[Idiopathic Ascending Aortic Thrombosis with Multiple Embolism:Report of a Case].

Ascending aorta thrombosis unaccompanied by an aneurysm or a primary hypercoagulable state is rare. We report a surgical case of ascending aorta thrombosis with multiple emboli. A 44-year-old woman visited the hospital for evaluation of dysarthria and was diagnosed with multiple cerebral infarcts. Contrast-enhanced computed tomography (CT) revealed a mass in the ascending aorta and the brachiocephalic artery. We performed emergency removal of the masses and endarterectomy with cardiopulmonary bypass under hypothermic circulatory arrest. Histopathological examination of the resected specimen showed thrombi. The patient had an uneventful recovery and was discharged 12 days postoperatively. No recurrent thrombus or hypercoagulable state was observed for 3 years postoperatively.

[Surgical Outcomes of Mycotic Aneurysm of the Aortic Arch].

Mycotic aneurysm of the aortic arch is a rare, but critical entity. We reviewed our surgical experience of mycotic aneurysm of the aortic arch. Between January 2007 and December 2015, we operated on six patients who had mycotic aneurysm of the aortic arch. The mean age was 72 years old, and four males were included. Preoperative white blood cell count was 18,266/µl and C-reactive peptide was 18.5 µg/dl, respectively. The initial presentations included fever( n=2), hoarseness( n=2), weakness of a leg( n=1), dyspnea (n=1) and hemoptysis (n=1). Preoperative blood cultures were positive in three patients. All patients underwent a total aortic arch repair with a four-branched vascular tube, and five received pedicled omental grafting. One patient who did not receive pedicled omental grafting died of recurrence of infection on postoperative day 21, and the other died of multi-organ failure on postoperative day 77. We experienced tracheostomy( n=1), minor stroke( n=1), and atrial fibrillation( n=1). During the follow-up period, no recurrence of infection was observed in four survivors. Our surgical strategy is satisfactory to achieve good clinical outcomes.

Pneumatosis intestinalis and hepatic portal venous gas caused by enteral feeding after a heart valve surgery.

An 81-year-old female with a history of type I diabetes mellitus underwent mitral valve repair and tricuspid annuloplasty for severe mitral and tricuspid regurgitation. A nasogastric tube was inserted on postoperative day 2, and enteral feeding was initiated. She complained about severe abdominal pain on postoperative day 7. Contrast-enhanced computed tomography revealed a massive hepatic portal venous gas and pneumatosis intestinalis of the small intestine. Emergency laparotomy showed no evidence of transmural necrosis. Bowel resection was not performed. On the next day, computed tomography showed an almost complete resolution of the portal venous gas and pneumatosis intestinalis. She was discharged home. Learning objective: Cardiac surgeons should still be aware that enteral feeding is a potential risk factor for pneumatosis intestinalis and hepatic portal venous gas as a sign of non-occlusive mesenteric ischemia due to impaired blood supply, intestinal distension, and toxic mucosal injury.

Midterm Outcomes After Surgical Management for Mitral Valve Regurgitation in Infancy.

BACKGROUND: Mitral valve repair is preferred for pediatric mitral valve disease. However, it is technically difficult because of complex lesions, poor surgical exposure, and tissue fragility, especially in infants. We investigated the midterm outcomes of mitral valve surgery for mitral regurgitation in infancy. METHODS: We retrospectively reviewed 18 patients (aged <12 months old) undergoing mitral valve surgery for mitral regurgitation at our institution between October 2005 and March 2019. The patients had 10 acquired and 8 congenital valve lesions as follows: torn chordae (n = 6), leaflet prolapse (n = 4), posterior leaflet hypoplasia (n = 3), anterior leaflet cleft (n = 2), infective endocarditis (n = 1), papillary muscle rupture (n = 1), and hammock valve (n = 1). RESULTS: All patients initially underwent mitral valve repair. There was no operative mortality, and 1 case of late death. The median follow-up period was 7 years and 9 months. Reoperation was performed in 3 patients, re-repair (twice) in 1 patient with a hammock valve, and mitral valve replacement in 2 patients. Fifteen patients had at most mild mitral regurgitation at the last follow-up. A transmitral mean pressure gradient of over 5 mm Hg was observed in 3 cases, including the patient with a hammock valve. Postoperative mitral annular diameter increased within the normal range in all patients. Survival and reoperation-free rates at 5 and 10 years were 94.4% and 83.0%, respectively. CONCLUSIONS: Mitral valve repair for mitral regurgitation in infancy is safe and feasible with satisfactory midterm outcomes, even under serious preoperative conditions.

[Primary Volvulus of the Small Intestine Mimicking Nonocclusive Mesenteric Ischemia Following Open-heart Surgery].

A 73-year-old female who underwent aortic valve replacement with a biological valve, coronary artery bypass, and left atrial appendage closure had sudden onset of nausea and abdominal pain 43 days after surgery. She had a history of nonocclusive mesenteric ischemia on 4th postoperative day, for which conservative management was successfully carried out. A contrast-enhanced computed tomography(CT) was performed because a recurrence of nonocclusive mesenteric ischemia was suspected. It revealed a whirl sign in the small intestine, suggestive of small intestine volvulus. At the subsequent emergency laparotomy, volvulus caused severe congestion in the small intestine, aproximately 40 cm from the cecum. However, there was no evidence of transmural necrosis, and reduction of torsion notably improved blood supply to the small intestine. Her regular diet was resumed on 4th postoperative day, and her postoperative course was uneventful. Volvulus should be considered as a differential diagnosis in the setting of acute abdominal pain after open-heart surgery.

Surgical strategy for treating mycotic aneurysms of thoracic and abdominal aorta and iliac artery: Analysis of long-term follow-up data.

Mycotic aneurysms of the aorta and iliac arteries are rare, but life-threatening conditions. We reviewed our experience to determine the best surgical strategy. Between 2007 and 2015, we operated 14 patients with mycotic aneurysms of the aortic arch (n = 6), descending aorta (n = 1), thoracoabdominal aorta (n = 2), abdominal aorta (n = 4), and iliac artery (n = 1). The mean age was 70.4 ± 8.8 years, and 10 males were included. Blood culture, tissue culture, or both were positive in 11 patients. Four of five patients with mycotic aneurysms of the abdominal aorta and iliac artery underwent extra-anatomical bypass. Ten underwent in-situ graft replacement for managing mycotic aneurysms of the thoracic aorta. One patient with a mycotic thoracoabdominal aortic aneurysm underwent visceral bypass of the descending aorta and extra-anatomical bypass. Omental pedicle grafting was performed in 10 patients. The mean follow-up period was 8.6 ± 3.1 years. Three patients (21.4%) died. Recurrent infection was observed in one patient with a mycotic aneurysm of iliac artery three months after the initial surgery. The patient underwent extra-anatomical bypass with omental pedicle grafting as a redo. Nine patients were discharged, and no recurrence of infection was observed. Two patients died of cancer and heart failure. The five- and seven-year survival rates were 100% ± 0.0% and 85.7% ± 13.2%, respectively. A combination of radical debridement of the infectious source and omental pedicle grafting with either in-situ graft replacement or extra-anatomical bypass is an effective strategy.

[Surgical Removal of a Fractured Guide Wire for Coronary Angioplasty and Coronary Artery Bypass Grafting:Report of a Case].

Guide wire fracture is a rare, yet potentially life-threatening complication of percutaneous coronary intervention. A 65-years old man underwent emergent coronary angioplasty for myocardial ischemia. Percutaneous coronary intervention for the residual lesions of left anterior descending artery (LAD) was planned. The protection guide wire for left circumflex artery( LCx) was entangled in the stent in LAD. Despite many attempts, the wire could not be retrieved. Finally, the wire was fractured and the stent in LAD was deformed. The patient was sent to our service to remove the fractured wire. We performed urgent removal of the guide wire and coronary artery bypass grafting( CABG). The postoperative course was uneventful. The timing of surgical removal of the guide wire and the indication for coronary artery reconstruction should be discussed by heart team.

[Surgery for a Massive Left Atrial Myxoma, Four Hours after a Thrombectomy for a Cerebral Embolism:Report of a Case].

A 48-year-old female patient was transferred with dysarthria and left-sided hemiplegia. Contrast-enhanced computed tomography revealed occlusion of the first branch of the right middle cerebral artery, for which an emergency thrombectomy was successfully performed within 2 hours of patient's initial symptoms. Postoperatively, transthoracic echocardiography revealed a massive mobile left atrial mass, measuring approximately 65×30 mm, a part of which moved in and out of the mitral valve without significant mitral regurgitation. Embolisms to the kidneys and the spleen were demonstrated. Another emergency cardiac surgery was performed, 4 hours after the thrombectomy, to resect the mass from the fossa oval with the atrial septum;the defect was closed using autologous pericardium. The histopathological findings of the specimen were consistent with a myxoma. The patient completely recovered and was discharged when ambulatory. We have discussed the importance of the timing of surgical intervention in the context of patients undergoing cardiac surgery after a cerebral embolism.

Hemodynamic performance of INSPIRIS RESILIA aortic bioprosthesis for severe aortic stenosis: 2-year follow-up in Japanese cohort.

The INSPIRIS RESILIA aortic bioprosthesis (Edwards Lifesciences LLC, Irvine, USA) was fixed in novel tissue preservation technology to ensure long-term durability. Hemodynamic performance after aortic valve replacement (AVR) for severe aortic stenosis (AS) has not been published in the Japanese cohort. Twenty-nine patients underwent AVR with INSPIRIS RESILIA bioprosthesis for severe AS between November 1, 2018 and December 31, 2020. The mean age was 75.1 ± 4.5 years with 19 female patients. Body surface area was 1.58 ± 0.19 m2 and New York Heart Association functional class was 2.2 ± 0.5. Hemodynamic performance was assessed using follow-up transthoracic echocardiographic data collected at 3-6 months, 1 year and 2 years. The mean follow-up time was 19.2 ± 7.2 months, with a 100% follow-up rate. One patient died of postoperative heart failure. The preoperative mean and peak transvalvular pressure gradients (PGs) were 51.9 ± 18.4 mmHg and 89.3 ± 34.9 mmHg, respectively, and effective orifice area 0.72 ± 0.26 cm2. They improved at 10.2 ± 3.5 mmHg (p < 0.0001), 19.3 ± 6.6 mmHg (p < 0.0001) and 1.73 ± 0.47cm2 (p < 0.0001) at discharge. The mean transvalvular PG at 3-6 months (n = 24), 1 year (n = 25) and 2 years (n = 15) was 11.2 ± 3.8 mmHg (p < 0.0001), 11.1 ± 3.2 mmHg (p < 0.0001) and 11.2 ± 3.3 mmHg (p < 0.0001), respectively. Left ventricular mass index decreased from 123.0 ± 35.0 g/m2 before surgery to 113.4 ± 35.0 g/m2 (p = 0.0133) at discharge. It has dropped to 88.0 ± 25.0 g/m2 (p = 0.0007) at 2 years. Constrictive pericarditis caused heart failure in one patient. INSPIRIS RESILIA bioprosthesis showed improved hemodynamic performance in the early postoperative phase. There were fewer valve-related events observed.

Ruptured Abdominal Aortic Aneurysm Treated by Double-Balloon Technique and Endovascular Strategy: Case Series.

PURPOSE: Mortality in patients with ruptured abdominal aortic aneurysms (rAAAs) has remained high despite advances in interventions. Endovascular aneurysm repair (EVAR) was recently developed for treatment of rAAAs. In this study, we assessed our endovascular strategy including a double-balloon technique for rAAA. METHODS: We analyzed 12 consecutive patients with rAAAs who were treated by our double-balloon technique and endovascular strategy from March 2013 to July 2016. RESULTS: The 30-day and 1-year mortality rates were both 17%. The mean times from admission to arrival at the hybrid operating room, from admission to aortic occlusion, and from admission to completion of EVAR were 46.8, 63.5, and 110.0 minutes, respectively. CONCLUSION: This study indicates that the herein-described double-balloon endovascular technique is feasible for use in the management of rAAA.

Hybrid procedure for a Kommerell's diverticulum in a right-sided aortic arch.

A rare case of an aneurysmal Kommerell's diverticulum in a right-sided aortic arch was successfully treated using a hybrid procedure comprising total arch replacement and percutaneous stent grafting. A 65-year-old man with dysphagia was diagnosed with an ectatic right-sided aortic arch and a saccular aneurysm of the Kommerell's diverticulum. Since its radical resection during a single surgery was unfeasible because of its complex configuration, a 2-stage procedure was adopted.

Isolated aneurysm of the proximal right subclavian artery treated with consideration toward cerebral circulation and vasculature.

A 65-year-old man with an isolated aneurysm of the proximal right subclavian artery (SCA) (diameter, 50 mm) was successfully treated with a deliberate surgical strategy described here. Because of the occluded left vertebral artery (VA) and poor development of the circle of Willis, the distal portion of the right SCA was bypassed from the ascending aorta before resecting the aneurysm in order to maintain blood flow to the brain through the right VA. Consequently, the patient recovered without neurological complications. We conclude that conventional surgery remains effective for complex vascular diseases even in the era of advanced endovascular surgeries.

Insights of stroke in aortic arch surgery: identification of significant risk factors and surgical implication.

PURPOSE: Although the outcomes of aortic arch surgery have improved, stroke remains one of the most devastating complications. Therefore, identification of true risk factors and understanding the pathogenesis of intraoperative stroke are necessary to decrease its occurrence. METHODS: From January 2002 to December 2010, a total of 251 consecutive patients underwent aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion in our hospital. Hemiarch replacement cases were excluded. Of the remaining patients, 190 elective cases that could be reviewed with full perioperative clinical data were analyzed. Strokes were classified into three subtypes according to their distribution on imaging studies: multiple-embolism type, hypoperfusion type, and solitary-embolism type. RESULTS: Operative death occurred in 1.1% of patients (2/190), and aortic arch surgery-related in-hospital death occurred in 5.3%. Among the 188 survivors, intraoperative strokes occurred in 5.9%. Multiple-embolism, hypoperfusion type, and solitary-embolism stroke occurred in 2.7%, 2.1%, and 1.6%, respectively. Multivariate analysis revealed that the risk factor for multiple-embolism stroke was high-grade atheroma in the ascending aorta [P < 0.001, odds ratio (OR) 118.0], and that for hypoperfusion type stroke was prolonged brain ischemia time over 120 min (P = 0.004, OR 31.5). No significant risk factor was found for solitary-embolism stroke. CONCLUSION: Intraoperative strokes during elective aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion are strongly influenced by the presence of a high-grade atheroma in the ascending aorta and prolonged brain ischemia time. The results suggest that these are key issues to reduce stroke in aortic arch surgery.

Occlusion of left coronary artery ostium by left coronary cusp fusion.

We report two cases of adults who had occlusion of the left coronary artery ostium by the left coronary cusp. Both patients were treated with the Bentall procedure, and both revealed a good, long-term course. We offer proper strategy of perioperative management consisting of precise preoperative diagnosis with a multimodality imaging study and adequate operative technique.

Fracture embolization of an Edwards-Duromedics valve with asymmetrical closure.

We report a case of sudden leaflet fracture of an Edwards-Duromedics mitral valve 17-years after its implantation. The patient had a history of an asymmetrical motion of the valve, five months earlier. A computed tomography scan showed two fragments that had embolized to the right brachiocephalic artery and left common iliac artery. An emergency mitral replacement surgery was successfully performed. Asymmetrical closure of the valve leaflet may have contributed to valve fracture.