Percutaneous drainage and staged valve replacement followed by laparoscopic splenectomy in infective endocarditis with splenic abscess.

Splenic abscess is a severe complication of infective endocarditis. The need for splenectomy to control prosthetic valve infection remains controversial. Here, we present the case of a 49-year-old man who complained of fever and general fatigue. Blood cultures grew Group G Streptococcus, and intravenous antibiotics were started. Abdominal computed tomography showed splenic abscess; thus, percutaneous drainage was performed. Two-dimensional transthoracic echocardiogram revealed a mobile vegetation on the right coronary cusp of the aortic valve with mild aortic regurgitation. The patient underwent aortic valve replacement using a 23-mm SJM Regent mechanic valve, followed by laparoscopic splenectomy 3 days later. The patient was asymptomatic without recurrence of infection 13 months postoperatively. Current guidelines recommend that splenectomy should be performed first, followed by valve replacement. However, we performed valve surgery first because of the risk of embolism. Depending on the patient's condition, performing splenic drainage and valve replacement first may be considered.

Surgical Strategy for Chronic Type B Dissecting Aortic Aneurysm to Prevent Aorta-Related Events.

BACKGROUND: This study was aimed to evaluate the outcomes of performing open repair or thoracic endovascular aortic repair for chronic type B dissecting aortic aneurysm. METHODS: From July 2004 to February 2019, 52 patients underwent surgery as open repair (n = 32) or endovascular repair (n = 20) for chronic type B dissecting aortic aneurysm. Replacement of the aorta was limited to the aneurysmal portion with or without reconstructing the visceral arteries or the segmental arteries. Stent grafts were deployed in the true lumen above the celiac artery to cover the primary entry for even DeBakey IIIb dissection. RESULTS: Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. In the endovascular repair group, 3 patients died due to rupture of residual false lumen in the early, and late postoperative follow-up. The 5-year rate of freedom from all-cause death, aorta-related death, and aorta-related event were 84% ± 6%, 94% ± 3% and 84% ± 6%. The endovascular repair was independently associated with all-cause death (hazard ratio [HR], 5.7; confidence interval [CI], 1.02-31.6; P = 0.04) and aorta-related event (HR, 30.9; CI 4.9-195.0; P < 0.001). In the open group, postoperative residual aortic diameter was an independent predictor of aorta-related events, and the threshold was 41 mm. CONCLUSIONS: Open repair remains a better option than simple endovascular repair alone in DeBakey IIIb dissection, but the distal un-resected aortic portion over 41 mm was associated with late aortic events.

Off-Pump Resection of an Epicardial Cyst by Using a Minimally Invasive Approach.

A 25-year-old man presented with palpitations and subsequently received a diagnosis of a large epicardial cyst (6.8 × 3.8 cm) originating from the left ventricle. The cyst compressed the left atrium and ventricle and led to left ventricular diastolic dysfunction. Contrast-enhanced chest computed tomography revealed that the circumflex artery passed over or through the cyst. We successfully resected the cyst without using cardiopulmonary bypass through a left mini-thoracotomy with thoracoscopic assistance. The diastolic dysfunction improved after the procedure. Most epicardial cysts may be treated in this fashion if the cyst is located in the left side of the heart.

Clinical impact of the repair technique for posterior mitral leaflet prolapse: Resect or respect?

BACKGROUND AND AIM: Leaflet resection and chordal reconstruction are established repair techniques for posterior mitral valve (MV) prolapse. This study aimed to compare the clinical results of the resect and respect approaches, with a particular focus on MV hemodynamics. METHODS: Overall, 291 patients who underwent elective MV repair for isolated posterior leaflet prolapse between 2012 and 2020 were enrolled. Patients who underwent leaflet resection alone were classified as the "resection" group (n = 166), while patients who underwent neochordal replacement with/without limited leaflet resection were classified as the "respect" group (n = 125). Early postoperative MV hemodynamics and midterm repair durability were compared between the groups. RESULTS: The annuloplasty ring size was significantly larger in the respect group than in the resection group (31.0 ± 2.1 vs. 30.4 ± 2.0 mm, p = .028). The respect group showed significantly lower mean MV gradient (2.6 ± 1.1 vs. 3.0 ± 1.4 mmHg, p = .03) and larger effective orifice area (EOA) (1.86 ± 0.48 vs. 1.66 ± 0.47 cm2 , p < .001) than the resection group. Multivariable analysis identified the respect approach, younger age, female sex, larger ring size, and partial band as independent determinants of larger EOA. The rate of freedom from moderate or greater recurrent mitral regurgitation 5 years postoperatively was 90.9% in both groups. CONCLUSIONS: The respect approach allowed for a lower MV gradient and a larger EOA than the resection approach, which is possibly due to the capability of implanting a larger annuloplasty ring.

Graft Traction Resolved Left Ventricular Outflow Tract Obstruction.

We admitted a 76-year-old woman for treatment of an ascending aortic aneurysm with left ventricular outflow tract (LVOT) obstruction and systolic anterior motion (SAM) of the mitral valve. Echocardiography showed an elevated velocity of the LVOT flow with a sigmoid septum. Mild mitral regurgitation was also detected due to SAM. We performed a graft replacement of the ascending aorta, after which the LVOT obstruction and SAM were resolved. We report a case in which the traction of a graft likely released the compression on the aortic root and ventricular septum.

Hypo-attenuated leaflet thickening and reduced leaflet motion after the implantation of the Perceval S sutureless bioprosthesis.

Hypo-attenuated leaflet thickening (HALT) is gaining attention as a relatively common issue after surgical or transcatheter aortic valve replacement (AVR). However, only a few reports have described HALT in sutureless bioprosthesis, which has emerged as a promising tool with excellent hemodynamics and enhanced implantability. We herein report a 75-year-old woman who underwent quintuple coronary artery bypass grafting and sutureless AVR with a Perceval S bioprosthesis (LivaNova PLC, London, UK). Despite an uneventful perioperative course, her recovery was slow with persistent pleural effusion. Echocardiography revealed an increased transvalvular pressure gradient, and HALT was confirmed by computed tomography. The patient received aggressive anticoagulation therapy with resolution of the HALT and made an uneventful recovery. Current guidelines provide no specific recommendations for peri-procedural antithrombotic therapy for sutureless AVR. However, HALT is not rare after sutureless AVR and can lead to significant clinical consequences. In this case, aggressive anticoagulation therapy with systemic heparinization was effective as HALT treatment following early post-sutureless AVR. Further investigation is required to determine the optimal antithrombotic strategy for sutureless AVR.

Papillary Muscle Reorientation for Systolic Anterior Motion After Mitral Valve Repair.

Systolic anterior motion (SAM) of the mitral valve is a well-known complication in mitral valve repair. Because excessive leaflet tissue is an important mechanism, surgical correction is sometimes required to reduce leaflet height or mobility. However, a different approach may be necessary in cases of normal leaflet height. Herein, we describe papillary muscle reorientation for treating SAM after isolated anterior leaflet repair. The papillary muscle heads were approximated and fixed to the posterior ventricular wall, relocating them away from the ventricular septum. This technique is useful for treating postrepair SAM, without addressing the leaflet, in patients with degenerative mitral disease.

Titanium plate to fix crossed rib can cause cardiac tamponade: A cautionary note.

A 78-year-old woman diagnosed with an infected descending aortic aneurysm underwent graft replacement through a left rib-cross thoracotomy. She developed shock suddenly on the postoperative day 3 owing to cardiac tamponade. We performed emergent surgery and identified a small myocardial laceration in the left ventricular obtuse marginal area and a small perforation on the pericardium. One of the claws used to fix the titanium plate in the cross-rib repair caused this complication. This is a cautionary note regarding this type of titanium plate, which is used in many procedures.

Surgical strategy for atrial fibrillation to prevent stroke in patients undergoing cardiac surgery.

OBJECTIVE: The aim of this study was to compare outcomes of the full maze procedure with left atrial appendage closure (LAAc) as concomitant procedures for atrial fibrillation (AF) in patients undergoing cardiovascular surgery. METHODS: A total of 151 patients (88 men, 62 women) underwent elective AF surgery concomitantly with cardiovascular surgery from April 2005 to December 2019. The mean age at time of operation was 70 years and the mean follow-up period was 5.2 ± 3.8 years. Patients were divided into two groups according to the procedure performed: the maze group (n = 87) and the LAAc group (n = 63). RESULTS: Patients in the LAAc group were significantly older and had more comorbidities than those in the maze group. The operative mortality rate was significantly higher in the LAAc group. There was no difference in the rate of freedom from cardiac-related death between the groups (p = 0.86). Furthermore, there was no difference in the 5-year rate of freedom from thromboembolic stroke between the maze group and the LAAc group (p = 0.17). However, the 5-year rate of freedom from heart failure was significantly higher in the maze group compared with the LAAc group (100% vs. 86% ± 6%, respectively; p = 0.006). CONCLUSIONS: Patients undergoing the maze procedure had good operative and long-term results, suggesting that this procedure should be performed if indicated. Concomitant LAAc may be effective for preventing thromboembolic stroke in patients with AF if they have no indication for the maze procedure.

Sutureless aortic valve replacement with concomitant aortic arch reconstruction.

Sutureless aortic valve replacement (AVR) offers an alternative approach to the standard AVR in aortic valve disease. We herein report a case of an 82-year-old woman with severe aortic insufficiency and a persistent type 1 endoleak following a thoracic endovascular aortic repair, who underwent successful combined aortic arch reconstruction and sutureless AVR. The bioprosthesis, Perceval (LivaNova PLC, London, UK), a self-anchoring, self-expanding, sutureless valve, which can be implanted in selected patients with aortic insufficiency was used. Although the patient was frail and at a high risk of open-heart surgery, she had an uneventful postoperative course. Hence, Perceval may be a useful option for combined aortic arch reconstruction and aortic valve surgery in high-risk elderly patients.

Stepwise mitral valve repair for Barlow's disease via a minimally invasive approach.

BACKGROUND AND AIM: Mitral regurgitation (MR) in Barlow's disease is complicated because of its mixed pathophysiology, leaflet billowing with or without organic prolapse, and abnormal annular dynamics that cause functional prolapse. Complex repair techniques, including aggressive leaflet resection and implantation of multiple artificial chordae, are conventionally performed; nevertheless, these are technically demanding, especially when performed using a minimally invasive approach. We aimed to standardize the repair technique for Barlow's disease and developed stepwise repair techniques. METHODS: Of 292 patients who underwent isolated minimally invasive mitral valve repair for MR, 29 patients (seven females, age 49 ± 10 years) were found to have Barlow's disease. Our repair technique consists of the following three steps: (a) stabilization of the mitral annulus by placing annuloplasty ring sutures; (b) distinction between organic and functional prolapse by a saline injection test; and (c) targeted repair for organic prolapse by leaflet resection or chordal replacement. RESULTS: Surgical techniques included leaflet resection in 22 patients, chordal replacement in 19 patients, and ring annuloplasty only in one patient. These procedures were applied to the anterior leaflet in one, posterior leaflet in eight, and both leaflets in 19 patients. The median annuloplasty ring size was 34 mm. The repair success rate was 100%. No patients developed moderate or greater MR during a mean follow-up period of 36 ± 21 months. CONCLUSIONS: A stepwise repair strategy facilitates mitral valve repair in patients with Barlow's disease and provides excellent outcomes even via a minimally invasive approach.

Minimally invasive coronary artery bypass grafting: useful routine option for coronary revascularization in selected cases.

OBJECTIVES: The safety and feasibility of minimally invasive coronary artery bypass grafting (MICS CABG) were evaluated. METHODS: From December 2012 to March 2019, 122 consecutive patients underwent MICS CABG via a left mini-thoracotomy under direct vision. The internal thoracic artery (ITA) was harvested from all, while bilateral ITAs (BITAs) were used in 36 patients, with the second ITA as an in situ (n = 18) or free (n = 18) graft. Proximal anastomosis of the free graft (ITA, radial artery, or saphenous vein segments) was performed directly onto the ascending aorta, or from the ITA as a Y- or I-composite graft. RESULTS: Patient ages ranged from 38 to 89 years (mean 66.9 ± 9.6 years) and 102 were males. MICS CABG was completed without conversion in 116 patients (95.1%), of whom 76 underwent multivessel bypass grafting, with 2 grafts used in 52 and 3 or more in 24 patients. A cardiopulmonary bypass was performed in 17 patients. Perioperative mortality occurred in 1 patient who died of advanced cancer. There were no cases of reoperation for bleeding, stroke, or chest wound infection. The perioperative transfusion rate was 11.2%. Early graft patency was noted in 97.1%. The rate of freedom from major adverse cardiac and cerebrovascular events (all-cause death, myocardial infarction, stroke, and repeated revascularization) was 89.7% at 5 years. CONCLUSIONS: MICS CABG is feasible and showed good mid-term outcomes. BITAs can be harvested with this approach; thus, allowing for various graft designs. We recommend this as a useful option for coronary revascularization in selected cases.

A New MultiSuction Heart Positioner for Minimally Invasive Coronary Artery Bypass Grafting.

Proper positioning of the heart through a small left thoracotomy is the main challenge during off-pump minimally invasive cardiac coronary artery bypass grafting. Here we report a novel technique for target vessel exposure using the Tentacles NEO (Sumitomo Bakelite, Co Ltd, Tokyo, Japan) multisuction heart positioner, a device with 3 independent small suction cups that can be applied to various surfaces of the heart and pulled toward any direction using attached traction cords. The armless design of the device enables the use of flexible exposure techniques and contributes to the safety and feasibility of minimally invasive coronary artery bypass grafting.

A Novel Approach to Prevent Perioperative Stroke in Patients Undergoing Debranching Thoracic Endovascular Aortic Repair with a Mini-Cardiopulmonary Bypass Support.

BACKGROUND: Perioperative stroke is a major complication after debranching thoracic endovascular aortic repair (TEVAR), with a reported incidence of 7.0-26.9%. Subsequent functional recovery is difficult in most cases. This study was performed to evaluate the efficacy of mini-cardiopulmonary bypass (mini-CPB) support in debranching TEVAR to prevent perioperative stroke. METHODS: From December 2010 to July 2017, 32 patients with a shaggy aorta or intimal irregularity in the aortic arch identified on preoperative computed tomography underwent debranching TEVAR. Nineteen patients underwent debranching TEVAR without mini-CPB, and 13 patients underwent debranching TEVAR with a mini-CPB support. Mini-CPB support had been used in November 2014 to treat perioperative stroke, which had occurred in 8 (42%) patients at that time. The form of the debranching arch vessels was not changed; bypass from the right axillary artery to the left axillary artery was performed for one debranching, and bypass from the right axillary artery to the left common carotid artery and left axillary artery was performed for two debranchings. After establishment of mini-CPB support through this debranching graft and right femoral vein cannulation, all endovascular manipulations were initiated. The left subclavian artery was occluded with a plug at the end of the procedure. RESULTS: The proximal landing zones of the endoprosthesis were as follows: zone 0 in 9 patients, zone 1 in 5 patients, and zone 2 in 5 patients in the no-CPB era and zone 1 in 3 patients and zone 2 in 10 patients in the CPB era. The mean mini-CPB support period was 51 minutes. Postoperative respiratory support and hospitalization were not prolonged with mini-CPB support. The incidence of perioperative stroke was 42% in the no-CPB era and 8% in the CPB era. No operative mortality was observed in the CPB era, although 5 (26%) patients died in the no-CPB era. The cause of operative mortality in the no-CPB era was perioperative stroke in 4 patients and acute myocardial infarction in 1 patient. No significant difference in the cumulative survival rate was found between patients with and without mini-CPB support. CONCLUSIONS: Our mini-CPB system may have the potential to prevent perioperative stroke during debranching TEVAR for treatment of aortic arch pathologies.

Usefulness of Abdominal Duplex Ultrasound for Detecting Endoleaks after Endovascular Aneurysm Repair.

Objective: The usefulness of abdominal duplex ultrasound (DUS) for the detection of endoleaks after endovascular aneurysm repair (EVAR) was evaluated. Materials and Methods: Among 286 patients who underwent EVAR between September 2007 and July 2017, 241 patients were followed up using abdominal DUS. Endoleaks were detected in 74 patients (31%), who were divided into enlarged and nonenlarged sac groups. Endoleak velocities and widths were measured using abdominal DUS every 6 months after EVAR and were compared between the 2 groups. Results: The aneurysm diameter in the nonenlarged sac group was 54.4±8.7 mm in the final follow-up. None of the patients in the nonenlarged sac group were subjected to reintervention, whereas all patients in the enlarged sac group were subjected to reintervention. The aneurysm diameter in the enlarged sac group was 62.8±8.8 mm at the time of reintervention, and the maximum endoleak flow velocities and endoleak widths were significantly higher in the enlarged sac group than in the nonenlarged sac group (p<0.05). The cutoff values on receiver operating characteristics curves for endoleak velocity and width were 83.4 cm/s and 4.0 mm, respectively. Conclusion: Follow-ups using abdominal DUS are useful after EVAR. Endoleak velocity and width measurements are important, and reintervention may be needed when these measurements exceed their cutoff values.

Usefulness of Glycemic Control Using an Artificial Pancreas Apparatus for Cardiovascular Surgery.

Blood glucose management is important for cardiovascular surgery using cardiopulmonary bypass. The usefulness of an artificial pancreas apparatus (STG-55) to control blood glucose in patients undergoing cardiopulmonary bypass was investigated. Subjects comprised 44 patients using the artificial pancreas during cardiopulmonary bypass between June 2016 and March 2017; 55 were initially enrolled, but 11 were excluded because of blood removal failure. Patients were divided into a monitoring group in which blood glucose levels were only monitored using the artificial pancreas (11 patients: six people with diabetes and 5 people without diabetes) and a management group with glycemic control by automatic insulin administration using the artificial pancreas (33 patients: people with diabetes and 21 people without diabetes). Mean maximum blood glucose levels and variation ranges significantly differed between the monitoring and management groups (p = 0.02). The variation range significantly differed between people with and without diabetes in the monitoring group (p = 0.008), but not in the management group. The artificial pancreas apparatus continuously and accurately reflected glycemic variations, facilitating strict and favorable control.

Physiological mitral annular dynamics preserved after ring annuloplasty in mid-term period.

OBJECTIVE: Mitral annular structure and dynamics after mitral ring annuloplasty using transesophageal echocardiography during the operation have been reported. We evaluated mitral annular structure and dynamics of three different rings in the mid-term period postoperatively. METHODS: Thirty-one patients underwent mitral valve repair for degenerative mitral insufficiency. The MEMO 3D ring (semi-flexible), Carpentier-Edwards Physio II ring (semi-rigid), and St. Jude Medical Rigid Saddle Ring (rigid) were implanted in 15, 12, and eight patients, respectively, from September 2009 to February 2015. Electrocardiogram-gated three-dimensional computed tomography was performed in the mid-term period postoperatively. RESULTS: The postoperative antero-posterior rate of reduction in diameter from end-diastole to end-systole was slightly larger in the MEMO3D (0.57 ± 0.69%) than in the Physio II (0.08 ± 0.60%) and Rigid Saddle Ring (0.11 ± 0.59%). There was no significant difference in the commissure-to-commissure rate of reduction in diameter among the groups. The postoperative end-systolic annular height to commissure width ratio was significantly larger in the Physio II (20.4 ± 1.7%) and Rigid Saddle Ring (21.3 ± 1.7%) than in the MEMO3D (10.8 ± 3.1%, both p < 0.0001). The rate of increase in the postoperative annular height to commissure width ratio from end-diastole to end-systole was significantly larger in the MEMO3D (2.1 ± 1.7%) than in the Physio II (0.1 ± 0.4%) and Rigid Saddle Ring (0.1 ± 0.6%). CONCLUSIONS: The Physio II and Rigid Saddle Ring can restore the physiological and three-dimensional annular shape, and the MEMO3D can preserve physiological annular dynamics in mid-term period postoperatively.

Pretreatment with the Free Radical Scavenger Edaravone Mitigates Kidney Glycogen Depletion and Neutrophil Infiltration after Leg Ischemia in a Rat Model: A Pilot Study.

Objective: We have previously shown that pretreatment with the free radical scavenger edaravone (Radicut®, Mitsubishi Tanabe Pharma Co., Japan) mitigated skeletal muscle damage due to ischemia reperfusion. In this study, we sought to validate its use in an experimental model of myonephropathic-metabolic syndrome (MNMS). Methods: Either edaravone (3.0 mg/kg; edaravone group; n=4) or saline (saline group; n=6) was intraperitoneally injected into male Lewis rats (508±31 g). Normal kidneys were harvested as control (n=3). MNMS was induced by bilaterally clamping the common femoral arteries for 5 h and declamping 5 h later. Kidney damage was evaluated by quantifying Periodic Acid Schiff (PAS)-positive area (glycogen storage) and esterase-positive cells (neutrophil infiltration). Results: The PAS-positive area in the saline group was significantly lower than that in the normal group (36.9±2.6 vs. 66.9±1.2%, P<0.01); the PAS-positive area in the edaravone group remained comparable to that in the normal group (52.9±0.9%, P<0.01). Esterase-positive cells in the saline group were significantly higher than in normal kidneys (62.4±5.6 vs. 17.5±2.4 cells/mm2, P<0.01), while they were significantly reduced in the edaravone group (32.8±5.7 cells/mm2, P<0.01). Conclusion: Edaravone pretreatment mitigates MNMS-induced kidney damage by reducing both glycogen depletion and neutrophil infiltration.