Publications by authors named "Hiroto Kitahara"

100 Publications

Transcatheter Versus Surgical Aortic Valve Replacement in Young, Low-Risk Patients With Severe Aortic Stenosis.

JACC Cardiovasc Interv 2021 Jun;14(11):1169-1180

Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA. Electronic address:

Transcatheter aortic valve replacement (TAVR) is approved for all patient risk profiles and is an option for all patients irrespective of age. However, patients enrolled in the low- and intermediate-risk trials were in their 70s, and those in the high-risk trials were in their 80s. TAVR has never been systematically tested in young (<65 years), low-risk patients. Unanswered questions remain, including the safety and effectiveness of TAVR in patients with bicuspid aortic valves; future coronary access; durability of transcatheter heart valves; technical considerations for surgical transcatheter heart valve explantation; management of concomitant conditions such as aortopathy, mitral valve disease, and coronary artery disease; and the safety and feasibility of future TAVR-in-TAVR. The authors predict that balancing these questions with patients' clear preference for less invasive treatment will become common. In this paper, the authors consider each of these questions and discuss risks and benefits of theoretical treatment strategies in the lifetime management of young patients with severe aortic stenosis.
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http://dx.doi.org/10.1016/j.jcin.2021.03.058DOI Listing
June 2021

A phase III, 52-week, open-label study to evaluate the safety and efficacy of 5% sofpironium bromide (BBI-4000) gel in Japanese patients with primary axillary hyperhidrosis.

J Dermatol 2021 Aug 26;48(8):1149-1161. Epub 2021 May 26.

Department of Dermatology, Tokyo Medical and Dental University, Tokyo, Japan.

A long-term study was conducted in Japanese patients with primary axillary hyperhidrosis who completed the preceding 6-week phase III, confirmatory study of 5% sofpironium bromide gel (hereinafter referred to as sofpironium) to evaluate the safety and efficacy of 52-week treatment with sofpironium. In the long-term study, 185 patients who completed the confirmatory study (94 and 91 patients in the vehicle and sofpironium groups, respectively) started to receive sofpironium (switching and extension groups, respectively), and all these patients were included in both the full analysis set (FAS) and the safety analysis set (SAF). In the FAS, there were more females than males (73.0% vs. 27.0%), and median age was 38.0 years. A total of 161 patients (86 and 75 patients in the switching and extension groups, respectively) completed the study at week 52. The proportions of patients with hyperhidrosis disease severity score of 1 or 2 and a 50% or more reduction in total gravimetric weight of sweat were 57.4% in the switching group and 58.2% in the extension group at week 52. The proportions of patients who achieved this efficacy end-point in the long-term study were similar to that (53.9%) in the sofpironium group in the confirmatory study. In the SAF, the incidences of adverse events (AEs) were 80.9% in the switching group and 83.5% in the extension group, and the incidences of adverse drug reactions were 39.4% and 45.1%, respectively. AEs that occurred in at least 20% of patients in both treatment groups were application site dermatitis (25.5% and 33.0%, respectively) and nasopharyngitis (31.9% and 23.1%, respectively). Reported AEs were generally mild, and there were no deaths. Serious AEs occurred in three patients, but none were considered related to the study drug. In this study, the efficacy of sofpironium was maintained during 52-week treatment, and no new safety risk was observed.
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http://dx.doi.org/10.1111/1346-8138.15927DOI Listing
August 2021

Edge-to-edge mitral repair for iatrogenic chordal rupture related to Impella 5.0.

J Card Surg 2021 Jul 14;36(7):2541-2542. Epub 2021 Apr 14.

Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Georgetown University School of Medicine, Washington, DC, USA.

Iatrogenic chordal rupture with severe mitral regurgitation is a rare but serious complication associated with the use of Impella device. We present a case of a 47-year-old man with ischemic cardiomyopathy who required insertion of an Impella 5.0 device. During Impella support, he developed acute pulmonary edema secondary to newly diagnosed posterior mitral valve chordal rupture and subsequent severe mitral regurgitation. He underwent implantation of a durable left ventricular assist device with concomitant edge-to-edge mitral valve repair through the apex.
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http://dx.doi.org/10.1111/jocs.15517DOI Listing
July 2021

Tricuspid valve injury after heart transplantation: how to monitor for rejection?

Eur Heart J Cardiovasc Imaging 2021 Jun;22(7):e91

MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA.

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http://dx.doi.org/10.1093/ehjci/jeab035DOI Listing
June 2021

A phase 3, multicenter, randomized, double-blind, vehicle-controlled, parallel-group study of 5% sofpironium bromide (BBI-4000) gel in Japanese patients with primary axillary hyperhidrosis.

J Dermatol 2021 Mar 7;48(3):279-288. Epub 2021 Jan 7.

Kaken Pharmaceutical Co., Ltd., Tokyo, Japan.

A phase 3 study was conducted to verify the efficacy and safety of 5% sofpironium bromide (BBI-4000) gel (hereinafter referred to as sofpironium) administrated for 6 weeks in Japanese patients with primary axillary hyperhidrosis. The primary efficacy end-point was the proportion of patients who satisfied both criteria of a Hyperhidrosis Disease Severity Score (HDSS) of 1 or 2 at the end of 6-week treatment and a 50% or more reduction in total gravimetric weight of sweat at the end of treatment relative to baseline. A total of 281 patients were randomized to receive 5% sofpironium (141 patients) or vehicle (140 patients), and all patients were included in the full analysis set (FAS). In the FAS, 70.1% of patients were female, and the median age was 35.0 years. The proportion of patients who achieved the primary efficacy end-point was 53.9% in the sofpironium group and 36.4% in the vehicle group, with a statistically significant difference of 17.5% (95% confidence interval, 6.02-28.93) between these two groups (P = 0.003). The incidence of adverse events was 44.0% in the sofpironium group and 30.7% in the vehicle group, and the incidence of adverse drug reactions was 16.3% in the sofpironium group and 5.0% in the vehicle group. Reported adverse events were generally mild or moderate in severity. In the sofpironium group, common events (incidence, ≥5%) were nasopharyngitis (14.2%) and dermatitis/erythema at the application site (8.5%/5.7%), with no serious adverse events reported. This study demonstrated the efficacy and safety of 5% sofpironium.
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http://dx.doi.org/10.1111/1346-8138.15668DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986147PMC
March 2021

Surgical Management of Aortoenteric Erosion Due to Pulsatile Stress After Aneurysm Repair: A Case Report.

Ann Vasc Dis 2020 Sep;13(3):355-357

Department of Cardiac Surgery, Asahikawa Medical University.

Secondary aortoenteric fistula or erosion (SAEFE), an abnormal connection between the aorta and gastrointestinal tract, is a rare but critical complication after abdominal aortic aneurysm repair. Most SAEFEs occur between the aorta or proximal graft anastomosis and the duodenum, and occurrence between the iliac graft and small intestine is rare. Standard SAEFE management involves graft removal and extra-anatomical bypass. However, this is extremely invasive and has a high mortality rate. We encountered a rare case of SAEFE with no sign of infection, which was successfully treated by ligating the iliac graft to reduce mechanical pulsatile stress and bleeding following the retroperitoneal approach.
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http://dx.doi.org/10.3400/avd.cr.20-00094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751083PMC
September 2020

Angiographic patency after robotic beating heart totally endoscopic coronary artery bypass grafting facilitated by automated distal anastomotic connectors.

Interact Cardiovasc Thorac Surg 2020 10;31(4):467-474

Section of Cardiothoracic Surgery, Department of Cardiothoracic Surgery, The University of Chicago Medicine, Chicago, IL, USA.

Objectives: Robotic totally endoscopic coronary artery bypass (TECAB) on the beating heart has been facilitated in our experience using distal coronary anastomotic connectors. In this study, we retrospectively reviewed graft patency in all robotic TECAB patients who underwent formal angiography at our current institution over a 5-year period.

Methods: Between July 2013 and June 2018, 361 consecutive patients underwent robotic beating-heart TECAB. Of these patients, 121 had a follow-up angiogram, which assessed graft patency. Eighty-four patients had an angiogram as part of planned hybrid procedures and 37 patients underwent an unplanned angiogram for clinical indications. Retrospective analysis of angiographic patency and clinical outcomes was performed.

Results: The mean Society of Thoracic Surgeons predicted risk of mortality was 1.8%. Single-vessel bypass was performed in 40 (33%) patients and multivessel grafting in 81 (67%). Average flow (ml/min) and pulsatility index in the grafts was 74.7 ± 39.1 and 1.42 ± 0.52, respectively. The number of grafts evaluated was 204 (130 left internal mammary artery and 74 right internal mammary artery grafts). The median time to angiography was 1.0 and 16.0 months and graft patency was 98% and 91% in the hybrid and non-hybrid groups, respectively. Overall graft patency was 95.6% (left internal mammary artery = 96%; right internal mammary artery = 93%). Left internal mammary artery to left anterior descending artery graft patency was 97%. Clinical follow-up was available for 316 (88%) patients at mean 22.5 ± 15.1 months. Freedom from major adverse cardiac events at 2 years was 92%.

Conclusions: In this consecutive series of patients undergoing formal angiography after robotic single and multivessel TECAB, we found satisfactory graft patency and 2-year clinical outcomes. Longer-term follow-up is warranted.
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http://dx.doi.org/10.1093/icvts/ivaa149DOI Listing
October 2020

A proposed redosing interval of del Nido cardioplegia solution in adult cardiac surgery: a propensity-matched study.

Perfusion 2021 Jul 10;36(5):463-469. Epub 2020 Sep 10.

Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.

Background: Recently, del Nido cardioplegia solution (DN) has been utilized in adult cardiac surgery. However, adequate interval of maintenance dose(s) is still unclear. The purpose of this study was to assess the safety and efficacy of our DN protocol by comparing with conventional cold whole blood cardioplegia (CWB).

Methods: A total of 1003 consecutive patients (DN group, N = 350 vs. CWB group, N = 653) underwent cardiovascular surgery between July 2013 and September 2018 were included in this study. The DN protocol was to administer 1000 to 1200 ml as an initial dose and to add maintenance dose(s) (500 ml each) every 60 minutes when the estimated cross-clamp time was over 90 minutes. CWB was given every 20 minutes, regardless of cross-clamp time. Propensity matching identified 254 matched pairs for analysis. The preoperative and postoperative data were reviewed.

Results: Cross-clamp time was significantly shorter in the DN group compared with the CWB group (107 ± 56 minutes vs. 116 ± 49 minutes, p = 0.0458). A retrograde cannula was used in 124 (48.8%) patients in the DN group and 181 (71.3%) patients in the CWB group (p < 0.0001). There were no significant differences in requiring postoperative cardiac supports (inotropes, mechanical circulatory supports) and major complications. In-hospital mortality was similar between two groups (DN group: 3.2% vs. CWB group: 2.4%, p = 0.5872).

Conclusions: Short-term clinical outcomes in the patients underwent cardiovascular surgery with the DN protocol including the redosing interval strategy were acceptable. Also, DN protocol was associated with shortened cross-clamp time and less usage of the retrograde cannula.
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http://dx.doi.org/10.1177/0267659120956534DOI Listing
July 2021

Correction to: A subcostal approach is favorable compared to sternotomy for left ventricular assist device exchange.

J Artif Organs 2020 Sep;23(3):302

Department of Surgery, Section of Cardiac and Thoracic Surgery, The University of Chicago Medicine, 5841 S. Maryland Ave., MC 5040, Chicago, IL, 60637, USA.

In the original publication, the title of the article was published incorrectly.
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http://dx.doi.org/10.1007/s10047-020-01187-8DOI Listing
September 2020

Proximalized Total Arch Replacement Can Be Safely Performed by Trainee.

Thorac Cardiovasc Surg 2021 06 7;69(4):336-344. Epub 2020 Jul 7.

Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan.

Background: The aim of the present study was to validate safety of total arch replacement (TAR) using a novel frozen elephant trunk device, operated by trainees as surgical education.

Methods: Sixty-four patients including 19 patients (29.6%) with acute aortic dissection type A (AADA) underwent TAR in our institute between April 2014 and March 2019 were retrospectively analyzed. Twenty-nine patients were operated by trainees (group T) and 35 patients were operated by attending surgeons (group A).

Results: Patient characteristics did not differ between groups. Operative time (409.4 ± 87.8 vs. 468.6 ± 129.6 minutes,  = 0.034), cardiopulmonary bypass time (177.7 ± 50.4 vs. 222.9 ± 596.7 minutes,  = 0.019), and hypothermic circulatory arrest time (39.5 ± 13.4 vs. 54.5 ± 18.5 minutes,  = 0.001) were significantly shorter in group A than in group T, but aortic clamping time did not differ between groups (115.3 ± 55.7 vs. 114.2 ± 35.0 minutes,  = 0.924) because the rate of concomitant surgery was higher in group A (37.1 vs. 10.3%,  = 0.014). Thirty-day mortality was 3.1% in the entire cohort. Although operation time was longer in group T, there were no significant difference in postoperative results between the groups, and the experience levels of the main operator were not independent predictors for in-hospital mortality + major postoperative complications. There was no difference in late death and aortic events between groups.

Conclusions: The present study demonstrated that TAR can be safely performed by trainees, and suggests TAR as a possible and safe educational operation.
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http://dx.doi.org/10.1055/s-0040-1713354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236320PMC
June 2021

Correction to: Hypothermic circulatory arrest induced coagulopathy: rotational thromboelastometry analysis.

Gen Thorac Cardiovasc Surg 2020 Oct;68(10):1224

Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.

The article "Hypothermic circulatory arrest induced coagulopathy: rotational thromboelastometry analysis", written by Hayato Ise, Hiroto Kitahara, Kyohei Oyama, Keiya Takahashi, Hirotsugu Kanda, Satoshi Fujii, Takayuki Kunisawa, Hiroyuki Kamiya, was originally published electronically on the publisher's internet portal on 7 June 2020 without open access.
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http://dx.doi.org/10.1007/s11748-020-01416-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522061PMC
October 2020

Hypothermic circulatory arrest induced coagulopathy: rotational thromboelastometry analysis.

Gen Thorac Cardiovasc Surg 2020 Aug 7;68(8):754-761. Epub 2020 Jun 7.

Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.

Objectives: Hypothermic circulatory arrest (HCA) has been considered to cause coagulopathy during cardiac surgery. However, coagulopathy associated with HCA has not been understood clearly in details. The objective of this study is to analyze the details of coagulopathy related to HCA in cardiac surgery by using rotational thromboelastometry (ROTEM).

Methods: We retrospectively analyzed 38 patients who underwent elective cardiac surgery (HCA group = 12, non-HCA group = 26) in our hospital. Blood samples were collected before and after cardiopulmonary bypass (CPB). Standard laboratory tests (SLTs) and ROTEM were performed. We performed four ROTEM assays (EXTEM, INTEM, HEPTEM and FIBTEM) and analyzed the following ROTEM parameters: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF) and maximum clot elasticity (MCE). The amount of perioperative bleeding, intraoperative transfusion and perioperative data were compared between the HCA and non-HCA group.

Results: Operation time and hemostatic time were significantly longer in the HCA group, whereas CPB time had no difference between the groups. The amount of perioperative bleeding and intraoperative transfusion were much higher in the HCA group. SLTs showed no difference between the groups both after anesthesia induction and after protamine reversal. In ROTEM analysis, MCE contributed by platelet was reduced in the HCA group, whereas MCE contributed by fibrinogen had no difference.

Conclusion: Our study confirmed that the amount of perioperative bleeding and intraoperative transfusion were significantly higher in the HCA group. ROTEM analysis would indicate that clot firmness contributed by platelet component is reduced by HCA in cardiac surgery.
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http://dx.doi.org/10.1007/s11748-020-01399-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378042PMC
August 2020

Pulmonary artery banding for initial treatment of ventricular septal rupture.

J Surg Case Rep 2020 Mar 17;2020(3):rjaa010. Epub 2020 Mar 17.

Division of Cardiovascular Surgery, Asahikawa Medical University, Asahikawa, Japan.

Ventricular septal rupture (VSR) is a serious and fatal mechanical complication after acute myocardial infarction. Emergent or urgent, surgical/transcatheter intervention is necessary to treat VSR, though the outcome is not favorable. We performed temporary pulmonary artery banding (PAB) in an 85-year-old man who presented with chest pain to adjust the shunt flow through the VSR, which prevented further pulmonary edema and delayed the timing of surgical repair. There has been no report showing successful PAB performed for VSR after myocardial infarction.
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http://dx.doi.org/10.1093/jscr/rjaa010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245388PMC
March 2020

Examination of Anterior Leaflet Pseudoprolapse Causing Severe Mitral Regurgitation and Its Ideal Surgical Procedure.

Heart Surg Forum 2020 04 13;23(2):E205-E211. Epub 2020 Apr 13.

Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan.

Background: The aim of this study is to evaluate severe mitral regurgitation caused by so called atrial leaflet "pseudoprolapse" and verify the effect of simple annular stabilization.

Methods: One-hundred-twenty-two patients underwent surgery for severe mitral regurgitation at our institute between January 2015 to July 2018. Of those, 32 cases diagnosed as anterior leaflet prolapse that underwent mitral repair were analyzed. Ten cases with pseudoprolapse, which is defined as anterior leaflet prolapse without dropping into the left atrium beyond the annular line causing eccentric regurgitation flow directed to the posterior atrium, were classified as the Pseudoprolapse Group. The other 22 cases had obvious anterior leaflet prolapse dropping into the left atrium; these cases were classified as the True Prolapse Group. We compared clinical findings between the 2 groups and reviewed pseudoprolapse cases.

Results: Patients in the Pseudoprolapse Group had lower ejection fraction and lower regurgitation volume than those in the True Prolapse Group. A2 lesion as main inflow of regurgitation was more included in the Pseudoprolapse Group. All but one patient in the Pseudoprolapse Group received only simple annuloplasty, and all patients in the True Prolapse Group received leaflet repair and annuloplasty. In both groups, mid-term regurgitation grade and the reoperation rate were satisfactory. In the Pseudoprolapse Group, 6 cases were clarified as atrial functional mitral regurgitation, and 4 cases were considered to have focal posterior leaflet tethering.

Conclusions: Pseudoprolapse cases could be characterized by low ejection fraction, low regurgitation volume, and A2 prolapse. For most cases with pseudoprolapse, simple annuloplasty may be enough, however further study is needed.
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http://dx.doi.org/10.1532/hsf.2895DOI Listing
April 2020

Invited Commentary.

Ann Thorac Surg 2020 03 23;109(3):667-668. Epub 2019 Nov 23.

Department of Cardiovascular Surgery, Piedmont Heart Institute, Marcus Valve Center, 95 Collier Rd, Ste 5015, Atlanta, GA 30309. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2019.09.096DOI Listing
March 2020

Successful Conservative Management of Inferior Mesenteric Artery Aneurysm with Arteriovenous Fistula: A Case Report.

Ann Vasc Surg 2020 Apr 31;64:410.e11-410.e15. Epub 2019 Oct 31.

Department of Cardiac Surgery, Asahikawa Medical University, Hokkaido, Japan.

Inferior mesenteric artery (IMA) aneurysm is a rare occurrence, accounting for 1% of all visceral artery aneurysms and is often found incidentally. Surgical resection and endovascular intervention have been first-line treatments because IMA aneurysms have a relatively high risk of life-threatening rupture. Herein, we report the case of a 57-year-old man having a large IMA aneurysm with an arteriovenous fistula that was treated conservatively. The IMA aneurysm was incidentally found using computed tomography (CT) and was connected to the splenic vein through the abnormally dilated tortuous vessels of an arteriovenous fistula. Surgical resection was planned initially; however, preoperative follow-up CT revealed that the aneurysm had shrunk with the growth of an intraluminal thrombus. Subsequently, the condition was conservatively managed with serial CT follow-up. Two years after the first visit, the aneurysm had shrunk and been completely replaced with a thrombus.
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http://dx.doi.org/10.1016/j.avsg.2019.10.067DOI Listing
April 2020

Surgical device exchange provides improved clinical outcomes compared to medical therapy in treating continuous-flow left ventricular assist device thrombosis.

Artif Organs 2020 Apr 9;44(4):367-374. Epub 2019 Dec 9.

Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.

The purpose of this study is to compare clinical outcomes of left ventricular assist device (LVAD) patients with device thrombosis who underwent device exchange (DE) or medical therapy (MT) alone. Consecutive patients undergoing LVAD implant between July 2008 and December 2017 were included. Device thrombosis was diagnosed with comprehensive assessments including ramp test, laboratory data, device parameters, and clinical presentations. First, MT was initiated in all patients. After MT, DE was considered if device thrombosis was refractory to initial MT, and it caused end-organ impairment and/or hemodynamic instability. Among 319 consecutive LVAD patients, 43 patients (13.5%) were diagnosed with device thrombosis. DE was performed in 28 patients (DE group); device explant was performed in 1 patient. MT was continued in 14 patients (MT group). In-hospital mortality was significantly lower in the DE group than the MT group (3.6% [1/28] vs. 28.6% [4/14], P = .0184). One-year survival was significantly better in the DE group (74.0% vs. 30.1%; log-rank = .001), and freedom from cerebrovascular accident (CVA) at 1 year was greater in the DE group (87.1% vs. 47.7%; log-rank = .004). DE was associated with improved 1-year survival and fewer CVAs. Surgical intervention, if feasible, is recommended for LVAD device thrombosis.
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http://dx.doi.org/10.1111/aor.13594DOI Listing
April 2020

Robotic totally endoscopic beating-heart bypass to the right coronary artery: first worldwide experience.

Eur J Cardiothorac Surg 2020 03;57(3):529-534

Department of Surgery, Section of Cardiac and Thoracic Surgery, The University of Chicago Medicine, Chicago, IL, USA.

Objectives: Left coronary vessels are the usual targets in totally endoscopic coronary artery bypass (TECAB). Grafting of the right coronary artery (RCA) has been limited using this approach because of anatomic and technical difficulties. We report a first series of robotic beating-heart TECAB to the RCA via a right-chest approach.

Methods: From July 2013 to April 2019, patients who underwent robotic beating-heart TECAB with the right internal mammary artery to the RCA were reviewed. Port placement in the right chest mirrored standard left-sided ports. Indications for right internal mammary artery to RCA bypass were RCA disease not amenable to percutaneous intervention and anomalous origin of the RCA.

Results: Right internal mammary artery-RCA bypass was performed in 16 patients (mean age 60.6 ± 13.5, 75% male). All cases were completed without conversion to sternotomy or mini-thoracotomy. Cardiopulmonary bypass was required in 1 patient to expose the posterior descending artery. Mean procedure time was 223 ± 49 min, with half of the patients extubated in the operating room (50%). Mean intraoperative transit-time graft flow was 87.0 ± 19.3 ml/min, and a pulsatility index of 1.2 ± 0.2. Mean length of stay was 2.3 ± 1.2 days. No mortality was observed at mean follow-up time of 20.6 months. One patient required repeat RCA revascularization for progression of native disease 43.7 months after the surgery.

Conclusions: Robotic beating-heart TECAB for isolated RCA disease is a feasible operation in selected patients. This technique is possible even for the posterior descending artery.
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http://dx.doi.org/10.1093/ejcts/ezz283DOI Listing
March 2020

Residual SYNTAX Score After Advanced Hybrid Robotic Totally Endoscopic Coronary Revascularization.

Ann Thorac Surg 2020 06 8;109(6):1826-1832. Epub 2019 Oct 8.

Department of Medicine, Section of Cardiology, University of Chicago Medicine, Chicago, Illinois.

Background: Advanced hybrid coronary revascularization (AHCR) combines multivessel robotic beating-heart totally endoscopic coronary artery bypass with percutaneous coronary intervention. The aim of this study was to quantify the remaining coronary artery disease after AHCR using the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) study score.

Methods: From July 2013 to September 2017, patients who had postoperative angiography after AHCR were reviewed. The cohort was divided into two groups: group 1, complete or near-complete revascularization (residual SYNTAX score of 8 or less); and group 2, incomplete revascularization (residual SYNTAX score more than 8).

Results: Among 308 patients who underwent totally endoscopic coronary artery bypass, 57 patients received AHCR and 51 patients had postoperative angiograms that allowed calculations of residual SYNTAX score. Mean baseline and residual SYNTAX scores were 33.1 ± 11.0 and 4.6 ± 6.5 respectively. There were 44 patients (86%) in the complete or near-complete revascularization group, and of these, 16 patients (31%) achieved true complete revascularization (residual SYNTAX score = 0). Overall graft patency was 96.2%. There were no differences in preoperative characteristics or postoperative outcomes between the two groups. Two-year survival rate and freedom from major adverse cardiac events (death, myocardial infarction, and repeat revascularization) were significantly higher in the complete or near-complete revascularization group compared with the incomplete revascularization group.

Conclusions: Advanced hybrid coronary revascularization at our institution was safely performed with excellent early outcomes, graft patency, and high achievement of complete or near-complete revascularization. Residual SYNTAX score might predict long-term ischemic events after hybrid coronary revascularization.
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http://dx.doi.org/10.1016/j.athoracsur.2019.09.011DOI Listing
June 2020

Benefit of Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass in Octogenarians.

Innovations (Phila) 2019 Nov/Dec;14(6):531-536. Epub 2019 Sep 18.

Department of Surgery, University of Chicago Medicine, IL, USA.

Objective: An important advantage of robotic beating-heart totally endoscopic coronary artery bypass (TECAB) is early functional recovery, in which fragile patients like octogenarians (age >80 years) benefit most. The aim of this study was to investigate the safety and feasibility of TECAB in octogenarians.

Methods: We retrospectively reviewed patients undergoing TECAB from July 2013 to September 2017 at our institution. Perioperative outcomes of octogenarian patients and that of younger patients were compared.

Results: Of 308 patients who underwent TECAB, 28 patients (9.1%) were octogenarians (mean age 83.8 ± 3.0 years). Octogenarians had a higher rate of hypertension and atrial fibrillation compared to younger patients. TECAB was successfully performed without conversion to any larger incisions in octogenarians. Mean operative time (299 ± 83 minutes vs 281 ± 89 minutes, = 0.309) and the rate of multivessel bypass (60.7% vs 58.2%, = 0.798) were similar between octogenarians and younger patients. New atrial fibrillation was observed more frequently in octogenarians compared to younger patients (35.7% vs 18.6%, = 0.031). Mean length of hospital stay was similar between the 2 groups (octogenarians: 3.9 ± 1.8 days vs younger patients: 3.5 ± 3.0 days, = 0.475). Twenty-two octogenarians (78.6%) were discharged directly to home. In-hospital mortality was zero in octogenarians.

Conclusions: Robotic beating-heart TECAB had favorable results in octogenarians with acceptable morbidity and mortality and excellent short length of stay similar to younger patients.
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http://dx.doi.org/10.1177/1556984519876901DOI Listing
April 2020

Commentary: In the management of aortic stenosis volume is not enough.

J Thorac Cardiovasc Surg 2020 04 22;159(4):1260-1261. Epub 2019 Aug 22.

Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.07.067DOI Listing
April 2020

Total debranching hybrid total arch replacement with a novel frozen elephant trunk for acute aortic dissection type A.

J Thorac Cardiovasc Surg 2019 Jul 11. Epub 2019 Jul 11.

Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan.

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http://dx.doi.org/10.1016/j.jtcvs.2019.06.064DOI Listing
July 2019

Transplantation of a decellularized mitral valve complex in pigs.

Surg Today 2020 Mar 29;50(3):298-306. Epub 2019 Aug 29.

Department of Cardiovascular Surgery, Keio University, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.

Purpose: Conventional mitral valve replacement is associated with the loss of natural continuity of the mitral valve complex. This study evaluated the morphologic/histological characteristics and function of a decellularized mitral valve used as a transplantable graft.

Methods: Hearts excised from pigs were decellularized by perfusion using detergent. Grafts with the mitral annulus, valve, chordae, and papillary muscle isolated from the decellularized heart were then transplanted into recipient pigs. After transplantation, the function of the graft was analyzed through echocardiography. A histological analysis was performed to evaluate the postoperative features of the decellularized graft.

Results: The decellularized graft was successfully transplanted in all cases but one. The remaining grafts maintained their morphology and function. They did not exhibit mitral regurgitation or stenosis. Only one animal survived for 3 weeks, and a histological analysis was able to be performed in this case. The transplanted valve was re-covered with endothelial cells. The microvessels in the papillary muscle were recellularized with vascular endothelial cells, and the papillary muscle was completely attached to the papillary muscle of the recipient.

Conclusion: The early outcome of decellularized mitral graft transplantation was acceptable. This native organ-derived acellular scaffold is a promising candidate for the replacement of the mitral valve complex.
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http://dx.doi.org/10.1007/s00595-019-01869-8DOI Listing
March 2020

Invited Commentary.

Ann Thorac Surg 2020 01 22;109(1):93. Epub 2019 Jul 22.

Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Georgetown University, 110 Irving St, Ste 6D15G, Washington, DC 20010. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2019.06.021DOI Listing
January 2020

Total arch replacement with bilateral extra-anatomical axillary artery bypass and frozen elephant trunk technique for Kommerell's diverticulum.

J Surg Case Rep 2019 Jul 11;2019(7):rjz211. Epub 2019 Jul 11.

Department of Cardiac Surgery, Asahikawa Medical University, Hokkaido, Japan.

A Kommerell's diverticulum is a rare congenital aortic arch anomaly associated with a high rate of aortic rupture or dissection. Therefore, surgical or endovascular repair should be considered early. A 64-year-old man was incidentally found to have an aortic arch anomaly, Kommerell's diverticulum, with a right aberrant subclavian artery and distal arch aneurysm. Hybrid total arch replacement with bilateral extra-anatomical axillary artery bypass and frozen elephant trunk technique was performed. This particular surgical approach would be a treatment option for any type of Kommerell's diverticulum.
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http://dx.doi.org/10.1093/jscr/rjz211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6622113PMC
July 2019

REPLY: Patch and unload.

J Thorac Cardiovasc Surg 2019 09 2;158(3):e98-e99. Epub 2019 Jul 2.

Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Georgetown University School of Medicine, Washington, DC.

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http://dx.doi.org/10.1016/j.jtcvs.2019.06.008DOI Listing
September 2019

Predictors of blood transfusion use in robotic beating-heart totally endoscopic coronary artery bypass with anastomotic connectors.

J Card Surg 2019 Sep 3;34(9):814-820. Epub 2019 Jul 3.

Department of Surgery, University of Chicago Medicine, Chicago, Illinois.

Background: We sought to identify the independent predictors of blood transfusion requirement in robotic beating-heart patients with totally endoscopic coronary artery bypass (TECAB).

Methods: We retrospectively reviewed patients undergoing TECAB with distal anastomotic connectors from July 2013 to May 2017 at our institution. The cohorts were divided into patients who received a blood transfusion (BT group) and patients who did not (non-blood transfusion [NBT] group).

Results: Two-hundred seventy-four consecutive patients underwent TECAB, and 47 patients (17%; BT group) received BT. The BT group had a lower preoperative hemoglobin level and a higher rate of preoperative risk profiles and higher society of thoracic surgeons (STS) predicted the risk of mortality. Kaplan Meier analysis showed decreased 1-year survival in the BT group compared with the NBT group (90.9% vs 96.4%; logrank, 0.017). The Youden index identified a preoperative hemoglobin cutoff value of 12.2 g/dL (sensitivity 60.9%, specificity 79.3%) and operative time of 300 minutes (sensitivity 61.7%, specificity 59.0%) for BT requirement. Multivariate logistic regression analysis identified a preoperative hemoglobin <12.2 g/dL (odds ratio, 6.03; 95% confidence interval, 3.01-12.1) and an operative time >300 minutes (odds ratio, 2.15; 95% confidence interval, 1.07-4.33) as independent factors associated with BT requirement.

Conclusions: We found that preoperative hemoglobin and operative time were independent predictors of BT requirement during robotic beating-heart TECAB. These data would help to select patients to minimize perioperative BT as well as predict outcomes after this procedure.
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http://dx.doi.org/10.1111/jocs.14150DOI Listing
September 2019

Novel Formula to Calculate Three-Dimensional Angle Between Inflow Cannula and Device Body of HeartMate II LVAD.

Ann Thorac Surg 2020 01 27;109(1):63-68. Epub 2019 Jun 27.

Department of Surgery, University of Chicago Medical Center, Chicago, Illinois. Electronic address:

Background: The acute angle between inflow cannula and device body of HeartMate II left ventricular assist device (LVAD) (Abbott, Pleasanton, California) is associated with device thrombosis. However, most studies utilized two-dimensional (2D) angle obtained from chest roentgenogram (CXR), which is unlikely accurate. We aimed to create and validate a formula to estimate actual three-dimensional (3D) angle.

Methods: We retrospectively reviewed the cohort undergoing HeartMate II LVAD implantation between 2008 and 2016. A formula for calculating 3D angles of the LVAD inflow cannula relative to the device body was mathematically derived, using simple 2D measurements from CXR.

Results: The cohort included consecutive 275 patients with HeartMate II (median age: 60 [25% quartile: 51, 75% quartile: 68] years). There was no significant difference between the calculated 3D angles (from formula) and actual 3D angles (from computed tomography) from the subset group with 3D computed tomography (n = 28) (71.7° ± 13.4° vs 71.1° ± 11.5°, P = .858). Among all participants, the calculated 3D angle (from formula) was 74.4° ± 14.2°, which was significantly larger than the 2D projected angle (from CXR) (65.2° ± 11.3°, P < .001). There was no statistical difference in the calculated 3D angles (from formula) between patients with/without device thrombosis, hemorrhagic stroke, ischemic stroke, or mortality (P > .05 for all).

Conclusions: We established a novel formula to mathematically calculate actual 3D angles between inflow cannula and device body of HeartMate II. The formula would help investigators to validate their findings of the relationship between 2D projected angle (from CXR) and device thrombosis.
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http://dx.doi.org/10.1016/j.athoracsur.2019.04.124DOI Listing
January 2020

Robotic cardiac surgery impact of a new patient-side assistant on outcomes.

Gen Thorac Cardiovasc Surg 2020 Jan 25;68(1):24-29. Epub 2019 Jun 25.

Department of Surgery, Section of Cardiac and Thoracic Surgery, The University of Chicago, 5841 S Maryland Avenue, MC5040, STE E500, Chicago, IL, 60637, USA.

Objective: Very few studies have focused on the experience of the patient-side assistant in robotic cardiac surgery. We investigated whether the retirement of a highly experienced robotic patient-side assistant and replacement with a new assistant had an effect on surgical outcomes.

Methods: In 4/2016, the established patient-side assistant retired after spending 8 months training a new patient-side assistant. A retrospective analysis of 216 patients was performed; 108 patients over a 9 month period just prior to arrival of the new patient-side assistant (Group 1), and 108 patients over 8 months just subsequent to departure of the established assistant (Group 2). Case distribution, pre-operative characteristics, and surgical outcomes were collected and compared.

Results: Case volume increased in Group 2 with the new assistant. The mean age and rate of pre-op CVA for Group 1 was lower, but, otherwise, patient demographics were not significantly different. Group 1 had more intracardiac cases and group 2 had more triple-vessel TECABs. Overall operative time was not different between the two groups. Perioperative outcomes including hospital length of stay major adverse cardiovascular events and mortality were similar between the two groups.

Conclusions: We conclude that the transition to a new robotic cardiac surgical patient-side assistant does not have to affect the progress of a busy robotic program. If adequate time for training and gradual assumption of responsibility is ensured, it is feasible to make this transition without loss of volume or compromise in patient outcomes.
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http://dx.doi.org/10.1007/s11748-019-01165-9DOI Listing
January 2020

First Human Totally Endoscopic Robotic-Assisted Sutureless Aortic Valve Replacement.

Ann Thorac Surg 2020 01 19;109(1):e9-e11. Epub 2019 Jun 19.

Section of Cardiac and Thoracic Surgery, The University of Chicago School of Medicine, Chicago, Illinois.

This is the first human case of totally endoscopic robotic-assisted aortic valve replacement using a sutureless valve. The patient is a 76-year-old man with symptomatic severe aortic valve insufficiency. A 12-mm robotic camera port and 25-mm working port were placed in the second intercostal space, and two 8-mm arm ports in the first and the third intercostal space with femoro-femoral cardiopulmonary bypass. Aortotomy, leaflet resection, confirmation of intraannular valve position, and aortic closure were all performed endoscopically with robotic instruments. The tableside assistant deployed the valve. The patient was discharged on postoperative day 2 without complications.
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http://dx.doi.org/10.1016/j.athoracsur.2019.04.093DOI Listing
January 2020
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