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PURPOSE: Although minimally invasive cardiac surgery (MICS) procedures are widely performed throughout Japan, nationwide data regarding treated cases are limited. Up-to-date results for cardiovascular surgery are vital for quality control in clinical practice. Presented here is the 2021 annual report based on data from the Japan Cardiovascular Surgery Database (JCVSD). METHODS: Records noted in the JCVSD of patients who underwent mitral valve surgery, aortic valve replacement (AVR), coronary artery bypass grafting (CABG), atrial septum defect (ASD) closure, or cardiac tumor resection via right or left minithoracotomy, as well as thoracoscopic- or port-assisted, or robotic-assisted approaches, in 2021 were examined. Perioperative parameters including mortality and morbidity was evaluated. RESULTS: The 30-day and in-hospital mortalities for isolated mitral valve repair (n = 1211) were 0.1% and 0.2%, respectively, while those for all mitral valve repair (n = 2017) were 0.05% and 0.2%, respectively. More than 100 facilities were found to perform fewer than five MICS mitral valve surgery cases per year. As for MICS-AVR, 30-day and in-hospital mortalities for isolated AVR (n = 818) were 0.5% and 0.5%, respectively, while those for all AVR (n = 987) were 0.6% and 1.1%, respectively. Additionally, those for MICS-CABG (n = 400) were 0.8% and 0.5%, respectively. Those for ASD (n = 183) and cardiac tumor (n = 96), were 0.5% and 0.5%, respectively, and 0% and 1.0%, respectively. CONCLUSION: This is the first report of MICS results of procedures performed in Japan based on the 2021 JCVSD data. Additional results obtained with a similar data collection method are expected and details on MICS are being collected starting 2024.

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Background: A transcatheter edge-to-edge repair (TEER) is disseminating gradually as a treatment for primary and secondary mitral regurgitation (MR) in patients with high surgical risk. In performing TEER, securing a safe access route is crucial. We report a case with a challenging access route due to the presence of a double inferior vena cava (IVC) and the patient's small body habitus. Case summary: An 84-year-old female presented with congestive heart failure due to severe MR. Despite receiving optimal medical therapy, her symptoms did not improve significantly. Transcatheter edge-to-edge repair was deemed challenging due to her extremely small body habitus [height: 131 cm; body surface area: 1.17 m2] and the presence of double IVC. However, considering her inoperable risk for surgical repair, she underwent TEER after a multidisciplinary heart team discussion. The steering guide catheter (SGC) encountered resistance, but gradual advancement and use of a bougie with a large bore sheath dilator successfully delivered the SGC to the right atrium. Following the TEER, there was a significant improvement in the symptoms. Discussion: Extremely small venous system in a small patient with double IVC presented a unique technical hurdle. Transcatheter edge-to-edge repair is potentially feasible even in such a patient by cautiously applying the technique described.

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The presence of an annular abscess complicates the operation for infective endocarditis. We report a case of a totally endoscopic repair of a mitral annular abscess using a staged strategy. A 28-year-old woman underwent endoscopic mitral valve repair for active infective endocarditis with Staphylococcus aureus. At the index operation, the mitral annular abscess was completely debrided, yielding an annular defect. The mitral valve was repaired with the autologous pericardial patch and an annuloplasty. Primary repair of the annular defect was not performed because of the fragility of oedematous tissues. Two weeks after index surgery, when the infection was under control, and the scar tissue had formed around the annulus, we performed the second stage operation involving repair of the annular abscess. The scar formation enabled annular reconstruction and additional repair of the mitral valve in a totally endoscopic fashion. The postoperative course was uneventful, and there was no recurrence at 5 months. An annular abscess may be repaired with staged surgery in select situations.

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BACKGROUND: The applicability of totally endoscopic surgical aortic valve replacement (AVR) in multivalve operations is unknown. This study describes an approach and perioperative outcomes of totally endoscopic isolated and concomitant AVR using various valve types. METHODS: A total of 216 patients (114 male; mean age, 71.3 ± 11.3 years) underwent totally endoscopic AVR from May 2017 to October 2022 in a tertiary care center. The 3-port technique was used: a 3- to 4-cm main port without rib spreading, a 10-mm 3-dimensional endoscopic port, and a 5-mm left-hand port with femoral cannulations. Sutures were hand tied with a knot pusher. Descriptive analyses compared perioperative outcomes between patients with or without concomitant procedures. RESULTS: Of 216 patients, concomitant surgery was performed in 33 (15.2%) patients. Of the 33, 21 (63.6%) had a concomitant mitral procedure. A stented bioprosthesis was implanted in 165 (76.3%) patients, a mechanical valve in 22 (10.2%) patients, and a rapid deployment or sutureless valve in 29 (13.4%) patients. Median operation time and aortic cross-clamp time were 175 minutes (interquartile range; 150-194 minutes) and 78 minutes (interquartile range; 67-92 minutes) for isolated AVR, respectively. Thirty-day mortality occurred in 1 patient (0.5%). Two patients (0.9%) had conversion to sternotomy. Major neurologic events occurred in 3 patients (1.4%). The major adverse event rate was similar between patients with or without concomitant procedures. CONCLUSIONS: Endoscopic AVR can safely address concomitant valve diseases.

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A left ventricular pseudoaneurysm is a rare complication that can occur after infective endocarditis, possibly leading to serious complications such as cardiac tamponade, rupture and recurrent infective endocarditis. We report a case of a totally-endoscopic repair of a pseudoaneurysm after endoscopic mitral valve repair. A 48-year-old woman underwent endoscopic mitral valve repair for active infective endocarditis. A left ventricular pseudoaneurysm was found 2 weeks after the surgery. The pseudoaneurysm was repaired through a left thoracotomy with a totally endoscopic platform. The postoperative course was uneventful, and there was no recurrence at 18 months. Left ventricular pseudoaneurysm may be repaired with a left thoracotomy totally endoscopic approach.

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Objectives: Some pathologies, including infective endocarditis or sclerotic changes of the mitral leaflet, make the conventional mitral valve repair challenging. Our previously described technique for reconstruction with a seamless pericardial patch makes the repair feasible in some of such difficult pathologies. However, the extent of mitral leaflet segments that could be safely repaired using this technique remains unknown. We investigated the association between the midterm outcome and the extent of mitral leaflet segments replaced by a pericardial patch. Methods: From January 2009 to January 2022, patients who underwent mitral valve repair with the seamless 1-patch reconstruction technique were included. The glutaraldehyde-treated pericardium was trimmed and anchored at the papillary muscle. The edge was sewn to the leaflet and the annulus. Results: A total of 49 patients (aged 60 ± 15 years) underwent mitral valve repair with this technique. The totally endoscopic approach was used in 27 patients (55%). No patient's repair was converted to valve replacement. No operative mortality or disabling stroke was observed during the early postoperative period. In the midterm follow-up, redo surgery was required in 9 patients (18%). Freedom from mitral valve reintervention rates at 1, 5, and 10 years were 84%, 82%, and 82% for all patients, respectively. Freedom from reoperation at 5 years was 100%, 92%, and 46% for commissural lesion, 1- to 2-segment involvement, and 3-segment involvement, respectively. There was a significant difference among the 3 groups with regard to mitral valve reoperation rate (P = .002). Conclusions: Mitral valve seamless patch reconstruction provides excellent midterm results if applied to commissural lesions or lesions involving up to 2 segments.

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Mitral valve repair for endocarditis in an acute setting is still challenging due to difficulties in debriding friable tissue and in leaving enough non-infected tissue for reconstruction. Endoscopic approaches for complex mitral valve procedures via a minimally invasive approach have been reported from high-volume programs. However, the role of endoscopic mitral valve surgery for acute infective endocarditis has not been clearly defined. We report our technique of endoscopic mitral valve repair using the cavitron ultrasonic surgical aspirator system for active endocarditis. The cavitron ultrasonic surgical aspirator with a low power setting provides enough debridement of the infective tissue and leaves healthy tissue adequate for repair under a totally endoscopic vision.

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Minimally invasive cardiac surgery is commonly used to treat degenerative mitral regurgitation. The totally endoscopic approach has emerged as an attractive alternative procedure especially for young patients and has been described in isolated mitral and aortic valve settings. The totally endoscopic double valve procedure, including mitral and aortic valves, extends this treatment option to a broader patient population. We describe our approach to performing a totally endoscopic concomitant aortic and mitral valve procedure that has overcome unique technical hurdles and has yielded favorable outcomes.

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PURPOSE: A cutting stapler is a well-established instrument in many surgical fields. However, its efficacy and safety have not been proven yet in resecting a left atrial appendage (LAA) in minimally invasive cardiac surgery (MICS). METHODS: A cutting stapler was used to resect the LAA in 98 consecutive patients who underwent MICS. Of these, 26 patients underwent aortic valve replacement, 72 mitral valve repair/replacement, 25 tricuspid annuloplasty, 7 closure of atrial septal defect, and 26 the Maze procedure (contains overlapping). The ascending aorta was elevated using a retractor, and a 12-mm shaft motor-driven cutting stapler was inserted through the transverse sinus. As a control group, 150 patients who underwent suture resection/closure of the LAA either from inside or outside were compared. RESULTS: There was one mortality in each group. They were not related to the LAA resection/closure. In the suture group, the LAA suture was taken down in one patient because of a suspected obstruction of the circumflex artery, and two patients had re-exploration for bleeding from the LAA. In the stapler group, there was no complication related with the LAA. The rate of complication did not reach a statistical difference. CONCLUSION: A cutting stapler is considered to be a useful instrument to resect the LAA in MICS.

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BACKGROUND: Stroke and paraplegia are serious complications of total aortic arch replacement (TAR). Hypothermic circulatory arrest and cerebral perfusion reduce the risk of neurologic complications, but longer circulatory arrest time remains a risk factor for such complications. We utilized a frozen elephant trunk (FET) with endo-balloon occlusion under mild systemic hypothermia, which allowed us to shorten circulatory arrest time. METHODS: Between April 2007 and May 2020, 72 patients underwent elective TAR using antegrade cerebral perfusion (ACP). They were divided into 2 groups. 64 patients received conventional TAR with moderate systemic hypothermic (bladder temperature, 25-28°C) circulatory arrest (group C). We used a FET with endo-balloon occlusion and retrograde perfusion through the femoral artery for the newest 8 patients who had mild hypothermic (bladder temperature of 30°C) circulatory arrest (group B). RESULTS: The mean operation time (257.5 ± 42.1 versus 327.8 ± 84.9 min, P = .023), CPB time (144.4 ± 28.1 versus 178.2 ± 26.4 min, P = .003), cardiac arrest time (75.5 ± 21.2 versus 95.7 ± 56.4 min, P < .001), SCP time (100.8 ± 25.5 versus 124 ± 23.2 min, P < .001), lower body circulation arrest time (17.2 ± 4.2 versus 62.5 ± 19.3 min, P < .001) were significantly shorter in the endo-balloon occlusion group. There were no perioperative neurological and renal complications or mortality in FET group. The new technique enabled a decrease in mechanical ventilation time (8.6 ± 1.4 versus 13.9 ± 5.7 min, P = .015) and hospital length of stay (9.7 ± 1.8 versus 18.3 ± 4.6 min, P = .005). CONCLUSION: FET using an endo-balloon occlusion with mild hypothermia is a safe and an effective approach in TAR.

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BACKGROUND: Hypo-attenuated leaflet thickening (HALT) in bioprosthetic aortic valve has been studied, but its equivalent in bioprosthetic mitral valve (bMV) remains uncharacterized. We sought to identify the prevalence, hemodynamic characteristics, and significance of anticoagulation therapy in bMV HALT. METHODS: A single-center cross-sectional study of 53 consecutive patients who underwent mitral valve replacement (MVR) with bMV between 2007 and 2017 was conducted. Cardiac-gated contrasted CT scans were obtained. Anticoagulant and antiplatelet therapy use were ascertained at the time of hospital discharge and CT scanning. Patient characteristics, postoperative stroke, and hemodynamic profile by echocardiogram were obtained to descriptively characterize the prevalence and characteristics associated with bMV HALT. RESULTS: Three patients (5.7%) were found to have a HALT on bMV. The mean time from index MVR to CT scan was 3.4 ± 0.8 years in HALT cohort and 3.4 ± 2.7 years in non-HALT cohort. Fifty patients (94.3%) were discharged on warfarin, and 37 patients (69.8%) were on warfarin at the time of CT scans. One patient with HALT was on therapeutic warfarin at the time of the CT scan that identified HALT. All three patients were asymptomatic at the time of CT scan. In patients with HALT, mean transmitral pressure gradient were 8, 5, and 2.7 mmHg, all with trivial or mild mitral regurgitation. CONCLUSIONS: In this study, the prevalence of HALT was low at 5.7%, all presenting without symptoms. One patient presented with HALT while on therapeutic oral anticoagulation, which may suggest thrombotic etiology may not adequately explain HALT.

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BACKGROUND: The optimal management of preexisting severe aortic stenosis (AS) in patients undergoing noncardiac surgery (non-CS) remains uncertain. This study aimed to investigate the safety and effectiveness of percutaneous aortic valve intervention (PAVI) in patients with AS before non-CS. METHODS: We analyzed pooled data within a multicenter Japanese registry from 118 patients with severe AS who underwent PAVI before non-CS. Sixty patients underwent percutaneous balloon aortic valvuloplasty (BAV) and 58 patients underwent transcatheter aortic valve replacement (TAVR). The groups' baseline characteristics, perioperative complications, and 30-day mortality and midterm mortality after non-CS were compared. RESULTS: The postprocedural mean pressure gradient was higher in the BAV group than in the TAVR group (35.0 ±â€¯11.5 mmHg vs. 11.5 ±â€¯4.8 mmHg, p < 0.001). The non-CS operation risk did not differ between the groups (p = 0.69). One patient in each group experienced a noncardiac death (p = 0.74), and the 30-day mortality rate after non-CS was 1.7%. Heart failure occurred in 2 patients in each group (p = 0.68). One patient in the TAVR group experienced a non-disabling stroke, and no myocardial infarctions occurred. Consequently, the combined adverse events were 5.0% and 6.9% in the 2 groups (p = 0.48). The bleeding rates during the non-CS were similar in both groups (33.3% vs. 25.9%, p = 0.25). There were no differences between the groups regarding midterm mortality (p = 0.60), whereas 53.3% of the patients in the BAV group required invasive treatment of their AS during follow-up. CONCLUSIONS: Among patients with severe AS, PAVI before non-CS reduces the AS severity and may contribute to procedural safety during non-CS.

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OBJECTIVES: To compare different configurations of the bilateral internal thoracic arteries for the left coronary system and examine early and late outcomes, including mid-term graft patency. METHODS: We reviewed 877 patients who underwent primary isolated coronary artery bypass grafting using in situ bilateral internal thoracic arteries [in situ right internal thoracic artery (RITA)-to-left anterior descending artery (LAD) grafting, n = 683; in situ left internal thoracic artery (LITA)-to-LAD grafting, n = 194]. We compared mid-term patency between the grafts. Propensity score matching was performed to investigate early and long-term outcomes. RESULTS: The 2-year patency rate for RITA-to-LAD and LITA-to-LAD grafts were similar. Multivariate analysis revealed that RITA-to-non-LAD anastomosis (P = 0.029), postoperative length of stay (P = 0.003) and chronic obstructive pulmonary disease (P = 0.005) were associated with graft failure. After statistical adjustment, 176 propensity-matched pairs were available for comparison. RITA-to-LAD grafting enabled a more distal anastomosis. Kaplan-Meier analysis revealed that the incidences of death, repeat revascularization and myocardial infarction were significantly higher in the LITA-to-LAD group among both the unmatched and matched samples (P = 0.045 and 0.029, respectively). CONCLUSIONS: The mid-term patency and outcomes of RITA-to-LAD grafting are good and reduces future cardiac event, in contrast to LITA-to-LAD grafting.

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We describe our experience of a novel 'two-window' technique designed to assist in totally 3D-endoscopic mitral valve repair. A 10-mm trocar for a 3D-endoscope was inserted through the 4th intercostal space in the mid-axillary line. A main small incision (3 cm, 4th intercostal space) without rib spreading, and a second 1 cm incision (1-2 intercostal spaces above,) were made in the anterior axillary line. Soft tissue retractors were applied on both ports. A left atrial retractor, a left ventricular vent, and right-hand instruments were inserted through the main working port. A flexible aortic cross-clamp, an antegrade cardioplegia line, and left-hand instruments were inserted through the second port. Our two-window technique is safe, effective, and reproducible for totally endoscopic mitral valve repair.

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In this study, we describe a rare case of a 45-year-old man with a recurrence of aortopulmonary window (APW) 41 years after the initial patch closure for an APW at the age of 4. He presented with persistent cough and exertional dyspnoea. Imagings revealed a recurrence of APW, ascending aorta saccular aneurysm, and severe mitral and tricuspid regurgitation. Re-patch closure, ascending aortic replacement, and mitral and tricuspid annuloplasties were performed, followed by an uneventful postoperative course. The relapse of APW in the remote postoperative period is extremely rare.

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