Patterns of collateral arteries to the spinal cord after thoracoabdominal aortic aneurysm repair.

OBJECTIVES: To evaluate postoperative patterns of collateral arteries to the spinal cord during occlusion of the segmental arteries supplying the artery of Adamkiewicz (AKA). METHODS: Between April 2011 and December 2022, 179 patients underwent thoraco-abdominal aortic aneurysm repair; 141 had an identifiable AKA on preoperative multidetector computed tomography (MDCT) scans, 40 underwent thoraco-abdominal aortic aneurysm replacement (TAAR), and 101 underwent thoracic endovascular aortic repair (TEVAR). New postoperative collateral blood pathways invisible on preoperative contrast-enhanced computed tomography scans were identified in 42 patients (10 patients in TAAR vs 32 patients in TEVAR) who underwent preoperative and postoperative MDCT scanning for AKA identification. RESULTS: The thoracodorsal and segmental arteries were the main collateral pathways in both groups. Th9-initiated collaterals were the most common. Collaterals from the internal thoracic artery were observed in the TEVAR group but not in the TAAR group. One patient in the TEVAR group experienced postoperative paraparesis, which was not observed in the TAAR group. Postoperative paraplegia was more common in the non-Th9-origin group, but this difference was non-significant. CONCLUSIONS: Thoracodorsal and segmental arteries may be important collateral pathways after TEVAR and TAAR. For thoracodorsal arteries, preserving the thoracodorsal muscle during the approach would be crucial; for segmental arteries, minimizing the area to be replaced or covered would be paramount. An AKA not initiated at the Th9 level poses a high risk of postoperative paraplegia.

Twenty-year experience following aortic valve replacement in patients younger than 60 years of age.

OBJECTIVE: Reports on long-term outcomes of surgical aortic valve replacement (AVR) for patients aged < 60 years are scarce in Japan. Hence, we aimed to evaluate these outcomes in patients aged < 60 years. METHODS: Between March 2000 and December 2020, 1477 patients underwent aortic valve replacement. In total, 170 patients aged < 60 years who underwent aortic valve replacement were recruited. Patients aged < 18 years were excluded. Patient data collected from the operative records and follow-up assessments were reviewed. RESULTS: The mean age was 49 ± 9 years, and 64.1% of patients were male. One-hundred-and-fifty-two patients (89.4%) underwent aortic valve replacement with a mechanical valve and 18 (10.6%) with a bioprosthetic valve. The mean follow-up period was 8.1 ± 5.5 years. No operative mortality occurred, and in-hospital mortality occurred in one patient (0.6%). Ten late deaths occurred, with seven cardiac-related deaths. The overall survival rate was 95.4 ± 1.7%, 93.9 ± 2.3%, 90.6 ± 3.9%, and 73.2 ± 11.8% at 5, 10, 15, and 20 years, respectively. Freedom from major bleeding was 96.4 ± 1.6% at 5, 10, and 15 years, and 89.0 ± 7.3% at 20 years. Freedom from thromboembolic events was 98.7 ± 1.3%, 97.3 ± 1.9%, 90.5 ± 4.5%, and 79.0 ± 11.3% at 5, 10, 15, and 20 years, respectively. Freedom from valve-related reoperation was 99.4 ± 0.6% at 5 years, 97.8 ± 1.7% at 10 and 15 years, and 63.9 ± 14.5% at 20 years. CONCLUSIONS: Patients aged < 60 years undergoing aortic valve replacement with a high mechanical valve implantation rate had favorable long-term outcomes.

A case of severe ureteral injury repaired by renal autotransplantation with an iliac vein patch using bovine pericardium.

Introduction: Renal autotransplantation is considered a surgical procedure for extensive ureteral defects. Herein, we report a case of severe ureteral injury repaired by laparoscopic nephrectomy and renal autotransplantation with an iliac vein patch using bovine pericardium. Case presentation: A 56-year-old woman who had previously undergone gynecological surgery complained of right-sided abdominal pain. She was then later diagnosed with a right middle ureteral injury with a 5-cm long defect. We performed retroperitoneal laparoscopic nephrectomy and renal autotransplantation. As the iliac vein was fragile, venous patching using bovine pericardium was performed. The patient's renal function was well preserved after surgery. Conclusion: Laparoscopic nephrectomy and renal autotransplantation is an effective method for repairing severe ureteral injury with the preservation of renal function. A venous patch using bovine pericardium might be considered as a replacement for a fragile vein.

A Comparison of Retrospective ECG-Gated CT and Surgical or Angiographical Findings in Acute Aortic Syndrome.

The best cardiac phases in retrospective ECG-gated CT for detecting an intimal tear (IT) in aortic dissection (AD) and an ulcer-like projection (ULP) in an intramural hematoma (IMH) have not been established. This study aimed to compare the detection accuracy of diastolic-phase and systolic-phase ECG-gated CT for IT in AD and ULP in IMH, with subsequent surgical or angiographical confirmation as the reference standard.In total, 81 patients (67.6 ± 11.8 years; 41 men) who underwent emergency ECG-gated CT and subsequent open surgery or thoracic endovascular aortic repair for AD (n = 52) or IMH (n = 29) were included. The accuracies of detecting IT and ULP were compared among only diastolic-phase, only systolic-phase, and both diastolic-phase and systolic-phase methods of retrospective ECG-gated CT; surgical or angiographical findings were used as the reference standard. The detection accuracy for IT and ULP using only diastolic-phase, only systolic-phase, and both diastolic-phase and systolic-phase methods of ECG-gated CT was 93% [95% CI: 87-97], 94% [95% CI: 88-97], and 95% [95% CI: 90-97], respectively. There were no significant differences in detection accuracy among the 3 acquisition methods (P = 0.55). Similarly, there were no significant differences in the accuracy of detecting IT in AD (P = 0.55) and ULP in IMH (P > 0.99) among only diastolic-phase, only systolic-phase, and both diastolic- and systolic-phase ECG-gated CT.Retrospective ECG-gated CT for detecting IT in AD and ULP in IMH yields highly accurate findings. There were no significant differences seen among only diastolic-phase, only systolic-phase, and both diastolic-phase and systolic-phase ECG-gated CT.

Risk of Coronary Occlusion Due to Sinus Sequestration by Redo Transcatheter Aortic Valve Implantation in Japanese Patients With SAPIEN 3.

Background: Transcatheter aortic valve (TAV)-in-TAV is an attractive treatment for degenerated TAV. The risk of coronary artery occlusion due to sequestration of the sinus of Valsalva (SOV) in TAV-in-TAV has been reported, but the risk in Japanese patients is unknown. This study aimed to investigate the proportion of Japanese patients who are expected to experience difficulty with the second TAV implantation (TAVI) and evaluate the possibility of reducing the risk of coronary artery occlusion. Methods and Results: Patients (n=308) with an implanted SAPIEN 3 were divided into 2 groups: a high-risk group, which included patients with a TAV-sinotubular junction (STJ) distance <2 mm and a risk plane above the STJ (n=121); and a low-risk group, which included all other patients (n=187). The preoperative SOV diameter, mean STJ diameter, and STJ height were significantly larger in the low-risk group (P<0.05). The cut-off value for predicting the risk of SOV sequestration due to TAV-in-TAV in the difference between the mean STJ diameter and area-derived annulus diameter was 3.0 mm (sensitivity 70%; specificity 68%; area under the curve 0.74). Conclusions: Japanese patients may have a higher risk for sinus sequestration caused by TAV-in-TAV. The risk of sinus sequestration should be assessed before the first TAVI in young patients who are likely to require TAV-in-TAV, and whether TAVI is the best aortic valve therapy must be carefully decided.

Hepatic-to-azygos vein redirection after a failed bifurcated graft Fontan conversion.

A successful hepatic-to-azygos vein redirection was performed in a patient with absent inferior vena cava using a long vascular graft to address a pulmonary arterio-venous fistula after a failed Fontan conversion. No exacerbation was observed 5 years postoperatively.

Symptomatic subdural hemorrhage following heart valve surgery: a retrospective cohort study.

OBJECTIVE: Subdural hemorrhage (SDH) has been reported to be the most frequent intracranial hemorrhagic complication following open heart surgery; however, its clinical features and pathophysiology remain unclear. The aim of this retrospective study was to elucidate the incidence, clinical course, and factors associated with the development of symptomatic SDH following heart valve surgery. METHODS: A retrospective review of medical records on the development of symptomatic SDH after heart valve surgery involving cardiopulmonary bypass (CPB) from April 2011 to March 2016 was performed. Patients who had undergone preoperative cranial computed tomography (CT) or brain magnetic resonance imaging (MRI) were included in this study, and factors associated with SDH following heart valve surgery were analyzed. When neurological symptoms developed after heart valve surgery, cranial CT or brain MRI was performed. RESULTS: A total of 556 patients who had undergone heart valve surgery were analyzed. Among these patients, symptomatic SDH occurred in 11 (2.0%). The mean duration of symptomatic onset was 10.1 days (range 2-37 days). Ten of 11 patients (90.9%) developed SDH in the posterior fossa or occipital convexity. Logistic regression analysis revealed longer aortic clamp time (95% CI 1.00-1.10, p = 0.04), higher dose of heparin after surgery (95% CI 1.00-1.02, p = 0.001), and higher pulmonary artery pressure (PAP) just before disconnection of the CPB (95% CI 1.01-1.37, p = 0.04) as significantly associated with the development of SDH. CONCLUSIONS: The incidence of symptomatic SDH following heart valve surgery was 2.0%. Symptoms due to SDH usually developed a few days to 1 month after surgery. Surprisingly, most SDHs developed in the posterior fossa or occipital convexity following heart valve surgery. A longer aortic clamp time, higher dose of heparin after surgery, and higher PAP just before disconnection of the CPB were related to the development of symptomatic SDH following heart valve surgery.

Thoracoabdominal aortic aneurysm repair based on pre- and postoperative evaluation of the artery of Adamkiewicz.

OBJECTIVES: The aim of this study was to evaluate our experience with thoraco-abdominal aortic aneurysm repair based on the pre- and postoperative evaluation of the artery of Adamkiewicz (AKA). METHODS: Between April 2017 and May 2021, 32 patients who underwent thoracoabdominal aortic repair underwent pre- and postoperative multidetector row computed tomography (MDCT) for AKA evaluation. Based on the identification of the AKA on preoperative MDCT, only 1 critical segmental artery was reattached to the AKA (CSA-AKA). Postoperative MDCT was used to evaluate the patency of the reattached CSA-AKA. RESULTS: Pre- and postoperative MDCT helped identify and visualize the AKA in all patients (100%). In 8 patients, alternative continuity to the AKA developed through collateral circulation. The total number of CSA-AKA with collateral circulation was 48 among the 32 cases; the number of reattached segmental arteries per case was 1.3 ± 0.9 (range, 0-4). The overall rate of patency of the reattached CSA-AKA was 53% (23/43). Three patients exhibited spinal cord injuries (paraplegia, 2; paraparesis, 1). In the 2 paraplegia cases exhibiting partial or complete occlusion of the reattached CSA-AKA, the development of collateral circulation was not visualized via postoperative MDCT. In the paraparesis case, postoperative MDCT helped visualize the development of collateral circulation to the CSA-AKA, resulting in full recovery at discharge. CONCLUSIONS: The study findings suggest that spinal cord injuries do not occur in the presence of a patent preoperatively identified CSA-AKA or the development of collateral circulation. Pre- and postoperative identification of collateral pathways to the AKA may help reveal paraplegia risk factors.

Distal arch replacement for aortic aneurysm associated with pseudocoarctation through the L-incision approach.

We report the case of a 16-year-old boy in whom we successfully repaired a distal aortic arch aneurysm associated with pseudocoarctation using double aortic cannulation and antegrade selective cerebral perfusion through the L-incision approach. This approach provided excellent exposure from the ascending aorta to the descending aorta, which enabled total body perfusion. We avoided cardiac arrest and hypothermic circulatory arrest during the surgery. The L-incision approach could be a better alternative for aortic arch surgery in adolescents.

Aortic Elongation in Bicuspid Aortic Valve with Aortic Stenosis Assessed by Thin-Slice Electrocardiogram-Gated Computed Tomography.

Bicuspid aortic valve (BAV) patients with aortic stenosis (AS) are known to develop dilatation of the ascending aorta at a younger age, but the morphology of the aorta in these patients is yet to be investigated. Thus, in this study, we aim to evaluate the aortic morphology of BAV patients with severe AS using thin-slice electrocardiogram (ECG) -gated computed tomography (CT) and identify the possible contributing effect of age.In this retrospective study, 122 BAV and 154 tricuspid aortic valve (TAV) patients who received aortic valve replacement for severe AS were assessed by thin-slice ECG-gated CT and three-dimensional reconstruction. The morphology of the ascending aorta was also evaluated among BAV patients aged < 70 (n = 72) and ≥ 70 (n = 50) years old. As per our findings, BAV patients with severe AS had significantly greater diameter (P < 0.01), elongation (P < 0.01), and tortuosity (P = 0.03) of the ascending aorta; minimum aortic arch angle (P < 0.01); and significantly lower calcified plaque (P < 0.01) compared with those of TAV patients even after adjusting for background. Multiple regression analysis showed that standardized partial regression coefficients (ß) of dilatation (0.5) and elongation (0.35) were higher among other measurements of aortic morphology for BAV patients. BAV patients with severe AS aged ≥ 70 years had significantly greater diameter (42.0 [37.2-46.1] mm versus 40.4 [35.2-44.2] mm, P = 0.049) and elongation (133.8 [123.5-147.3] mm versus 127.0 [111.0-140.0] mm, P = 0.01) of the ascending aorta than those aged < 70 years.BAV patients with severe AS were determined to have greater dilatation and elongation of the ascending aorta. Moreover, BAV patients older than 70 years had greater diameter and elongation of the ascending aorta.

Safety and feasibility of retrograde INOUE-BALLOON for balloon aortic valvuloplasty without rapid ventricular pacing during transcatheter aortic valve replacement.

Rapid ventricular pacing (RVP) is commonly employed during transcatheter aortic valve replacement (TAVR); however, frequent TAVR is associated with worse prognoses. The retrograde INOUE-BALLOON® (IB) allows balloon aortic valvuloplasty (BAV) without RVP. The aim of this study was to evaluate the feasibility of retrograde IB for TAVR preparation. The study population included 178 consecutive patients (mean age, 84 ± 5 years; male, 47%) who underwent retrograde BAV before prosthetic valve replacement via the transfemoral approach. Patients were divided into a retrograde IB group without RVP (n = 74) and a conventional balloon (CB) group with RVP (n = 104). The primary endpoint was prolonged hypotension after BAV (reduced systolic pressure < 80 mmHg for over 1 min or vasopressor drug requirement). The incidence of prolonged hypotension after BAV was significantly lower in the IB group compared with the CB group (4% vs. 16%, p = 0.011). Balloons were able to penetrate and expand the aortic valve in both groups. RVP was used less for total TAVR in the IB group compared with the CB group. The aortic valve area-index after BAV was not significantly different between the two groups (0.72 ± 0.14 cm2/m2 vs. 0.71 ± 0.12 cm2/m2; p = 0.856). Multivariate analysis demonstrated that IB use was associated with avoidance of prolonged hypotension (OR, 0.27 [0.059-0.952]; p = 0.041). In conclusion, BAV using retrograde IB without RVP is both safe and feasible. More stable hemodynamics were achieved using retrograde IB by avoiding RVP during TAVR.

Intrapulmonary artery septation for unilateral absence of the pulmonary artery.

We describe a seven-month-old boy with tetralogy of Fallot and an absent left pulmonary artery. Due to the diminutive size of the left pulmonary artery, we performed a native tissue left pulmonary artery reconstruction and intrapulmonary artery septation procedure with a left modified Blalock-Taussig shunt. After confirming left pulmonary artery growth, the patient underwent tetralogy of Fallot repair, removal of septation patch, and division of the Blalock-Taussig shunt. Nine months post-surgery, we confirmed his balanced lung perfusion (R/L ratio 6:4). The intrapulmonary artery septation procedure would be suitable for both the resuscitation and reconstruction of the hypoplastic absent pulmonary artery.

Ruptured Abdominal Aortic Aneurysm Repair Using Open Proximal Anastomosis Under Deep Hypothermic Circulatory Arrest.

Proximal aortic clamping under normothermia is generally adequate for operative repair of abdominal aortic rupture; however, the hypothermic circulatory arrest (HCA) technique is not as common. Proximal exposure and clamping are sometimes difficult due to the risk of bleeding, rerupture, and ischemia. We present a successful case of a ruptured abdominal aortic aneurysm (AAA) that was repaired using cardiopulmonary bypass with HCA. A 75-year-old man presented with sudden back pain and was diagnosed with a ruptured AAA using computed tomography. The aneurysm had a maximal diameter of 100 mm and protruded anteriorly just below the renal arteries. The rupture site was close to the renal arteries, and thus, there was a high risk of bleeding and shock during proximal exposure. Cardiopulmonary bypass was established by cannulation of the right axillary artery and right femoral vein, following which open laparotomy was performed. Proximal exposure and anastomosis could be safely performed using HCA. This cardiopulmonary bypass with HCA technique may be useful as a surgical strategy for ruptured juxta-renal AAAs.

[Valve Re-replacement after Aortic Valve Replacement with Starr-Edwards Ball Valve Forty-five Years Ago:Report of a Case].

The patient was a 67-year-old man. At 22 years of age, he underwent aortic valve replacement with Starr-Edwards ball valve. At 67 years of age, he complained of fatigue of the New York Heart Association (NYHA) class Ⅲ condition. He was diagnosed with mitral regurgitation, tricuspid regurgitation, ascending aortic aneurysm and chronic atrial fibrillation. Transthoracic and transesophageal echocardiograms showed a mobile, elongated echogenic mass attached to the valve cage and floating downstream. We performed Bentall procedure, ascending aortic replacement, mitral valve replacement, tricuspid annuloplasty and left atrial appendage closure. Explanted ball valve showed extensive cloth destruction and partial cloth tear. Mild pannus formation was observed beneath the valve. Despite 45 years after initial operation, significant valve dysfunction was not observed.

The rare case of a MitraClip device migrating into the left ventricular apex.

A 79-year-old man with atrial fibrillation and heart failure due to grade 4 + mitral valve regurgitation after coronary artery bypass underwent the MitraClip procedure using two clips. Three days after the procedure, chest radiographs indicated migration of one of the two clips into the left ventricle. He suffered from 3 + recurrent mitral regurgitation, tricuspid valve regurgitation. The echocardiogram and computed tomography scans indicated migration of the clip into the left ventricular apex; he underwent mitral valve replacement, removal of the migrated clip to prevent embolism, left atrial appendage closure, and tricuspid valve ring-annuloplasty. In the postoperative acute phase, embolism by detached and lost MitraClip device is possible, which can be difficult to remove.

Additive Value of CT to Age, Aortic Diameter, and Echocardiography in Diagnosis and Classification of Bicuspid Aortic Valve in Patients with Severe Aortic Stenosis.

PURPOSE: To develop and validate a CT diagnostic algorithm for bicuspid aortic valve (BAV) classification. MATERIALS AND METHODS: This retrospective study included 212 consecutive patients with severe aortic stenosis who underwent CT followed by aortic valve replacement (mean age, 71 years [range, 27-93 years]; 125 women; 37% with a BAV) from 2012 to 2017. BAV diagnosis and BAV category were determined by using the CT diagnostic algorithm developed and were compared with those attained through surgical diagnosis. Reproducibility and agreement were assessed using the Cohen kappa (κ) coefficient. The value of adding CT to age, aortic diameter index, and transthoracic echocardiography (TTE) was evaluated by using the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), and decision-curve analysis. RESULTS: Intra- and interobserver reproducibility were good or excellent for all CT diagnoses (κ ≥ 0.6 for all). Agreement between CT and surgical diagnoses was excellent (κ = 0.90) for BAV detection and good (κ = 0.69) for BAV categorization. Sixteen percent (five of 31) of patients with functional BAV diagnosed by using CT received a diagnosis of congenital BAV at surgery. The addition of CT to age, aortic diameter, and TTE showed a higher AUC (with CT, 0.97 [95% CI: 0.91, 0.99] vs without CT, 0.91 [95% CI: 0.85, 0.95]; P = .003) and NRI (1.79 [95% CI: 1.65, 1.92], P < .001) and a higher net benefit among all BAV probabilities. CONCLUSION: CT diagnosis was consistent with surgical diagnosis and had an additive value over traditional diagnostic methods; however, there was a risk of overlooking congenital BAV in patients with functional BAV diagnosed by using CT.Supplemental material is available for this article.© RSNA, 2021.

Coronary artery bypass grafting for an anomalous origin of the right coronary artery: is it a valid surgical procedure?

The right internal thoracic artery to the right coronary artery bypass with ligation of the proximal native vessel is a simple and reliable option for the treatment of an anomalous aortic origin of the right coronary artery arising from the left sinus of Valsalva without an intramural course. Coronary artery bypass grafting is an uncomplicated option for elderly patients, those with connective tissue diseases, and those for whom combined aortic valve procedures are planned. Herein, we present four cases of this anomaly that underwent right internal thoracic artery anastomosis to the distal right coronary artery along with proximal right coronary artery ligation using a surgical clip. There was no occurrence of complications such as hypoperfusion syndrome, graft occlusion, recurrent symptoms, or late cardiac events.

Outcomes of primary sternal closure for postoperative mediastinitis in children.

OBJECTIVES: We retrospectively analysed outcomes of debridement and primary sternal closure for postoperative mediastinitis in children. METHODS: Between January 2007 and July 2019, 1285 patients under the age of 20 years underwent congenital heart surgery at the Iwate Medical University. Of these, 22 children had postoperative mediastinitis (1.7%). We performed adequate debridement and primary sternal closure with pectoralis major muscle advancement flaps. We evaluated hospital survival rates, reintervention, duration of intravenous antibiotic treatment, intensive care unit (ICU) stay and hospital stay. RESULTS: The median age and weight at surgery were 12.5 months (range 0-228 months) and 7.8 kg (range 2.2-64.2 kg), respectively. Two patients (9%) had a history of delayed sternal closure. Staphylococcus was the most common causative agent for infection (82%). All cases were categorized as Robicsek's classification type II mediastinitis. The hospital survival rate was 95%, and freedom from reintervention for infectious complications was observed in 91% of the patients. The median durations of intravenous antibiotic treatment, ICU stay and hospital stay were 18 days (range 9-46 days), 4 days (range 1-87 days) and 22.5 days (range 11-87 days). The median follow-up time was 89 months (range 2-148 months), and there was no evidence of recurrent mediastinitis, musculoskeletal growth, physical deformity, breast development and upper trunk or limb movement. CONCLUSIONS: Primary sternal closure is an effective procedure for children as it can significantly shorten treatment duration and reduce physical and psychological burdens. Its results compare favourably with those of conventional therapy in terms of mortality and complications.