Clinical Features of Cardiac Calcified Amorphous Tumor: A Narrative Review.

A cardiac calcified amorphous tumor (CAT) is a non-neoplastic cardiac mass composed of calcified nodules surrounded by amorphous fibrous tissue in a context of degeneration and chronic inflammation. Although CAT cases are increasingly reported, its clinical manifestation remains unclear. We aimed to conduct a narrative review of CAT and identify its clinical characteristics. We conducted a comprehensive literature search using PubMed, with the keyword "Cardiac Calcified Amorphous Tumor" to identify relevant articles. A total of 113 articles published between 1997 and 2022 were retrieved. The clinical features allowing for assess patient background, differences with and without end-stage renal disease (ESRD), symptom-related factors, risk factors for embolism caused by CAT, and features of CAT, such as shape, location, mobility, pathology, and treatment, were statistically analyzed in 106 criteria-matched cases. The mean patient age was 60.2 ± 18.6 years, with 45 men and 61 women. Of the data collected from 21 countries, 52 patients were from Japan. Mobile CAT was more common in the chronic renal failure group. Linear, club-shaped, and spindle-shaped CAT tended to be mobile and more common in the ESRD group as well as located in the mitral valve region. The shape, mobility, location, and underlying mechanism of CAT depended on the presence or absence of ESRD. The risk of embolism was considered high because mobile CAT was more common in the ESRD group, and CAT originated in the mitral valve region. Hence, early diagnosis based on periodic examination in patients with ESRD and aggressive surgical treatment are necessary.

Is systolic blood pressure high in patients with acute aortic dissection on first medical contact before hospital transfer?

Acute aortic dissection (AAD) cases are thought to have high blood pressure (BP) on admission; however, little data are available on BP prior to admission. The purpose of this study was to investigate systolic blood pressure (SBP) very early after symptom onset and before hospital transfer in patients with AAD to determine whether SBPs were high, and also whether SBPs were higher or lower compared with SBPs at hospital admission. We obtained results using three-year data derived from the Tokyo Acute Aortic Super Network Database. First, we selected 830 patients with AAD for which the "duration from symptom onset to first medical contact by ambulance crews" (SO-FMC) was within 60 min. We examined the SBPs of such patients. Next, we selected 222 patients with AAD whose SBPs were measured both at FMC, within 15 min after symptom onset, and at hospital admission, and compared SBPs at FMC with those at hospital admission. Among types A (n = 190) and B (n = 117), in patients with an SO-FMC ≤ 15 min, the median SBP was 100 mmHg and 178 mmHg (p < 0.001), respectively; 9% and 50% (p < 0.001) of such patients, respectively, exhibited an SBP ≥ 180 mmHg; and 43% and 10% (p < 0.001) of such patients, respectively, had an SBP < 90 mmHg. Of patients with types A (n = 124) and B (n = 98) AAD whose SBPs were measured both at FMC, within 15 min after symptom onset, and at hospital admission, SBPs at FMC were higher than those at hospital admission for the SBP ≥ 180 mmHg subgroups of both type A (194 mmHg vs. 159 mmHg, p < 0.001) and type B (199 mmHg vs. 186 mmHg, p < 0.001). Approximately 10 min after symptom onset and before hospital transfer, the measured SBPs of many patients with type A AAD were not necessarily high. However, the SBPs of cases with type B AAD were high as previously reported for SBP on admission. In addition, for the subgroup of SBP ≥ 180 mmHg at FMC within 15 min after symptom onset, SBPs at FMC were significantly higher than those at hospital admission for both types A and B; the higher SBP at symptom onset may have been partially associated with being a trigger of AD.

New Treatment for Percutaneous Sites in Patients with a Ventricular Assist Device: Nihon University Crystal Violet Method.

BACKGROUND: Infection of the percutaneous site of a ventricular assist device (VAD) is a challenging complication. We report our experience with crystal violet Solbase (Nihon University crystal violet method) for prevention of driveline or cannula infections in VAD patients. PATIENTS AND METHODS: The crystal violet method was used in 10 patients (prophylaxis in nine and treatment in one). Eight patients had an extracorporeal VAD (Nipro) and two had an implantable VAD (Heart Mate II). RESULTS: The infection-free period was 4-623 days (mean: 144.2 ± 222.9 days). All eight patients with an extracorporeal VAD died, while the two patients with an implantable VAD (Heart Mate II) survived. Infection was improved in a patient with MRSA, and the results of bacteriological examination were always negative in the patients receiving prophylaxis. The two patients with an implantable VAD had no infection for 2 and 20 months after implantation. CONCLUSION: These findings suggest that the Nihon University crystal violet method is effective for prevention and treatment of driveline or cannula infections in patients with a VAD.

New Treatment for Infection of the NIPRO LVAD Cannula Site: Nihon University Crystal Violet Method.

Driveline and cannula site infections are still a frequent adverse event in patients with a ventricular assist device (VAD), and it is important to treat and prevent them because the spread of local infection may cause sepsis in some cases. We report our experience with a patient in whom infection of the NIPRO LVAD cannula site after implantation of an extracorporeal VAD was controlled by treatment with crystal violet Solbase (Nihon University crystal violet method).

Surgical Extirpation of Apical Left Ventricular Thrombus in Takotsubo Cardiomyopathy.

We report a patient with takotsubo cardiomyopathy who underwent surgical resection of apical left ventricular thrombus. A 59-year-old woman was transferred to our hospital in shock with hypothermia and diabetic ketoacidosis. The electrocardiogram showed ST segment elevation, while echocardiography revealed a reduced ejection fraction with apical and midventricular akinesis. Emergency coronary angiography showed normal coronary arteries, so takotsubo cardiomyopathy was diagnosed. Follow-up echocardiography revealed improvement of the ejection fraction. A mobile apical thrombus was also detected. Thrombectomy was performed via a left apical incision and postoperative recovery was uneventful.

An Infected Abdominal Aortic Aneurysm Caused by Helicobacter cinaedi.

We present a rare case of an infected abdominal aortic aneurysm due to Helicobacter cinaedi that was detected by blood culture. A 79-year-old man with lumbago and left lower quadrant pain was admitted for the treatment of an infected abdominal aortic aneurysm. H. cinaedi was isolated from a blood culture, which was obtained on admission. The aneurysm was successfully treated with antibiotic therapy, aneurysmectomy, debridement, replacement of a bifurcated Dacron prosthesis, and omental wrapping. Our present case suggests that H. cinaedi should be considered as the causative agent of an infected aortic aneurysm.

A persistent sciatic artery aneurysm containing a free-floating thrombus: report of a case.

A persistent sciatic artery is a rare vascular anomaly in which the sciatic artery, which involutes in the embryonic stage, persists as the blood supply to the lower limb. This vascular anomaly is often associated with aneurysm formation. A persistent sciatic artery aneurysm is a rare cause of peripheral arterial embolic disease. We herein describe the case of a 72-year-old female with a free-floating thrombus in a persistent sciatic artery aneurysm. She underwent iliac-popliteal artery bypass and exclusion of the aneurysm to prevent an embolic event.

Papillary fibroelastoma of the right ventricular free wall.

Papillary fibroelastoma is a rare benign cardiac tumor that usually arises from the valvular endocardium and its development in the cardiac chambers is extremely rare. A 52-year-old woman complained of palpitations and echocardiography revealed a cardiac tumor. Resection was performed via the right ventricle and main pulmonary artery under cardiopulmonary bypass. Histological examination of the resected tumor showed that it was a papillary fibroelastoma. The patient's postoperative course was unremarkable and no complications have been detected on followup.

Surgical repair of ruptured abdominal aortic aneurysm with non-bleeding aortocaval fistula.

We present a case of an aortocaval fistula (ACF) without bleeding because a clot was covering the fistula. A 60-year-old man was diagnosed as having a ruptured abdominal aortic aneurysm (AAA) and an aortocaval fistula, by enhanced computed tomography (CT). After the aneurysm had been opened, the fistula was detected, but there was no bleeding because it was covered with clot. After graft repair, bleeding from the fistula occurred when the clot was removed by suction. Direct closure of the fistula was achieved after bleeding was controlled by digital compression.

[Modified infarct exclusion technique of postinfarction ventricular septal perforation].

Ventricular septal perforation is one of the most serious complications of acute myocardial infarction, and is often fatal unless treated surgically. Despite the development of various surgical techniques for repair of postinfarction ventricular septal perforation, the operative mortality remains high. We report 3 consecutive cases in which a modified infarct exclusion technique was used to repair ventricular septal rupture after anterior myocardial infraction. The septal rupture was closed by the 1st pericardial patch with buttressed mattress sutures. Then buttressed mattress sutures were passed sequentially through the septal portion of the 2nd patch, the ventricular septum, and the free wall of the right ventricle to exclude the infarcted myocardium and septal perforation. The pericardial patch was sutured to the free wall of the left ventricle with a continuous suture for reconstruction of the left ventricular cavity. The ventriculotomy was closed with buttressed mattress sutures and a continuous suture. All 3 patients had an acceptable postoperative course and were discharged in satisfactory conditions. This technique seems to achieve satisfactory early results when used in the acute phase of myocardial infarction.

Prognosis of patients undergoing emergency surgery for type A acute aortic dissection without exclusion of the intimal tear.

OBJECTIVES: To investigate the prognosis after emergency surgery for acute type A aortic dissection with an unknown entry site and to identify the predictors of postoperative aortic dilatation. METHODS: The subjects were 102 patients undergoing emergency surgery for acute type A dissection from July 2005 to October 2010. They were divided into group I (n = 45) undergoing aortic surgery without tear resection and group II (n = 57) undergoing resection that included the intimal tear. RESULTS: The postoperative hospital mortality was similar, 13.3% (n = 6) in group I and 12.3% (n = 7) in group II. Of the 102 patients, 69 underwent follow-up computed tomography scanning after discharge, and the aortic diameter was significantly increased in group I compared with that in group II (P = .035). Dilatation of the descending aorta occurred in 21 patients (30.4%). Multivariate logistic regression analysis revealed that a patent false lumen (P = .027) and nonexclusion of the entry site (P = .012) were independent risk factors for aortic dilatation. No difference was found in the freedom from aorta-related clinical events at 4 years, with a rate of 81.9% in group I and 74.4% in group II. Also, no difference was found in the 4-year actuarial survival rate between groups I and II (86.4% and 78.5%, respectively). CONCLUSIONS: The prognosis of patients without exclusion of the entry site was acceptable. Careful follow-up is needed for patients with a patent false lumen or nonexcluded entry because of the risk of aortic dilatation.

Ruptured common femoral artery aneurysm or abdominal aortic aneurysm?

We encountered a patient with a large retroperitoneal hematoma due to rupture of a common femoral artery aneurysm. A 77-year-old man was transferred to our hospital with left groin pain and shock. Computed tomography demonstrated a large retroperitoneal hematoma involving the left iliofemoral segment with extravasation of contrast into the left groin from a ruptured left common femoral artery aneurysm. The patient also had an abdominal aortic aneurysm. Reconstruction of the common femoral artery with a graft was performed successfully. The patient had an uneventful postoperative course and subsequently underwent Y-graft replacement of the abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysm with left-sided inferior vena cava.

We present a case of ruptured abdominal aortic aneurysm with left-sided inferior vena cava. An 82-year-old man was admitted to our hospital with a sudden onset of severe abdominal pain and loss of consciousness. Computed tomography revealed rupture of an infrarenal abdominal aortic aneurysm and a left-sided inferior vena cava. At surgery, the inferior vena cava was found to cross anteriorly over the abdominal aorta at the usual level of the renal vein. Graft replacement was successfully performed, with careful mobilization and retraction of the inferior vena cava. The patient had an uneventful postoperative course without any deterioration of renal function.

Stanford type A aortic dissection with intimal intussusception.

A 51-year-old man presented with acute chest pain and loss of consciousness. Computed tomography showed no intimal flap in the ascending aorta and clear dissection involving the aortic root and arch, as well as the descending aorta. At surgery, the intimal tear was found to be circumferential and dissection extended to the proximal aortic arch with intussusception of the intimal layer. Emergency graft replacement of the ascending aorta was performed successfully and his postoperative course was uneventful.

Arrhythmia and sleep-disordered breathing in patients undergoing cardiac surgery.

BACKGROUND: Recently, the role of sleep-disordered breathing (SDB) in cardiovascular disease has attracted attention. In this study, we investigated the influence of SDB on postoperative arrhythmias after cardiac surgery. METHODS AND RESULTS: In 89 patients undergoing cardiac surgery, postoperative portable monitoring for SDB and Holter electrocardiography were performed. The primary end-points were the apnea-hypopnea index (AHI) and occurrence of arrhythmia. The secondary end-points were: (1) patient background factors; (2) average heart rate; (3) maximum heart rate (total, daytime, and nighttime); (4) minimum heart rate (total, daytime, and nighttime); (5) minimum SaO(2) during sleep; and (6) an independent predictor for arrhythmia. Twenty-six patients (29.2%) had an AHI≥15 and they were classified into the SDB group, while patients with an AHI<15 formed the non-SDB group (70.8%). Although there was no significant difference in atrial fibrillation, frequent nocturnal premature ventricular contractions were significantly more common in the SDB group (19.2%) than the non-SDB group (3.2%) (p=0.01). Maximum daytime and nighttime heart rates were also significantly higher in the SDB group. AHI was a significant predictor for frequent nocturnal premature ventricular contractions. CONCLUSIONS: This study showed that SDB is common among patients undergoing cardiac surgery, and that SDB might be closely associated with arrhythmia in these patients.

Intrathoracic left subclavian artery aneurysm: report of a case.

Aneurysms of the intrathoracic subclavian artery are extremely rare. A 74 year-old man was referred to our hospital with an abnormal chest X-ray film. Contrast computed tomography revealed an intrathoracic left subclavian artery aneurysm. Via left 4th posterolateral thoracotomy, the aneurysm was exposed under systemic deep hypothermia and circulatory arrest. The distal arch was replaced with a 26 mm single-branched graft and the left subclavian artery was reconstructed with a 10 mm graft.

Low-dose atrial natriuretic peptide for chronic kidney disease in coronary surgery.

PURPOSE: Chronic kidney disease (CKD) is an independent risk factor for cardiovascular disease. We investigated the effectiveness of human atrial natriuretic peptide (hANP) infusion in CKD patients undergoing coronary artery bypass grafting (CABG). PATIENTS AND METHODS: We analyzed 134 consecutive cases in which CABG had been performed in our hospital from 2002 to 2005. They were divided into four groups: Group A (n = 19) was CKD + placebo, Group B (n = 30) was non-CKD + placebo, Group C (n = 22) was CKD + hANP, and Group D (n = 63) was non-CKD + hANP). The serum creatinine (mg/dl) and estimated glomerular filtration rate (ml/min/1.73 m²) were measured as evaluation values. RESULTS: The value of sCr changed preoperatively and at 1 year postoperatively from 1.09 ± 0.09, 51.3 ± 4.4 to 1.26 ± 0.42, 49.4 ± 14.4 in Group A, from 0.77 ± 0.14, 75.5 ± 12.1 to 0.91 ± 0.40, 72.3 ± 19.5 in Group B, from 0.99 ± 0.12, 54.8 ± 3.0 to 0.93 ± 0.16, 64.2 ± 12.3 in Group C and from 0.77 ± 0.13, 77.7 ± 13.4 to 0.83 ± 0.17, 75.9 ± 16.2 in Group D, respectively. There was a significant difference between Group A and Group C regarding the change of creatinine (p =0.0022). CONCLUSION: Our study has confirmed that an infusion of hANP during CABG in patients with CKD not only improves perioperative renal function, but also prevents the progression of CKD.

Results of low-dose human atrial natriuretic peptide infusion in nondialysis patients with chronic kidney disease undergoing coronary artery bypass grafting: the NU-HIT (Nihon University working group study of low-dose HANP Infusion Therapy during cardiac surgery) trial for CKD.

OBJECTIVES: The purpose of this comparative study is to prove the efficacy of the human atrial natriuretic peptide (hANP) in patients with chronic kidney disease (CKD) undergoing coronary artery bypass graft surgery (CABG). BACKGROUND: CKD is an important risk factor for cardiac surgery. METHODS: This was a randomized controlled study of 303 patients with CKD who underwent CABG, and were divided into a group who received carperitide infusion and another group without carperitide. The primary endpoints were: 1) the post-operative dialysis-free rate; and 2) serum creatinine (sCr) and estimated glomerular filtration rate. The secondary endpoints were: 1) the early post-operative outcome; 2) outcome at 1 year post-operatively; 3) the maximum sCr, the rate of increase of sCr, and an increase of sCr by ≥ 0.3 mg/dl compared with the pre-operative value; and 4) ANP and cyclic-guanosine monophosphate levels. RESULTS: The post-operative sCr was significantly lower in the hANP group not only in the post-operative acute stage but also in the first year. The maximum Cr and Cr increase rate were significantly lower in the hANP group (p = 0.00665, p < 0.0001). There was no difference in mortality rate in the first year post-operatively, and fewer cardiac events and patients going on dialysis were found in the hANP group (p < 0.0001 and p = 0.0014, respectively). CONCLUSIONS: In the post-operative acute stage, carperitide showed cardiorenal protective effects that prevented post-operative cardiac events and initiation of dialysis. Thus, perioperative infusion of low-dose carperitide may have a significant role in management of patients with renal dysfunction undergoing on-pump CABG. (Effectiveness of hANP for Cardiac Surgery in Patients With Moderate to Severe Preoperative Renal Dysfunction Without Dialysis [NU-HIT for CRF]; UMIN000001462).

Total arch replacement and open stent graft implantation using a newly developed stent graft: report of a case.

We experienced a case in which a total arch replacement and an open stent implantation were performed for a distal aortic arch aneurysm using a newly developed stent graft (Ube CL-0201; Ube Medical, Tokyo, Japan). This novel stent graft is composed of a woven polyester graft and a nickel-titanium alloy stent, and has been under evaluation in clinical trials at four institutions in Japan, including our hospital, since 2008. The patient was weaned from the respirator on the day after surgery, and 9 months have passed since the surgery with no complications. A follow-up computed tomography scan showed that the stent part was sufficiently open, and no complications, such as an endoleak, have been observed.

Continuous low-dose infusion of human atrial natriuretic peptide in patients with left ventricular dysfunction undergoing coronary artery bypass grafting: the NU-HIT (Nihon University working group study of low-dose Human ANP Infusion Therapy during cardiac surgery) for left ventricular dysfunction.

OBJECTIVES: Continuous low-dose infusion of human atrial natriuretic peptide (hANP) in patients undergoing cardiac surgery on cardiopulmonary bypass (CPB) inhibits the renin-angiotensin-aldosterone system and compensates for the adverse effects of CPB. BACKGROUND: We examined the influence of hANP infusion on cardiac and renal function in patients with left ventricular dysfunction undergoing coronary artery bypass grafting (CABG). METHODS: The subjects were 133 patients who underwent CABG and had a pre-operative ejection fraction < or =35%. They were randomized to receive 0.02 microg/kg/min of hANP from the initiation of CPB (hANP group) or placebo (saline) infusion. RESULTS: Early post-operative mortality did not show a significant difference between the 2 groups, but perioperative complications were significantly less frequent in the hANP group (p = 0.015). Long-term all-cause mortality showed no difference, but the cardiac death-free rate at 5 or 8 years post-operatively was 98.5% in the hANP group and 85.5% in the placebo group (p = 0.0285). Post-operative ejection fraction was significantly larger and the post-operative brain natriuretic peptide level was significantly lower in the hANP group. Serum creatinine was significantly lower in the hANP group than the placebo group at 1 month, 6 months, and 1 year post-operatively, whereas the estimated glomerular filtration rate was significantly higher in the hANP group at these times. CONCLUSIONS: In patients with left ventricular dysfunction undergoing CABG, hANP showed renal- and cardio-protective effects and reduced post-operative complications. It also improved the long-term prognosis. We suggest that hANP should be considered as part of perioperative management of patients with cardiac dysfunction undergoing cardiac surgery. (NU-HIT trial for LVD; UMIN000001652).