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.

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.

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.

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.

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 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.

Experimental investigation of "hANP shot" using human atrial natriuretic peptide for myocardial protection in cardiac surgery.

BACKGROUND: We investigated myocardial protection by human atrial natriuretic peptide (hANP) during cardiac surgery without cardioplegia and determined whether suppression of myocardial ischemic reperfusion injury by hANP allows intraoperative aortic cross-clamp time to be prolonged. METHODS AND RESULTS: Thirty-two pigs were placed on cardiopulmonary bypass. Experimental pigs were divided into 4 groups: 15 min clamping; hANP 15 min clamping; 30 min clamping; and hANP 30 min clamping. In both hANP groups, a 100 µg dose of hANP was administered after clamping. Left ventricular function, premature ventricular contractions (PVCs), histopathological studies, 8-isoprostane, myocardial Ca(2+), and ATP concentrations were determined. Comparison of the myocardial contractile force indicator E(max), in the 30 min groups, showed a significantly higher recovery rate in the hANP than in the control group. PVC numbers were significantly lower in the hANP than in the control groups for both arrest durations. On microscopic examination, hANP reduced ischemic reperfusion injury in the 30 min groups. The myocardial ATP level was significantly higher in the hANP 30 min than in the control 30 min group. Increases in 8-isoprostane and myocardial Ca(2+) concentrations were significantly inhibited in both hANP groups. CONCLUSIONS: This study demonstrated that hANP ameliorates ischemic reperfusion injury, improves postoperative myocardial contractility, and reduces reperfusion arrhythmias. We suggest that hANP allows aortic cross-clamping to be prolonged and thereby exerts a direct myocardial protective effect against cardiac arrest during cardiac surgery.

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.

Successful management of fulminant myocarditis with left ventricular assist device: report of a severe case.

We report a 65-year-old man with fulminant myocarditis undergoing percutaneous cardiopulmonary support (PCPS) and left ventricular assist device (LVAD). PCPS and intra-aortic balloon pumping was initially introduced for cardiogenic shock in the emergency department. We switched to LVAD because cardiac function did not recover despite PCPS for 5 days. Cardiac function then gradually improved, and the device was successfully weaned after 11 days of the LVAD support. He was discharged on postoperative day 63 with no complications. We here report the appropriate timing of LVAD application for fulminant myocarditis.

Successful recovery using surgical intervention to treat ischemic cardiomyopathy and cardiogenic shock.

We report here a successful case of recovery from cardiogenic shock resulting from ischemic cardiomyopathy, treated by using a left ventricular assist device (LVAD). The LVAD was successfully explanted at the time of simultaneous coronary artery bypass grafting and left ventricular restoration after recovery from end-organ dysfunction by LVAD support.

Assessment of the St. Jude Medical Regent prosthetic valve by continuous-wave Doppler and dobutamine stress echocardiography.

BACKGROUND: The St. Jude Medical (SJM) Regent prosthetic valve (St. Paul, MN), a recently developed mechanical valve, is an improvement on the conventional SJM valve, having a wider valve area than the SJM HP valve. We evaluated this mechanical valve by Doppler echocardiography and dobutamine stress echocardiography (DSE). METHODS: The functions of the SJM Regent valve were evaluated by continuous-wave Doppler echocardiography and DES in 58 cases of aortic valve replacement during a stable postoperative period. RESULTS: The peak pressure gradient of the replaced valves sized 17, 19, 21, and 23 mm was 27.5 +/- 11.1, 20.0 +/- 9.8, 15.6 +/- 5.7, and 14.3 +/- 9.1, mm Hg respectively, and the effective orifice area index was 0.97 +/- 0.32, 1.01 +/- 0.29, 1.09 +/- 0.30, and 1.41 +/- 0.54 cm(2)/m(2), respectively, with prosthesis-patient mismatch (PPM) found in 1, 3, 2, and 0 cases for the 17-, 19-, 21- and 23-mm valves, respectively, with a total incidence of 10.3%. In 20 cases, the peak pressure gradient and the effective orifice area index were significantly increased during DSE compared with those at rest. CONCLUSIONS: Although the PPM incidence was 6.6%, it was deemed from the data of DSE and clinical symptoms that there were no clinical issues for such cases of PPM in the early and intermediate phases after operation. Particularly, the effectiveness of the 17- and 19-mm valves in patients with a small aortic annulus was demonstrated, confirming the satisfactory functions of the SJM Regent prosthetic valve.

Cardiac angiosarcoma with cardiac tamponade diagnosed as a ruptured aneurysm of the sinus valsalva.

Primary cardiac angiosarcoma is a rare, diagnostically elusive disease with a poor prognosis. In this report, we describe the case of a 56-year-old woman with a right atrial angiosarcoma. The patient presented with impending cardiac tamponade caused by right atrial perforation, but was misdiagnosed as a ruptured aneurysm of the sinus valsalva based on findings of a continuous murmur and an aorta to right atrium shunt by echocardiography. In the emergent operation that ensued, we found a right atrial perforation and a right coronary artery fistula to the right atrium. Coronary artery fistula is a rare complication of primary cardiac angiosarcoma, and a continuous murmur is also extremely rare as a clinical finding of angiosarcoma. We report the case and review the literature.

Outcome of less invasive proximal arch replacement with moderate hypothermic circulatory arrest followed by aggressive rapid re-warming in emergency surgery for type A acute aortic dissection.

BACKGROUND: The mid-term outcome of quick proximal arch replacement with moderate hypothermia followed by aggressive rapid re-warming in emergency surgery for type A acute aortic dissection (AAD) was assessed. METHODS AND RESULTS: Eighty-five patients were divided into 2 groups: group I consisted of 43 patients undergoing surgery for deep hypothermic circulatory arrest and selective cerebral perfusion; and group II consisted of 42 patients who recently underwent aggressive rapid re-warming. During open distal anastomosis in group II patients with a rectal temperature of 28 degrees C but who did not suffer any cerebral perfusion, circulating blood in the cardiopulmonary bypass (CPB) circuit was warmed to 40 degrees C. As soon as distal anastomosis was completed, rapid re-warming was initiated by a 40 degrees C blood perfusion. The duration of CPB (I: 182.1 vs II: 85.3 min), overall operation (305.0 vs 150.8 min), postoperative mechanical ventilation (44.3 vs 9.1 h), and hospital stay (31.4 vs 9.6 days) were significantly shorter in group II patients. The incidence of postoperative brain complication (I: 14.0 vs II: 2.4%), renal failure (14.0 vs 0%), pneumonia (18.6 vs 4.8%), and mortality (9.3 vs 0%) was significantly less in group II patients. CONCLUSIONS: Moderate hypothermia followed by a rapid re-warming procedure was safe and effective in the proximal arch replacement for AAD.

Optimal clinical pathway for the patient with type B acute aortic dissection.

BACKGROUND: The traditional medical treatment for type B acute aortic dissection (AAD) is widely accepted, but the optimal clinical pathway has not been confirmed. Methods and Results From admissions over the past 12 years, 210 patients with uncomplicated type B AAD were divided into 2 groups: Conventional therapy group (CG) of 90 who were treated by 7 days of bed rest and intravenous antihypertensive agents and the Clinical pathway group (CPG) of 120 who were treated by early rehabilitation. In the CPG, patients were administered oral medication from the first day after onset and took a short walk from the third day after onset. The incidence of respiratory complications, and of delirium, was significantly decreased in the CPG. Early mortality was similar: 3.3% and 2.5%, respectively. The diameter of the aorta had not enlarged in either group 1 month later. Conclusions The clinical pathway of treatment for uncomplicated type B AAD was safer and better for preventing early complications and cost benefit.

Surgical treatment of an aortoesophageal fistula caused by stent implantation for esophageal stenosis: report of a case.

An aortoesophageal fistula is uncommon, but almost always fatal. We report a case of an aortoesophageal fistula that developed after stent dilation for an esophageal stricture caused by benign esophagitis. As soon as esophageal hemorrhaging was identified by endoscopy, the patient was transferred to the operating theater; however, the uncontrollable and massive bleeding resulted in pulseless shock. The digestive surgeon put side-clamps on the descending aorta and esophagus and transferred the patient to our hospital. We identified an aortoesophageal fistula, 3.0 mm in diameter, in the descending aorta, and performed a graft replacement of the descending aorta and esophagectomy. It was immediately evident that the edge of the stent had been sticking into the aortic wall, which had caused the fistula. To our knowledge, this is the first report of successful surgical treatment of an aortoesophageal fistula caused by esophageal stent dilatation.

Prophylactic reoperation after mitral valve replacement with the Starr-Edwards ball valve: a report of four cases.

PURPOSE: The Starr-Edwards ball valve was first applied clinically in 1960. In our hospital, this valve has been used since 1963, and some patients have been followed up for 30 years or more. Based on our experience, therapeutic strategies included revalve replacement as a preventive procedure in the absence of valve-related complications. In this study, we investigated whether prophylactic reoperation after valve replacement with the Starr-Edwards ball valve is appropriate. PATIENTS AND METHODS: Of 58 patients in our institute who underwent mitral valve replacement with the Starr-Edwards ball valve, 12 underwent revalve replacement. Of these 12, the subjects of the present study were 4 patients who underwent prophylactic revalve replacement. RESULTS: The mean postoperative follow-up of the 4 patients was 31.0+/-3.7 years. There were no operative deaths or postoperative complications. On examination of the extirpated Starr-Edwards valves, cloth wear was observed in all 4 patients. Although there was no influence on the range of ball motion, they showed the entity of "thrombus/pannus." CONCLUSION: In this study, all of the patients showed cloth wear in the absence of complications. Therefore we consider that prophylactic reoperation after valve replacement with the Starr-Edwards valve should be performed to prevent complications.

Prognosis for patients with type B acute aortic dissection: risk analysis of early death and requirement for elective surgery.

BACKGROUND: The long-term outcome of medical treatment in patients with type B acute aortic dissection (BAD) was assessed and predictors of early in-hospital death were investigated, as well as the need for surgical intervention. METHODS AND RESULTS: In the past 11 years, 180 patients were admitted to hospital and medically treated at the time of onset. If the maximum diameter of the dissected aorta exceeded 60 mm, or rapid enlargement or vital organ ischemia were identified, early or elective surgery was performed. Emergency operation was required in 7 patients. Elective surgery was required for 31 patients (19.1%). The operation-free rate was 76.0% at 10 years. Actuarial survival rate was 89.4% at 5 years and 71.8% at 10 years. Multivariate analysis indicated that refractory hypertension (odds ratio (OR), 4.08, 95% confidence interval (CI), 3.06-21.44, p=0.0434) and rupture (OR 5.87, 95% CI, 2.21-9.12, p=0.0154) were predictors of early hospital mortality. The only significant predictor for elective surgery was a maximum diameter exceeding 40 mm at the time of onset (OR 13.4, 95% CI, 1.93-6.89, p=0.0003). CONCLUSIONS: Medical treatment for BAD produced good results. Strict control of blood pressure is important for patients with a dissected aortic diameter exceeding 40 mm at the time of onset.

A surgical case of left ventricular pseudoaneurysm complicating myocardial infarction in a diabetic patient on dialysis.

A 57-year-old man was hospitalized with dyspnea and heart failure. We performed an electrocardiogram, coronary angiogram, echocardiogram, and magnetic resonance imaging. He was diagnosed with a left ventricular pseudoaneurysm (i.e., heart tumor) at the posterolateral wall. Minimal contrast medium was utilized when making the diagnosis as the patient was on dialysis. We subsequently repaired the ventricular unruptured pseudoaneurysm and performed a coronary artery bypass grafting. This case presented difficulty in ascertaining the difference between a cardiac tumor and a ventricular pseudoaneurysm.