[Retrograde Stanford Type A Aortic Dissection of Marfan Syndrome Long After Thoracic Endovascular Aortic Repair:Report of a Case].

A 52-year-old woman with Marfan syndrome developed Stanford type B aortic dissection and was treated with thoracic endovascular aortic repair. However, 29 months later, she presented with retrograde Stanford type A aortic dissection. We successfully performed aortic arch replacement with the frozen elephant trunk technique and valve-sparing aortic root replacement. The advantages of the frozen elephant trunk technique are that the distal anastomosis can be created without stent-graft resection and the cardiac arrest time is shortened. Therefore, the frozen elephant trunk technique was considered valuable and safe in this potentially lethal situation.

[Congenital Unicuspid Aortic Valve Diagnosed by Intraoperative Findings].

A unicuspid aortic valve is an extremely rare congenital aortic valvular abnormality. We herein present 2 cases of unicuspid aortic valve diagnosed based on intraoperative findings. In case 1, a 75-year-old man was admitted to our hospital because of severe aortic regurgitation. We performed aortic valve replacement using a bioprosthetic valve, and a unicuspid aortic valve was definitively diagnosed according to the intraoperative findings. In case 2, a 54-year-old man developed dyspnea due to severe aortic stenosis. Aortic valve replacement using mechanical valve was performed, and we were able to diagnose unicuspid aortic valve intraoperatively. Achieving a preoperative definitive diagnosis of congenital unicuspid aortic valve by transthoracic echocardiography is reportedly difficult;however, transesophageal echocardiography may be effective for preoperative definitive diagnosis.

Safety of perioperative cerebral oxygen saturation during debranching in patients with incomplete circle of Willis.

OBJECTIVES: The consequences of common carotid artery (CCA) cross-clamping during debranching before thoracic endovascular aortic repair are unclear. We examined the safety of a simple CCA cross-clamping procedure under regional cerebral oxygen saturation monitoring (rSO2) in patients with a complete or incomplete circle of Willis (CoW) anatomy. METHODS: Twenty-eight patients with thoracic aneurysm underwent elective debranching thoracic endovascular aortic repair with bilateral frontal rSO2 monitoring at our institution between January 2012 and October 2015. Before CCA cross-clamping, we maintained a systemic mean arterial pressure of >100 mm Hg with a vasopressor. We recorded the bilateral frontal rSO2 before, during and after CCA cross-clamping. RESULTS: The CoW was incomplete in 11 (39.3%) patients. Of these, 6 patients had a complication of ischaemic potential. The left frontal rSO2 was <50% in 3 patients but did not fall below 40%. Compared with baseline values (mean ± SD 64.6 ± 6.9%), the left frontal rSO2 showed no significant change perioperatively in those with a complete CoW on the left CCA cross-clamping (during: 61.0 ± 7.9%, P = 0.17; after: 65.1 ± 5.9%, P = 0.09). In patients with an incomplete CoW with ischaemic potential, the left frontal rSO2 did not change significantly after cross-clamping (baseline: 59.8 ± 3.2%, during: 55.5 ± 5.0%; P = 0.10) but increased significantly on declamping (62.8 ± 4.5%, P = 0.023). The extent of the changes in the mean left frontal rSO2 on clamping and declamping decreased and increased by 7.3% and 11.7%, respectively, in patients with an incomplete CoW, when compared with 5.3% and 5.8% in those with a complete CoW (P = 0.65 and 0.31, respectively). No perioperative cerebrovascular events were observed. CONCLUSIONS: Simple CCA cross-clamping during debranching was safe when arterial pressure was supported and rSO2 was monitored, even with an incomplete CoW and ischaemic potential.

Perigraft fluid collection mimicking graft infection in patients with a para-anastomotic aneurysm.

We herein report two cases of perigraft effusion mimicking graft infection after debranching thoracic endovascular repair for an anastomotic pseudoaneurysm of the distal ascending aorta. Both patients presented with a bulging tumor on the sternum. Enhanced computed tomography showed no endoleak, but extension of periprosthetic graft fluid to a subcutaneous sternal wound was present. We suspected a deep sternal wound infection; however, cultures of débrided tissues were negative. After drainage of the subcutaneous fluid or negative pressure wound therapy, both patients were doing well without recurrence of effusion. Endotension was considered to have been associated with enlargement of the perigraft effusion.

Less-Invasive Endovascular Treatment of Arch Aneurysm With Aberrant Right Subclavian Artery.

We report a patient with an arch aneurysm with an aberrant right subclavian artery who underwent successful endovascular treatment with the chimney technique and bilateral carotid artery-to-subclavian artery bypasses. We used a chimney graft in the left carotid artery to preserve its flow. The bilateral carotid-to-subclavian artery bypasses preserved perfusion of the bilateral vertebral arteries. A thoracic stent graft was subsequently deployed in the aortic arch over the chimney graft of the left carotid artery. There have been few reports about less-invasive treatment for arch aneurysm with aberrant right subclavian artery. This technique was an effective strategy to avoid a high-risk open operation.

Mitral valve repair for atrial functional mitral regurgitation in patients with chronic atrial fibrillation.

OBJECTIVES: Atrial functional mitral regurgitation (MR) has been recently described in patients with chronic atrial fibrillation (AF). However, the results of surgical mitral valve (MV) repair for this type of MR have not been comprehensively reported. Our study aimed to address this deficiency. METHODS: We retrospectively studied 10 chronic AF patients who underwent MV repair for atrial functional MR with normal left ventricular dimension and preserved left ventricular systolic function. All patients had chronic heart failure (HF) symptoms and at least one prior admission for HF complicated by severe MR. RESULTS: Ring annuloplasty was performed in all patients; the median ring size was 26 mm (range, 26-30 mm). Concomitant tricuspid valve repair was undertaken in all patients. Preoperatively, left atrial (LA) diameter on the parasternal long-axis view, LA volume index and mitral annular diameter were 52 ± 9 mm, 72 ± 26 ml/m(2) and 33 ± 4 mm, respectively. There was no mortality and no re-admission due to HF during follow-up (range, 10-52 months). MR at the most recent examination was mild or improved in degree in all patients. The LA volume index decreased from the preoperative period, measuring 48 ± 17 ml/m(2) at the most recent period (P = 0.03). The New York Heart Association functional class dramatically improved from the preoperative period to the most recent period (from 3.0 ± 0.7 to 1.2 ± 0.4, P < 0.0001). CONCLUSIONS: Our results suggest that MV repair leads to reductions in MR, LA size and HF symptoms, and that it may prevent future HF events in patients with atrial functional MR.

[Surgical treatment for pseudoaneurysm of the sinus of valsalva ruptured into the right atrium after mycotic right coronary artery aneurysm repair;report of a case].

A 67-year-old man was admitted to our hospital by ambulance after syncope due to complete A-V block. He had received surgical treatment for mycotic aneurysm of the right coronary artery 3 months before, with patch plasty of the right sinus of Valsalva and bypass grafting to the right coronary artery (RCA) as well as the left anterior descending branch. Computed tomography revealed pseudoaneurysm of the right Valsalva sinus of about 8 cm in diameter and a shunt flow to the right atrium. The previous bypass graft to RCA had been occluded due to compression by the aneurysm. As he was in a shock state, emergency operation was performed. Cardiopulmonary bypass was first established, and after the rectal temperature reached to 26 degrees centigrade, the chest was opened. The pseudoaneurysm burst out when the sternum was re-opened. Under circulatory arrest, the ascending aorta was clamped, and then the circulation was resumed. The previous bovine pericardium patch repairing the Valsalva sinus was detached due to infection, and mural thrombus and pus were observed in the aneurysm. At the bottom of the aneurysm, a fistula connected to the right atrium was found. Debridement around the aneurysm was performed as much as possible. The defect of the Valsalva sinus was repaired with a Dacron patch immersed in gentian violet. The postoperative course was uneventful without any recurrence of infection.

Successful surgical treatment of traumatic transection of the innominate artery: a case report.

Blunt traumatic injury to the innominate artery is relatively rare. We present the case of a 40-year-old woman who fell from a fourth-floor window and was transferred to our hospital with multiple injuries, hemodynamic shock, and disturbance of consciousness. Computed tomography with image reconstruction revealed transection of the innominate artery near its origin. Emergent surgery required establishment of cardiopulmonary bypass before sternotomy in preparation for uncontrollable hemorrhage. Proximal aortic arch replacement with a branch to the right axillary artery was successfully performed using circulatory arrest and selective cerebral perfusion.

Aortoesophageal fistula after endovascular repair for aberrant right subclavian artery aneurysm.

A 76-year-old woman with malignant rheumatic arthritis developed dysphagia and hoarseness secondary to an aberrant right subclavian artery aneurysm. We performed a hybrid endovascular repair with concomitant surgical treatment for the aberrant right subclavian artery aneurysm. One month after discharge, she was emergently admitted to our hospital because of chest pain and fever. We diagnosed aortoesophageal fistula and stent graft infection based on computed tomography, gallium scintigraphy, and esophagoscopy results. Esophagectomy, elimination of the infected stent graft, and muscle plombage were performed during several surgeries. However, she died of hemorrhagic shock secondary to an aortobronchial fistula.

Does rich coronary collateral circulation distal to chronically occluded left anterior descending artery compete with graft flow?

OBJECTIVES: In coronary artery bypass grafting (CABG), graft flow distal to a mild stenosis can compete with relatively preserved native flow through the stenosis and the competition can result in graft stenosis. In chronic total occlusion (CTO), coronary collateral circulation, which is essential to maintain myocardial viability distal to CTO, varies in extent among patients and the extent can be scored by Rentrop grade in coronary angiography. We investigated whether rich collateral circulation distal to CTO competes with distally anastomosed graft flow in association with Rentrop grade. METHODS: Of 666 patients who underwent CABG from January 2001 to December 2012, 70 patients whose left internal thoracic artery (ITA) was grafted distal to CTO in the left anterior descending artery (LAD) were divided into three groups: Poor collaterals (Rentrop grades 0 and 1, Group P, n = 22), Moderate collaterals (grade 2, Group M, n = 23) and Rich collaterals (grade 3, Group R, n = 25). The intraoperative measurements of mean graft flow (MGF) and pulsatility index (PI) of left ITA grafts, early graft patency and long-term clinical outcomes were compared. RESULTS: The MGF and PI of left ITA grafts differed significantly among the three groups (P = 0.025 and P = 0.046, respectively). Lower Rentrop grade was associated with preferable results of higher MGF and lower PI. The graft flow pattern in Group P showed a significantly higher MGF (P = 0.020) and lower PI (P = 0.041) than those in Group R. All early postoperative coronary angiograms showed patent left ITA grafts. Serial echocardiographic evaluations, survival rates and cardiac event-free rates were comparable with the follow-up of 5.00 ± 3.11 years. CONCLUSIONS: Rich collateral circulation distal to CTO in LADs can potentially compete with graft flow, although the competition seems not to affect clinical outcomes probably due to the regression of collaterals surmounted by the graft flow. Rentrop grade is shown to certainly reflect the degree of collateral haemodynamic circulation distal to CTO and especially important to evaluate intraoperative graft flow appropriately, considering the possible phenomenon of graft flow competition.

[Axillo-axillary bypass for coronary-subclavian steal syndrome].

We describe a case of coronary-subclavian steal syndrome in a 77-year-old man who presented with progressive coronary ischemia 8 years after coronary artery bypass grafting with an in-situ left internal thoracic artery graft. Coronary and left subclavian artery angiogram revealed completely patent internal thoracic artery graft and 90% stenosis in the proximal left subclavian artery. We performed axilloaxillary artery bypass using expanded polytetrafluoroethylene (ePTFE)[8 mm] graft. No coronary ischemia was noted postoperatively. Axillo-axillary artery bypass grafting was effective for coronary subclavian steal syndrome.

Adding coronary artery bypass grafting to aortic valve replacement increases operative mortality for elderly (70 years and older) patients with aortic stenosis.

OBJECTIVE: This retrospective study aimed to determine the effect of simultaneous aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) on operative outcomes and long-term survival in elderly patients with a high prevalence of comorbidity. METHODS: One hundred and fifty-seven elderly patients (70 years old or older) undergoing isolated AVR (n = 120) or combined AVR/CABG (n = 37) were evaluated. Operative outcomes were compared between the two surgical groups. Long-term survival was also compared between the groups using the Kaplan-Meier method and long-rank (Mantel-Cox) test. RESULTS: Operative mortality was 0.8 % for the isolated AVR group and 5.4 % for the combined AVR/CABG group (p = 0.076). The length of the intensive care unit stay for the combined AVR/CABG group was significantly longer than that for the isolated AVR group (median: 40 vs. 21 h, p = 0.008). However, the occurrence rate of hospital complications, such as reoperation for bleeding, deep sternal infection, supra-ventricular arrhythmia, and neurological complications, was similar between the two groups. Actuarial survival at 3 and 5 years was 82.3 and 80.9 % for the isolated AVR group, and 88.3 and 73.0 % for the combined AVR/CABG group, respectively (p = 0.637). CONCLUSIONS: The satisfactory operative and long-term results in our study support a more aggressive simultaneous coronary revascularization combined with AVR for aortic valve stenosis in elderly patients.

Mitral valve surgery in a patient with systemic artery-to-pulmonary artery fistulas.

We report the case of a 68-year-old woman with severe mitral valve regurgitation and concomitant multiple systemic artery-to-pulmonary artery fistulas. Endovascular embolization of the fistulas was unable to control her heart failure, and mitral valve replacement was also performed. Steps were taken during mitral valve surgery to ensure an adequate operative field in the left atrium, despite the large volume of in-pouring blood from the pulmonary vein.

A surgical case of prosthetic valve endocarditis with a difficult diagnosis.

Early diagnosis and treatment of prosthetic valve endocarditis (PVE) is important because it has a high mortality rate. We report a case of PVE which was difficult to diagnose. A 36-year-old man, who had undergone an aortic valve replacement (AVR) 7 years prior, was hospitalized with a high fever of unknown origin. We could not detect a stuck valve, vegetations or abscesses using echocardiography, and the peak aortic transvalvular pressure gradient had increased to 81 mmHg. We suspected PVE and initiated intravenous antibiotic therapy immediately. On day 5, echocardiography demonstrated an abnormal shadow directly under the prosthesis, and we definitively diagnosed PVE and performed an operation. Intraoperatively, the prosthesis was not vegetative, but the left ventricular outflow tract was filled with vegetation that was nearly obstructing it. After dissecting the infectious focus, we performed a re-AVR. Postoperative echocardiography showed that the peak left ventricular aortic pressure gradient decreased to 30 mmHg. Obstructive vegetation is difficult to diagnose by preoperative echocardiography.

Simple supra-annular prosthesis insertion for dialysis patients with extensive mitral annular calcification.

BACKGROUND AND AIM OF THE STUDY: Mitral annular calcification (MAC) occurs mainly at the posterior half of the annulus, and is often seen in dialysis-dependent patients who have a high risk for cardiac surgery. A simple supra-annular prosthesis insertion ('half-and-half') technique was applied to five dialysis patients with extensive MAC to prevent catastrophic complications. METHODS: Five dialysis patients with extensive MAC underwent mitral valve replacement (MVR) using the 'half-and-half' technique. In all patients, everted mattress sutures were anchored to the left atrial wall just around the posterior half of the calcified annulus with minimum debridement, while horizontal mattress sutures were placed from the left ventricular side to the left atrial side on the non-calcified anterior half of the annulus. In one patient with an entirely calcified annulus who underwent double valve replacement, the anterior MAC was removed through the aorta to enable mitral valve sutures to be placed on the annulus. St. Jude Medical (SJM) valves were secured in the supra-annular position in all patients. RESULTS: No valve dysfunction was observed in any patient. Among the four hospital survivors, there were no valve-related events, except for a trivial paravalvular leak in one patient, during follow up periods ranging from 11 to 33 months. CONCLUSION: This simple supra-annular prosthesis insertion technique was safely and easily performed with minimum debridement of the calcified annulus in five dialysis patients. The technique may represent an alternative approach for high-risk patients with extensive MAC. The SJM valve, with its hinge protruding into the atrial side, is suitable for use in this technique.

Clinical management of lower limb ischemia secondary to a persistent sciatic artery aneurysm: report of a case.

A persistent sciatic artery (PSA) is a rare congenital malformation, frequently complicated by atherosclerotic changes such as aneurysmal formation. Optimal treatment is dependent on the individual situation. We report a case of a PSA aneurysm complicated by lower limb ischemia. Graft interposition with distal balloon angioplasty and thrombectomy from the posterior transgluteal approach was performed successfully, without any complications.