Emergency Open Surgical Repair for Ruptured Abdominal Aortic Aneurysm in Octogenarians and Nonagenarians: A Single-Center Retrospective Observational Study.

BACKGROUND: In the endovascular aneurysm repair era, open surgical repair (OSR) is performed for ruptured abdominal aorta aneurysm (RAAA) in patients with complex aneurysm neck and technical difficulties. Understanding the risk factors of OSR is essential for the clinical selection of the ideal surgical procedure. We aimed to re-evaluate the outcomes of OSR and treatment options for RAAA. METHODS: Patients who underwent OSR for RAAA between January 2010 and December 2022 were enrolled in this single-center retrospective observational study. Preoperative status, operative findings, and postoperative course were retrospectively reviewed. The Cox proportional hazards model was used to evaluate the association between age and early postoperative mortality. RESULTS: Among 142 patients, 43 (30.3%) and 99 (69.7%) were aged ≥80 and <80 years, respectively. Postoperative mortality within 30 days occurred in 24 (16.9%) patients (11/43 [25.6%] and 13/99 [13.1%] patients aged ≥80 and <80 years, respectively; hazard ratio = 1.95; P = 0.069). In a multivariable analysis, increased postoperative mortality within 30 days was associated with age ≥80 years (adjusted hazard ratio, aHR = 2.36; P = 0.049), the presence of preoperative or intraoperative cardiopulmonary arrest (aHR = 12.0; P < 0.001), and postoperative gastrointestinal disorder (aHR = 4.42; P = 0.003). CONCLUSIONS: Endovascular aneurysm repair may be preferable in older people; however, its use in cases of preoperative or intraoperative cardiopulmonary arrest or perioperative gastrointestinal disorders remains controversial, and a careful discussion on the surgical indications is needed in such cases.

Pulmonary Tumor Thrombotic Microangiopathy Suspected to be COVID-19 Vaccine-Related Myocarditis: A Case Report.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a very rare condition that can lead to acute severe pulmonary hypertension and circulatory failure. It is caused by tumor cell microvascular obstruction and is usually difficult to diagnose; in fact, it is often diagnosed after death. We report the case of a patient who experienced a sudden cardiac arrest and developed severe pulmonary hypertension two days after receiving the coronavirus disease (COVID-19) vaccine. The patient was initially diagnosed with vaccine-associated myocarditis, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) implantation with median sternotomy was performed. The patient survived for more than two weeks. PTTM was later diagnosed during a pathological autopsy.

Temporary Epicardial Pacing Wire Migration to the Pulmonary Artery in the Early Postoperative Stage.

Temporary epicardial pacing wires (TEPWs) are widely used during open heart surgery to treat postoperative bradycardia or arrhythmia. They are usually removed, but the wire is cut at the skin entrance site if there is resistance upon removal. Residual TEPWs have risks of complications such as infection, but they rarely migrate to distant organs. We report a case of TEPW migration from the right ventricle to the pulmonary artery during the early stage after acute type A aortic dissection surgery. Residual TEPW migration was detected incidentally during follow-up imaging for aortic dissection, and no other complications, such as residual wire infection or thrombus, were noted. The residual TEPW was safely treated using catheter therapy. This case report utilized existing patient information without intervention for research purposes, and the requirement for obtaining written patient consent was waived.

Early mortality of emergency surgery for acute type A aortic dissection in octogenarians and nonagenarians: A multi-center retrospective study.

OBJECTIVES: The clinical data on postoperative mortality and central nervous system (CNS) complications in older adults who underwent acute type A aortic dissection are limited. Thus, in this study we aimed to evaluate the association between age and early postoperative mortality and occurrence of CNS complications. METHODS: This multicentric retrospective cohort study included 5 tertiary hospitals in Japan. All patients who underwent emergency surgery for acute type A aortic dissection between October 1998 and December 2019 were enrolled. The multilevel Cox proportional hazards model, which considered years as level 1, institutions as level 2, and surgeons as level 3, was used to evaluate the association between age and early postoperative hospital mortality and occurrence of CNS complications. RESULTS: Of the 1037 patients, 227 (21.9%) were ≥80 years old and 810 (78.1%) were <80 years old. Overall, 134 patients (12.9%) died within 30 days postoperatively; among them, 42/227 (18.5%) and 92/810 (11.4%) were aged ≥80 and <80 years, respectively (hazard ratio [HR], 1.63; P = .0046). CNS complications within 30 days postoperatively occurred in 140/1037 (13.5%) patients; among them, 42/227 (18.5%) and 98/810 (12.1%) were aged ≥80 and <80 years, respectively (HR, 1.63; P = .011). In multivariate analysis, age ≥80 years was associated with mortality within 30 days postoperatively (adjusted HR, 2.37; 95% CI, 1.23-4.57; P = .01) but not with CNS complications (adjusted HR, 1.58; 95% CI, 0.93-2.69; P = .091). CONCLUSIONS: The early postoperative mortality in older patients was approximately 50% higher than in the younger population. A thorough discussion regarding the surgical indications should be done.

Experiences in Emergency Cardiac Surgery of COVID-19-Positive Patients: A Case Series.

The coronavirus disease-2019 (COVID-19) pandemic has placed many restrictions on medical care. The timing of surgical treatment has been particularly affected, with patients experiencing delayed operation dates. This report describes three patients with preoperative COVID-19-positive diagnoses, tested with reverse transcription-polymerase chain reaction, who were urgently treated surgically with excellent results. Case 1 involved an 89-year-old woman with a left ventricular rupture after a myocardial infarction. Case 2 involved a 52-year-old male patient with an acute type A aortic dissection. Case 3 involved a patient with an occlusion of an autologous dialysis shunt. All patient conditions were either life-threatening or overwhelmed hospital beds without surgical treatment. In Japan, we still experience cases where surgery is refused because of COVID-19 positivity, even if emergency surgery is necessary. This report describes three cases where standard precautions were taken, postoperative management was devised, and good results were achieved.

Utility of cardiac magnetic resonance imaging for pre-operatively evaluating the degree of caseous calcification of the mitral annulus infiltration within the left ventricular myocardium: a case report.

Background: Depending on the degree of infiltration of dry mitral annulus calcification (MAC) into the left ventricular myocardium, calcification removal may cause thinning of the left ventricular wall and increase the risk of post-operative left ventricular rupture. Therefore, the degree of pre-operative infiltration into the left ventricular myocardium should be assessed as accurately as possible. We report a case of caseous calcification of the mitral annulus (CCMA), a subtype of MAC, in an 84-year-old woman; cardiac magnetic resonance imaging (MRI) was useful in assessing the degree of left ventricular infiltration of calcification. Case summary: The patient was referred to our hospital for surgery due to respiratory distress and severe mitral insufficiency. Echocardiography revealed a mass under the posterior mitral annulus adjacent to the mitral valve ring, suspected to be a CCMA. Cardiac MRI was performed to assess the risk of left ventricular rupture. Pre-operatively, no valve ring or left ventricular myocardium infiltration was confirmed. Surgical caseous calcification removal and artificial valve implantation within the preserved valve annulus were then performed. The patient had an uneventful post-operative course and was discharged without complications on the 21st post-operative day. Discussion: In this CCMA case, a pre-operative cardiac MRI was useful for evaluating the degree of the valve annulus and left ventricular myocardial involvement and estimating the risk of left ventricular rupture.

Effect of waiting time for COVID-19 screening on postoperative outcomes of type A aortic dissection: An institutional study.

BACKGROUND: Since November 2020, all patients undergoing emergency surgery at our hospital have been subjected to preoperative reverse transcription polymerase chain reaction (RT-PCR) screening to prevent nosocomial COVID-19 infection, with admission to the operating room requiring a negative result. Herein, we compared the pre- and postoperative outcomes of acute type A aortic dissection surgery before and after implementing the RT-PCR screening for all patients. METHODS: We compared the postoperative results of 105 patients who underwent acute type A aortic dissection emergency surgery from January 2019 to October 2020 (Group I) and 109 patients who underwent the surgery following RT-PCR screening from November 2020 to March 2022 (Group II). RESULTS: The average waiting time from arrival at the hospital to admission to the operating room was 36 and 81 min in Groups I and II, respectively. Ruptured cardiac tamponade was observed preoperatively in 26.6% and 21.1% of Groups I and II patients, respectively. The preoperative waiting time due to RT-PCR screening did not contribute to the cardiac tamponade. Surgical complications such as bleeding (reopened chest), respiratory failure, cerebral neuropathy, or mediastinitis did not increase significantly. The number of deaths 30 days after surgery (Group I = 13 and Group II = 3) showed no significant difference between the groups. There were no cases of nosocomial COVID-19 infections. CONCLUSIONS: Preoperative COVID-19 screening is an important method to prevent nosocomial infections. The associated waiting time did not affect the number of preoperative ruptures or affect postoperative complications or mortality.

A rare case of asymptomatic right coronary artery ectasia associated with giant aneurysm.

A rare case of giant coronary artery ectasia associated with coronary artery aneurysm was recognized. A 69-year-old woman presented with an ischemic electrocardiogram changes during a medical check-up. Coronary computed tomography angiography showed right coronary artery (RCA) ectasia associated with a giant aneurysm originating from the distal RCA. She was asymptomatic and exhibited no risk factors, including Kawasaki disease, hypertension, diabetes mellitus or family history. The patient underwent surgery for giant coronary aneurysms to prevent rupture. The aneurysm was on the peripheral side of the right coronary artery; hence, coronary artery bypass was not performed. The patient's postoperative course was uneventful. Histopathological examination of the aneurysm revealed degeneration due to atherosclerosis. She was prescribed warfarin and aspirin for thrombus prevention.

[Four Times Aortic Valve Replacement for Recurrent Aortic Annulus Destruction Due to Behçet's Disease:Report of a Case].

Surgical results of aortic regurgitation with Behcet's aortitis is associated with high morbidity and mortality due to risk of annular dehiscence. Here we describe a case of severe aortic regurgitation with Behcet's disease in 51-year-old man who underwent aortic valve replacement and subannular patch reconstruction for suspected infectious endocarditis with severe aortic regurgitation and subannular abcess. Then we performed three times aortic valve replacement for recurrent prosthetic valve dehiscence. Before the fourth operation, the patient was diagnosed with Behcet's disease and given immunosuppressant. Postoperative course was uneventful and he was discharged on postoperative day 59th, and doing well.

[Mobile mass in the descending aorta with multiple embolism].

A 46-year-old man was referred to our hospital for abdominal pain. Computed tomography (CT) revealed mobile mass in the descending aorta and multiple systemic embolism. Emergent operation was indicated. Under femoral vein to femoral artery bypass, removal of mobile mass was performed. We resected the mass with stem including aortic wall and closed the aortic defect with the pericardial patch. Postoperative course was uneventful. Histopathology of the mass was organized thrombus with inflammatory change.

[Cylindrical patch repair for circumferential subvalvular abscess due to prosthetic valve endocarditis].

A 51-year-old male underwent aortic valve replacement and vascular prosthesis implantation due to an aneurysm of the ascending aorta combined with aortic regurgitation caused by the bicuspid aortic valve. Semi-emergency surgery was performed due to severe paravalvular leakage with prosthetic valve endocarditis 16 months after the 1st operation. The circumferential annular abscess cavities were closed with a cylindrical patch, and a mechanical valve was installed on the upper edge of the sutured cylindrical patch. A vascular prosthesis was reimplanted to the ascending aorta. Use of the cylindrical patch provides a good exposure of operative field to close circumferential annular abscess cavity.