Left ventricular free wall perforation by a right ventricular pacemaker lead: a case report.

BACKGROUND: Lead perforation is one of the major complications of pacemaker implantation, but cases of right ventricular (RV) lead perforation through the septum and left ventricle are rarely reported. We described a rare case of left ventricular (LV) free wall perforation by an RV lead and the management of this complication. CASE SUMMARY: An 84-year-old man was admitted with a dual-chamber pacemaker due to pacing failure caused by an RV lead fracture. New lead implantation was performed on the next day, but pacing failure occurred again on the second post-operative day (POD). We found the lead perforation on the fluoroscopy during temporary pacemaker insertion. Computed tomography scan and transthoracic echocardiogram showed that the added lead perforated through both the septum and LV free wall. A new lead was inserted on the fourth POD, and an off-pump open chest surgery for extraction of the penetrating lead was performed uneventfully on the 20th POD. DISCUSSION: We considered that some features of the lead (SelectSecure 3830-69, Medtronic) may be related to this complication, as the lead was very thin, had a non-retractable bare screw and was inserted with a dedicated delivery catheter. We have to be careful when performing implantation of this kind of lead to avoid such a rare complication.

Extended thoracic endovascular aortic repair for residual aortic dissection after type A aortic dissection repair.

OBJECTIVE: We investigated the outcomes of extended coverage of the descending thoracic aorta by thoracic endovascular aortic repair (TEVAR) for residual chronic type B aortic dissection after type A aortic dissection (TAAD) repair. METHODS: From November 2015 to August 2020, 36 patients underwent extended TEVAR for residual intimal tear after TAAD repair. We specifically investigated the methods and outcomes of this procedure. RESULTS: TEVAR consisted of isolated TEVARs (n = 29), single-vessel debranching TEVAR (6), and two-vessel debranching TEVAR (1). The mean time from TAAD repair to TEVAR was 27 ± 33 months (2-86 months). The TEVAR devices used were Valiant (28 cases), GORETAG (4), Relay plus (2), and TX2 (2). Technical success of TEVAR was 100%. The distal ends of the stent grafts were T 8 (1 case), T 9 (5), T 10 (6), T 11 (9), and T 12 (15), with an average of T 11 ± 1. The average length of hospital stay after TEVAR was 9 ± 3 days (5-17 days). There were no surgical/hospital deaths or complications. The average postoperative follow-up period was 21 ± 15 months without death or reintervention. CONCLUSIONS: The short-term outcomes of extended TEVAR for residual chronic type B aortic dissection after TAAD repair were acceptable without perioperative SCI. Aggressive descending thoracic aorta coverage may prevent aortic events, and extended TEVAR may be a preemptive treatment for the downstream aorta. Mid- to long-term results should be clarified.

Successful Treatment of Giant Ascending Aortic Aneurysm with Takayasu Arteritis.

A 50-year-old man who suffered from dyspnea on effort with hearing loss was referred to our hospital. Computed tomography angiography revealed a giant 90-mm diameter ascending aortic aneurysm with severe calcification and neck vessel occlusion. Transthoracic echocardiography revealed moderate-to-severe aortic regurgitation. His condition was diagnosed as Takayasu arteritis and he underwent aortic valve reimplantation with total arch replacement. Postoperative computed tomography angiography showed complete aneurysm resection and the patient was discharged without any complications and his hearing loss improved. He is currently being followed up as an outpatient.

Aortic valve neocuspidization in patients under 65 years old.

OBJECTIVE: We aimed to elucidate the surgical outcomes of aortic valve neocuspidization (AVNeo) in patients under 65 years old. METHODS: From December 2010 to February 2019, we performed AVNeo in a total of 168 patients. Of them, we evaluated 36 patients aged under 65 years. Twenty-three patients had aortic regurgitation (AR) and 13 had aortic stenosis (AS). There were 20 patients who had isolated AVNeo, and the concomitant procedures were coronary artery bypass grafting in 5, mitral valve procedures in 4, ascending aorta replacement in 4, MAZE in 3, closure of atrial septum defect in 1, and tricuspid valve annuloplasty in 1. In the AS series, preoperative echocardiography revealed an average peak pressure gradient of 81 ± 33 mmHg. In the AR series, preoperative echocardiography revealed 15 patients with severe AR and 8 patients with moderate-severe AR. RESULTS: There were no conversions to valve replacement. There were two in-hospital deaths owing to low output syndrome and sepsis in the emergent cases. In the AS series, postoperative echocardiography showed an average peak pressure gradient of 23 ± 15 mmHg 1 week post-procedure and 19 ± 9 mmHg 26 months post-procedure. In the AR series, postoperative echocardiography revealed no AR in 11, trivial in 9, and moderate in 1. Three patients underwent reoperation. The freedom from reoperation rates were 100% and 93% at 36 and 60 months of follow-up, respectively. CONCLUSIONS: AVNeo in patients aged under 65 years appears to be suitable considering its early and midterm outcomes. Verification and follow-up of its long-term outcomes and reliability are indispensable.

Midterm outcome of aortic valve neocuspidization for aortic valve stenosis with small annulus.

OBJECTIVE: At our institution, we actively perform aortic valve neocuspidization (AVNeo) for aortic valve stenosis (AS) with a small annulus. In this report, we aimed to evaluate the midterm outcome of AVNeo for AS with a small annulus. METHODS: From February 2011 to May 2017, we performed AVNeo for AS with a small annulus in 34 patients. Their mean age was 77.0 ± 9.1 years. Preoperative transthoracic echocardiography (TTE) revealed a mean peak pressure gradient average of 84.2 ± 31.1 mmHg. The effective orifice area index (EOAi) was 0.45 ± 0.14 cm2/m2. The mean annulus diameter was 18.4 ± 1.1 mm. Our procedure complies with the three cuspid suturing to the aortic annulus with glutaraldehyde-treated autologous pericardium. RESULTS: There were no conversion to aortic valve replacement and no concomitant annulus enlargement. There were two inhospital mortalities resulting from a noncardiac cause. Three patients underwent reoperation owing to aortic regurgitation (n = 2) and infective endocarditis (n = 1). One patient underwent a pacemaker implantation for complete atrioventricular block. The mean follow-up period was 28.0 ± 22.7 months. Postoperative TTE showed a mean peak pressure gradient average of 18.3 ± 9.4 mmHg and a calculated mean EOAi of 1.18 ± 0.35 cm2/m2. The freedom from reoperation rates were 94.1% and 90.8% at 1 year and 5 years of follow-up, respectively. The overall survival rates were 91.2% and 76.8% at 1 and 5 years of follow-up, respectively. CONCLUSIONS: The midterm outcome of AVNeo for AS with a small annulus was excellent. The long-term outcome and reliability of this procedure must be fully clarified.

Patterns of aortic remodelling after total arch replacement with frozen elephant trunk for acute aortic dissection.

OBJECTIVES: We investigated the outcomes of total arch replacement with frozen elephant trunk (FET) for Stanford type A acute aortic dissection and the patterns of postoperative aortic remodelling from computed tomographic (CT) findings. METHODS: From April 2015 to November 2018, we performed total arch replacement with FET for Stanford type A aortic dissection in 30 patients. Postoperative contrast-enhanced CT showed the position of the FET distal end, the number and the site of communications between the lumina and the presence or absence of aortic remodelling. RESULTS: Primary entry tear was found in the ascending aorta (n = 6), proximal arch (n = 6), aortic arch (n = 11) and distal arch (n = 7). The mean diameter and length of FET were 26 ± 2 and 84 ± 18 mm, respectively. Postoperative contrast-enhanced CT was performed in 26 patients. When the number of communications between the lumina was 0, complete aortic remodelling was achieved in all cases (n = 12). In the case of the most proximal tear in the descending aorta (n = 9), aortic remodelling was not recognized in 3 cases, and additional TEVAR was performed because of diameter enlargement. In the remaining 6 patients, neither aortic remodelling nor aortic diameter enlargement was recognized. When the most proximal tear was below the diaphragm (n = 5), aortic remodelling occurred up to the most proximal tear, but not in the periphery. CONCLUSIONS: We investigated the patterns of aortic remodelling after total arch replacement with FET for Stanford type A aortic dissection from postoperative CT findings. Regardless of the position of the most proximal tear in the descending aorta, aortic remodelling did not occur as long as the most proximal tear was located in the descending aorta. When the most proximal tear occurred in the descending aorta, TEVAR as a pre-emptive treatment can be effective in preventing postoperative aortic adverse events.

Combined Direct Endarterectomy and Fogarty Thrombectomy with Endovascular Therapy for Subacute Occlusion of the Superficial Femoral Artery.

A 78-year-old woman with a prior history of a right femoropopliteal bypass 5 years before and a coronary artery bypass graft 3 months before was admitted for a non-healing ulcer on her right foot. A computed tomography angiogram revealed occlusion of her superficial femoral artery (SFA) from its orifice to the anastomotic site of the bypass graft. The lesion was thought to consist of a partial atherosclerotic plaque with a large number of relatively fresh thrombi, referring to an angiogram of her lower extremity 3 months ago. We recanalized the occlusive SFA by Fogarty thrombectomy, and endovascular therapy preceded by direct SFA endarterectomy.

Early and mid-term results of isolated aortic valve neocuspidization in patients with aortic stenosis.

OBJECTIVES: This study aimed to elucidate the surgical outcome of aortic valve neocuspidization (AVNeo) in patients with aortic stenosis (AS). METHODS: From December 2010 to June 2017, we performed AVNeo for aortic valve pathologies in 144 patients. Of them, we evaluated 57 patients with AS who underwent AVNeo. Their mean age was 77.5 ± 8.8 years. Fifty-five patients had AS from degenerative changes, 1 from pericardium endocarditis, and 1 from prosthetic valve endocarditis. Forty patients had a tricuspid aortic valve, 1 had a unicuspid valve, 14 had a bicuspid valve, 1 had a quadricuspid valve, and 1 had postoperative aortic valve replacement (AVR). Preoperative echocardiography revealed an average peak pressure gradient of 89 ± 32.9 mmHg and a mean pressure gradient of 52 ± 18.8 mmHg. The surgical procedure complies with the 3 cuspid suturing to the aortic annulus with the glutaraldehyde-treated pericardium. RESULTS: There were no conversions to AVR. There were 2 noncardiac-related deaths owing to liver failure and sepsis. Postoperative echocardiography showed an average peak pressure gradient of 22 ± 10.7 mmHg 1 week after the procedure and 19.2 ± 9.7 mmHg 20 months after the procedure. Two patients underwent reoperation owing to infective endocarditis and recurrent aortic regurgitation. The mean follow-up period was 30.4 ± 20.8 months. The freedom from reoperation rates was 98.1 and 95.3% at 12 and 81 months of follow-up, respectively. CONCLUSIONS: AVNeo is suitable for patients with AS considering its early and mid-term outcomes. Verification of long-term outcomes and reliability is necessary.

Comparison of aortic annulus dimensions after aortic valve neocuspidization with those of normal aortic valve using transthoracic echocardiography.

OBJECTIVES: This study aimed to elucidate the physiological feasibility of aortic valve neocuspidization (AVNeo) by comparing the aortic annulus dimensions between patients after AVNeo and patients with normal aortic valves. METHODS: From December 2010 to October 2017, we performed AVNeo for various aortic valve pathologies in 147 patients. Of these patients, the aortic annulus dimensions were measured in 25 patients who underwent AVNeo for aortic valve disease as follow-up examination and compared with those measured in 15 patients who had normal aortic valves. Measurements were recorded using electrocardiography-gated transthoracic echocardiography. RESULTS: No significant differences in the aortic annulus dimensions were observed between the patients who had undergone AVNeo and those who had normal aortic valves. In a cardiac cycle, the annulus area in the systolic phase was consistently larger than that in the diastolic phase, which was a physiological condition. CONCLUSIONS: The movement of the aortic annulus after AVNeo is comparable with that of the aortic annulus of a normal aortic valve. Thus, AVNeo can be regarded as a more physiological operation in that it maintains the characteristics of the aortic valve similar to those of a normal aortic valve.

Optimal Time for Pharmacological Treatment of Abdominal Aortic Aneurysm.

BACKGROUND: Abdominal aortic aneurysm (AAA), if left untreated, poses the main risks of progressive expansion, rupture, and hemorrhage, leading to death. Large AAA with a risk of rupture is usually treated by graft replacement or endovascular aneurysm repair. Nonsurgical treatment is not an alternative for large AAA, but is potentially beneficial for small AAA which usually requires a watchful waiting approach with medication. OBJECTIVE: We introduce current clinical research regarding the pharmacological treatment of small AAA and assess the optimal time for starting the treatment. RESULTS: Data from current clinical researches on pharmacological treatment of AAA investigating the efficacy of pharmacological treatment to limit AAA growth were presented and introduced the medicines currently evaluated by randomized controlled trials for their efficacy for AAA. CONCLUSION: The optimal time to administer pharmacological treatment for AAA is during the stage wherein its diameter is still small. To detect early small-diameter AAA, screening tests are mandatory in high-risk patients. For pharmacological treatment, the drug that shows acceptable results in clinical tests and is the most effective for the patient's condition should be carefully selected. Lifestyle changes should also accompany pharmacological treatment.

Treatment of prosthetic valve endocarditis by aortic valve neocuspidization using bovine pericardium.

A 78-year-old man who had undergone aortic valve and ascending aorta replacements presented with fever and was referred to our hospital. Blood culture revealed Gram-positive cocci, thus antibiotic therapy was started. Brain magnetic resonance imaging showed fresh cerebral infarction without cerebral haemorrhage or mycotic aneurysm. Transoesophageal echocardiogram revealed a vegetation that was attached to the right coronary cusp. The patient underwent successful aortic valve neocuspidization using glutaraldehyde-treated bovine pericardium. The postoperative course was uneventful with intravenous antibiotics administered for 6 weeks after confirming a negative blood culture, and no cardiac events occurred on follow-up by transthoracic echocardiogram 14 months postoperatively.

Left ventricular perforation and dissecting subepicardial hematoma after catheter ablation for Wolff-Parkinson-White syndrome.

Radiofrequency catheter ablation of accessory bypass tracts has become a widely accepted therapy for Wolff-Parkinson-White (WPW) syndrome. The procedure typically has a high success rate with a low incidence of complications. Left ventricular perforation is a rare but serious complication of catheter ablation. Here we describe a patient who developed left ventricular perforation and a dissecting subepicardial hematoma with cardiac tamponade following catheter ablation for WPW syndrome. Immediate hematoma evacuation and direct repair of the fragile myocardium were performed under cardiopulmonary bypass, and the patient survived with no further complications.

Barium-enhanced imaging of the coronary vasculature of the porcine myocardium: empirical investigation into the theory of the ventricular myocardial band.

OBJECTIVE: The ventricular myocardium is thought to exist as a single continuous muscle band that extends from the pulmonary artery to the aorta, wrapped into a double helical coil Torrent-Guasp's theory of the ventricular myocardial band (VMB). The purpose of this study was to examine the coronary blood supply to the VMB and to evaluate the effect of coronary blood systems on structure-function relations in the myocardium. METHODS: VMBs of nine swine hearts were unwrapped after postmortem barium coronary angiography. Unwrapped VMBs underwent radiography, and vascular images of barium remaining in the VMBs were evaluated. RESULTS: We were able to achieve a single longitudinal and stretched myocardial band in all nine porcine hearts. The corresponding regions supplied by each coronary artery were clearly distinguishable in the VMBs. The right segment of the basal loop was supplied by the right coronary artery. The left segment of the basal loop was supplied by the left circumflex artery. Most of the descending segment of the apical loop was supplied by the left anterior descending artery, with an inferior portion supplied by the right coronary artery. Most of the ascending segment of the apical loop was supplied by the left anterior descending artery, with a posterior portion supplied by the left circumflex artery. CONCLUSION: Understanding the trinity of structure, function, and coronary blood supply from the viewpoint of the VMB should facilitate development of more effective surgical treatment for severe ischemic heart disease.

A surgical case of lung cancer in a patient with the left superior and inferior pulmonary veins forming a common trunk.

The anatomical abnormalities of the pulmonary veins may have a serious impact on complications that may arise during pulmonary lobectomy. We present a surgical case of left lung cancer in a patient, who was a 69-year-old male, with the left superior and inferior pulmonary veins forming a common trunk outside the pericardium. In this present case, because of extensive adhesions, incomplete lobulation, and tumor infiltration of the main pulmonary artery, we could not identity the common trunk with certainty before excising the left upper lobe. Although this patient was fortunately discharged without complications, there was no choice but to perform pneumonectomy because of the interruption of the inferior pulmonary vein. Retrospectively, the preoperative CT films showed the anatomical anomalies involving the pulmonary veins. However, since the length of the common trunk outside the pericardium was short and the inferior pulmonary vein was thinner than usual and its venous distribution conformed to a normal structure, the anatomy appeared normal. In excising the pulmonary lobe, it is mandatory to ascertain the distribution of the vascular system prior to surgery.