Faculty Profiles - KOTANI Yasuhiro

Papers - KOTANI Yasuhiro

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Repair of Intramural Coronary Artery in Anomalous Aortic Origin of a Coronary Artery Invited Reviewed

Kotani Y, Sano S, Kasahara S

Operative Techniques in Thoracic and Cardiovascular Surgery 23 ( 1 ) 40 - 48 2018.10

Chylothorax and pleural effusion in contemporary extracardiac fenestrated fontan completion. Reviewed International journal

Mauro Lo Rito, Osman O Al-Radi, Arezou Saedi, Yasuhiro Kotani, V Ben Sivarajan, Jennifer L Russell, Christopher A Caldarone, Glen S Van Arsdell, Osami Honjo

The Journal of thoracic and cardiovascular surgery 155 ( 5 ) 2069 - 2077 2018.5

Language：English Publishing type：Research paper (scientific journal)

BACKGROUND: We hypothesized that chylothorax could be a sign of intolerance to the Fontan physiology, and thus patients who develop chylothorax or pleural effusion have worse medium-term to long-term survival. METHODS: A total of 324 patients who underwent the Fontan operation between 2000 and 2013 were included. Chylothorax was defined as ≥5 mL/kg/day of chylomicron-positive chest drainage fluid no earlier than postoperative day 5 or drainage with >80% lymphocytes. Outcomes were compared between the chylothorax and non-chylothorax groups by the Kaplan-Meier method and log-rank test. Independent predictors of chylothorax and number of days of any chest drainage were analyzed with multivariable logistic regression and multivariable generalized negative binomial regression for count data, respectively. RESULTS: Chylothorax occurred in 78 patients (24%). Compared with the non-chylothorax group, the chylothorax group had a longer duration of chest tube requirement (median, 18 days vs 9 days; P < .000) and a longer length of hospital stay (median, 19 days vs 10 days; P < .000). Eight patients (10.3%) required thoracic duct ligation. The chylothorax group had lower freedom from death (P = .013) and from composite adverse events (P = .021). No predictor was found for chylothorax. Pulmonary atresia (P = .031) and pre-Fontan pulmonary artery pressure (P = .01) were predictive of prolonged pleural effusion (>14 days). CONCLUSIONS: Occurrence of chylothorax following the Fontan operation can be a marker of poorer medium-term clinical outcomes. It is difficult to predict occurrence of chylothorax owing to its multifactorial nature and involvement of lymphatic compensatory capacity that is unmasked only after the Fontan operation.

DOI： 10.1016/j.jtcvs.2017.11.046

Fontan Failure and Death in Contemporary Fontan Circulation: Analysis From the Last Two Decades. Reviewed International journal

Yasuhiro Kotani, Devin Chetan, Jiaquan Zhu, Arezou Saedi, Lisa Zhao, Luc Mertens, Andrew N Redington, John Coles, Christopher A Caldarone, Glen S Van Arsdell, Osami Honjo

The Annals of thoracic surgery 105 ( 4 ) 1240 - 1247 2018.4

Authorship：Lead author Language：English Publishing type：Research paper (scientific journal)

BACKGROUND: We sought to evaluate the incidence of Fontan failure or complication and its relation to death in patients having contemporary Fontan strategies over 2 decades. METHODS: Five hundred patients who underwent Fontan completion (extracardiac, n = 326; lateral tunnel, n = 174) from 1985 to 2012 were reviewed. Patient characteristics, modes of Fontan failure/complication and death, and predictors for Fontan failure/complication and death were analyzed. RESULTS: There were 23 early deaths (4.6%) and 17 late deaths (3.4%), with no early death since 2000. Survival has improved over time (p < 0.001). Twenty-three of 40 patients who died were identified as Fontan failure before death, including ventricular dysfunction (n = 14), pulmonary vascular dysfunction (n = 4), thromboembolism (n = 2), and arrhythmia (n = 4). Mode of death was circulatory failure (n = 18), multiorgan failure (n = 6), pulmonary failure (n = 3), cerebral/renal (n = 5), and sudden death (n = 4). Modes of failure/complication were directly (65%) or conceivably (10%) related to death in 30 of 40 patients (75%). Forty-eight percent of survivors had late Fontan complication(s). Five-year freedom from late Fontan complication was lower among patients who died compared with patients who survived (29.4% versus 53.3%, p < 0.001). Ventricular dysfunction (p = 0.001) and higher pulmonary artery pressures (p < 0.001) after Fontan were predictors for death. Longer cardiopulmonary bypass time (p = 0.032) and reinterventions (p < 0.001) were predictors for late Fontan complication. CONCLUSIONS: Early death in the early era has been overcome. Yet the incidence and causes of late death remain unchanged. There was a strong causative relationship between the mode of Fontan failure/complication and death, indicating the importance of early recognition and treatment of Fontan failure/complication.

DOI： 10.1016/j.athoracsur.2017.10.047

Surgery for tricuspid regurgitation in a case of anomalous systemic venous return. Reviewed International journal

Koki Eto, Yasuhiro Kotani, Yasuyuki Kobayashi, Daichi Edaki, Shingo Kasahara, Zenichi Masuda

Asian cardiovascular & thoracic annals 26 ( 3 ) 227 - 230 2018.3

Language：English Publishing type：Research paper (scientific journal)

A 75-year-old woman presented with severe tricuspid regurgitation requiring surgical repair. She had extremely rare anomalies in systemic venous return in spite of situs solitus: persistent left superior vena cava with absent right superior vena cava, infrahepatic inferior vena cava interruption, and hemiazygos continuation to a persistent left superior vena cava. These unusual systemic venous anomalies had significantly enlarged the coronary sinus, and the stretched coronary sinus orifice changed the geometry of the tricuspid annulus and triggered tricuspid regurgitation. There were technical difficulties in establishing cardiopulmonary bypass and achieving successful tricuspid valve repair.

DOI： 10.1177/0218492318759153

Aortopexy for left pulmonary vein obstruction. Reviewed International journal

Yasuhiro Kotani, Toshikazu Sano, Sadahiko Arai, Shingo Kasahara

The Journal of thoracic and cardiovascular surgery 155 ( 2 ) e69-e70 2018.2

Nonbacterial thrombotic endocarditis involving all four cardiac valves. Reviewed International journal

Sachiko Kawada, Mitsuhito Kuriyama, Yasuhiro Kotani, Shou Tsushima, Atsushi Tanabe, Yukio Kioka

Asian cardiovascular & thoracic annals 26 ( 1 ) 44 - 46 2018.1

Authorship：Lead author Language：English Publishing type：Research paper (scientific journal)

This report describes a case of nonbacterial thrombotic endocarditis caused by Waldenström macroglobulinemia, with diffuse endocardial lesions and involvement of all 4 cardiac valves. A 77-year-old man presented with heart failure due to severe regurgitation of all 4 cardiac valves; surgical repair using bioprosthetic valves was indicated. A pathological study revealed fibrin-triggered thrombus formation that confirmed the diagnosis of nonbacterial thrombotic endocarditis. In cases of nonbacterial thrombotic endocarditis, the underlying cause should be investigated.

DOI： 10.1177/0218492317748091

Intracoronary Cardiac Progenitor Cells in Single Ventricle Physiology: The PERSEUS (Cardiac Progenitor Cell Infusion to Treat Univentricular Heart Disease) Randomized Phase 2 Trial. Reviewed International journal

Shuta Ishigami, Shinichi Ohtsuki, Takahiro Eitoku, Daiki Ousaka, Maiko Kondo, Yoshihiko Kurita, Kenta Hirai, Yosuke Fukushima, Kenji Baba, Takuya Goto, Naohiro Horio, Junko Kobayashi, Yosuke Kuroko, Yasuhiro Kotani, Sadahiko Arai, Tatsuo Iwasaki, Shuhei Sato, Shingo Kasahara, Shunji Sano, Hidemasa Oh

Circulation research 120 ( 7 ) 1162 - 1173 2017.3

Language：English Publishing type：Research paper (scientific journal)

RATIONALE: Patients with single ventricle physiology are at high risk of mortality resulting from ventricular dysfunction. The preliminary results of the phase 1 trial showed that cardiosphere-derived cells (CDCs) may be effective against congenital heart failure. OBJECTIVE: To determine whether intracoronary delivery of autologous CDCs improves cardiac function in patients with single ventricle physiology. METHODS AND RESULTS: We conducted a phase 2 randomized controlled study to assign in a 1:1 ratio 41 patients who had single ventricle physiology undergoing stage 2 or 3 palliation to receive intracoronary infusion of CDCs 4 to 9 weeks after surgery or staged reconstruction alone (study A). The primary outcome measure was to assess improvement in cardiac function at 3-month follow-up. Four months after palliation, controls had an alternative option to receive late CDC infusion on request (study B). Secondary outcomes included ventricular function, heart failure status, somatic growth, and health-related quality of life after a 12-month observation. At 3 months, the absolute changes in ventricular function were significantly greater in the CDC-treated group than in the controls (+6.4% [SD, 5.5] versus +1.3% [SD, 3.7]; P=0.003). In study B, a late CDC infusion in 17 controls increased the ventricular function at 3 months compared with that at baseline (38.8% [SD, 7.7] versus 34.8% [SD, 7.4]; P<0.0001). At 1 year, overall CDC infusion was associated with improved ventricular function (41.4% [SD, 6.6] versus 35.0% [SD, 8.2]; P<0.0001) and volumes (P<0.001), somatic growth (P<0.0001) with increased trophic factors production, such as insulin-like growth factor-1 and hepatocyte growth factor, and quality of life, along with a reduced heart failure status (P<0.0001) and cardiac fibrosis (P=0.014) relative to baseline. CONCLUSIONS: Intracoronary infusion of CDCs after staged palliation favorably affected cardiac function by reverse remodeling in patients with single ventricle physiology. This impact may improve heart failure status, somatic growth, and quality of life in patients and reduce parenting stress for their families. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01829750.

DOI： 10.1161/CIRCRESAHA.116.310253

[Delayed Diagnosis of Aortic Dissection Following Thrombolytic Therapy in a Patient with Acute Ischemic Stroke;Report of a Case]. Reviewed

Yosuke Miyamoto, Zenichi Masuda, Yasuhiro Kotani, Suguru Tarui, Yosuke Kuroko, Yasuhiro Fujii, Susumu Ozawa, Shunji Sano

Kyobu geka. The Japanese journal of thoracic surgery 69 ( 12 ) 1037 - 1040 2016.11

Language：Japanese Publishing type：Research paper (scientific journal)

Diagnosis of aortic dissection complicating cerebral ischemic stroke is difficult. A 60-year-old patient presented at an emergency department of a hospital with a sudden development of left-sided weakness, but without chest pain. During administration of recombinant tissue plasminogen activator with diagnosis of cerebral infarction, he developed symptomatic hypotension and was transferred to our hospital. His chest computed tomography revealed Stanford type A aortic dissection. Replacement of the ascending aorta and aortic arch was successfully performed on the 4th day.

A staged decompression of right ventricle allows growth of right ventricle and subsequent biventricular repair in patients with pulmonary atresia and intact ventricular septum. Reviewed International journal

Yasuhiro Kotani, Shingo Kasahara, Yasuhiro Fujii, Takahiro Eitoku, Kenji Baba, Shin-Ichi Otsuki, Yosuke Kuroko, Sadahiko Arai, Shunji Sano

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 50 ( 2 ) 298 - 303 2016.8

Authorship：Lead author Language：English Publishing type：Research paper (scientific journal)

OBJECTIVES: To achieve the growth of right-sided heart structures, our choice of the first palliation for patients with pulmonary atresia and intact ventricular septum (PA-IVS) includes a modified Blalock-Taussig shunt (BTS) with pulmonary valvotomy. We sought to analyse the impact of the first palliation on the growth of right-sided heart structures and factors associated with a choice of definitive surgical procedure. METHODS: Fifty patients with PA-IVS who underwent a staged surgical approach from 1991 to 2012 were retrospectively reviewed. RESULTS: Right ventricular (RV)-coronary artery fistulas were seen in 42% of patients at the time of birth. All 50 patients had a modified BTS with pulmonary valvotomy. Six patients died after the first palliation or inter-stage. Thirty patients achieved a biventricular repair (BVR group), 6 patients had a 1 + 1/2 ventricular repair (1 + 1/2V group) and 5 patients had a Fontan completion (Fontan group). After modified BTS with pulmonary valvotomy, tricuspid valve z-score did not increase in any of the group (BVR: pre -2.79 vs post -2.24, 1 + 1/2V: pre -5.25 vs post -6.69, Fontan: pre -6.82 vs post -7.94). Normalized RV end-diastolic volume increased only in BVR group after modified BTS with pulmonary valvotomy (BVR: pre 32% vs post 64%, 1 + 1/2V: pre 43% vs post 42%, Fontan: pre 29% vs post 32%). Major RV-coronary artery fistula was a strong factor with proceeding single-ventricle palliation [BVR: 4/30 (13%) patients, 1 + 1/2V: 1/6 (17%) and Fontan: 4/5 (80%)]. CONCLUSIONS: Tricuspid valve growth was not obtained by modified BTS with pulmonary valvotomy; therefore, tricuspid valve size at birth appeared to be a predictor for achieving BVR. Proportionate RV growth was seen only in patients who achieved BVR. However, RV growth was not seen in patients having 1 + 1/2 ventricular repair. Major RV-coronary artery fistula was a strong predictor for proceeding single-ventricle palliation.

DOI： 10.1093/ejcts/ezw124

Impact of Norwood versus hybrid palliation on cardiac size and function in hypoplastic left heart syndrome. Reviewed International journal

Heynric B Grotenhuis, Bram Ruijsink, Devin Chetan, Andreea Dragulescu, Mark K Friedberg, Yasuhiro Kotani, Christopher A Caldarone, Osami Honjo, Luc L Mertens

Heart (British Cardiac Society) 102 ( 12 ) 966 - 74 2016.6

Language：English Publishing type：Research paper (scientific journal)

OBJECTIVE: The hybrid approach for hypoplastic left heart syndrome (HLHS) could theoretically result in better preservation of right ventricular (RV) function then the Norwood procedure. The aim of this study was to compare echocardiographic indices of RV size and function in patients after Norwood and hybrid throughout all stages of palliation. METHODS: 76 HLHS patients (42 Norwood, 34 hybrid) were retrospectively studied. Echocardiography was obtained before stage I, before and after stage II, and before and after Fontan. Median follow-up was 4.9 years (range 1.1-8.5). RESULTS: Baseline characteristics before stage I were similar. Hybrid patients demonstrated a significant decrease in RV fractional area change (FAC) between baseline and pre-stage II (36±9% vs 27±6%; p<0.01); Norwood patients remained stable (32±10% vs 32±7%; p=0.21). At pre-stage II, moderate/severe tricuspid valve (TV) regurgitation was found in nine Norwood (33%) and four hybrid (18%) patients (p=0.19). After stage II, the difference in FAC became insignificant (29±7% vs 25±8%, p=0.08) and moderate/severe TV regurgitation (TR) was found in 13 Norwood (48%) and four hybrid patients (19%) (p=0.18). At pre-Fontan, RV FAC was similar after Norwood and hybrid (34±5% vs 33±6%, p=0.69), which remained unchanged after Fontan. After Fontan, one Norwood and one hybrid patient had moderate TR. RV and TV size were similar for both groups at each time point. CONCLUSIONS: Patients after Norwood and hybrid procedures had equivalent indices of RV size, and systolic and diastolic function throughout all stages of palliation. Small differences in individual RV and TV indices are likely to be explained by differences in physiology or surgical timing rather than by intrinsic differences in myocardial and valve function.

DOI： 10.1136/heartjnl-2015-308787

A STAGED DECOMPRESSION OF RIGHT VENTRICLE ALLOWS REGRESSION OF RIGHT VENTRICLE TO CORONARY ARTERY FISTULA AND SUBSEQUENT ACHIEVEMENT OF BIVENTRICULAR REPAIR IN PATIENTS WITH PULMONARY ATRESIA AND INTACT VENTRICULAR SEPTUM Reviewed

Takahiro Eitoku, Yasuhiro Kotani, Kenji Baba, Maiko Kondou, Shingo Kasahara, Sadahiko Arai, Shinichi Ohtsuki, Shunji Sano

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 67 ( 13 ) 947 - 947 2016.4

Surgical outcome of hypoplastic left heart syndrome with intact atrial septum. Reviewed International journal

Sadahiko Arai, Yasuhiro Fujii, Yasuhiro Kotani, Yosuke Kuroko, Shingo Kasahara, Shunji Sano

Asian cardiovascular & thoracic annals 23 ( 9 ) 1034 - 8 2015.11

Language：English Publishing type：Research paper (scientific journal)

BACKGROUND: The surgical outcomes of hypoplastic left heart syndrome with intact atrial septum remains very poor in spite of the introduction of prenatal diagnosis before the Norwood operation. The hybrid operation consisting of bilateral pulmonary artery banding and balloon atrioseptectomy is one of the treatment strategies to potentially improve this patient population, however, the long-term outcomes are unknown. METHODS: Six consecutive patients with hypoplastic left heart syndrome with intact atrial septum, who underwent the hybrid operation between October 2006 and July 2014, were retrospectively reviewed. Hypoplastic left heart syndrome with highly restrictive atrial communication was excluded. RESULTS: Three patients died after the hybrid operation, due to sepsis, cerebral bleeding, and heart failure. Three patients underwent the modified Norwood operation. One of these died due to severe hypoxia while awaiting the bidirectional Glenn operation. The others underwent a bidirectional Glenn operation and subsequent Fontan completion but died due to lung dysfunction and sudden hemoptysis. CONCLUSIONS: The hybrid operation for hypoplastic left heart syndrome with intact atrial septum may have improved the neonatal outcome and Fontan completion rate in this extremely high-risk group of patients, but the long-term outcome remains dismal. Considering the late mortality related to pulmonary complications, aggressive fetal intervention to create a nonrestrictive atrial septal communication to promote normal development of the pulmonary vessels may be the last resort to improve the long-term outcome.

DOI： 10.1177/0218492315606581

The Chicken or the Eggs? Examining the Causal Relationship Between the Development of Atrioventricular Valve Regurgitation and Ventricular Dysfunction in Patients With Functionally Single Ventricle Physiology Reviewed

Yasuhiro Kotani, Devin Chetan, Selvi Senthilnathan, Arezou Saedi, Christopher A. Caldarone, Glen S. Van Arsdell, Luc Mertens, Osami Honjo

CIRCULATION 132 2015.11

Left Ventricular Myxoma Occluding the Suprarenal Abdominal Aorta in an Infant. Reviewed International journal

Takuya Kawabata, Shingo Kasahara, Shin-ichi Ohtsuki, Yosuke Kuroko, Yasuhiro Kotani, Yasuhiro Fujii, Ko Yoshizumi, Sadahiko Arai, Shunji Sano

The Annals of thoracic surgery 100 ( 1 ) 309 - 11 2015.7

Language：English Publishing type：Research paper (scientific journal)

Myxoma is the most common primary cardiac tumor in adults; however, it is extremely rare in infants. Acute occlusion of the abdominal aorta by a cardiac myxoma is also rare. We report the case of an infant with acute occlusion of the suprarenal abdominal aorta by a left ventricular myxoma. The patient underwent successful catheter embolectomy of the abdominal aorta and surgical resection of the cardiac myxoma. This is a very rare case report of the combination of infantile left ventricular myxoma and acute occlusion of the abdominal aorta.

DOI： 10.1016/j.athoracsur.2014.08.066

The Utility of Aortic Blood Flow Measurements in the Prediction of Pulmonary Artery Banding Outcome. Reviewed International journal

Yasuhiro Kotani, Michael Coles, Nimesh D Desai, Osami Honjo, Christopher A Caldarone, John G Coles, Glen S Van Arsdell

The Annals of thoracic surgery 99 ( 6 ) 2096 - 100 2015.6

Authorship：Lead author Language：English Publishing type：Research paper (scientific journal)

BACKGROUND: The purpose of this study was to evaluate the clinical utility of intraoperative aortic blood flow measurements on clinical outcome in patients undergoing pulmonary artery banding (PAB). METHODS: We reviewed 12 patients who underwent a PAB between September 2008 and March 2013 who also had intraoperative aortic blood flow measurements. Diagnosis included biventricular physiology in 6, single-ventricle physiology in 4, and inadequate systemic ventricle in 2 patients. Aortic blood flow was measured at the time of surgery by Transonic flow probe (Transonic Systems Inc, Ithaca, NY). Aortic flow, intraoperative hemodynamics, and clinical outcomes were analyzed to determine the potential predictive utility of intraoperative variables on postoperative outcomes. RESULTS: The aortic flow increased after PAB from 1.56 ± 0.73 to 2.20 ± 1.10 L · min(-1) · m(-2) (41.0% increase; p = 0.001). The efficacy of the PAB procedure was found to be directly related to the percentage increase in aortic blood flow measured intraoperatively. Three patients with less than 20% increase in aortic blood flow died, required re-PAB, or developed ventricular dysfunction, while patients with successful PAB had more than 40% increase in aortic blood flow. The percentage increase in aortic blood flow was not predictable based on pre-band or post-band absolute aortic blood flow measurements. The percentage increase in aortic blood flow was inversely correlated to the tightness of the PAB as defined relative to that predicted by the Trusler formula (r = 0.67; p = 0.01). CONCLUSIONS: This study identifies the change in the aortic blood flow as a new, physiologically based parameter to help predict PAB outcome.

DOI： 10.1016/j.athoracsur.2015.01.066

Anatomical risk factors, surgical treatment, and clinical outcomes of left-sided pulmonary vein obstruction in single-ventricle patients. Reviewed International journal

Yasuhiro Kotani, Jiaquan Zhu, Lars Grosse-Wortmann, Osami Honjo, John G Coles, Glen S Van Arsdell, Christopher A Caldarone

The Journal of thoracic and cardiovascular surgery 149 ( 5 ) 1332 - 8 2015.5

Authorship：Lead author Language：English Publishing type：Research paper (scientific journal)

BACKGROUND: Patients with single-ventricle physiology frequently develop left-sided pulmonary vein obstruction (PVO), in which the pulmonary veins traverse the descending thoracic aorta. We hypothesized that a combination of cardiomegaly and an anteriorly positioned descending aorta is associated with PVO. METHODS: Among 494 consecutive single-ventricle patients, 15 were diagnosed with PVO by cardiac magnetic resonance, defined as anatomically localized narrowing of the pulmonary vein diameter. Using axial slices at the level of the left lower pulmonary vein, normalized dimensions were obtained to characterize the anatomic relationships of intrathoracic structures. Measurements were compared between patients with PVO and "control" patients (single-ventricle patients with normal pulmonary veins, n = 12). RESULTS: Patients with cardiac magnetic resonance-diagnosed PVO had larger cardiac size and more antero-laterally located descending aorta when compared with controls (normalized dimensions: cardiac/thoracic area ratio: 0.43 vs 0.38, P = .035, distance from vertebra to descending aorta normalized by the horizontal dimension of thoracic cavity: 0.09 vs 0.08, P = .049). Seven (47%) patients underwent PV sutureless repair, and 3 (of 7) failed to achieve Fontan. Patients who failed to achieve Fontan had a larger normalized cardiac size than those who achieved Fontan (cardiac/thoracic area ratio: 0.49 vs 0.39, P = .001). CONCLUSIONS: The combination of relative cardiomegaly within the context of the thoracic cavity at the level of the pulmonary veins and antero-lateral displacement of the aorta is associated with left-sided PVO and subsequent failure to achieve Fontan completion. Further characterization of these unique geometric relationships may help inform both surveillance strategies and decision making in the timing of interventions, and guide the intraoperative objectives at the time of PVO repair.

DOI： 10.1016/j.jtcvs.2014.11.089

Persistent fenestration may be a marker for physiologic intolerance after Fontan completion. Reviewed International journal

Yasuhiro Kotani, Devin Chetan, Arezou Saedi, Jiaquan Zhu, Lars Grosse-Wortmann, John G Coles, Christopher A Caldarone, Glen S Van Arsdell, Osami Honjo

The Journal of thoracic and cardiovascular surgery 148 ( 6 ) 2532 - 8 2014.12

Language：English Publishing type：Research paper (scientific journal)

BACKGROUND: We sought to evaluate the medium-term implications of fenestration status. METHODS: Between 1994 and 2012, 326 patients received an extracardiac Fontan (hospital mortality n = 6, 1.8%). A fenestration was routinely created (n = 306, 94%) unless there was technical difficulty. Three hundred patients discharged with an open fenestration were included. The primary end points were death and Fontan failure. Secondary outcomes were Fontan complications such as venovenous collaterals, protein-losing enteropathy, pacemaker requirement, and arrhythmias. RESULTS: The fenestration was closed in 260 patients: 185 as a catheter intervention (62%) and 75 (25%) spontaneously. Forty patients (13%) had the fenestration open at a median follow-up period of 5.05 years. Of these patients, catheter-based closure failed in 10 (3%). There was no statistically significant difference in pre-Fontan hemodynamic parameters, such as pulmonary artery pressure and pulmonary vascular resistance between the patients with open fenestration and the ones with closed fenestration. Patients with an open fenestration had significantly more late deaths (P < .001), Fontan failure (P = .021), and Fontan complications (P = .011) compared with those with a closed fenestration. Multivariable Cox regression revealed open fenestration (P < .001) and indeterminate ventricular morphology (P = .002) as risk factors for death/Fontan failure, and ventricular dysfunction (P = .014) and open fenestration (P = .009) as risk factors for Fontan complications. CONCLUSIONS: Persistent fenestration was a marker for physiologic intolerance as noted by increased rates of mortality and a higher incidence of Fontan failure/complications. The specificity of pre-Fontan physiologic data for fenestration status may not have the fidelity needed for long-term care and thus, the consequences of decision making regarding fenestration status may not be determined until well after the operation.

DOI： 10.1016/j.jtcvs.2014.06.062

Fate of the hypoplastic proximal aortic arch in infants undergoing repair for coarctation of the aorta through a left thoracotomy. Reviewed International journal

Yasuhiro Kotani, Shirley Anggriawan, Devin Chetan, Lisa Zhao, Nishanthi Liyanage, Arezou Saedi, Luc L Mertens, Christopher A Caldarone, Glen S Van Arsdell, Osami Honjo

The Annals of thoracic surgery 98 ( 4 ) 1386 - 93 2014.10

Authorship：Lead author Language：English Publishing type：Research paper (scientific journal)

BACKGROUND: Extended end-to-end anastomosis (EEEA) through a left thoracotomy for coarctation of the aorta (CoA) and tubular hypoplasia of the aortic arch (THAA) leaves an unaugmented hypoplastic proximal aortic arch (PAA) segment, which may increase late reintervention for PAA obstruction. We sought to assess PAA growth and reintervention for PAA obstruction after EEEA. METHODS: Preoperative and follow-up echocardiographic images of 140 patients who underwent EEEA for CoA from 2005 to 2012 were reviewed. Patients were divided into two groups on the basis of preoperative PAA z-scores: THAA group, z-score less than -3; non-THAA group, z-score greater than or equal to -3. RESULTS: Eighty (57%) patients were identified as having THAA. There were three surgical reinterventions (PAA in 2 patients and distal aortic arch in 1 patient) and nine catheter reinterventions (all related to anastomotic stenosis) during a median follow-up period of 18 months. Both patients who required PAA reintervention had preoperative PAA z-scores below -8. Freedom from reintervention at 3 years was comparable between the groups (THAA group, 90.0% vs non-THAA group, 87.9%, p = 0.483). Follow-up echocardiography revealed PAA catch-up growth in the THAA group (z-score, preoperative -4.63 vs follow-up -1.17, p < 0.001); however, there was a nonsignificant trend toward smaller PAA in the THAA group (z-score: THAA, -1.17 vs non-THAA, -0.55, p = 0.057). All but 2 patients with preoperative PAA z-scores above -6 did not have any PAA obstruction. CONCLUSIONS: The hypoplastic PAA segment in patients with CoA/THAA grew significantly after EEEA but remained smaller than in those without THAA. Our data support that CoA and PAA with z-scores as small as -6 can be repaired through a thoracotomy approach with a low risk of reintervention.

DOI： 10.1016/j.athoracsur.2014.05.042

Is restrictive atrial septal defect a risk in partial anomalous pulmonary venous drainage repair? Reviewed International journal

Jiaquan Zhu, Yasuhiro Kotani, Devin Chetan, Lisa Zhao, John G Coles, Christopher A Caldarone, Glen S Van Arsdell, Osami Honjo

The Annals of thoracic surgery 97 ( 5 ) 1664 - 70 2014.5

Language：English Publishing type：Research paper (scientific journal)

BACKGROUND: The creation or enlargement of an atrial septal defect (ASD) in partial anomalous pulmonary venous drainage (PAPVD) repair may pose a risk of postoperative pulmonary vein stenosis (PVS), superior vena cava stenosis (SVCS), and atrial rhythm disturbances. METHODS: 155 children who underwent repair of right PAPVD between 1990 and 2010 were reviewed. PVS and SVCS were defined by mean gradients on echocardiography: mild=3 to 5 mm Hg; severe=6 mm Hg or higher. Postoperative cardiac rhythms were categorized as sinus, transient nonsinus, and persistent nonsinus rhythms. Outcomes were compared between patients who underwent the creation or superior enlargement of an ASD (group A) and those who did not (group B). RESULTS: There was no early or late death. Freedom from any PVS at 15 years after operation was lower in group A than in group B (76.1% vs 96.5%, p=0.002), and no differences were found in freedom from severe PVS (p=0.103), any SVCS (p=0.419), or severe SVCS (p=0.373). Group A patients had more PVS-related reoperations (p=0.022). Nineteen patients had nonsinus rhythm, and 4 patients experienced first-degree atrioventricular block, but no significant difference was found between the groups. Cox regression revealed the creation or superior enlargement of an ASD as a predictor for postoperative PVS (p=0.032). A case-match analysis confirmed a higher risk of PVS in patients with the creation or superior enlargement of an ASD (p=0.018). CONCLUSIONS: Late outcomes after repair of PAPVD are excellent. The subgroup that requires creation or superior enlargement of an ASD in repair of a right PAPVD is at a higher risk of late PVS and a subsequent increase in PVS-related reoperation. The presence of restrictive ASD did not increase SVCS, sinus node, or atrial conduction dysfunction.

DOI： 10.1016/j.athoracsur.2014.01.051

Anatomical factors determining surgical decision-making in patients with transposition of the great arteries with left ventricular outflow tract obstruction. Reviewed International journal

Osami Honjo, Yasuhiro Kotani, Tara Bharucha, Luc Mertens, Christopher A Caldarone, Andrew N Redington, Glen Van Arsdell

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 44 ( 6 ) 1085 - 94 2013.12

Language：English Publishing type：Research paper (scientific journal)

OBJECTIVES: Transposition of the great arteries (TGA) and left ventricular outflow tract obstruction (LVOTO) with or without ventricular septal defect have multiple surgical treatment options. We sought to identify pre- and intraoperative factors that determine the timing of repair, procedure type and subsequent LVOT outcome. METHODS: Twenty-eight (8.2% of all TGA) patients with TGA with LVOTO (double outlet ventricle, n = 5, TGA/intact septum, n = 1) between 2000 and 2012 were reviewed. Anatomical factors were identified by prerepair echocardiography. LVOTO complexity was characterized by the degree of obstruction (0 = none, 0.33 = mild, 0.66 moderate and 1 = severe) at various levels: pulmonary valve (PV) dysplasia/hypoplasia, posterior deviation of the infundibular septum, fibromuscular ridge, tissue tag and abnormal chordal attachment. Summation of the obstruction score, at each level, yielded the LVOT complexity score. The descriptive analysis of intraoperative decision-making at late repair was performed. OPERATIONS: early arterial switch operation (ASO) + LVOT resection (n = 9, 32%), late ASO + LVOT resection (n = 3, 10%), Nikaidoh (n = 8, 29%), Rastelli (n = 6, 21%), single-ventricle palliation (n = 2, 7%). The primary LVOT obstruction mechanism was posterior deviation of the infundibular septum (n = 16, 57%) and PV dysplasia (n = 6, 21%). The early ASO group had a lower PV complexity score (0.42 ± 0.22 vs 0.96 ± 0.55, P = 0.007), tissue tag score (0.03 ± 0.15 vs 0.26 ± 0.34, P = 0.018) and LVOT complexity score (2.11 ± 0.86 vs 3.2 ± 0.96, P = 0.006). The LVOT complexity score in the Nikaidoh group was higher than in the late ASO group (P = 0.019). Of 16 candidates for the Nikaidoh procedure, 6 patients underwent a Rastelli operation due to coronary artery patterns (single coronary, n = 3, 1RL-2Cx, n = 2 or an abnormal left anterior descending coronary artery course, n = 1). Two patients underwent single-ventricle palliation due to the interference of essential chordae. All patients survived the operation. The 3-year survival was 96%. One patient who underwent late ASO required re-LVOT resection. CONCLUSIONS: A newly developed scoring system, the LVOT complexity score, helped to quantify the LVOT complexity and was correlated with our choice of the surgical procedure of TGA with LVOTO. The current strategy achieved reasonable survival and LVOT outcome with three quarters of the patients having an anatomically aligned LVOT. The coronary anatomy pattern was the primary determinant in the decision-making between the Nikaidoh procedure and the Rastelli operation.

DOI： 10.1093/ejcts/ezt283

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