松橋 和己

BACKGROUND: Immune-mediated inflammatory diseases (IMIDs) are associated with increased cardiovascular risk, but surgical outcomes in the modern era of immunosuppressive therapy remain unclear. We evaluated early and late outcomes after cardiac and thoracic aortic surgery in patients with IMIDs, focusing on the impact of glucocorticoids and disease-modifying antirheumatic drugs (DMARDs). METHODS: A total of 140 patients with IMIDs who underwent cardiac or thoracic aortic surgery between 2008 and 2025 were retrospectively analyzed. The primary endpoints were in-hospital mortality and long-term overall survival. RESULTS: Median age was 70 [61-76] years, and 62% were women. Rheumatoid arthritis was the most common IMID (36%). Prednisolone and DMARDs were used in 68% and 33% of patients, respectively. Procedures included valve (43%), ischemic (26%), and thoracic aortic surgery (23%). In-hospital mortality was 4.3%. During a median follow-up of 5.9 years (93% completeness), overall survival was 91% at 1 year, 87% at 3 years, 78% at 5 years, and 62% at 10 years, respectively. Outcomes did not differ by a surgical category or IMID subtype. Glucocorticoid use was independently associated with worse late survival (HR, 2.91; 95% CI, 1.01-8.41; p = 0.048), whereas DMARD use showed a trend toward improved survival (HR 0.46; 95% CI, 0.19-1.09; p = 0.08). Notably, a dose-dependent relationship was observed, with high-dose prednisolone (≥ 5 mg/day) showing significantly worse survival compared with low-dose (< 5 mg/day) or no glucocorticoid use (p = 0.004). Diabetes mellitus and preoperative anemia were also independent predictors of late mortality. CONCLUSIONS: Cardiac surgery in patients with IMIDs provides acceptable early outcomes but suboptimal long-term survival. Glucocorticoid use was associated with worse late survival, with a dose-dependent relationship, whereas DMARD use showed a nonsignificant trend toward better survival, underscoring the importance of optimized immunosuppressive management.

PURPOSE: Nurse practitioners (NPs) were introduced in Japan to reduce physicians' workloads through task shifting. Three cardiac surgical NPs (CSNPs) were employed in our department. This study aimed to describe their clinical practices and evaluate their contributions to task shifting. METHODS: We reviewed the medical records of patients treated between January 2019 and December 2024. Three analyses were conducted: (I) quantification of medical procedures performed by CSNPs, (II) assessment of CSNP participation as surgical assistants, and (III) evaluation of delegated medical order entries. RESULTS: (I) Among 1,822 patients, the most frequently performed CSNP procedures were ventilator setting adjustments, peripherally inserted central catheter placement, and arterial blood sampling. (II) The median annual number of surgeries involving CSNPs was 191 (44%), with a median cumulative operative time of 1,137 h. (III) CSNP-delegated orders accounted for 19.2% of outpatient and 36.6% of inpatient entries. Increased CSNP order entries were significantly correlated with decreased surgeon entries in both outpatient (r = 0.67, p < 0.001) and inpatient (r = 0.59, p < 0.001) settings. CONCLUSIONS: The inverse correlation between CSNP and surgeon order entries indicates that CSNPs substantially support task shifting and help reduce surgeons' workloads in cardiac surgery.

Background: Compared with isolated aortic valve replacement (AVR), echocardiographic hemodynamics after Wheat and Bentall procedures, both involving replacement of the proximal ascending aorta with a smaller-diameter graft, have been less thoroughly investigated. Methods: We analyzed 213 patients who received 21 mm or 23 mm aortic bioprostheses (AVR, n = 138; Wheat, n = 43; Bentall, n = 32). Transthoracic echocardiography was performed before and after surgery, and the proximal ascending aortic area (Aa) was assessed using contrast-enhanced computed tomography. Results: The maximal pressure gradient (PG max), derived from the simplified Bernoulli equation, was significantly lower in the Bentall group, whereas pressure recovery (PR), calculated using Voelker's equation, was lower in the AVR group. A smaller Aa was associated with a higher PG max in the AVR group. The Bentall group exhibited significantly lower energy loss (EL). In propensity score-matched analyses to minimize potential confounding factors, the AVR group showed a significantly lower PR and higher EL than the Wheat group; a significantly higher PG max, lower PR, and higher EL than the Bentall group; and a significantly similar PR but lower EL in the Bentall group compared with the Wheat group. Conclusions: Although limited to bioprosthetic valves, caution is warranted when interpreting echocardiographic PG max after AVR in patients with a small ascending aorta. However, overestimation of PG max was not observed in either the Wheat or Bentall groups, even though both demonstrated higher PR and lower EL compared with the AVR group.

OBJECTIVE: To investigate the impact of the discrepancy between the predicted annuloplasty ring size determined by preoperative transesophageal echocardiography and the actual ring size on the outcomes of mitral valve repair (MVr) using primarily the loop technique. METHODS: Among 370 patients who underwent MVr between January 2008 and December 2024, 154 who underwent MVr with the semirigid ring for degenerative disease were involved in this study. Ring size was estimated according to the lengths of A2 and P2 by transesophageal echocardiography. Patients were classified into 3 groups-small, match, and large-based on the discrepancy between the predicted and actual ring sizes. RESULTS: Compared with the other small and match groups, patients in the large group had shorter anterior leaflet length (P = .03), smaller posterior leaflet angle (P = .01) and smaller coaptation depth (P = .03) in the coaptation triangle. There was no significant difference in coaptation length among the 3 groups. The cumulative incidence of mitral regurgitation (MR) grade ≥2 was 0.6% at 1 year, 5% at 5 years, and 24% at 10 years, whereas that of a mean transmitral pressure gradient ≥5 mm Hg were 5%, 13%, and 16%, respectively. Fine-Grey multivariable analysis identified larger posterior leaflet angle after repair as a risk factor for recurrence of MR grade ≥2 and larger body surface area, smaller prosthesis size, and shorter coaptation length as risk factors for functional mitral stenosis. CONCLUSIONS: Size mismatch of the prosthesis ring did not change the coaptation length, late MR recurrence, or functional mitral stenosis after MVr.

Fractional flow reserve (FFR) has been well validated as a modality for evaluating myocardial ischemia, demonstrating the superiority of FFR-guided percutaneous coronary intervention (PCI) over conventional angiography-guided PCI. As a result, the strategy for coronary artery bypass grafting (CABG) is shifting toward FFR guidance. However, the advantage of FFR-guided CABG over angiography-guided CABG remains unclear. While FFR-guided CABG can help avoid unnecessary grafting in cases of moderate stenosis, it may also carry the risk of incomplete revascularization. The limited use of FFR due to the need for hyperemia has led to the development of non-hyperemic pressure ratios (NHPRs). NHPR pullback provides trans-stenotic pressure gradients, which may offer valuable insights for CABG strategies. Recently, computed tomographic coronary angiography (CTCA) has emerged as a non-invasive modality that provides accurate data on lesion length, diameter, minimum lumen area, percentage stenosis, and the volume and distribution of high-risk plaques. With the introduction of FFR-CT, CTCA is now highly anticipated to provide both functional evaluation (of myocardial ischemia) via FFR-CT and anatomical information through serial quantitative assessment. Beyond the diagnostic phase, CTCA, augmented by automatic artificial intelligence, holds great potential for guiding therapeutic interventions in the future.