Coronary artery bypass grafting transiently improves myocardial flow reserve in patients with impaired left ventricular function.

BACKGROUND: Myocardial flow reserve (MFR) derived from 13N-ammonia positron emission tomography is an index used to evaluate ischemic cardiomyopathy and predict the prognosis of patients with coronary artery disease (CAD). This study aimed to evaluate the short-term changes in MFR in patients who underwent coronary artery bypass grafting (CABG). In addition, as a reference, we showed the changes in MFR in the percutaneous coronary intervention (PCI) and optimal medical therapy (OMT) patient groups. METHODS: To determine the short-term effects of CABG in CAD with left ventricular dysfunction, myocardial blood flow (MBF) and MFR were measured before and after CABG. Additionally, we showed changes in MBF and MFR of the PCI and OMT patient groups during treatment. RESULTS: We observed that resting MBF did not significantly increase from baseline to post-CABG (0.84 ± 0.32 vs. 0.83 ± 0.23, P = 0.958); however, stress MBF increased significantly from baseline to post-CABG (1.23 ± 0.64 vs. 1.49 ± 0.42, P < 0.001). The global MFR increased significantly from baseline to post-CABG (1.49 ± 0.42 mL/g/min vs. 1.91 ± 0.51 mL/g/min, P < 0.001). Additionally, stress and resting ejection fraction (EF) significantly increased (stress EF: 42 ± 18.7% vs. 50.9 ± 18%, P = 0.005; resting EF: 45.8 ± 19.5% vs. 52.1 ± 19.4%, P = 0.031). CONCLUSIONS: This study demonstrated that CABG significantly improved MFR in a short period of time with left ventricular dysfunction. These findings suggest that epicardial coronary artery patency restores myocardial microcirculatory dysfunction in the short term.

Delayed paraplegia after endovascular repair of an abdominal aortic aneurysm after lumboperitoneal shunting.

Spinal cord ischemia is a rare but catastrophic complication of elective endovascular abdominal aortic aneurysm repair. We report a case of delayed spinal cord ischemia after the elective endovascular repair of an infrarenal aortic aneurysm in a patient who previously underwent lumboperitoneal shunting. This case demonstrates that spinal cord ischemia could cause the inability to control spinal cord pressure and that patients who undergo endovascular aortic repair with lumboperitoneal shunting may be more vulnerable to spinal cord ischemia. This case report also suggests that spinal cord pressure can be a major contributor to spinal cord ischemia.

Chronic expanding intrapericardial hematoma associated with blunt chest trauma 50 years earlier.

Chronic expanding intrapericardial hematoma can be treated surgically; however, a correct diagnosis is not always established, thus the condition remains untreated. A 76-year-old man was referred to us with a diagnosis of congestive heart failure. The patient had experienced blunt trauma to the chest 50 years earlier (during bar practice). Cardiac computed tomography revealed a cystic mass wrapped in a calcified membrane that was impeding inflow to the right atrium and ventricle. Cardiac catheterization revealed that the right ventricular pressure had a dip and plateau pattern. We diagnosed the patient with constrictive pericarditis-induced chronic expanding intrapericardial hematoma and agreed upon surgical management. We removed the hematoma and performed a pericardiectomy. The postoperative course was uneventful. In conclusion, chronic expanding intrapericardial hematoma can develop after blunt chest trauma and can be diagnosed precisely with cardiac computed tomography. Learning objective: A 76-year-old man presented with congestive heart failure. The patient had experienced blunt trauma to the chest 50 years earlier. Cardiac computed tomography (CT) revealed a cystic mass within a calcified membrane that was impeding inflow in the right atrium and ventricle. We diagnosed chronic expanding intrapericardial hematoma (CEIH). We successfully removed the hematoma and performed a pericardiectomy. CEIH can develop after blunt chest trauma and could be diagnosed earlier with cardiac CT.

Collapse of Najuta endograft (aortic arch graft) in patient with intermittent paraparesis.

A 50-year-old male underwent thoracic endovascular aortic repair (TEVAR) for distal arch traumatic aortic dissection. Following placement of a Najuta endograft (Kawasumi Laboratories, Inc., Tokyo, Japan) from zone 0 to zone 4, patency of the three vessels was confirmed. Later, the patient suddenly experienced complete intermittent loss of motor and sensory functions in the bilateral lower extremities. Contrast computed tomography (CT) findings indicated endograft stenosis. Following an additional TEVAR procedure, the paraparesis state was temporarily improved. Thereafter, he was readmitted due to congestive heart failure with intermittent paraparesis and contrast CT findings indicated endograft collapse. An emergency procedure for re-expansion of the collapsed endograft and urgent surgery for replacement of the aortic arch was successful. In cases with intermittent paraparesis, endograft collapse should be considered.

Single direct right axillary artery cannulation using a modified Seldinger technique in minimally invasive cardiac surgery.

OBJECTIVES: Single direct right axillary artery cannulation is uncommon in minimally invasive cardiac surgery; however, the risk of cerebral infarction due to retrograde perfusion using the femoral artery remains high in patients with thoracoabdominal aortic atheroma. In our institution, we perform right axillary artery cannulation using a modified Seldinger technique in patients with atherosclerotic disease. This study aimed to evaluate the safety and effectiveness of this technique in minimally invasive cardiac surgery. METHODS: Data of all peripheral cannulation cases in patients who underwent minimally invasive cardiac surgery between March 2014 and December 2019 were obtained from our institutional database. Right axillary artery cannulation was successfully performed in 175 patients, 112 of whom underwent magnetic resonance imaging. RESULTS: Procedures comprised single-valve 86.3% (n = 151, 86.3%), double-valve (n = 21, 12%), and triple-valve (n = 3, 1.7%) surgeries. In-hospital mortality rate was 1.7% (n = 3). Stroke rate was 1.1% (n = 2); these 2 patients developed stroke at 3 and 5 days postoperatively. Forty-one (36.9%) patients were diagnosed with silent brain infarction on postoperative magnetic resonance imaging. There were no instances of intraoperative local axillary arterial injury, dissection, rupture, or surgical wound infection. Two patients had axillary wound hematoma and 2 had temporary right limb neuropathy, which resolved before discharge. No cases of pseudoaneurysm were found at the cannulation site. Limb ischemia and compartment syndrome were not reported. CONCLUSIONS: There were no complications of postoperative symptomatic cerebral infarction following minimally invasive cardiac surgery with single direct right axillary artery cannulation using a modified Seldinger technique, even though patients had significant atherosclerotic vascular disease.

Surgical outcomes of minimally invasive aortic valve replacement via right mini-thoracotomy for hemodialysis patients.

OBJECTIVES: Minimally invasive valve surgery has become increasingly accepted as an alternative to conventional median sternotomy in low-risk patients. However, there have been no reports regarding the outcomes of this procedure on high-risk hemodialysis patients. The purpose of this investigation was to assess the surgical outcomes of minimally invasive aortic valve replacement (AVR) via right mini-thoracotomy (MIAVR) in hemodialysis patients compared with those of conventional AVR (CAVR) via full sternotomy. METHODS: Two hundred and seventy-four patients underwent isolated AVR for severe AS, and 42 hemodialysis patients were included in this study. MIAVR was performed in 17 cases and CAVR in 25 cases. We compared the short-term surgical outcome among the two groups. RESULTS: There was no difference in the aortic cross-clamp or cardiopulmonary bypass time. However, the procedure time was significantly shorter in the MIAVR group. Patients in the MIAVR group had less bleeding and a smaller amount of transfused red blood cells. There were four hospital deaths (18.2%) in the CAVR group. For postoperative complications, there were 2 (9.1%) cerebrovascular incidents, 2 (9.1%) cases of respiratory failure, 1 (4.5%) re-exploration for bleeding in CAVR group. The postoperative ventilation time was significantly shorter in the MIAVR group. There was no difference in the length of postoperative intensive care unit stay or of postoperative hospital stay. CONCLUSION: The surgical outcomes of MIAVR in hemodialysis patients were acceptable, with a low incidence of morbidity, reasonable lengths of hospital stay, and no mortality among the patients studied.

Successful Aortic Valve Replacement With Perceval Bioprosthesis for Aortic Stenosis With Membranous Ventricular Septum Aneurysm.

Membranous ventricular septum aneurysm (MVSA) is extremely rare, especially when coexisting with aortic stenosis (AS), and reports regarding the available treatment for MVSA with AS are limited. Aortic valve replacement (AVR) can be challenging because of anatomical reasons. In this case report, a patient with MVSA and severe AS was treated with AVR with the sutureless Perceval bioprosthesis. After implantation, no paravalvular leakage was detected in echocardiography, and no other postoperative complications were observed. Postoperative electrocardiography-gated computed tomography revealed no contrast enhancement for MVSA. The MVSA was closed by the Perceval bioprosthetic valve. Thus, patients with simultaneous MVSA and AS may be effectively treated with AVR using a Perceval bioprosthesis.

Early and mid-term outcomes of minimally invasive mitral valve repair via right mini-thoracotomy: 5-year experience with 129 consecutive patients.

OBJECTIVES: This study analyzed the experience of a single institution with minimally invasive mitral valve repair (MIMVr) via a right mini-thoracotomy (RT), including short and mid-term morbidity and mortality as surgical outcomes, and rates of reoperation. Late follow-up findings regarding mitral regurgitation (MR) were also assessed. METHODS: Between January 2014 and January 2020, a total of 141 consecutive patients underwent MIMVr for mitral regurgitation at our institution via an RT, with late follow-up results (median 35 ± 15 months) available for 129 (91.4%). Findings regarding surgical approach, complications, reoperations, and late survival were examined. Late echocardiographic results showing recurrence of MR after mitral repair were also noted. Survival, freedom from reoperation, and recurrent MR (grade > 2) were evaluated by Kaplan-Meier analysis. RESULTS: Mean age was 63.9 ± 14.3 years, mean ejection fraction was 66.9 ± 10.4%, and 2 patients (1.6%) underwent a reoperation. Concomitant procedures included atrial fibrillation ablation (18%), tricuspid valve surgery (16%). None (0%) experienced intraoperative conversion to sternotomy. A learning curve was observed as the number of cases increased. Overall in-hospital mortality and stroke incidence were both 0%. Freedom from recurrent MR (grade > 2) at 1, 3, and 5 years was 99.2, 94.9, and 94.9%, respectively, while freedom from reoperation at 1, 3, and 5 years after mitral valve repair was 98.4, 98.4, and 98.4%, respectively. CONCLUSIONS: Early and mid-term results of MIMVr were satisfactory, with low rates of perioperative morbidity and recurrent MR, as well as reoperation and death. Furthermore, the protocols for patient selection and surgical approach were considered to be appropriate.

Perfusion strategy using axillary or femoral cannulation for minimally invasive cardiac surgery: experience in 270 patients with computed tomography-based criteria.

OBJECTIVES: In patients with atherosclerotic disease, minimally invasive cardiac surgery using retrograde perfusion for cardiopulmonary bypass via femoral cannulation (FC) carries a higher risk of brain embolization compared with antegrade perfusion. However, guidelines for selecting antegrade versus retrograde perfusion do not exist. We developed a computed tomography (CT)-based perfusion strategy and assessed outcomes. METHODS: We studied 270 minimally invasive cardiac surgery patients, aged 68 ± 13, 124 female, body surface area 1.6 ± 0.2 m2. Antegrade perfusion using axillary cannulation (AC) was selected if any of the following preoperative enhanced CT scan criteria were satisfied anywhere in the aorta or iliac arteries: thrombosis thickness >3 mm, thrombosis >one-third of the total circumference and calcification present in the total circumference. FC was selected otherwise. Asymptomatic brain injury was assessed by diffusion-weighted magnetic resonance imaging. RESULTS: AC and FC were selected in 95 (35%) and 175 patients, respectively. AC patients were 10 years older (P < 0.001) and had higher EuroSCORE II (2.7 ± 3.4 vs 1.7 ± 1.9, P = 0.002). The median cardiopulmonary time and cross-clamp times were not significantly different. No patients died in hospital. There was no immediate stroke in either group during 48 h after surgery. Asymptomatic brain injury was detected in 25 (26%) and 27 (15%) AC and FC patients, respectively, P = 0.03. CONCLUSIONS: We believe our CT-based perfusion strategy using AC or FC minimized brain embolic rates. AC can be a good alternative to prevent brain embolization for minimally invasive cardiac surgery patients with advanced atherosclerotic disease.

Successful off-pump reimplantation of the anomalous right coronary artery from the pulmonary artery: A case report.

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare occurrence that requires surgical repair, typically via cardiopulmonary bypass (CPB). In this study, we present the case of a patient with ARCAPA with a high risk of cerebral infarction and left main trunk stenosis. However, because of the high risk of cerebral infarction, CPB was no longer an option during surgical intervention. Instead, we performed off-pump reimplantation of the ARCAPA to the ascending aorta and coronary artery bypass grafting of the left coronary artery. The patient had an uneventful postoperative course. Based on the successful outcomes of this case, we suggest off-pump reimplantation of the ARCAPA to the ascending aorta as a useful alternative for patients who are not eligible to undergo CPB during surgical repair. .

Silent brain infarction after minimally invasive cardiac surgery with retrograde perfusion.

BACKGROUND AND AIM: There is no report on silent brain infarction (SBI) after minimally invasive cardiac surgery (MICS) with retrograde perfusion. Thus, the current study aimed to investigate the incidence of SBI after MICS using magnetic resonance imaging (MRI). METHODS: This study included 174 patients who underwent MICS with retrograde perfusion between July 2014 and July 2018. Preoperative computed tomography (CT) angiography was routinely performed and vascular pathology was evaluated for patient selection. Postoperative MRI was performed to investigate the occurrence of SBI. RESULTS: Out of the total 174 patients, 26 (14.9%) presented with SBI. A total of 61 SBI lesions were found in the 26 patients; of these, 34 (56%) SBI lesions were in the right hemisphere and 27 (44%) in the left hemisphere. SBIs were primarily observed in the posterior cerebral artery territory. Multivariate analysis revealed aortic stenosis to be the only risk factor of SBI. CONCLUSIONS: Retrograde perfusion via femoral cannulation may not increase the incidence of SBI in selected MICS patients based on preoperative CT findings.

Early and midterm results of minimally invasive aortic and mitral valve surgery via right mini-thoracotomy.

OBJECTIVES: There are few reports regarding minimally invasive aortic valve replacement concomitant with mitral valve surgery (MIAMVS). The aim of this study was to evaluate early and midterm MIAMVS results. METHODS: We reviewed the medical records of 21 consecutive patients (nine females, 43%) who underwent MIAMVS through a right mini-thoracotomy from December 2014 to April 2017. Mean patient age was 73 ± 7.4 years and four (19%) were New York Heart Association Class III or IV. Aortic stenosis and mitral valve insufficiency were the most common pathologies. All patients were followed for a mean period of 30 ± 8.5 months. RESULTS: The types of surgery consisted of aortic valve replacement with mitral valve repair in 11 (52%) patients, and replacement of both aortic and mitral valves in 10 (48%), while a tricuspid valve repair, was performed in four. No conversion to a full sternotomy was necessary in any of the cases. Postoperatively, the median intensive care unit and hospital stays were 4.7 and 11.8 days, respectively, with no in-hospital mortality. Following the initial treatment, all 21 patients were followed for a mean period of 30 ± 8.5 months (14-45 months). All patients returned to NYHA Class I or II following the procedure. During the follow-up period, there was no need for a heart valve reoperation for any of the patients and none showed recurrent mitral regurgitation (>mild), though one died from respiratory failure caused by pneumonia. CONCLUSIONS: MIAMVS can be performed via a right mini-thoracotomy, with acceptable early and midterm results expected. This may be a feasible alternative to the standard median sternotomy approach.

The learning curve of minimally invasive aortic valve replacement for aortic valve stenosis.

OBJECTIVE: Few clinical studies have been conducted to evaluate the learning curve of minimally invasive aortic valve replacement. The purpose of this study was to retrospectively analyze the learning curve of initial and isolated minimally invasive aortic valve replacement for aortic valve stenosis which performed at our institution. METHODS: This study included 126 patients who underwent initial and isolated minimally invasive aortic valve replacement via right infra-axillary mini thoracotomy for aortic valve stenosis. Patients were divided into the first 50 patients [1-50 cases: E group (n = 50)] and the last 76 patients [51-126 cases: L group (n = 76)]. RESULTS: A significantly shorter operative time (239.4 ± 35.2 min vs. 206.5 ± 25.5 min, P < 0.001), cardiopulmonary bypass time (151.1 ± 27.4 min vs. 126.9 ± 20.2 min, P < 0.001) and aortic cross-clamp time (115.2 ± 19.0 min vs. 93.9 ± 14.7 min, P < 0.001) were found in the L group. The learning curves of operative time, cardiopulmonary bypass time, and aortic cross-clamp time plateaued after 40 cases. CONCLUSIONS: Learning curves were observed in surgical processes such as operative time. A total of 40-50 cases are required to achieve a stable operative time. However, patient outcomes were not significantly different between the groups. This study could be helpful in introducing minimally invasive aortic valve replacement and designing training programs.

Left Internal Thoracic Artery Graft Assessment by Firefly Fluorescence Imaging for Robot-Assisted Minimally Invasive Direct Coronary Artery Bypass.

OBJECTIVE: The da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) cannot give tactile feedback to surgeons. This shortcoming may increase the risk of left internal thoracic artery (LITA) injury during its harvest. We utilized Firefly Fluorescence Imaging (Firefly) to assess LITA quality in robot-assisted minimally invasive direct coronary artery bypass (R-MIDCAB). METHODS: We retrospectively reviewed clinical records and intraoperative videos of 30 consecutive patients who underwent R-MIDCAB with LITA-left anterior descending (LAD) coronary bypass. All patients had post-harvest assessment of LITA blood flow by Firefly with 1 mL (2.5 mg/mL) of indocyanine green injection through a central line. RESULTS: Twenty-seven of the patients were male, mean age was 67.7 ± 10.7 years. In post-harvest assessment performed before transection of the distal LITA, blood flow in LITA was well visualized in 28 patients. In the remaining 2 patients, 1 had dissection and the other had severe spasm of the LITA. Firefly was also useful for locating LITA and LAD and for assessing blood flow of the graft after anastomosis. Time required for each Firefly assessment was approximately 20 seconds. There were no side effects or complications due to Firefly intraoperatively and postoperatively. Twenty-six patients had postoperative coronary computed tomography; LITA patency rate was 100% (26/26). CONCLUSION: Firefly is fast, simple, and effective for locating and assessing flow in LITA and LAD before and after anastomosis in R-MIDCAB.

[Usefulness of Thoracic Endovascular Aortic Repair for the Treatment of Massive Hemoptysis Due to Bronchiectasis;Report of Two Cases].

Massive hemoptysis caused by bronchiectasis threatens life, so early bronchial arterial embolization (BAE) is needed. In case 1, a 80-year-old female complained of hemoptysis and back pain caused by bronchiectasis and Stanford type B aortic dissection. In case 2, a 78-year-old male had history of the surgery of descending thoracic aortic aneurysm and bronchiectasis combined with aortopulmonary fistula. Both cases in bronchiectasis with massive hemoptysis were difficult to perform BAE due to complicated with acute aortic dissection and aortopulmonary fistula. We applied Thoracic endovascular aortic repair (TEVAR) to these cases by its occlusive effects of the orifice of bronchial artery and collateral flow from intercostal arteries. Their postoperative courses were satisfactory without hemoptysis. We suggest that TEVAR can become the one of the option for the treatment of massive hemoptysis that is not indicated to BAE.