[Graft Kink with Hemolytic Anemia Caused by Enlargement of the Residual False Lumen in the Aortic Root:Report of a Case].

A 67-year-old male underwent ascending aortic replacement for Stanford type A acute aortic dissection four years ago. Residual false lumen in the aortic root and mild to moderate aortic regurgitation were noted postoperatively. Two and a half years later, he presented with hemolytic anemia and shortness of breath. Computed tomography (CT) revealed aneurysmal aortic root and severely kinked vascular prosthesis, and echocardiography showed severe aortic regurgitation. It was considered that the proximal residual false lumen gradually enlarged, and the graft was pushed up distally and kinked, resulting in hemolytic anemia. Surgical treatment was indicated because of deteriorating shortness of breath due to hemolytic anemia (Hb 6.7 g/dl, LDH 1,528 U/l) and aortic regurgitation. Aortic root replacement was successfully performed and hemolytic anemia improved immediately after surgery.

Basilar Artery Dissection Complicated with Infective Endocarditis.

A 14 year-old boy developed infective endocarditis of the mitral valve caused by Methicillin-sensitive Staphylococcus aureus and became comatose. Isolated basilar artery dissection was initially observed on the 3rd day by magnetic resonance imaging (MRI), ie, it did not exist on day 1. He underwent successful urgent mitral valve repair on the 5th day because of highly mobile vegetations and a newly emerged brain infarction under optimal antibiotic administration. Postoperatively, he recovered well and the basilar artery dissection was found to have recovered on an MRI on the 25th day without any specific intervention. This clinical course indicated that intracranial artery dissection may occur as a complication of infective endocarditis and supports the importance of the careful evaluation of brain MRI in patients with infective endocarditis.

Infective endocarditis caused by Capnocytophaga canimorsus; a case report.

BACKGROUND: Capnocytophaga canimorsus is a gram-negative bacterium and an oral commensal in dogs and cats, but occasionally causes serious infections in humans. Septicemia is one of the most fulminant forms, but diagnosis of C. canimorsus infection is often difficult mainly because of its very slow growth. C. canimorsus infective endocarditis (IE) is rare and is poorly understood. Since quite a few strains produce ß-lactamase, antimicrobial susceptibility is pivotal information for adequate treatment. We herein report a case with C. canimorsus IE and the results of drug susceptibility test. CASE PRESENTATION: A 46-year-old man had a dog bite in his left hand 3 months previously. The patient was referred to our hospital for fever (body temperature > 38 °C), visual disturbance, and dyspnea. Echocardiography showed aortic valve regurgitation and vegetation on the leaflets. IE was diagnosed, and we initially administered cefazolin and gentamycin assuming frequently encountered microorganisms and the patient underwent aortic valve replacement. C. canimorsus was detected in the aortic valve lesion and blood cultures. It was also identified by 16S ribosome DNA sequencing. Ceftriaxone were started and continued because disk diffusion test revealed the isolate was negative for ß-lactamase and this case had cerebral symptoms. The patient successfully completed antibiotic treatment following surgery. CONCLUSIONS: We diagnosed C. canimorsus sepsis and IE by extended-period blood cultures and 16S ribosome DNA sequencing by polymerase chain reaction, and successfully identified its drug susceptibility.

Hemoptysis.

Hemoptysis is a rare complication of acute aortic dissection. A 77-year-old woman was admitted to our department with epigastralgia and hemoptysis. Computed tomography showed Stanford A acute aortic dissection and massive posterior mediastinal hematoma which extended along the right pulmonary artery. Hemoptysis is a lethal sign of aortic dissection, therefore, emergency ascending aortic replacement was performed with a good clinical outcome.

[Resection for the Recurrence of Hepatocellular Carcinoma in the Inferior Vena Cava and Right Atrium under Deep Hypothermic Circulatory Arrest].

A 77-year-old man underwent extended right lobectomy of the liver for rupture of hepatocellular carcinoma. Recurrence in the inferior vena cava andright atrium was noted 30 months after surgery. We performedextirpation of this tumor thrombosis under retrograde cerebral perfusion during deep hypothermic circulatory arrest. The pericardium was cut through sternotomy, and cooling was initiated. After cardiac arrest at 20.4°C, the inferior vena cava was separated. An incision was made in the right atrium andthe tumor thrombus was extirpated. In the meantime, brain protection was maintainedby retrograde cerebral perfusion. The patient was discharged on day 12 without postoperative complications. He remains alive 6 months after surgery without recurrence. This procedure prevented pulmonary embolism due to tumor thrombosis release. It was also possible to perform the procedure with retrograde cerebral perfusion.

Momentary and wide aortic regurgitation as an indicator of aortic dissection.

A 55-year-old female with a history of hypertension was admitted for dyspnea, epigastralgia and nausea. A chest X-ray showed pulmonary congestion. Transthoracic echocardiography (TTE) revealed severe left ventricular dysfunction with akinesis of the infero-posterior wall and Doppler color-flow mode showed mild aortic regurgitation (AR). Noninvasive positive pressure ventilation, intravenous heparin and diuretics were administered. Follow-up TTE revealed a dissection flap as well as momentary and wide AR only during isovolumetric relaxation. Contrast-enhanced computed tomography of the chest revealed Stanford type A aortic dissection. A momentary and wide AR in echocardiograms might serve as an important and useful indicator of aortic dissection in patients with acute myocardial infarction and congestive heart failure.

Effects of Preoperative ß-Blocker Use on Clinical Outcomes after Coronary Artery Bypass Grafting: A Report from the Japanese Cardiovascular Surgery Database.

BACKGROUND: The authors evaluated the effect of preoperative ß-blocker use on early outcomes in patients undergoing coronary artery bypass grafting (CABG) in Japan. METHODS: The authors analyzed 34,980 cases of isolated CABGs, performed between 2008 and 2011, at the 333 sites recorded in the Japanese Cardiovascular Surgical Database. In addition to the use of multivariate models, a one-to-one matched analysis, based on estimated propensity scores for patients with or without preoperative ß-blocker use, was performed. RESULTS: The study population (mean age, 68 yr) comprised 20% women, and ß-blockers were used in 10,496 patients (30%), who were more likely to have risk factors and comorbidities than patients in whom ß-blockers were not used. In the ß-blocker and non-ß-blocker groups, the crude in-hospital mortality rate was 1.7 versus 2.5%, whereas the composite complication rate was 9.7 versus 11.6%, respectively. However, after adjustment, preoperative ß-blocker use was not a predictor of in-hospital mortality (odds ratio, 1.00; 95% CI, 0.82 to 1.21) or complications (odds ratio, 0.99; 95% CI, 0.91 to 1.08). When the outcomes of the two propensity-matched patient groups were compared, differences were not seen in the 30-day operative mortality (1.6 vs. 1.5%, respectively; P = 0.49) or postoperative complication (9.8 vs. 9.7%; P = 1.00) rates. The main findings were broadly consistent in a subgroup analysis of low-risk and high-risk groups. CONCLUSION: In this nationwide registry, the use of preoperative ß-blockers did not affect short-term mortality or morbidity in patients undergoing CABG.

A case of pulmonary sarcoma with significant extension into the right lung.

A female patient in her 30s was referred to us with a mass approximately 8 centimeters in diameter in right lung segment 6. Bronchoscopy was done, and a tumorous lesion obstructing right B6 was found. Biopsy of this lesion supported suspicions of sarcoma or spindle cell carcinoma. Contrast-enhanced CT showed that the mass extended to and obstructed the right main pulmonary artery. A skip lesion was also suspected in the periphery of pulmonary artery trunk. The tumor was removed by right pneumonectomy accompanied by resection of the main and left pulmonary arteries under cardiopulmonary bypass. The pulmonary artery trunk and the left pulmonary artery were reconstructed with a vascular graft. Collectively, intimal sarcoma originating from the right main pulmonary artery with extension into the right lung was diagnosed. Significant extension of pulmonary artery sarcoma into the lung, as was observed in the present case, is considered to be rare, and to our knowledge this is the first report in which the primary lesion was biopsied by bronchoscopy.

Uncertainty of axillary artery perfusion during surgery for acute aortic dissection.

We treated a patient with acute aortic dissection, which affected the innominate and carotid arteries. Although the true lumen was adequately wide and cerebral malperfusion deemed unlikely, extracorporeal circulation through the femoral artery caused right cerebral malperfusion, and addition of right axillary artery perfusion was ineffective. Several minutes after innominate artery snaring, cerebral blood flow was suddenly restored and the clinical outcome was favorable. Axillary artery perfusion is occasionally unreliable and inevitably demands careful cerebral flow monitoring. A dead-end false lumen in the innominate and carotid arteries requires special caution. A dual-artery perfusion strategy permits innominate artery occlusion as an emergency measure against unexpected malperfusion.

[Persistent cerebral malperfusion following central aortic repair for acute aortic dissection involving the right carotid artery; efficacy of direct carotid artery cannulation].

A 61-year-old man suddenly developed transient left hemiplegia and consciousness disturbance. Computed tomography showed acute Stanford type A aortic dissection. Dissection affected the entire right common carotid artery, and its false lumen extremely compressed the true lumen. The right common carotid artery, along with the right femoral and the left axillary arteries, was used as an inflow of cardiopulmonary bypass during emergency surgery. The ascending aorta that included a large intimal tear was replaced. However, systemic reperfusion either through the femoral artery or through a side branch of vascular prosthesis failed to restore the right cerebral blood flow due to persistent true lumen obstruction by the expanded false lumen in the innominate artery. Therefore, ascending aorta-right carotid artery bypass using that side branch was performed immediately. Though temporary cerebral malperfusion could cause dismal outcome, direct carotid artery cannulation played a key role in this successfully-treated patient.

Spontaneous increase in EVAHEART® pump flow at a constant pump speed during exercise examination.

PURPOSE: Ventricular assist devices have been used for the treatment of severe heart failure. Recently, many types of blood pumps have been developed to reduce major adverse events. EVAHEART® (Sun Medical Technology Research Corporation, Nagano, Japan) is an implantable centrifugal blood pump. In laboratory animal studies, the pump flow of EVAHEART® increases spontaneously during exercise with no changes in pump control parameters. However, this has not been confirmed clinically. The aim of this study was to analyze EVAHEART® performance during exercise. PATIENTS AND METHODS: Four male patients were implanted with an EVAHEART®. We evaluated the performance of the EVAHEART® during exercise. Fixed pump speeds were maintained during each test. Measurements during exercise were peak load, peak oxygen consumption (peak VO(2)), pre exercise pump flow, and peak velocity. RESULTS: Pump flow significantly increased from 4.1 ± 0.5 liters per minute (L/min) to 7.2 ± 1.8 L/min during exercise. VO(2) increased from 4.0 ± 0.7 milliliters per kilogram per minute (ml/kg/min) to 14.7 ± 3.3 ml/kg/min. CONCLUSION: These results indicate that EVAHEART® may support severe heart failure patients not only under static but also under dynamic conditions. Pump flow spontaneously increased during exercise at a constant pump speed.

Extremely localized aortic dissection and intussusception of the intimal flap into the left ventricle.

Stanford type A aortic dissection frequently deforms the aortic root and causes aortic regurgitation (AR). On the rare occasion, massive AR can occur due to circumferential intimal disruption and prolapse of the cylinder-shaped intimal flap into the left ventricle. Because of the critical, general, and hemodynamic state of such patients, surgery for this condition carries a high risk. A 62-year-old woman suffered acute chest pain and fell into cardiogenic shock. Computed tomography and transthoracic echocardiography failed to identify the etiology of this rapid hemodynamic collapse. Transesophageal echocardiography (TEE) demonstrated circumferential intimal disruption, 3 centimeters above the aortic valve annulus; a very localized aortic dissection in the proximal ascending aorta; and a to-and-fro motion of cylinder-shaped intima causing severe AR. The dissection did not affect the aorta beyond the intimal tear, and TEE was the only useful modality for the diagnosis. Emergency replacement of the ascending aorta and resuspension of the aortic valve was successfully performed. Residual AR was absent, and the postoperative course was uneventful.

Non-activated APJ suppresses the angiotensin II type 1 receptor, whereas apelin-activated APJ acts conversely.

Apelin and its G-protein-coupled receptor APJ are potent regulators of the cardiovascular system. Recent studies have suggested that apelin-APJ reverses the function of angiotensin II (Ang II)-the Ang II type 1 receptor (AT(1)). However, the mechanism remains unclear because of the accumulating evidences that apelin-APJ may contribute to both cardioprotection and pathological progression. In human embryonic kidney 293 cells, we found that coexpression with APJ significantly suppressed the phosphorylation of extracellular signal-regulated kinases 1/2 (ERK1/2) induced by Ang II-AT(1), whereas apelin abolished this attenuation through activated APJ independently of its heterodimerization. Pretreatment with the Gi/o-specific inhibitor pertussis toxin (PTX) restituted the ERK1/2 phosphorylation level similar to that found with AT(1) and APJ coexpression without apelin stimulation. In contrast, coexpression of the beta-2-adrenergic receptor or the pharmacologically non-activated Ang II type 2 receptor (AT(2)) pretreated with the AT(2)-specific antagonist, PD123319, did not affect ERK1/2 phosphorylation through AT(1). Pretreatment with 30 nM of the AT(1) blocker (ARB) TA-606A suppressed 50% of the AT(1)-mediated ERK1/2 phosphorylation, whereas 30 nM of TA-606A achieved 75% suppression when the non-activated APJ was coexpressed without ligand or PTX. However, 120 nM of TA-606A failed to reach the target phosphorylation when it was coexpressed with activated APJ with apelin. Based on these results, we demonstrated that non-activated APJ may suppress Ang II-AT(1) signaling, whereas this ligand-independent function was diminished with apelin activation. These results may be relevant to the potential contribution of apelin-APJ to ARB treatment in the clinical realm.

[Refractory pulmonary hypertension following mitral valve repair necessitating percutaneous cardiopulmonary support].

A 37-year-old woman underwent semi-emergency mitral valve plasty for severe mitral regurgitation and congestive heart failure. Although repair was successfully performed and the left ventricular function was maintained, refractory pulmonary hypertension precluded cessation of cardiopulmonary bypass. Inhalation of nitric oxide was ineffective, and assist circulation was required. All data obtained from the Swan-Ganz catheter and other routine monitors were devastating, and the patient showed no clinical recovery in the early postoperative period. However, transesophageal echocardiography (TEE) performed on the 2nd postoperative day (POD) revealed much better filling of the left heart and the patient was weaned from assist circulation on the 4th POD. Pulmonary vascular disease was denied histologically. Late cardiac catheterization disclosed normal pulmonary artery pressure and resistance. TEE played a key role during very complicated postoperative management. Monitoring of the left atrial pressure might be necessary in cases that require assist circulation due to pulmonary vasoconstriction.

A novel external counterpulsation system for coronary artery disease and heart failure: pilot studies and initial clinical experiences.

External counterpulsation (ECP) is a beneficial and noninvasive treatment for coronary artery disease or heart failure; however, it still has a lot of limitations. We used a novel ECP system, Compact CP, the main feature of which is the double-lumen cuff that reduces the impact of cuff inflation and the size of the air compressor. The first lumen was a contact cuff that was attached to the legs with a constant pressure (8 kPa). The second lumen was a main cuff that was inflated and deflated with a driving pressure and synchronized to the cardiac cycle. In this report, we describe the results of four pilot studies in a total number of 39 healthy volunteers and initial clinical experiences of this system in three patients. The pilot studies demonstrated that the ECP system provided significant diastolic augmentation and systolic unloading. It also achieved a satisfactory diastolic/systolic pressure ratio (1.00 ± 0.06) with a high comfort level at a driving pressure of 40 kPa. Higher pressure (50-70 kPa) increased the assist performance but decreased the comfort level. ECP was also applied with a patient with chronic refractory angina and two patients with postoperative heart failure following cardiac surgery. The clinical conditions improved. No adverse effect was observed. Our novel ECP system is safe, effective, and promising in the treatment of coronary artery disease or heart failure. Further clinical investigations are needed to support the significance of this system.

[Aortic valve replacement without blood transfusion in a patient with osteogenesis imperfecta].

Osteogenesis imperfecta (OI) is a hereditary systemic connective tissue disorder that is rarely associated with valvular heart diseases. Cardiovascular surgery for patients with OI carries high morbidity and mortality, which mostly results from bleeding tendencies caused by tissue and capillary fragility. We report a 47-year-old male with isolated aortic regurgitation, who underwent aortic valve replacement (AVR) with a mechanical prosthesis without blood transfusion. The perioperative course was uneventful. We believe that a meticulous technique and a planned strategy to avoid every damage to fragile tissues, particularly to bones, are very important during surgery for patients with OI.