Satsuki Fukushima

Acute coronary syndrome (ACS) remains underrecognized in patients with Kawasaki disease (KD). The population at risk for KD-associated ACS is increasing, yet current ACS guidelines are largely derived from atherosclerotic disease and do not adequately address the distinctive mechanisms, anatomy, and thrombosis risk associated with KD. Because the pathophysiology and management of KD-associated ACS differ in fundamental ways from those of atherosclerotic coronary artery disease, its management requires a coordinated team response, with collaboration between pediatric and adult cardiologists. Recent advances in coronary imaging, interventional techniques, and antithrombotic therapies provide an opportunity to establish a more disease-specific approach. This review synthesizes current evidence on the epidemiology and pathophysiology of coronary artery aneurysms, interventional coronary imaging, acute management, revascularization strategies, antithrombotic therapy, and post-ACS surveillance in patients with KD to guide clinical decision-making and treatment for patients with KD presenting with ACS.

De novo aortic regurgitation (AR) remains a clinically significant complication of continuous-flow left ventricular assist device support, including the HeartMate 3 (HM3). Contemporary durability and safety data for concomitant aortic valve plasty (AVP) in HM3 recipients—particularly those bridged with temporary mechanical circulatory support (tMCS)—are limited. We retrospectively analyzed 115 consecutive adults undergoing primary HM3 implantation between August 2019 and December 2024; 35 (30%) received concomitant AVP. Time-to-event outcomes were estimated using Kaplan–Meier methods with a 30 day landmark and corroborated by Aalen–Johansen competing-risk cumulative incidence functions. One early technical failure (postoperative day 1) was excluded from the primary analysis, and one additional de novo event occurred during follow-up. Freedom from greater than or equal to moderate AR in the AVP cohort was 100% at 1 year and 94.7% (95% confidence interval [CI], 68.1–99.2) at 2–3 years; AR severity distributions remained stable, with no severe AR. Operative and cardiopulmonary bypass times were longer in the AVP group, whereas early hemodynamics and in-hospital and midterm adverse-event rates were comparable. These findings support selective concomitant AVP as a feasible valve-sparing strategy in contemporary HM3 practice, including tMCS-exposed recipients. Prospective multicenter studies are warranted to refine patient selection and to characterize long-term durability.

Objectives: Transcatheter aortic valve implantation (TAVI) via the transfemoral (TF) approach is widely used. However, patients with unsuitable peripheral arterial anatomy require alternative transthoracic access. In such patients, the transaortic TAVR via right mini-thoracotomy (Rt-TAo) approach offers a less invasive option than conventional sternotomy. Therefore, this study aimed to evaluate the procedural and 2-year clinical outcomes of TF TAVI versus Rt-TAo TAVI. Methods: Patients who underwent TAVI via the TF approach or the Rt-TAo approach between January 2012 and November 2023 were retrospectively reviewed. Baseline characteristics and clinical outcomes were compared, and propensity score matching was performed to adjust for baseline differences. The primary end-points were in-hospital mortality, stroke, other periprocedural morbidities, and postprocedural length of hospitalization. Secondary end-points included overall survival, freedom from cardiac-related death, and major adverse cardiac and cerebrovascular events (MACCE) at 2 years. Results: A total of 767 consecutive patients were included in the analysis, of whom 694 underwent TF TAVI and 73 underwent Rt-TAo TAVI. Before matching, the Rt-TAo group had higher baseline prevalences of comorbidities and Society of Thoracic Surgeon risk scores. After matching, the Rt-TAo group had a longer procedural time, higher transfusion requirements, and longer lengths of intensive care unit and total hospital stays. However, the 2 groups had similar rates of periprocedural stroke, coronary obstruction, annular rupture, access-related complications, and in-hospital mortality. The 2 groups had similar 2-year rates of survival and freedom from MACCE. Conclusions: The Rt-TAo TAVI is a safe and feasible alternative for patients with unsuitable peripheral arterial access, demonstrating comparable 2-year outcomes to TF TAVI.

Background: Robotic mitral valve repair (MVr) offers superior visualization and dexterity, potentially overcoming challenges in severe thoracic deformity such as pectus excavatum. This study compared surgical outcomes after MVr in patients with and without thoracic deformity and assessed the impact of thoracic deformity on operative times in robotic MVr.Methods and Results: We reviewed 359 patients undergoing robotic MVr for degenerative mitral regurgitation (2018–2022). Patients with a Haller index ≥3.25 categorized as the deformity group (Group D; n=35), and those with a Haller index <3.25 were in the non-deformity group (Group N; n=324). Group D was younger, but repair techniques and concomitant surgery were similar. In the results, there was no significant difference in operative time and aortic cross-clamp time (80±29 vs. 80±30 min; P=0.969) between the 2 groups. No correlation was found between thoracic dimensions and cross-clamp time. Early outcomes, including intensive care unit stay (1.92±1.59 vs. 1.77±1.26 days; P=0.519), hospital stay, mortality, stroke, and re-exploration, were comparable. Perioperative redo occurred in 4 patients in Group N (hemolysis from regurgitant jet, residual P2 prolapse, suture dehiscence) and 2 patients in Group D (systolic anterior motion-induced mitral regurgitation, poor posterior leaflet coaptation). One-year mitral regurgitation grade, survival, and freedom from reoperation were similar.Conclusions: Among patients with thoracic deformity deemed suitable for robotic MVr, outcomes were not worse compared with patients without deformity.

Background: The long-term prognosis of patients supported by durable left ventricular assist devices (LVAD) while receiving immunosuppressive therapy remains unclear. Underlying conditions such as cardiac sarcoidosis, recurrent myocarditis, or post-organ transplantation may necessitate concomitant immunosuppressive therapy during LVAD support. In particular, patients requiring prolonged immunosuppressive therapy exceeding low-dose corticosteroids represent a clinically challenging population in whom infectious complications and long-term outcomes have not been well characterized. Case summary: We retrospectively reviewed 241 consecutive LVAD recipients (HeartMate II and HeartMate 3) at a single centre (2013–24). Five patients (2.1%) required prolonged immunosuppressive therapy exceeding low-dose corticosteroids. Underlying cardiac conditions included myocarditis (n = 3), cardiac sarcoidosis (n = 1), and dilated cardiomyopathy following liver transplantation (n = 1). The mean duration of immunosuppressive therapy during LVAD support was 2.3 years (0.8–4.5 years). One patient developed LVAD-specific infections including driveline infection. Two underwent successful heart transplantation without perioperative complications. One was tapered to low-dose corticosteroid monotherapy due to a non-device-related infection, and two remained stable on LVAD support. Discussion: This case series underscores the complexity of managing LVAD patients requiring extended immunosuppressive therapy and highlights a unique and underreported patient population. Our findings suggest that successful heart transplantation may be achievable in immunosuppressed LVAD patients when supported by vigilant infection surveillance and individualized treatment strategies. This topic is of increasing clinical importance, particularly in regions where DT indications have recently been expanded.

Background: Patients undergoing durable left ventricular assist device (LVAD) implantation frequently require prolonged perioperative respiratory support. However, the long-term pulmonary consequences of different surgical pump placement strategies remain unclear. We investigated longitudinal pulmonary function changes following intrathoracic versus extrathoracic LVAD implantation. Methods: This single-center retrospective cohort study included patients who underwent LVAD implantation and completed pulmonary function testing (PFT) preoperatively and at 1 year postoperatively. Intrathoracic HeartMate 3 recipients were compared with extrathoracic HeartMate II recipients. Linear mixed-effects models assessed longitudinal changes in forced vital capacity (FVC), percent predicted FVC (%FVC), forced expiratory volume in 1 s (FEV₁), and percent predicted FEV₁ (%FEV₁), adjusting for age, sex, body surface area, and surgery era. Results: Among 190 patients (intrathoracic, n = 76; extrathoracic, n = 114), greater declines in FVC, %FVC, and FEV₁ were observed at 1 year in the intrathoracic group. Significant time-by-placement interactions were identified for FVC ( P = 0.010), %FVC ( P = 0.010), and FEV₁ ( P = 0.011), whereas %FEV₁ showed comparable trends between groups. Smaller body surface area and female sex were independently associated with lower lung volumes, whereas the apparent association with female sex was largely explained by body size. Conclusions: Intrathoracic LVAD implantation was associated with greater restrictive changes in pulmonary function at one year. These findings suggest that surgical pump positioning and patient body size may influence long-term respiratory trajectories and may be relevant for perioperative planning and postoperative follow-up.

Background: The treatment of patients with biventricular heart failure using a left ventricular assist device (LVAD) remains a significant challenge. For patients with cardiac arrest (CA), biventricular assist device (BiVAD) support is necessary; however, it severely impacts their quality of life. We present three patients with CA who initially required BiVAD but were successfully weaned to isolated LVAD therapy. Case Summary: Three men with acute lymphocytic fulminant myocarditis developed cardiogenic shock and CA. After temporary mechanical circulatory support, they received extracorporeal BiVAD, followed by HeartMate3 (HM3) LVAD implantation with continued extracorporeal right ventricular assist device (ex-RVAD) support. Management was focused on ex-RVAD removal by minimizing pulmonary vascular resistance (PVR) with sildenafil (60 mg daily), incrementally adjusting the HM3 pump speed, and intensive lower leg training. The first patient underwent an adjunctive extracardiac total cavopulmonary connection at the time of ex-RVAD removal and has been stable for 27 months. The other two patients underwent ex-RVAD removal without the Fontan procedure and have been stable for 12 and 11 months, respectively. All patients received prophylactic aortic valvuloplasty using Park’s stitch (AVP) and multiple diuretics, which enabled hospital discharge. Discussion: These cases demonstrate that long-term isolated LVAD support can be established in patients with CA regardless of adjunctive Fontan procedure. The key principles for successful isolated LVAD support include: (i) minimizing PVR; (ii) incremental adjustment of the LVAD pump speed; and (iii) proactive AVP. This approach enables the hospital discharge of patients who would otherwise require permanent hospitalization with BiVAD.

Root enlargement via traditional transverse or oblique aortotomy disrupts the anatomical features of smooth continuity and symmetry from the aortic root to the proximal ascending aorta. A straight longitudinal aortotomy, extended vertically into nadir of noncoronary aortic annulus, achieves smooth continuity and symmetrical enlargement from the aortic root to the proximal ascending aorta with a tear-drop-shaped bovine pericardial patch. Herein, we report successful symmetrical root enlargement following straight longitudinal aortotomy via right anterior minithoracotomy.