Cardiopulmonary resuscitation at operating room entry in acute aortic dissection type A patients: is surgery contraindicated?

Background: This study aimed to compare the short-term outcomes of surgical treatment for acute type A aortic dissection between patients undergoing cardiopulmonary arrest at the time of entry into the operating room and patients who received successful preoperative cardiopulmonary resuscitation before entering the operating room or patients who had cardiopulmonary arrest on the operating room table after entering the operating room without cardiopulmonary arrest. In the present study, we focused on the circulatory status at the time of entering the operating room because it is economically and emotionally difficult to cease intervention once the patient has entered the operating room, where surgeons, anesthesiologists, nurses, and perfusionists are already present, all necessary materials are packed off and cardiopulmonary bypass have already been primed. Methods: Twenty (5.5%) of 362 patients who underwent surgical treatment for acute type A aortic dissection between January 2016 and March 2022 had preoperative cardiopulmonary arrest. To compare the early operative outcomes, the patients were divided into the spontaneous circulation group (n = 14, 70.0%) and the non-spontaneous circulation group (n = 6, 30.0%) based on the presence or absence of spontaneous circulation upon entering the operating room. The primary endpoint was postoperative 30-day mortality. The secondary endpoints included in-hospital complications and persistent neurological disorders. Results: Thirty-day mortality was 65% (n = 13/20) in the entire cohort; 50% (n = 7/14) in the spontaneous circulation group and 100% (n = 6/6) in the non-spontaneous circulation group. The major cardiopulmonary arrest causes were aortic rupture and cardiac tamponade (n = 16; 80.0%), followed by coronary malperfusion (n = 4; 20.0%). Seven patients (50.0%) survived in the spontaneous circulation group, and none survived in the non-spontaneous circulation group (P = .044). Five survivors walked unaided and were discharged home; the remaining two were comatose and paraplegic. Conclusions: The outcomes were extremely poor in patients with acute type A aortic dissection who had preoperative cardiopulmonary arrest and received ongoing cardiopulmonary resuscitation at entry into the operating room. Therefore, surgical treatment might be contraindicated in such patients.

The David Operation Offers Shorter Hemostasis Time Than the Bentall in Case of Acute Aortic Dissection Type A.

Background The aim of the present study was to compare the clinical outcome of the David operation and the Bentall operation in patients with Stanford type A acute aortic dissection (AADA) from the viewpoint of hemostasis. Methods Between April 2016 and April 2020, 235 patients underwent emergent surgery for AADA. Of them, 38 patients required aortic root replacement (ARR: The David operation 17, the Bentall operation 21). The mean age was 59.3±12.6 years. In the present series, the David operation was the first choice for relatively young people, and the Bentall operation was performed for relatively elderly patients and cases in which valve-sparing seemed impossible. Results Between the David and the Bentall group, the 30-day mortality rate did not differ significantly. However, hemostasis time (144.6±50.3 vs. 212.5±138.1 min, p=0.047), defined as the interval from the cessation of cardio-pulmonary bypass (CPB) to the end of the operation, and total operation time (477.8±85.7 vs. 578.3±173.6 min, p=0.027) were significantly shorter in the David group than in the Bentall group, and the amount of blood transfusion was less in the David group than in the Bentall group (red blood cells: 3.5±3.6 vs. 9.2±5.9 units, p=0.013; fresh frozen plasma: 4.1±4.7 vs 9.4±5.1 units, p=0.002; platelet concentrate: 33.2±11.3 vs 42.2±12.0 units, p=0.025). Conclusion David operation offers a shorter hemostasis time and consequently shorter operation time than the Bentall operation in the setting of AADA, probably due to double suture lines, despite its surgical complexity.

Calcified amorphous tumor located on a severely calcified mitral annulus in a patient with normal renal function.

A calcified amorphous tumor (CAT) of the heart is a rare, nonneoplastic, intracavitary cardiac mass. Histological examination shows that it contains calcified and amorphous fibrous material with underlying chronic inflammation. Surgical excision is generally recommended to avoid future embolism. The risk of embolism has been reported to be especially high in mitral-annular-calcification-related CAT, which constitutes a subgroup of CAT that is often associated with end-stage renal disease. A case of a CAT attached to the anterior annulus of the mitral valve that was easily removed with a light touch of the forceps through aortotomy is reported.

Tapentadol Safety and Patient Characteristics Associated with Treatment Discontinuation in Cancer Therapy: A Retrospective Multicentre Study in Japan.

INTRODUCTION: Tapentadol has analgesic effects comparable to those of conventional opioids and is associated with fewer side effects, including gastrointestinal symptoms, drowsiness, and dizziness, than other opioids. However, the safety of tapentadol in the Japanese population remains unclear; the present multicentre study aimed to examine the safety of tapentadol and the characteristics of patients likely to discontinue this treatment owing to adverse events. METHODS: The safety of tapentadol was assessed retrospectively in patients with any type of cancer treated between August 18, 2014 and October 31, 2019 across nine institutions in Japan. Patients were examined at baseline and at the time of opioid discontinuation. Multivariate analysis was performed to identify factors associated with tapentadol discontinuation owing to adverse events. RESULTS: A total of 906 patients were included in this study, and 685 (75.6%) cases were followed up until tapentadol cessation for any reason. Among patients who discontinued treatment, 119 (17.4%) did so because of adverse events. Among adverse events associated with difficulty in taking medication, nausea was the most common cause of treatment discontinuation (4.7%), followed by drowsiness (1.8%). Multivariate analysis showed that those who were prescribed tapentadol by a palliative care physician (odds ratio [OR] 2.60, 95% confidence interval [CI] 1.36-4.99, p = 0.004), patients switching to tapentadol due to side effects from previous opioids (OR 2.19, 95% CI 1.05-4.56, p = 0.037), and patients who did not use naldemedine (OR 5.06, 95% CI 2.47-10.37, p < 0.0001) had an increased risk of treatment discontinuation owing to adverse events. CONCLUSIONS: This study presents the safety profile of tapentadol and the characteristics of patients likely to discontinue this treatment owing to adverse events in the Japanese population. Prospective controlled trials are required to evaluate the safety of tapentadol and validate the present findings. TRIAL REGISTRATION NUMBER: UMIN 000044282 (University Hospital Medical Information Network).

[Coronary Artery Bypass Grafting for Coronary Aneurysms Causing Acute Myocardial Infarction;Report of a Case].

Coronary aneurysms are relatively rare. However, myocardial infarction associated with thrombus formation in the aneurysm and rupture of the aneurysm are clinical problems. There are no specific guidelines for the treatment of coronary aneurysms. Here, we report a case of a 47-year-old female with acute myocardial infarction. She had a history of collagen disease, which was suspected to be Kawasaki disease. She underwent thrombus aspiration supported by intra-aortic balloon pumping( IABP) because of acute thrombosis of coronary aneurysms, followed by coronary artery bypass grafting on 2 stages. The operative course was uneventful.

Ventricular septal perforation followed by papillary muscle rupture with acute myocardial infarction: efficacy of venoarterial extracorporeal membrane oxygenation.

The occurrence of multiple mechanical complications after myocardial infarction in the same patient may be extremely rare, and the surgical strategy may be very complex because each mechanical complication can be extremely fatal. The case of a patient who underwent repair of a ventricular septal perforation by venoarterial extracorporeal membrane oxygenation (VA-ECMO), then mitral valve replacement and VA-ECMO for papillary muscle rupture 2 weeks after the ventricular septal perforation repair, is reported. Immediate preoperative stabilization with VA-ECMO may play a crucial role in treating multiple mechanical complications after myocardial infarction.

[Surgical Treatment for Postoperative Chylothorax after Aortic Arch Replacement via Median Sternotomy].

Postoperative chylothorax is known as a possible complication after thoracic surgery, but no treatment strategy has been established. We report a case of successful surgical treatment for postoperative chylothorax after redo aortic arch replacement via median sternotomy. A 48-year-old man, who had undergone redo aortic arch replacement for aortic pseudoaneurysm due to prosthetic vascular graft infection, developed postoperative chylothorax. Despite the conservative treatment with fasting and administration of octreotide for 4 days, there was no effect on reduction in drainage. Surgical repair was performed on postoperative day 13. About 3 hours before surgery, milk was administered from the nasogastric tube to make the drainage milky. After median re-sternotomy, a stump of the thoracic duct was clearly identified and exposed in the posterior mediastinum, and the thoracic duct was easily closed by clipping. There was no recurrence of chylothorax and oral intake was re-started on day 2. Early operation might be effective against postoperative chylothorax.

Total arch replacement with bilateral extra-anatomical axillary artery bypass and frozen elephant trunk technique for Kommerell's diverticulum.

A Kommerell's diverticulum is a rare congenital aortic arch anomaly associated with a high rate of aortic rupture or dissection. Therefore, surgical or endovascular repair should be considered early. A 64-year-old man was incidentally found to have an aortic arch anomaly, Kommerell's diverticulum, with a right aberrant subclavian artery and distal arch aneurysm. Hybrid total arch replacement with bilateral extra-anatomical axillary artery bypass and frozen elephant trunk technique was performed. This particular surgical approach would be a treatment option for any type of Kommerell's diverticulum.

[Trial of the Profit Optimization of the Department of Cardiac Surgery in the Local National University Hospital].

In recent years economic sense is required in hospital management, the national university hospital is also no exception. We performed duty improvement efforts as well as the current state analysis in the department of cardiac surgery for the purpose of revenue optimization in our hospital. At result, we succeeded in the improvement of the medical index as well as medical profit and found the key of solution to the serious problem that national university hospital has.

[Vacuum-assisted Closure (VAC) Treatment for Sternal Infection in a Patient after Cardiovascular Surgery; Report of a Case].

One year ago, a 42-year-old woman underwent aortic root replacement because of a pseudoaneurysm that developed at the site of an anastomosis after ascending aortic replacement for acute aortic dissection. Six months later, she complained of fever and cough. A computed tomography revealed recurrence of the peudoaneurysm at the proximal anastomosis of the aortic root replacement. After emergency re-do aortic root replacement, she was admitted to intensive care unit (ICU) without sternal closure because of mediastinitis. The mediastinitis was managed by debridement and lavage drainage, followed by vacuum-assisted closure (VAC) treatment. The VAC treatment facilitated wound healing and active rehabilitation using a portable device. Finally, the wound was closed completely using a skin graft. VAC treatment is considered very useful in a case of post-sternotomy madiastinitis.

[Early rehabilitation program in uncomplicated Stanford type B acute aortic dissection].

Between December 2009 and August 2011, 120 patients with uncomplicated Stanford type B acute aortic dissection( UBAD) received medical treatment. In October 2010, we initiated an early rehabilitation program for UBAD patients in an acute phase. This early rehabilitation program, which was aimed at enabling the patient to walk around the ward within 2 days, was conducted for 87 consecutive patients;the remaining 33 were subjected to the conventional rehabilitation program. Mortality was not significantly different between the 2 groups. The incidence of atelectasis, need for mechanical ventilation, and intensive care unit syndrome during medical treatment occurred in 48% (16/33), 15% ( 5/33), and 30% ( 10/33), respectively, of the conventional group and in 3.4% ( 3/87), 1.1% (1/87), and 3.4% ( 3/87), respectively, of the early rehabilitation group. The outer diameter of the aorta was dilated after 4 weeks' rehabilitation in smaller percentage of patients in the early rehabilitation group than the conventional one. Thus, the early rehabilitation program was more effective for patients with UBAD than the conventional one.

[Surgical treatment for prosthetic valve endocarditis after aortic root replacement].

Aorto-left ventricular continuity destruction due to prosthetic valve endocarditis is rare, but it is one of the fatal complications after aortic root operation. We report a case of surgical treatment for prosthetic valve endocarditis after aortic root replacement. A 47-year-old man, who had undergone aortic root replacement with a composite graft was transferred to our hospital with sudden chest pain and high fever. Enhanced computed tomography showed a large space with contrast enhancement suggesting perivalvular leakage around the artificial composite graft. Emergency operation including aortic root re-replacement and reconstruction of the left ventricular outflow tract was performed successfully. We focused on its technical aspect.

[Surgical treatment for traumatic injury of the ascending aorta and aortic arch; report of a case].

We herein report a rare case of surgical treatment for blunt traumatic injury of the ascending aorta and aortic arch. A 60-year-old male was crushed by an arm of a forklift while working. He suffered from multiple thoracic traumas, including injury of the ascending aorta and aortic arch, multiple fractures of the ribs and bilateral hemopneumothorax. An emergency surgery for aortic repair was performed because there were no other severe hemorrhagic compilations due to organ injures. There was a massive hematoma around the aortic arch, and the intimae of several parts of the distal ascending aorta and aortic arch were disrupted circumferentially. The aorta was replaced with a prosthetic graft from sinotubular junction to the aortic arch, between the left common carotid artery and the left subclavian artery. The patient's postoperative course was uneventful, and he was transferred to a rehabilitation facility on the 13th day after surgery.

[Successful surgical treatment for acute type a aortic dissection in a patient with late pregnancy].

We report a case of successful surgical treatment for acute type A aortic dissection in a patient in late pregnancy. The patient was a 42-year-old woman who was pregnant for the 1st time. She was taken to hospital with a sudden onset of chest pain at 30 weeks' gestation. She was diagnosed with acute type A aortic dissection with annuloaortic ectasia (AAE) and aortic regurgitation, and was transferred to our hospital for further treatment. Emergency cesarean section and hysterectomy were performed, followed by modified Bentall operation on the next day. The postoperative course was uneventful for both the mother and the infant. Considering the severity of acute type A aortic dissection with AAE, aortic repair might have been performed as soon as possible after cesarean section.

A safe and rapid direct true lumen cannulation for acute type A aortic dissection.

OBJECTIVE: For the repair of acute type A aortic dissection (AADA), the optimal site of arterial cannulation remains controversial. We herein describe and investigate a technique for direct true lumen cannulation in patients with AADA. METHODS: Between January 2011 and April 2012, 176 consecutive patients underwent emergency surgery for repair of AADA using the direct true lumen cannulation. Using this method, following temporary circulatory arrest, the dissected ascending aortic wall is incised transversely and the true lumen is identified. An aortic cannula is inserted into the true lumen directly, and the ascending aorta is snared tightly. RESULTS: The manipulation was performed within 30 s in all patients. There were no technical problems with this method. The mean operative time, cardiopulmonary bypass time, cross-clamp time, and the circulatory arrest time were 241 ± 79, 158 ± 85, 123 ± 97 and 58 ± 39 min, respectively. There were no permanent neurological disorders following surgery. Seven patients (4.0 %) experienced temporary neurological disorders. Twenty-four patients (14 %) died in the hospital from several complications unrelated to technical problems of direct true lumen cannulation. CONCLUSIONS: Antegrade perfusion can be established safely and easily using the direct true lumen cannulation, which may be a promising standard arterial cannulation technique for the repair of AADA.

Less invasive direct coronary artery bypass grafting using H graft for a patient with advanced prostatic cancer.

Minimally invasive direct coronary artery bypass grafting (MIDCAB) using an H graft was performed on a 74-year-old man with advanced prostatic cancer who needed coronary revascularization. Through a left anterior small thoracotomy, the left internal thoracic artery (LITA) and the left anterior descending artery (LAD) were cleared, and a short radial artery (RA) was placed in an end-to-side fashion between the LITA and LAD. The distal LITA was ligated to avoid potential steal phenomenon. A flow pattern through the RA graft evaluated by transit time flow measurements demonstrated good diastolic flow with a mean value of 37 mL/min. The total surgical duration was 80 min, and no blood products were required. A postoperative angiogram showed a widely patent H graft. The patient was relieved of chest pain and was discharged. The H graft procedure is a useful alternative technique to minimize the surgical trauma in limited situations such as a high-risk case.

Portable coronary active perfusion system for off-pump coronary artery bypass grafting.

PURPOSE: The present study was performed to develop a new perfusion system for off-pump coronary artery bypass grafting and to examine whether even a simple coronary perfusion system can maintain adequate blood flow delivery during anastomosis. DESCRIPTION: The experiment was performed in two stages. In procedure 1, 3 pigs with left anterior descending artery occlusion were used to evaluate optimal perfusion flow rate and coronary artery internal pressure, and to evaluate the safety area of perfusion. In procedure 2, 6 pigs were used to validate the new portable coronary perfusion system. EVALUATION: The optimal blood flow in the portable coronary active perfusion system was less than approximately 40 mL/min. The small, easy to use pump system (ie, the portable coronary active perfusion system) may prevent hemodynamic deterioration and ventricular arrhythmia during coronary occlusion, resulting in better maintenance of left ventricular function. CONCLUSIONS: Even a simple pump system can achieve effective perfusion for safe anastomosis. Further studies are required to allow the clinical use of this system.

Hybrid surgical angiogenesis: omentopexy can enhance myocardial angiogenesis induced by cell therapy.

BACKGROUND: The conditions at the injection site are important in cell transplantation for severe ischemic heart disease. The omentum is both a well-vascularized tissue and a source of angiogenic factors. We examined the effectiveness of autologous bone marrow-derived mononuclear cells (BM-MNCs) with or without omentopexy in a large animal model. METHODS: Myocardial infarction was generated in the lateral wall by ligation of coronary artery branches in miniswine. Animals received BM-MNC injection with or without omentopexy. Controls received saline only. Three weeks after surgery, regional myocardial blood flow and contractility were measured, and density of arterioles was evaluated immunohistologically. Angiography and postmortem examinations were performed to determine collateral communication. RESULTS: Regional myocardial contractility was significantly improved by BM-MNC transplantation both with and without omentopexy (0.29 +/- 0.02 vs 0.11 +/- 0.03, p < 0.01, 0.30 +/- 0.02 vs 0.12 +/- 0.01, p < 0.01, respectively). Relative regional myocardial blood flow in the combined omentopexy group was significantly higher than the controls both at rest (1.05 +/- 0.11 vs 0.57 +/- 0.07, p < 0.01) and under stress (1.09 +/- 0.08 vs 0.40 +/- 0.10, p < 0.01). The number of arterioles (< 50 microm) in both groups were higher than the controls (88.1 +/- 5.00 vs 38.1 +/- 8.99, p < 0.01 and 109.2 +/- 9.91 vs 38.1 +/- 8.99, p < 0.01, respectively). The number of large arterioles (> 50 microm) in the combined omentopexy group was significantly higher than in both BM-MNC alone (26.9 +/- 2.4 vs 17.6 +/- 1.8, p = 0.011) and controls (26.9 +/- 2.4 vs 10.0 +/- 1.3, p < 0.01). Collateral communication between the omentum and myocardium was demonstrated by angiography and postmortem injection. CONCLUSIONS: The BM-MNC transplantation may attenuate cardiac contractile dysfunction, and omentopexy may enhance angiogenesis induced by BM-MNC transplantation.

Instant myocardial blood flow monitor: its calibration and assessment of flow capacity of the intracoronary shunt tube.

BACKGROUND: We developed a new instant regional myocardial blood flow (RMBF) monitor utilizing the thermal diffusion method in which the RMBF value is presented as the value inversely proportional to the thermocouple voltage output (1/V). The purposes of this study were (1) to validate the accuracy of RMBF measurement by the instant RMBF monitor in comparison with the colored microsphere method for calibration; (2) to investigate influences of it on the RMBF; and (3) to assess changes in RMBF caused by the shunt tube insertion. METHODS: Twenty pigs were used for this study: 4 for comparison between the instant RMBF meter and the colored microsphere method, 4 for validation of reproducibility, and 6 for measurement of RMBF during shunt tube. RESULTS: The relation between RMBF values obtained by the colored microsphere method and 1/V values by instant RMBF monitor was colored microsphere = 140,992 (1/V)--231 in epicardial layer (R2 = 0.819) and colored microsphere = 111,381 (1/V)--165 in endocardial layer (R2 = 0.693). The correlation coefficient and R2 values between RMBF values measured by both methods were 0.985 and 0.839 in epicardial layer, and 0.963 and 0.679 in endocardial layer, respectively. The RMBF at each layer did not change after the attachment of the monitor. Fifteen minutes after shunt tube insertion, RMBF measured by the colored microsphere method decreased to 31.1% (p = 0.0001) and 33.7% (p = 0.0001) in epicardium and endocardium, respectively, and no difference was observed from the value measured by the instant RMBF monitor. CONCLUSIONS: This instant RMBF monitor can provide instantaneous and continuous information of RMBF without requiring tissue examination.

Skeletonization of gastroepiploic artery graft in off-pump coronary artery bypass grafting: early clinical and angiographic assessment.

BACKGROUND: Recently skeletonization has been recognized as an alternative to pedicle harvesting of the internal thoracic artery as a technique that increases the length and caliber size of the graft compared with pedicled internal thoracic artery grafts; however, this is not yet popular for harvesting the gastroepiploic artery (GEA). We report here our experience of skeletonized GEA grafting in off-pump coronary artery bypass grafting with early clinical and angiographic results. The purpose of this study was to evaluate skeletonization of GEA grafting in off-pump coronary artery bypass grafting with a large patient volume. METHODS: One hundred sixty-eight patients including 131 men and 37 women (mean age, 65 years; range, 45 to 87 years) underwent the skeletonized GEA grafting in off-pump coronary artery bypass grafting. These patients represent 41% (168 of 407 patients) of those who underwent off-pump coronary artery bypass grafting operations during the same period. We used the GEA graft of choice in patients with right coronary artery lesion. Skeletonization was performed in a unique manner we developed. RESULTS: There were no in-hospital deaths among the study patients. One patient had a perioperative myocardial infarction, which was considered a result of vasospasm of the GEA graft. None of the other patients had severe morbidity. The patency rate of the skeletonized GEA graft was 98.1% (151 of 154 distal anastomoses). CONCLUSIONS: This study suggests that skeletonization of the GEA graft can enlarge its caliber size and improve its flow capacity. In addition, the acceptable early clinical and angiographic outcome suggests that use of the skeletonized GEA graft in off-pump coronary artery bypass grafting surgery is safe and effective.