Safety and efficacy of physician-modified thoracic endovascular aortic repair using a low-profile device for aortic arch lesions.

BACKGROUND: We investigated the safety and efficacy of physician-modified thoracic endovascular aortic repair using a low-profile device for aortic arch lesions. METHODS: A total of 42 consecutive patients (mean age 67.2 ± 12.7 years; 32 men) with aortic arch lesions were treated by physician-modified thoracic endovascular aortic repair using a low-profile device (Zenith Alpha Thoracic Endovascular Graft) with four scallops or 13 fenestrations for the common carotid artery and 38 fenestrations or 30 branches for the left subclavian artery. The aortic repair indications were acute type B aortic dissection (n = 17, 40.5%), degenerative aneurysm (n = 14, 33.3%), chronic dissection aneurysmal degeneration (n = 4, 9.5%), and ulcer-like projection (n = 2, 4.8%). The mean iliac artery diameter was 7.6 ± 1.1 mm. RESULTS: There were no branches covered unintentionally or patients who died and suffered from severe spinal cord ischemia perioperatively. One patient (2.4%) experienced a postoperative minor stroke with full neurological recovery. The mean follow-up time was 18 ± 11 months, with 28 patients (66.7%) having at least 12 months. One access-related complication (2.4%) occurred. Two residual Ia (4.8%) and three residual IIIa (7.1%) endoleaks were treated by reintervention. There were no open repair conversions, ruptures, or other aortic complications. CONCLUSION: Physician-modified thoracic endovascular aortic repair using the low-profile device may be a safe, feasible, and time-saving method for preserving the cervical artery and has high reproducibility and anatomical reconstruction. However, its durability requires long-term follow-up.

Total arch replacement with extended branched stented anastomosis frozen elephant trunk repair for type A dissection improves operative outcome.

Objective: Emergency surgical repair is the standard treatment for acute aortic dissection type A. However, the surgical risk of total arch replacement remains high. The Viabahn Open Revascularization TEChnique has been used for supra-aortic reconstruction during total arch replacement. This Cleveland Clinic technique is called "branched stented anastomosis frozen elephant trunk repair." Our total arch replacement with reconstructed extended branched stented anastomosis frozen elephant trunk repair requires no unnecessary cervical artery exposure. We compared the outcomes of extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement in acute aortic dissection type A. Methods: We compared the clinical course of patients undergoing total arch replacement using sutureless direct branch vessel stent grafting with frozen elephant trunk (extended branched stented anastomosis frozen elephant trunk repair) for acute aortic dissection type A with patients undergoing conventional total arch replacement. For the procedure, the aortic arch was transected circumferentially distal to the brachiocephalic artery origin. Frozen elephant trunk was fenestrated by heating with a cautery, and the self-expandable stent graft was delivered into the branch vessels through the fenestration. Results: Of 58 cases, 21 and 37 were classified in the extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement groups, respectively. The times (minutes) of selective antegrade cerebral perfusion (75 ± 24, 118 ± 47), total operation (313 ± 83, 470 ± 151), and cardiopulmonary bypass (195 ± 46, 277 ± 96) were significantly better in the extended branched stented anastomosis frozen elephant trunk repair group (P < .001). Six surgical deaths occurred: 2 (9%) in the extended branched stented anastomosis frozen elephant trunk repair group and 4 (10%) in the conventional total arch replacement group. In all cases, only 1 patient (2%) in the conventional total arch replacement group had a branch artery-related complication during the postoperative follow-up period. In the extended branched stented anastomosis frozen elephant trunk repair group, blood product use significantly decreased (P < .05). Conclusions: Extended branched stented anastomosis frozen elephant trunk repair has shown comparable safety and efficacy to conventional total arch replacement and can be used for acute aortic dissection type A emergency repair. It optimizes true lumen perfusion and facilitates supra-aortic artery remodeling.

A surgical sealant, AQUABRID decreased the volume of intraoperative blood transfusions and operative time for acute aortic dissection repair.

BACKGROUND: The effect of the surgical sealant AQUABRID on outcomes after acute aortic dissection repair has not been evaluated. The objective of this study was to examine whether the use of AQUABRID affects the volume of intraoperative blood transfusion or operative time in patients undergoing emergency surgery to repair acute aortic dissection. METHODS: A multicenter retrospective cohort study from January 2007 to December 2021. A total of 399 patients underwent emergency acute aortic dissection repair. Propensity score matching was used to adjust for the type of surgery and other patient characteristics. RESULTS: A total of 387 of the eligible 399 patients were included in this study and propensity score matching yielded 94 patients for whom characteristics were not significantly different between the two groups. The type of surgery was exactly matched (ascending aorta replacement: 19 [40%]; partial arch replacement: 13 [28%]; total arch replacement: 15 [32%] in each group). Within the matched cohort, there was a statistically significant difference in the volume of intraoperative blood transfusion. (AQUABRID vs. control: 34 [26-38] vs. 50 [38-60] U in Japan, p = .03). Operating time was significantly shorter in the AQUABRID group (total operation: mean ± SD, 343 ± 92 vs. 402 ± 161 min, p = .03; reconstruction for arch vessels: 29 ± 17 vs. 56 ± 22, p < .01). The rate of postoperative complications was comparable in the two groups. Failure to use AQUABRID was a significant predictor of the need for massive transfusion (>40 U) (odds ratio: 7.20; 95% confidence interval: 2.56-20.23; p < .01). CONCLUSIONS: The use of AQUABRID during emergency acute aortic dissection repair significantly decreased the volume of intraoperative blood transfusion and the duration of surgery.

Comparison of patency of single and sequential radial artery grafting in coronary artery bypass.

OBJECTIVES: Sequential radial artery (RA) grafting has the potential to enhance arterial revascularization compared to single grafting. Sequential RA grafting was performed predominantly with a single side-to-side anastomosis. The study aimed to assess if sequential RA grafting improved long-term graft patency compared to single RA grafting. In addition, the anastomotic patencies of side-to-side and end-to-side anastomoses in sequential RA grafting were assessed. METHODS: Two hundred nineteen patients underwent isolated coronary artery bypass grafting with skeletonized RA conduits between 2005 and 2016. Of these, 208 patients underwent radiological graft assessment; thus, 125 and 83 patients underwent single and sequential RA grafting, respectively. The graft and anastomotic patency rates were estimated using the Kaplan-Meier method. RESULTS: The median follow-up period was 9.1 years, and the radiological assessment lasted 5.1 years. The overall RA graft patency rates at 1, 5 and 10 years were 99.4%, 92.7% and 88.1%, respectively. The RA graft patency rate for sequential grafting was similar to that for single grafting (88.7% vs 87.4% at 10 years; P = 0.88). In the stratified analysis of anastomotic patency, the patency rate of side-to-side anastomoses of sequential RA grafting was significantly better than that of end-to-side anastomoses (100% vs 88.7% at 10 years; P = 0.01). CONCLUSIONS: The long-term RA graft patencies of sequential and single grafting were equally high. The anastomotic patency of side-to-side anastomoses of sequential RA grafting was remarkably high. Considering these findings, the RA can be effectively used for multiple arterial coronary revascularizations.

Full PETTICOAT in acute type B aortic dissection with patent false lumen may offer positive remodeling for the distal aorta.

OBJECTIVE: The provisional extension to induce complete attachment (PETTICOAT) technique is a unique thoracic endovascular aortic repair (TEVAR) for aortic dissection, which consists of proximal descending aortic endografting plus distal bare-metal stenting. This study aimed to investigate the efficacy of the PETTICOAT technique in patients with acute-sub-acute complicated type B aortic dissections. In particular, we compared the remodeling effect of full PETTICOAT covering down to the abdominal aorta with that of simple entry closure. METHODS: In this retrospective pre-post study, we compared the clinical course of consecutive patients undergoing TEVAR with the PETTICOAT technique in which proximal entry tear was excluded with a covered stent, and extension bare stents were placed down to the abdominal segment for acute-sub-acute complicated type B aortic dissections, between 2015 and 2017, with a control group treated with TEVAR with entry closure between 2011 and 2015. Outcomes included the aortic remodeling rate and the aortic diameter up to 1 year after surgery. RESULTS: Subjects consisted of 47 patients (21 in full PETTICOAT group, 26 in the simple entry closure group). The remodeling rate of the abdominal aorta in the full PETTICOAT group was significantly higher than in the simple entry closure group (p < 0.05), while that of the thoracic aorta was comparable between the two groups. CONCLUSIONS: This study suggests that the full PETTICOAT technique achieves better aortic remodeling compared to entry closure alone, and might lead to less reintervention.

[Thrombectomy for right atrial thrombosis complicating a pyogenic liver abscess].

Vascular complications from a liver abscess are rare but life-threatening. Herein, we report the case of a man in his 40s with a pyogenic hepatic abscess complicated by an inferior vena caval thrombus extending to the right atrium. His presenting complaint was a high fever. Blood tests revealed elevated inflammatory markers and liver enzymes. An abdominal CT demonstrated a 10cm abscess in the right hepatic lobe. A blood culture grew Streptococcus intermedius, which was sensitive to ampicillin sulbactam. He was diagnosed with a pyogenic liver abscess and treated with metronidazole and ampicillin sulbactam. Three days following admission, an abdominal CT scan revealed the thrombus extending from the liver abscess into the right atrium. He underwent thrombectomy and received antibiotic therapy. Postoperatively, abdominal ultrasound revealed a significant decrease in the size of the hepatic abscess. The patient was discharged in good condition on the 46th day of hospitalization. When encountering a hepatic abscess, it is important to consider that it may be associated with a thrombus extending from the inferior vena cava into right atrium.

Giant Aneurysm of Coronary Artery Fistula Successfully Treated by Surgical Repair.

An asymptomatic 65-year-old woman was identified with an oversized round-shaped hypoechoic lesion (62 mm in diameter) between right and left atria by echocardiogram. A contrast-enhanced 320-slice multidetector computed tomography demonstrated a giant aneurysmatic fistula branched from the left main coronary trunk towards right atrium. The patient underwent an elective surgical repair. The aneurysm was resected, followed by coronary artery bypass graft surgery using bilateral internal thoracic arteries. The surgery was successful, and the patient enjoys normal life without any symptoms for 15 months.

Left atrial myxoma detected after an initial diagnosis of polymyalgia rheumatica.

We herein report the case of a 69-year-old woman with left atrial myxoma detected following treatment with glucocorticoids for an initial diagnosis of polymyalgia rheumatica (PMR). The glucocorticoids markedly improved the patient's symptoms, and the tumor was excised after rapidly tapering the glucocorticoid dose. The PMR-like symptoms did not recur and the inflammatory marker levels returned to normal after surgery. The patient's clinical course indicated that the initial PMR-like symptoms were entirely caused by the left atrial myxoma. This case demonstrates that glucocorticoid treatment for suspected PMR can mask the symptoms of myxoma, leading to a delay in diagnosis.

Reconstruction of the free margin of the anterior mitral leaflet with autologous pericardium in active infected endocarditis.

In patients with active infective endocarditis mitral valve repair is better than mitral valve replacement, but it remains a challenge when there has been massive destruction of the rough zone of the anterior leaflet. We report a technical modification of mitral valve repair for advanced active infective endocarditis in which a widely infected rough zone and the chordae were successfully replaced with autologous pericardium and multiple artificial chordae. The procedure described here is capable of improving the prospects of mitral valve repair in advanced infective endocarditis.

Apicoaortic valved conduit with an apical connector for aortic stenosis with a calcified aorta.

We report a case of apicoaortic bypass using an apical connector for severe aortic stenosis. A 74-year-old woman suffered from severe aortic stenosis, with a small aortic annulus and a severely calcified aorta. A valved conduit with an apical connector was placed between the left ventricular apex and the descending thoracic aorta because the risk of aortic valve replacement was high. Use of an apical connector facilitated a secure connection between the conduit and the left ventricular apex. The pressure gradient across the native aortic valve fell from 64 mm Hg before the operation to 19 mm Hg afterward. Apicoaortic bypass using the apical connector is a reliable option for relieving obstruction of the left ventricular outflow tract in the presence of aortic stenosis when aortic valve replacement is a high risk.

Administration of granulocyte colony-stimulating factor after myocardial infarction enhances the recruitment of hematopoietic stem cell-derived myofibroblasts and contributes to cardiac repair.

The administration of granulocyte colony-stimulating factor (G-CSF) after myocardial infarction (MI) improves cardiac function and survival rates in mice. It was also reported recently that bone marrow (BM)-derived c-kit(+) cells or macrophages in the infarcted heart are associated with improvement of cardiac remodeling and function. These observations prompted us to examine whether BM-derived hematopoietic cells mobilized by G-CSF administration after MI play a beneficial role in the infarct region. A single hematopoietic stem cell from green fluorescent protein (GFP)-transgenic mice was used to reconstitute hematopoiesis in each experimental mouse. MI was then induced, and the mice received G-CSF for 10 days. In the acute phase, a number of GFP(+) cells showing the elongated morphology were found in the infarcted area. Most of these cells were positive for vimentin and alpha-smooth muscle actin but negative for CD45, indicating that they were myofibroblasts. The number of these cells was markedly enhanced by G-CSF administration, and the enhanced myofibroblast-rich repair was considered to lead to improvements of cardiac remodeling, function, and survival rate. Next, G-CSF-mobilized monocytes were harvested from the peripheral blood of GFP-transgenic mice and injected intravenously into the infarcted mice. Following this procedure, GFP(+) myofibroblasts were observed in the infarcted myocardium. These results indicate that cardiac myofibroblasts are hematopoietic in origin and could arise from monocytes/macrophages. MI leads to the recruitment of monocytes, which differentiate into myofibroblasts in the infarct region. Administration of G-CSF promotes this recruitment and enhances cardiac protection.

Cerebral perfusion using the tissue oxygenation index in mitral valve repair in a patient with porcelain aorta and aortic regurgitation.

We report successful mitral valve repair in a patient with porcelain aorta, complicated by aortic regurgitation, severe cerebrovascular disease, and multiple cerebral infarctions. The patient was a 77-year-old male who had congestive heart failure as a result of severe mitral regurgitation. Mitral valve repair was performed without aortic cross-clamping, using moderate hypothermic cardiopulmonary bypass. Aortic regurgitation was likely to worsen upon retracting the atrial septum to expose the mitral valve, complicating the operative procedure. We therefore controlled the regurgitation by lowering the blood temperature and using systemic perfusion flow. During systemic low-flow perfusion, we used near-infrared spectroscopy (NIRS) and the bispectral index to prevent cerebral hypoperfusion. The tissue oxygenation index value derived from NIRS was maintained above 55% during the procedure. The repair was performed safely with no difficulty. The postoperative course was satisfactory, with no neurological complications; echocardiography revealed no mitral regurgitation. The use of NIRS is valuable in preventing neurological complications in mitral valve operations complicated by porcelain aorta and aortic regurgitation.

Resection of giant right atrial lymphoma using vacuum-assisted cardiopulmonary bypass without snaring the inferior vena cava.

A 53-year-old man sustained hemodynamic collapse due to a huge right atrial tumor and was transferred to our hospital and underwent a life-saving emergency operation. The tumor arose from the inferolateral wall of the right atrium, occupying almost the whole right atrial cavity and obstructing not only the inflow of the right ventricle but also the orifice of the inferior vena cava. Venous cannulation via the right atrial wall and placing a snare around the inferior vena cava were impossible. With a cardiopulmonary bypass using vacuum-assisted venous drainage, the tumor was successfully resected and the tricuspid valve was replaced with a bioprosthetic valve without snaring the inferior vena cava. Postoperative histological examination demonstrated the tumor to be a large B-cell non-Hodgkin type malignant lymphoma. When the tumor is large and it is difficult to establish total cardiopulmonary bypass, the vacuum-assisted cardiopulmonary bypass is a useful option. This can achieve a bloodless operative field and is not blocked by the incoming air, due to the venous drainage being continually pressure-regulated.

Changes in left ventricular volume and predictors of cardiac events after endoventricular circular patch plasty.

OBJECTIVE: The aim of this study was to identify predictors of cardiac events after endoventricular circular patch plasty (Dor operation) by analyzing our experience with Dor operation. METHODS: Thirty patients with left ventricular aneurysm and/or ischemic cardiomyopathy who underwent Dor operation were included in this study. Hemodynamic and clinical results were analyzed, and the predictors of cardiac events were examined. RESULTS: Hospital mortality was 3.3%. Postoperative clinical status and left ventricular (LV) function in all survivors significantly improved. The survival rates at 1, 3, and 5 years after operation were 93%, 89% and 89%. The corresponding cardiac event-free rates were 75%, 67% and 49%. Pre- and postoperative LV function and volume did not differ significantly between patients with or without cardiac events. However, the proportion of reduced end-diastolic volume index (EDVI) (preoperative EDVI-postoperative EDVI) to preoperative EDVI was significantly higher in patients with cardiac events than in cardiac event-free patients. Postoperative LV volume re-increased in the cases with cardiac events during follow-up. Cox regression analysis confirmed that preoperative clinical premature ventricular contraction and end-systolic volume index (ESVI), postoperative EDVI, ESVI, and ejection fraction were independent predictors of late cardiac events. There was a significant positive correlation between preoperative ESVI and postoperative EDVI. CONCLUSION: Though LV function significantly improved after Dor operation, LV reconstruction with excessive reduction can cause restarting LV remodeling and increasing mortality and morbidity. Therefore, LV reconstruction of appropriate sizes and shapes, considering the function of residual myocardium, has a significant effect on prognosis. It is highly reasonable to expect that preoperative ESVI can predict the optimal size of reconstructed left ventricle.

Mortality and morbidity after total arch replacement using a branched arch graft with selective antegrade cerebral perfusion.

BACKGROUND: The early outcome after aortic arch surgery has improved. However, some operative survivors have died as a result of postoperative problems soon after discharge. This study determines the factors affecting mortality within 1 year of total arch replacement. METHODS: Between July 1993 and November 2001, 103 patients (mean age 65 +/- 11 years, 26 women, 35 dissections) underwent total arch replacement through a median sternotomy using a branched arch graft with selective cerebral perfusion. Eighteen operations including 14 acute dissections were performed on an emergency basis. Concomitant procedures were root replacement in 5 patients, mitral valve replacement in 1, coronary artery bypass in 14, and open endovascular stent-graft in 9. The average time (minutes) for bypass, aortic cross-clamp, selective cerebral perfusion, and distal arrest were respectively 273 +/- 79, 163 +/- 54, 145 +/- 36, and 69 +/- 22. RESULTS: Mechanical heart support was necessary in 3 patients. Stroke occurred in 9 patients, transient neurologic dysfunction in 7, and paraplegia/paraparesis in 4. The only independent determinant for postoperative stroke was a history of stroke (odds ratio 16.3, 95% confidence interval: 2.8 to 93.8). Thirty-one patients required ventilator support for more than 5 days. Hemodialysis was needed in 5 patients. Sternal infection or mediastinitis occurred in 6 patients. The in-hospital mortality was 12% (12 of 103). The actuarial survival rate at 1 year was 83%, and was 67% at 5 years. For the 1-year mortality independent determinants were emergency surgery (odds ratio 5.3, 95% confidence interval: 1.6 to 17.9) and age 75 years or older (odds ratio 4.0, 95% confidence interval: 1.1 to 13.9). CONCLUSIONS: Total arch replacement using a branched arch graft with selective antegrade cerebral perfusion has a favorable 1-year mortality rate except for patients undergoing emergency surgery and for elderly patients.

Apico-pulmonary artery conduit repair of congenitally corrected transposition of the great arteries with ventricular septal defect and pulmonary outflow tract obstruction: a 10-year follow-up.

BACKGROUND: In conventional repair of the congenitally corrected transpositions of the great arteries associated with ventricular septal defect and pulmonary outflow tract obstruction, the placement of the left ventricle-pulmonary artery conduit is at risk owing to probable compression by the sternum, heart block, or injury to the mitral anterior papillary muscle. Apical placement of the left ventriculotomy for the inflow conduit rather than in the midportion or base placement may avoid these complications, although this results in a long and winding extracardiac conduit that may be short-lived because of the proliferation of pseudointima. METHODS: Between 1985 and 1990, a nonvalved Dacron woven-fabric graft conduit was placed between the left ventricular apex and pulmonary artery in 5 patients (mean age, 6.2 +/- 1.7 years) who were then followed for at least 10 years. RESULTS: No iatrogenic heart blocks or mitral regurgitation developed. All patients were complaint-free during the follow-up period, although 1 patient who was clinically well died suddenly in the 10th follow-up year. Cardiac catheterization in the 10th follow-up year indicated a pressure gradient of 21 +/- 6 mm Hg across the conduit, and angiography revealed that the conduit diameter was 91% +/- 6% of the original conduit diameter. CONCLUSIONS: The reportedly poor early and late outcomes that occur after a conventional repair of congenitally corrected transpositions of the great arteries associated with ventricular septal defect and pulmonary outflow tract obstruction, which places an extracardiac conduit between the left ventricle and the pulmonary artery, may be partially neutralized by relocating the inflow position to the apex.

Liberal use of tricuspid valve detachment for transatrial ventricular septal defect closure.

BACKGROUND: Although temporary tricuspid valve detachment is useful for improved visualization of ventricular septal defect through right atriotomy, liberal use of this adjunct is not widely supported, mainly because of concerns about iatrogenic complications such as heart blocks and tricuspid valve dysfunction. The objective of this study was to determine whether liberal use of this adjunct can improve operative outcome. METHODS: Between January 1997 and March 2002, trans-atrial closure of isolated ventricular septal defect (conoventricular or canal type) was performed in 87 consecutive patients. Tricuspid valve detachment was used in 4 out of 44 patients (prudent-use group) and 19 out of 43 patients (liberal-use group) in the first and second half of this period, respectively (p = 0.0002). Patient demographics and use of other surgical and cardiopulmonary bypass techniques remained virtually unchanged during this period. RESULTS: In the prudent-use group, there was one operative death with prolonged bypass time and one residual defect that required reoperation; neither of these patients underwent tricuspid valve detachment. All other patients (both groups) were free from mortality and clinically significant complications, including heart block, tricuspid regurgitation, and residual defect. The liberal-use group had shorter cardiopulmonary bypass time than the prudent-use group (59 +/- 14 vs 67 +/- 22 minutes, p = 0.037). CONCLUSIONS: Tricuspid valve detachment should be used liberally for moderate- or even low-difficulty exposure of ventricular septal defect, regardless of patient background, because it is a safe and effective adjunct that can improve speed, programmability, reproducibility, and reliability.