Complete surgical repair for enlarging coronary aneurysm with coronary-pulmonary artery fistula.

A 46-year-old male patient was referred to our hospital due to the presence of a coronary aneurysm showing a tendency to enlarge. Subsequent coronary angiography revealed a diagnosis of coronary aneurysm with a concomitant coronary-pulmonary artery fistula. The patient underwent a successful surgical repair, and postoperatively, experienced an uneventful recovery with no residual shunt or aneurysm.

Repeated endovascular approaches achieve successful complete remodelling for type IIIb acute aortic dissection.

Thoracic endovascular repair for type IIIb aortic dissection results in the disappearance of false lumen perfusion in the abdominal aorta in only about 20% of cases, with concern for expansion in the long term. Staged endovascular therapy with intervention on all re-entries can lead to complete false lumen thrombosis and remodelling of the entire aorta. This approach could be an option in cases in which long-term expansion is anticipated.

Obicetrapib as an Adjunct to Stable Statin Therapy in Japanese Subjects: Results from a Randomized Phase 2 Trial.

AIMS: Obicetrapib is a highly selective cholesteryl ester transfer protein (CETP) inhibitor shown to reduce low-density lipoprotein cholesterol (LDL-C) and apolipoprotein B (apoB), when taken as monotherapy and in combination with ezetimibe on a background of statins, in clinical trials predominantly conducted in Northern European/Caucasian participants. We characterized the efficacy, safety, and tolerability of obicetrapib within an Asian-Pacific region population. METHODS: This double-blind, randomized, phase 2 trial examined obicetrapib 2.5, 5, and 10 mg/d, compared with placebo, for 8 weeks as an adjunct to stable statin therapy (atorvastatin 10 or 20 mg/d or rosuvastatin 5 or 10 mg/d) in Japanese men and women who had not achieved 2022 Japan Atherosclerosis Society Guidelines and had LDL-C ＞70 mg/dL or non-high-density lipoprotein cholesterol (non-HDL-C) ＞100 mg/dL and triglycerides (TG) ＜400 mg/dL. Endpoints included LDL-C, non-HDL-C, HDL-C, very low-density lipoprotein cholesterol, apolipoproteins, TG, steady state pharmacokinetics (PK) in obicetrapib arms, safety, and tolerability. RESULTS: In the 102 randomized subjects (mean age 64.8 y, 71.6% male), obicetrapib significantly lowered median LDL-C, apoB, and non-HDL-C, and raised HDL-C at all doses; responses in the obicetrapib 10 mg group were -45.8%, -29.7%, -37.0%, and +159%, respectively (all p＜0.0001 vs. placebo). The PK profile demonstrated near complete elimination of drug by 4 weeks. Obicetrapib was well tolerated and there were no adverse safety signals. CONCLUSIONS: All doses of obicetrapib taken as an adjunct to stable statin therapy significantly lowered atherogenic lipoprotein lipid parameters, showed near complete elimination of drug by 4 weeks, and were safe and well tolerated in a Japanese population, similar to previous studies of obicetrapib conducted in predominantly Caucasian participants.

[Left Ventricular Outflow Tract Obstruction After Transcatheter Aortic Valve Replacement due to Pannus Formation].

We experienced a case of surgical aortic valve re-replacement due to structural valve deterioration caused by pannus formation 4 years after transcatheter aortic valve replacement( TAVR). The patient underwent surgery because the mean transvalvular pressure gradient increased to 48 mmHg on echocardiography. Contrast-enhanced computed tomography (CT) was useful for predicting the site of adhesion to surrounding tissue preoperatively and exploring the presence of the pannus. Intraoperative findings showed the TAVR valve was covered with neointima except around the origins of the left and right coronary arteries and was firmly adhered to the surrounding tissues. As residual pannus was present in the subvalvular tissues, it was carefully removed. The explanted TAVR valve functioned well with good opening and closure. The postoperative course was uneventful. Pannus formation can result from mechanical stress. TAVR valves put significantly greater stress on the left ventricular outflow tract than surgical valves and may be more likely to cause pannus formation.

[Surgical Explantation of a Bioprosthesis Nine Months After Transcatheter Aortic Valve Implantation].

CASE: 82-year-old female. In October 2020, the patient underwent transcatheter aortic valve implantation( TAVI)[Evolut PRO R 23 mm] via left subclavian artery approach for severe aortic valve stenosis. The patient was discharged home without any issues. However, nine months after surgery, the patient was hospitalized at another hospital for a right upper arm fracture and developed a fever. The patient was transferred to our hospital and was diagnosed with Enterococcal bacteremia while receiving antibiotic treatment. Echocardiography revealed leaflet thickening and cord-like structure on the artificial valve, and a diagnosis of prosthetic valve endocarditis (PVE) was made. The patient then underwent surgical removal of the valve. The patient had a good postoperative course and completed 4 weeks of antibiotic treatment before being transferred back to the referring hospital 31 days after surgery. TAVI made unprecendented revolution in the treatment of aortic valve stenosis. TAVI is often used for elderly patients with comorbidities because of high perioperative risk is for surgical aortic valve replacement. Although TAVI is widely promoted for its benefits, it is not without limitations. In cases with more than one year of follow-up, there are many complications and the risk of surgery is high. There have been few reports of cases from Japan requiring surgical removal of TAVI valve. In this case, PVE was diagnosed nine months after TAVI and the patient had a good outcome.

[Valve Replacement for Isolated Pulmonary Valve Infective Endocarditis without Congenital Heart Defects:Report of a Case].

We report a rare case of isolated pulmonary valve endocarditis in a 60-year-old man without congenital heart defects. He had a persistent fever and back neck pain after pulling out his teeth. Echo cardiography revealed a mobile vegetation (measuring 53 mm in size) adhering to the pulmonary valve and blood cultures showed the presence of Staphylococcus aureus( S. aureus). Because of mobile vegetation, pulmonic embolism and presence of S. aureus, surgical treatment was selected. During surgical procedure, we found that the vegetation had destroyed markedly pulmonary valve leaflets. After excising pulmonary valve leaflets, we implanted a bioprosthetic valve and enlarged the pulmonary artery with autologous pericardium. A year after surgery, the patient is stable with no sign of infection.

[Concomitant Tricuspid Annuloplasty with Resection of a Giant Right Atrial Myxoma:Report of a Case].

Myxomas account for the vast majority of heart tumors in adults. About 70% originate in the left atrium, while about 10% of these are reported to originate in the right atrium. A 70-year-old man with dyspnea, was found to have a giant right atrial mass by echocardiography, and tumor resection was performed under cardiopulmonary bypass( CPB) through a median sternotomy. At weaning from CPB the patient was hemodynamically unstable. Intraoperative echocardiography showed severe tricuspid regurgitation( TR), and tricuspid annuloplasty was performed. The postoperative course was uneventful and histopathological examination confirmed that the tumor was a myxoma. It is important to keep in mind that regurgitation of the atrio-ventricular valve might occur after resection of atrial myxoma.

[Surgical Treatment of Abdominal Aortic Aneurysm with Ectopic Kidney with Stanford Type A Acute Aortic Dissection;Report of a Case].

We experienced a surgical case of Stanford type A acute aortic dissection with abdominal aortic aneurysm (AAA) associated with ectopic kidney. Computerized tomography did not detect any ulcer-like projections, but 3 days later, it appeared, and emergency surgery was performed. Second-stage surgery was selected and done later to repair AAA. The right kidney was an ectopic pelvic kidney. The renal arteries had branched off from the left common iliac artery, and the renal artery lumen narrowed. With a 4 Fr catheter, cold Ringer's solution was given to protect the kidneys during surgery. The patient showed no deterioration of kidney function and made good progress. After rehabilitation, the patient had no complications and was discharged from the hospital.

[Treatment Strategy for Stanford Type A Acute Aortic Dissection].

The fundamental treatment of Stanford type A acute aortic dissection is a lifesaving emergency surgery in our hospital. We perform hemiarch replacement with a focus on entry tear, but an extended surgery is also performed only when resection of the entry tear is difficult. The outcomes of current therapeutic policy, along with the short-term and the long-term outcomes of different sites of entry tear, were examined retrospectively. Three hundred and twenty surgery of Stanford type A acute aortic dissection were performed between 1991 and 2015 at our hospital. Their short-term and long-term outcomes were examined after dividing them into 7 groups according to their entry sites. We also investigated surgical methods and effects of presence/absence of residual entry tear. As a result, overall hospital mortality was 13.1%. There was no significant difference in either shortterm or long-term outcome among the groups. Likewise, no significant difference was observed in the surgical methods or the presence/absence of residual entry tear. Recently, minimally invasive procedures, such as stent-grafting, have been applied to manage the residual entry tear. Therefore, an aggressive extended surgery is no longer inevitable and our current therapeutic policy is considered reasonable.

[Gradual Enlargement of Saphenous Vein Graft Aneurysm Causing Chest Symptom after Coronary Artery Bypass Grafting;Report of a Case].

A 70-year-old man was admitted to our hospital because of shortness of breath. He had undergone coronary artery bypass grafting at another hospital 18 years before. We had detected his saphenous vein graft to the right coronary artery being aneurysmal 3 years before. The aneurysm had grown from 23 mm to 42 mm during the follow-up. Because of an angina-like symptom and the possibility of rupture, we performed resection of the aneurysm and redo coronary artery bypass grafting to the right coronary artery using another saphenous vein. His symptom has disappeared since then. Saphenous vein graft aneurysm needs close follow-up even when conservative therapy is selected.

Cases of two patients with aortoduodenal fistula who underwent emergency operation.

INTRODUCTION: Aortoduodenal fistula (ADF) is a rare but life-threating condition, and it is an important cause of massive gastrointestinal bleeding. Primary ADF often occurs as a result of aortic aneurysm, and secondary ADF develops after the placement of aortic prosthetic graft. PRESENTATION OF CASES: Case 1: A 64-year-old man with hematemesis was transferred to our hospital. The patient was diagnosed with primary ADF. Thus, we performed prosthetic graft replacement for an aortic aneurysm, and suturing of the duodenal fistula and duodenojejunal side-to-side anastomosis were performed. He was then discharged on the 35th postoperative day. After 2 years and 10 months, he died of other diseases. Case 2: A 76-year-old man with a history of abdominal aortic aneurysm repair with a prosthetic graft 5 years back who presented with hematemesis and melena was transferred to our hospital. The patient was diagnosed with secondary ADF, and an emergency endovascular aneurysm repair (EVAR) and suturing of the duodenal fistula were perfomed. He was transferred for rehabilitation purposes on the 108th postoperative day but eventually died of pneumonia 6 months after surgery. DISCUSSION: ADF is associated with high mortality. Initial bleeding is usually minor and often intermittent. However, it leads to severe bleeding and hemorrhagic shock. EVAR is preferred over open surgery because it can be performed faster and is less invasive. Recently, in case of hemorrhagic shock, EVAR is used as first-line treatment. CONCLUSION: Accurate diagnosis and immediate treatment are important for the survival of patients with ADF.

[Ruptured Left Ventricular Pseudoaneurysm Representing Cardiac Tamponade;Report of a Case].

A 64-year-old woman was followed by the other hospital because of left ventricular false aneurysm after percutaneous coronary intervention for acute myocardial infarction of which culprit lesion was left circumflex artery. She admitted to the hospital suffering from nausea and dyspnea. Echocardiography showed huge pericardial effusion and cardiac tamponade due to ruptured left ventricular false aneurysm and transferred to our hospital under pericardial drainage. She presented with symptoms such as shock, so we performed emergent left ventricular reconstruction. She uneventfully left our hospital on 18 post-operative day.

Hybrid endovascular repair for an arch aneurysm combined with aberrant right subclavian artery.

This report describes a hybrid endovascular approach to a 9.3-cm saccular aneurysm of the left sided aortic arch combined with an aberrant right subclavian artery. The two-step procedure consisted of a bilateral carotid-subclavian bypass, followed by an ascending aorta-bicarotid bypass and completed by an endovascular exclusion of the aneurysm by covering the whole aortic arch and its branches. The patient had no postoperative complications and was discharged 10 postoperative day. Hybrid procedures may be useful in complex aortic arch pathologies and may reduce postoperative complications in comparison with conventional open surgery.

Combined total arch replacement and bypass from the ascending aorta to the bilateral profunda femoris arteries.

A 72-year-old woman who had aortic arch aneurysm was admitted. The patient was unable to walk without assistance because of aortoiliac occlusive disease. Total arch replacement and the ascending aorta to the bilateral profunda femoris artery bypass were performed during the same operation. On outpatient visits, the patient was able to walk with a cane and the ankle-brachial pressure index was markedly improved. This combined procedure is an option for patients with aortoiliac occlusive disease who are not candidates for alternate inflow procedures, especially when the patient has another indication for median sternotomy.

Surgical repair of Kommerell's diverticulum and an aberrant subclavian artery.

PURPOSE: The coexistence of Kommerell's diverticulum and an aberrant subclavian artery (ASCA) is a rare congenital variation of the vascular structure. We report our experience of treating aneurysms associated with these anomalies. METHODS: Between June 2007 and November 2011, five consecutive patients underwent repair of an aneurysm associated with Kommerell's diverticulum and an ASCA at Shiga University Hospital. Four of the five patients had a right-sided aortic arch associated with the ASCA. One patient underwent emergency surgery for a ruptured thoracic aneurysm. The operations performed were descending aorta replacement through right thoracotomy in one patient and total arch replacement through a median thoracotomy, under deep hypothermic circulatory arrest and selective cerebral perfusion, in four patients. No staged operation was required. RESULTS: One patient died of mediastinitis, subsequent to a ruptured Kommerell's diverticulum, 45 days postoperatively. There were no other deaths in the early or late (6-58 months) postoperative period. One patient required re-exploration for bleeding, but none of the patients suffered neurologic complications. CONCLUSIONS: Aortic disease with an ASCA and Kommerell's diverticulum can be repaired safely under elective conditions.

Off-pump coronary artery bypass grafting using skeletonized in situ arterial grafts.

Skeletonization is an advanced technique of graft harvesting for coronary artery bypass grafting (CABG), and while it requires meticulous attention, it has many advantages. For example, skeletonization of internal thoracic artery (ITA) can minimize sternal ischemia and lower the risk of mediastinitis, and is longer and larger than pedicled ITA. In this article we describe the surgical techniques demonstrated in our video, which details our techniques of skeletonization of arterial grafts and off-pump coronary artery bypass (OPCAB) exclusively using these in situ grafts. Our method of right gastroepiploic artery (GEA) skeletonization has only three technical steps. The first step is to pass thin vessel loops under the GEA. The second step is to unroof the tissue surrounding the GEA. The last step is to seal and sever all the branches. Skeletonization of the GEA not only prevents vasospasm but also leads to GEA dilatation, and facilitates inspection and makes sequential anastomosis easier. Bilateral use of the skeletonized ITA and use of the skeletonized GEA can cover most coronary artery target sites without any manipulation of the ascending aorta. In our consecutive series of over 1,000 patients, the stroke rate was 0.5%. Our method helps to make the technique simple and secure in this technically demanding operation, and we believe that OPCAB with these grafts provides the best possible coronary revascularization.

Early and long-term patency of in situ skeletonized gastroepiploic artery after off-pump coronary artery bypass graft surgery.

BACKGROUND: There is at present no accurate figure for the long-term patency rate of the skeletonized gastroepiploic artery (GEA). METHODS: From January 2002 to July 2012, 956 consecutive patients underwent isolated off-pump coronary artery bypass graft (OPCABG) surgery at our institution. Of these, the 424 who underwent GEA grafting and postoperative GEA graft evaluation were the subjects of the present study. Of these 424 subjects, 155 (36.6%) underwent long-term outpatient evaluation using multidetector computed tomography angiography. RESULTS: No patient was converted from off pump to on pump surgery. Overall 30-day mortality was 0.5% (2 of 424). The overall early (4 to 21 days after surgery) patency rate of the skeletonized GEA was 98.2% (599 of 610 anastomoses). A total of 215 GEA anastomoses, including 55 sequential bypasses, were followed for long-term evaluation, of which 12, including three sequential bypasses, were found to be occluded. The overall patency rate in skeletonized GEA grafting over a mean follow-up period of 73 months was 94.4% (203 of 215). The cumulative patency rate of the skeletonized GEA was 97.8% at 30 days, 96.7% at 1 year, 96.0% at 3 years, 94.7% at 5 years, and 90.2% at 8 years after surgery. Multivariate Cox proportional hazard regression analysis showed that target vessel stenosis (p = 0.008, hazard ratio 0.086, 95% confidence interval: 0.014 to 0.53) was the only independent predictor of late graft occlusion. CONCLUSIONS: We demonstrated an accurate long-term patency rate for the skeletonized GEA superior to that for pedicled GEA or saphenous vein graft. A low-grade degree of target vessel stenosis was the only risk factor for late GEA occlusion.

Mid-term results for the use of the extended sandwich patch technique through right ventriculotomy for postinfarction ventricular septal defects.

OBJECTIVES: Postinfarction ventricular septal defect (VSD) is a rare, but feared, complication after acute myocardial infarction. Although numerous techniques and materials have been used, the best technique has not yet been settled upon. We present a novel technique of VSD closure through the VSD via right ventricular (RV) incision and assess short- and mid-term outcomes. METHODS: Between April 2008 and March 2012, 15 consecutive patients presenting with postinfarction VSD underwent surgical repair using this technique in our department. RESULTS: Thirty-day mortality was 20% (3 patients). Two patients died from low cardiac output. No early complications related to the VSD repair were observed, such as shunt recurrence, severe septal dyskinesia or pseudoaneurysmal change in the left ventricular myocardium. The left ventricle was contracted well without mitral regurgitation. The mean follow-up period was 17 ± 15 months. The Kaplan-Meier estimate of 3-year cumulative survival is 76%. At the mid-term stage, one trivial residual leak was noted, but no patient required reoperation. RV function was within the normal range after the operation. CONCLUSIONS: This method of VSD repair using right ventricle incision and trans-VSD approach is safe and simple and reduces the postoperative recurrence of VSD.

Selective cerebral perfusion with mild hypothermic lower body circulatory arrest is safe for aortic arch surgery.

OBJECTIVES: The antegrade selective cerebral perfusion (SCP) technique, which extends the safe time limit for arch surgery, has now gained acceptance. However, neither the optimal hypothermic temperature nor the optimal SCP flow rate has been clearly determined. METHODS: From January 2008 to February 2012, a total of 105 patients underwent total arch replacement under a single surgeon (A.T.) at Shiga Medical University Hospital. The patients were 85 males and 20 females with a mean age of 73 years (range 41-88). The cause of the aneurysm was atherosclerosis in 90 patients and dissection in 15. Eighty-one patients with chronic lesion underwent elective surgery and 24 underwent emergent surgery. Univariate analysis of postoperative neurological dysfunction and early mortality was performed. RESULTS: The mean operation time, cardiopulmonary bypass (CPB) time, coronary ischaemic time, lower body circulatory arrest (CA) time and SCP time were 277 ± 83 min, 164 ± 40 min, 92 ± 33 min, 58 ± 22 min and 95 ± 28 min, respectively. Thirty-day mortality occurred in 1 ruptured emergent case (1%). Hospital mortality (>30 days) occurred in 3 cases (3%), 2 due to multisystem organ failure following emergent rupture and the other to cerebrovascular accident in an elective surgery case. Permanent neurological dysfunction (PND) occurred in 3 patients (3%) and temporary neurological dysfunction (TND) also in 3 patients (3%). CONCLUSIONS: SCP under mild hypothermia can be safely applied to aortic arch surgery and is associated with a low rate of hospital mortality and morbidity. However, prolonged SCP time is associated with incidences of postoperative neurological deficit.