well-designed studies of adequate power and duration to measure all-cause mortality, stroke, myocardial infarction, reoperation, and thromboembolic events should be conducted. Future studies should also address cost-effectiveness relative to standard of care.

P05-6 - Inhaled nitric oxide in adult cardiovascular surgery patients - our 5-years experiences -

P05-6 - Inhaled nitric oxide in adult cardiovascular surgery patients - our 5-years experiences -

Cerebral oximetry for cardiac surgery: a preoperative comparison of device characteristics and pitfalls in interpretation.

Regional cerebral oximetry using near-infrared spectroscopy devices is commonly used for detecting cerebral ischemia during cardiopulmonary bypass, and aim to avoid poor cerebral perfusion which may result in perioperative neurological impairment. Today, several devices that can detect cerebral ischemia are commercially available. Although these devices operate on the same measurement principles, their algorithms for detecting and calculating cerebral ischemia are different and no criteria for directly comparing values measured by such different devices exist. From January 2017 to August 2017, 80 adult cardiovascular surgery patients were enrolled in the prospective study. In each patient, preoperative regional cerebral oxygen saturation values were measured by two different devices and their correlations with various preoperative factors were evaluated. Regional cerebral oxygen saturation levels were significantly higher for values of FORE-SIGHT ELITE (CAS Medical Systems, Branford, CT, USA) (F value) than those of the INVOS 5100C (Medtronic, Minneapolis, MN, USA) (I value). Scalp-cortex distance, hemoglobin concentration, and the presence or absence of hemodialysis showed significant correlations with ratios of measured values specific to each device (F/I). An appropriate device should be selected according to preoperative patient characteristics, and factors influencing regional cerebral oxygen saturation values should be considered to ensure the correct interpretation of measured values. This research was conducted with the approval of the ethics committee of our university (approval number: B16-96).

Propensity-matched analysis of a side-clamp versus an anastomosis assist device in cases of isolated coronary artery bypass grafting.

The use of an anastomosis assist device during coronary artery bypass grafting (CABG) is considered less invasive for the ascending aorta than the use of a side-biting clamp (Side-clamp) and to possibly be associated with a lower incidence of postoperative stroke. However, this benefit has not yet been clearly demonstrated. This study was to evaluate whether the use of an anastomosis assist device will minimize the postoperative stroke and other complications in patients undergoing off-pump CABG in comparison with the use of the Side-clamp. Patients undergoing isolated off-pump CABG were retrospectively reviewed using the Japan Adult Cardiovascular Surgery Database (2013-2016). We performed a one-to-one matched analysis based on the estimated propensity scores of those who underwent off-pump CABG with an anastomosis assist device (Device group, n = 14 213) or a side-biting clamp (Side-clamp group, n = 7374) and obtained 2 cohorts (n = 7348 each). We compared the early outcomes and the details of postoperative complications using the Pearson's χ2 test. P-values of <0.05 were considered to indicate statistical significance. No significant differences were observed in the rates of 30-day mortality (Side-clamp versus Device: 0.8% vs 0.8%, P = 0.93) or stroke (1.4% vs 1.4%, P = 0.46). Transient ischaemic attack/reversible ischaemic neurological deficit/delirium occurred more frequently in the Side-clamp group (1.3% vs 0.9%, P = 0.020), whereas new-onset atrial fibrillation (11.0% vs 12.8%, P < 0.001) and prolonged ventilation (2.0% vs 2.9%, P < 0.001) occurred more frequently in the Device group. There was no difference in the length of intensive care unit stay. The use of an anastomosis assist device partially provided better results with regard to the transient neurological complications; however, no overall benefit was observed in this study.

Surgical Outcomes of Isolated Coronary Artery Bypass Grafting for Acute Coronary Syndrome - Based on the Japan Adult Cardiovascular Surgery Database.

The present study aimed to clarify the current use and outcomes of coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) based on the Japan Adult Cardiovascular Surgery Database (JACVSD) in stratified risk categories, and also to provide guidance on selection of optimal surgical strategies for ACS.Methods and Results:From January 2008 through December 2012, 7,867 isolated CABG procedures for ACS were identifiedfrom the JACVSD. Patients were stratified into 3 subgroups (<2%, 2-9.9%, ≥10%) according to preoperative risk estimations based on this database. Off- and on-pump CABG surgical outcomes were evaluated in each subgroup. Off-pump CABG (OPCAB) was the predominant surgical strategy in all subgroups. The proportion of on-pump beating CABG increased in the higher-risk groups. Although average observed mortality rates were compatible with preoperative estimated risk in all subgroups, those after OPCAB were significantly lower in the medium (2-9.9%) risk group with lower incidence of major complications. In the low (<2%) and high (≥10%) risk groups, observed mortality rates did not show statistically significant differences between off- and on-pump CABG. In this study in Japan, OPCAB was mainly performed in patients with ACS, particularly those with estimated risk <10%, with lower mortality rates, whereas on-pump beating CABG was selected for higher-risk patients with ACS, with reasonable mortality rates.

Influence of Timing After Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissection

This study aimed to analyze the influence of the timing of intervention from presentation of symptoms to thoracic endovascular aortic repair (TEVAR) and its relation to major complications. Data were collected from the Japan Adult Cardiovascular Surgery Database. We retrospectively analyzed the data of 680 patients who underwent TEVAR for acute and subacute type B dissection between January 2008 and January2013. Thoracic endovascular aortic repair for type B dissection was performed in 680 patients: 295 repairs were performed within 24 hours of presentation of symptoms (hyperacute); 97 between 24 hours and 14 days (acute); and 288 between 14 days and 6 weeks (subacute). Hyperacute patients more frequently had immediate life-threatening complications from type B dissection such as rupture or malperfusion than did acute or subacute patients (41.0% [121 of 295] versus 7.2% [7 of 97] versus 4.2% [12 of 288]; p < 0.001; and 17.3% [51 of 295] versus 8.3% [8 of 97] versus 5.6% [16 of 288]; p < 0.001, respectively). Operative mortality and severe complications including aortic dissection were more common among hyperacute patients (11.9% [35 of 295] versus 0% [0 of 97] versus 1.7% [5 of 288]; p < 0.001; and 32.5% [96 of 295] versus 10.3% [10 of 97] versus 8.3% [24 of 288]; p < 0.001, respectively) and did not differ significantly between acute and subacute patients (p= 0.191 and p= 0.553, respectively). Although TEVAR performed for aortic dissection within 24 hours of presentation of symptoms was associated with worse outcomes, TEVAR performed between 24 hours and 14 days, as compared with TEVAR between 14 days and 6 weeks, does not appear to increase the risk of perioperative complications.

Clinical significance of chronic obstructive pulmonary disease in patients undergoing elective total arch replacement: analysis based on the Japan Adult Cardiovascular Surgery Database.

We investigated the impact of chronic obstructive pulmonary disease (COPD) on in-hospital outcomes of patients undergoing conventional total aortic arch replacement (TAR), based on the Japan Adult Cardiovascular Surgery Database. A total of 12 590 patients who underwent elective TAR between 2008 and 2013 were retrospectively reviewed. Patients were divided into 4 categories: normal respiratory function (control), with ratio of forced expiratory volume of air in 1 s (FEV 1 ) to forced vital capacity (FVC) of 76% or greater (TAR, n = 10 040); mild COPD, with FEV 1 /FVC ratio 60-75% and/or use of bronchodilator (TAR, n = 1890); moderate COPD, FEV 1 /FVC ratio 50 to 59% and/or use of steroids (TAR, n = 504); and severe COPD, FEV 1 /FVC ratio less than 50% and/or presence of respiratory failure (TAR, n = 156). In-hospital mortality was 5.7% (5.2% in controls, 7.0% in mild COPD, 9.3% in moderate COPD and 9.0% in severe COPD). A significant trend towards the severity of COPD was noted ( P < 0.0001). A higher incidence of postoperative pneumonia (6.0% in control, 11.0% in mild COPD, 12.3% in moderate COPD and 15.4% in severe COPD; P < 0.0001) and a greater need for prolonged ventilation (17.5% in control, 22.0% in mild COPD, 26.6% in moderate COPD and 29.5% in severe COPD; P < 0.0001) were observed in cases of more severe COPD. The odds ratio of moderate/severe COPD for in-hospital mortality was 1.44 with confidence interval of 1.08-1.91 ( P = 0.012). There was a significant increase in in-hospital mortality and morbidity with increasing severity of COPD in patients who underwent TAR.

Previous Percutaneous Coronary Intervention Does Not Increase Adverse Events After Coronary Artery Bypass Surgery

Adverse effects of previous percutaneous coronary intervention (PCI) on clinical outcomes after coronary artery bypass grafting (CABG) are unclear. This study aimed to evaluate the effect of previous PCI on early outcomes after subsequent CABG by using data from the Japanese national database. This study analyzed data from 48,051 consecutive patients that were retrieved from the Japan Adult Cardiovascular Surgery Database. These patients underwent primary, isolated, elective CABG between January 2008 and December 2013. Early mortality and morbidity rates in patients with previous PCI (n= 12,457, 25.9%) were compared with those in patients with no PCI (n= 35,594, 74.1%) by using multivariate logistic regression analysis and propensity score analysis. Operative mortality rates (no PCI, 1.2%; previous PCI, 1.2%; P= 0.970) and morbidity rates (no PCI, 7.4%; previous PCI, 7.2%; p= 0.436) were similar between the two groups. In risk-adjusted multivariate logistic-regression analysis, previous PCI (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.82 to 1.22; p=0.995) and morbidity (OR, 0.97; 95% CI, 0.89 to 1.05; p= 0.391) were not significant risk factors of operative mortality. Inverse probability of treatment weighting using the propensity score confirmed these results. This study shows that a previous PCI procedure does not increase postoperative adverse events after subsequent CABG. In the setting of repeat coronary revascularization, the most appropriate method of revascularization should be selected by the heart team, without being affected by a history of a previous PCI procedure.

Telemedicine in Cardiology - Perspectives in Bosnia and Herzegovina.

Introduction:Aim of article was to present perspectives of telemedicine in the field of cardiology in Bosnia and Herzegovina.Material and methods:Article has descriptive character and present review of literature.Results:Information technology can have the application in the education of students, starting from basic medical sciences up to clinical subjects. Information technologies are used for ECG analysis, 24h ECG Holter monitoring, which detects different rhythm disorders. By developing software packages for electrocardiogram analysis, which can be divided and interpreted by mobile phones, and complete the whole of the patient in the ambulance, specialist, experienced specialists, or even consultations in various illnesses and cities. Image segmentation algorithms have significance in the quantization and diagnostics of anatomic and pathological structures, and 3D representation has an important role in education, topography and clinical anatomy, radiology, pathology, as well as in clinical cardiology itself, especially in the sphere of coronary arteries identification in the multislice computerized angiography of coronary arteries. Interactive video consultations with subspecialists from the state and the region in adult cardiology, adult interventional cardiology, cardiovascular surgery, pediatric invasive and non-invasive cardiology enable better access to heart specialists and subspecialist, accurate diagnosis, better treatment, reduction of mortality, and a significant reduction in costs.Conclusion:Telemedicine by slow steps in entering the soil of Bosnia and Herzegovina, but the potential exists. It is necessary to educate the medical staff, as well as to provide a tempting environment for software engineers. Investing in infrastructure and equipment is imperative, as well as a positive climate for the its implementation.

Invited Commentary

Invited Commentary

Off-pump versus on-pump coronary artery bypass grafting in patients with left ventricular dysfunction

ObjectiveUsing data from the Japan Adult Cardiovascular Surgery Database, we evaluated the prognostic influence of off-pump technique in patients with low ejection fraction who underwent coronary artery bypass grafting. MethodsWe analyzed 2187 patients with an ejection fraction <0.30 who underwent primary, nonemergency, isolated coronary artery bypass grafting between 2008 and 2012, as reported in the Japan Adult Cardiovascular Surgery Database. Patients were divided into on-pump (n = 1134; 51.1%) and off-pump (n = 1053; 48.9%) coronary artery bypass grafting groups. Propensity-score matching for 20 preoperative variables was performed, and early mortality and morbidity were compared between matched groups. ResultsPropensity-score matching created 918 pairs. Of the 918 patients in the off-pump group, conversion to an on-pump procedure occurred in 56 (6.1%). Compared with on-pump, off-pump technique was associated with significantly lower incidences of 30-day death (1.7% vs 3.7%; P = .01), operative death (3.3% vs 6.1%; P = .006), mediastinitis (1.9% vs 3.4%; P = .041), reoperation for bleeding (0.9% vs 3.5%; P < .001), and prolonged ventilation (8.2% vs 13.4%; P < .001). Comparison of patients undergoing off-pump versus on-pump procedures demonstrated no significant differences in the incidence of stroke (1.5% vs 2.1%; P = .38), renal failure (6.1% vs 7.4%; P = .26), and postoperative dialysis (3.1% vs 4.4%; P = .14). Institutional volume-adjusted analysis confirmed most of these results. ConclusionsOff-pump coronary artery bypass grafting is associated with significantly reduced early mortality and morbidity in patients with an ejection fraction <0.30.

Abstract 16999: Analysis of Risk Factors for Mortality and Morbidity of Surgical Aortic Valve Replacement for Aortic Stenosis: Risk Models From a Japanese Database

Background: Surgical aortic valve replacement (sAVR) is the standard treatment for atherosclerotic aortic stenosis; however, trans-catheter aortic valve replacement (tAVR) is being increasingly used for high risk patients. The risks associated with sAVR have usually been assessed by operative mortality. However, it may be meaningful to assess the risk for operative morbidity. Purpose: This study aimed to create risk models associated with sAVR for mortality, as well as for combined mortality and morbidity (M-M), using the Japan Adult Cardiovascular Surgery Database. Methods: A total of 14,100 patients who underwent sAVR with/without CABG between 2009 and 2012 were retrospectively evaluated. We excluded patients with contraindications to tAVR, except for chronic dialysis. Multiple logistic regression analysis was used to create a risk model for mortality (30 days postoperative and in-hospital), and for M-M (patient was hospitalized longer than 90 days or patient’s daily activities were disturbed with a modified Rankin scale of 4 or more at discharge). Results: Mortality was 3.1%, and rate of M-M was 10.9%. Significant risk factors are listed in the table. Risk factors common to both mortality and M-M were older age, chronic dialysis, atrial fibrillation, higher NYHA class, chronic lung disease, cerebrovascular disease, and congestive heart failure. Risk factors specific to M-M were history of psychoneurotic disorder, diabetes mellitus, obesity, and left ventricular dysfunction. Conclusions: Analyzing the risk factors not only for mortality but also for M-M may be useful in identifying appropriate candidates for tAVR.

Abstract 12340: Risk Model of Aortic Valve Replacement After Cardiovascular Surgery based on 2,227 Cases From a National Japanese Database: The Japan Cardiovascular Surgery Database (JACVSD)

Objective: To create a risk model to assess outcomes of aortic valve replacement after cardiovascular surgery (ReAVR) using a national Japanese database. Methods: The Japan Adult Cardiovascular Surgery Database is a web-based data system involving more than 500 hospitals. Between 2007 and 2012, 2,227 patients who underwent ReAVR for aortic stenosis were retrospectively analyzed. Patients with a previous history of AVR were also included. Results: The background of prior surgery (including overlapping cases) was: CABG, 30.9%; valve, 65.4%; and thoracic aorta, 14.7%. The mean age was 70.4. Types of prosthesis used were: bioprosthesis, 51.3%; and mechanical valve, 48.7%. The rate of isolated ReAVR was 59.5%. Concomitant procedures were: CABG, 14.6%; mitral valve surgery, 30.4%; and aortic surgery, 5.7%. The overall hospital mortality rate was 8.7%. Major complications (reoperation, prolonged ventilation, mediastinitis, stroke, and newly required dialysis) occurred in 26.0%. The incidence of stroke was 3.7%, and that of AV block was 3.5%. ORs for hospital mortality were as follows: age, 1.4 (reference ≦60, 5-year increments); male, 1.4; urgency, 1.7; EF ≦30%, 2.0; NYHA classification IV, 1.7; MR ≧2, 1.5; creatinine &gt;2.0 mg/dL, 2.7; liver dysfunction (cirrhosis, AST or ALT &gt;100 U/L, or bilirubin &gt;1.5 mg/dL), 2.3; peripheral artery disease, 1.6; and recent stroke (&lt;2 weeks), 4.8. The type of previous surgery was not a predictor for mortality. In addition to the above-mentioned risk factors, ORs for the composite outcome (mortality and major complications) were as follows: carotid stenosis, 2.5; respiratory dysfunction (FEV1.0 &lt;75%, or bronchodilator use), 1.8; prior valve surgery, 1.3; preoperative inotropic agents, 2.0; endocarditis, 1.7; concomitant CABG, 1.4; and concomitant valve surgery, 1.5. As a performance metric model, C-indexes of hospital mortality and the composite outcome were 0.77 and 0.71, respectively. Conclusions: Based on a national Japanese database, early outcomes after ReAVR were satisfactory, despite these operations being associated with a higher risk than the primary operations. The type of previous surgery was not a risk for mortality after ReAVR.

Teruhisa Kazui (18 May 1941-8 February 2015): a giant of aortic surgery.

Dr. Teruhisa Kazui passed away on 8 February 2015 in Sapporo, Japan, at the age of 73. He was born in mainland China on 18 May 1941. After World War II, he and his family moved to Sapporo, where he spent his school days until he graduated from the Sapporo Medical University (M.D.) in 1967. He passed the ECFMG exam while he was a medical student and spent a 1-year internship at the United States Naval Hospital, Yokosuka, Japan. There is no doubt that Dr. Juro Wada, a pioneer in cardiothoracic surgery in Japan, who was serving as a professor of surgery at the Sapporo Medical University, mentored him in his decision. Indeed, Dr. Kazui said in his reminiscences that Dr. Wada gave American-style lectures to medical students in English and inspired many medical students to pursue careers in surgery. After completing his internship, he returned to Sapporo and began his career as a cardiovascular surgeon under the direction of Dr. Wada. Meanwhile, he enrolled in the graduate school of medicine of the Sapporo Medical University and obtained a Ph.D. degree in 1972 with his thesis on immunosuppression in organ transplantation. After getting married to his lifelong partner Sanae, Dr. Kazui left Sapporo for the United States in 1972 to become a clinical fellow at the Arizona Heart Institute/St. Joseph Hospital for 2 years. Then he moved to New York and spent 1 year at the Upstate Medical University as a research fellow. He returned to the Sapporo Medical University in 1975 and became an instructor and the chief of an adult cardiovascular surgery team. Six years later, he was appointed as an assistant professor there. In 1984, he spent 2 months in Helsinki, Finland, in an exchange program. During this time, he started experimental and clinical work on aortic arch surgery, and established a standardized technique of total aortic arch replacement using a branched aortic prosthesis and selective antegrade cerebral perfusion, through friendly competition with Dr. Nobuyuki Nakajima, late professor emeritus at Chiba University, Japan. The technique is sometimes called the Kazui method now. Dr. Kazui made great worldwide contributions on this topic, and presented many distinguished papers. As a result, he was invited by the German Academic Exchange Service in 1994 as a visiting professor at the Hannover Medical School, Germany, by St. Antonius Hospital Nieuwegein, the Netherlands, in 1995, and also by the University of Massachusetts Medical School, the United States, as a visiting professor in 1996. & Norihiko Shiiya shiyanor@hama-med.ac.jp

TRALI or ARDS or TDGE versus blood transfusion.

1Hospital Ana NeryPediatric Cardiovascular Surgery; Hospital Santa Izabel Adult and pediatric Cardiovascular Surgery, Salvador, Brazil. E-mail: brunorochaccv@hotmail.com More recently in 2012 an International Task Force on ARDS-acute respiratory distress syndrome has changed the terminology of acute respiratory disorders gathering several terms in a single nomenclature, then TDGE-transient dysfunction of gas exchange was abandoned[1]. Thus, ARDS was categorized according to PaO2/FiO2 levels into three degrees of hypoxemia: mild (200 to 300 mmHg), moderate (100 to 200 mmHg) and severe (<100 mmHg). Rodrigues et al.[2] focused on postoperative acute respiratory disorder concerning adult patients submitted to cardiac surgery. In this retrospective cohort of 717 patients, they accounted for over 60% of patients with moderate or important degree of hypoxemia as above-mentioned. This considerable number of patients with respiratory impairment had an impact in outcomes as ICU (Intensive Care Unit) length of stay and rose susceptibility to pulmonary infection. Three risk factors were identified on multivariate analysis: renal replacement therapy [P=0.0005, Odds ratio (OR) 2.34], cardiac arrhythmia (P=0.045, OR 1.79) and blood transfusion (P=0.0001, OR 1.72). Indeed, blood transfusion has been considered a key point of TDGE, but in fact it is unduly burdensome. Certainly TRALItransfusion-related acute lung injury is a well-known acronym used in ICU settings by health personnel as well as TDGE[3]. There is also a widespread concerning about reducing blood transfusion to prevent TRALI or ARDS or TDGE, hence decreasing morbimortality rates[4]. The etiology may be different for acute respiratory distress, but pathophysiology is alike no matter which name is given. For practical purposes, several studies compared restrictive transfusion strategy < 7 g per dL of hemoglobin (class IIalevel of evidence C) versus a liberal transfusion trigger of 10 g per dL of hemoglobin (class III-C). Some strategies have been used in cardiac surgery as intraoperative auto-transfusion (class IIb-C), OPCABG (Off-Pump Coronary Artery Bypass Graft) (class IIa-A), centrifugation of pump-salvaged blood (class IIb-A), red cell savage (class I-A), minicircuits (class I-A), recombinant human erythropoietin (class IIa-A) as other drugs and manoeuvres to prevent blood loss[5].