Early and Late Outcomes of Aortic Valve Replacement with Aortic Annular Enlargement: A Propensity Analysis.

Objectives Early and late outcomes were evaluated in Japanese patients undergoing aortic valve replacement (AVR) with or without aortic annular enlargement (AAE). Propensity matching adjusted for baseline differences in this study. Methods Between January 2001 and July 2014, 589 patients underwent AVR for aortic stenosis. Of these, 58 patients received AVR with AAE (AAE group), and the others received standard AVR without annular enlargement (sAVR group). Of these 589 patients, 116 patients were selected using propensity score matching analysis. We compared early and late outcomes between the two groups. Results Compared with the sAVR group, cardiopulmonary bypass time (177 ± 42 vs. 157 ± 39 minutes) and aortic cross-clamp time (126 ± 32 vs. 110 ± 34 minutes) were significantly longer in the AAE group. However, there were no significant differences between the AAE group and the sAVR group in 30-day mortality (1.7 vs. 3.4%) and in-hospital mortality (1.7 vs. 3.4%). There was no severe patient-prosthesis mismatch after AVR in the AAE group. The overall survival rate and freedom from cardiac events in the AAE group and in the sAVR group at 10 years were 92.4 versus 75.9% (p = 0.477) and 89.5 versus 82.8% (p = 0.076), respectively. No differences were found between the two groups. Conclusions AAE was performed safely in Japanese patients with small aortic annulus. Surgical outcomes of the AAE group were not inferior to those of sAVR. Using this technique, which did not require advanced skills, it was easy to avoid severe patient-prosthesis mismatch.

[Early and Late Outcomes of Valve Surgery in Active Infective Endocarditis Patients with Cerebral Complications].

We carried out a retrospective evaluation of the early and late outcomes of valve surgery for acute endocarditis patients with cerebrovascular disease. Between January 2002 and August 2014, a total of 17 patients (early group, n=10;delayed group, n=7) underwent valve surgery with or without an additional procedure. Craniotomy was performed in 1 patient in the early group and 2 patients in the delayed group before valve surgery. There was 1 in-hospital death due to acute respiratory distress syndrome in the early group and 1 death due to intestinal bleeding in the delayed group. Postoperative deterioration was observed in 1 in the delayed group. Overall survival in the early group was 90% and was not significantly different from survival in the delayed group (86%). In conclusion, our study demonstrated good early and mid-term outcomes for valve surgery in active endocarditis patients with cerebrovascular disease. There was no postoperative deterioration in the early group. Thus, an early operation for these patients may be acceptable.

Early and late outcomes of AVR with aortic annular enlargement in octogenarian.

OBJECTIVE: There is no clear consensus on the procedures for octogenarians with a small aortic annulus who require aortic valve replacement (AVR). We evaluated surgical results in octogenarians who underwent AVR with aortic annular enlargement, Nicks procedure, for aortic stenosis with a small aortic annulus. METHODS: Between January 2001 and March 2014, 131 octogenarian patients were treated at our institution. Nineteen patients received AVR with aortic annular enlargement (AAE group), and the others received standard AVR without annular enlargement (sAVR group). We compared early and late outcomes between the two groups. RESULTS: There were no significant differences in early complications between the groups. The rates for use of a mechanical valve (32 vs 22 %, p = 0.590), in-hospital mortality (5.3 vs 5.4 %, p = 1.000), and severe patient-prosthesis mismatch (PPM) (0 vs 6.3 %, p = 0.593) were also similar between the AAE and sAVR group. In the AAE group, there was no cardiac-related death, bleeding event, thromboembolism, or stroke during the follow-up period (mean 37.6 months). The rates of freedom from cardiac events at 8 years were 94 % in the AAE group and 57 % in the sAVR group (p = 0.292). The overall survival rates at 8 years were 77 % in the AAE group and 77 % in sAVR group (p = 0.462). There were no significant differences in these rates between the groups. CONCLUSION: AVR with aortic annular enlargement in octogenarians with small aortic annulus was safe and led to good operative and long-term outcomes.

Heart failure caused by renal arteriovenous fistula with giant renal artery aneurysms.

We encountered an extremely rare case of a renal arteriovenous fistula (AVF) with 2 giant renal artery aneurysms (RAAs) in a 75-year-old woman who presented with congestive heart failure and pulmonary hypertension. A chest x-ray revealed cardiomegaly with a cardiothoracic ratio (CTR) of 65%. Computed tomography showed 2 giant left RAAs (diameter, 45 × 40 mm(2) and 75 × 60 mm(2)) associated with an AVF, dilated inferior vena cava, and dilated pulmonary arteries. A radical nephrectomy was performed through a transverse laparotomy after the left renal vein, and arteries were dissected from the inferior vena cava and aorta, respectively. The patient's postoperative course was uneventful, and her condition improved. Her cardiomegaly was ameliorated, as manifested by a decrease in CTR to 57% and the absence of volume overload.

Descending aorta-external iliac artery bypass for middle aortic syndrome.

We encountered a surgical case of middle aortic syndrome (MAS) in a 56-year-old man who had resistant hypertension. Computed tomography showed severe stenosis of the abdominal aorta from below the superior mesenteric artery to above the inferior mesenteric artery. Although bilateral renal artery stenosis was confirmed, renal function was within normal limits. A 10-mm vascular prosthetic graft was used to perform a descending aorta to left external iliac artery bypass. His hypertension was well controlled without medication. This extra-anatomic bypass may be a simple and useful approach for treating MAS if it is not necessary to reconstruct the renal artery or visceral artery.

[Early and mid-term outcomes of aortic valve replacement for aortic stenosis in hemodialysis patients].

We carried out a retrospective evaluation of the early and mid-term outcomes of aortic valve replacement (AVR) for aortic stenosis in hemodialysis patients. Between 2004 and 2012, a total of 40 dialysis patients underwent AVR with or without an additional procedure. Hemodialysis was performed routinely the day before and during the operation. At surgery, decalcification was performed using a cavitron ultrasonic surgical aspirator(CUSA) and a high performance mechanical valve was then implanted, with the exception of elderly patients or those in whom use of oral anticoagulation is contraindicated. A mechanical valve was used in 33 patients and a bioprosthetic valve in 7 patients. Hemodialysis was resumed on the 2nd postoperative day in the majority of patients. There was no intra-operative death and in-hospital mortality was 5%, due to sepsis and intestinal ischemia in 2 of the 40 patients. The mean follow-up period was 33 months. There was no structural valve deterioration in patients with the bioprosthetic valve. Of the 8 late deaths, the reason for deaths was cardiac in 4 patients. Overall survival in the 40 patients was 92%, 79%, and 54% at 1, 3, and 5 years, respectively. Our study demonstrated good early and mid-term outcomes for aortic valve replacement in hemodialysis patients. CUSA was useful for patients with a calcified valve and annulus. A bioprosthetic valve was acceptable for use in elderly patients.

[Simplified aortic root replacement in the era of complex operation].

OBJECTIVES: The purpose of the present study is to assess the clinical results of aortic root replacement using the Carbo-Seal composite graft( CS) compared with the other type of homemade composite grafts. Fifty-nine patients who underwent aortic root replacement between January 1998 to December 2010 were retrospectively analyzed. Twenty-six received homemade composite graft( group 1;1998 ~ 2005) and 33 received CS( group 2;2005 ~ 2010). RESULTS: The duration of operation was longer in group 1:469.2±143.5 min versus 380.3±153.9 min (p=0.03). Although there was no statistically significant difference, group 2 had a higher complex operation rate compared with group1(23.1% versus 45.5%, p=0.07). Overall hospital mortality was 11.5% in group1 versus 3.0% in group2. Prevalence of major complication was significantly lower in group 2 (46.2% versus 18.2%, p=0.02).Requirement of intraoperative blood transfusion (group 1;1,130.8±854.7 ml versus group 2;598.2±836.4 ml) and amount of blood loss in the 1st 12 hours post operation (group 1;628.3±474.6 ml versus group 2;447.8±253.2 ml) were significantly lower in group 2. By univariate analysis, duration of operation, duration of cardio-pulmonary bypass (CPB), blood transfusion, acute dissection were independent risk factors and CS use was negative risk factor for major events. Aortic root replacement with use of CS can be performed with a relatively low early mortality and morbidity. Because a complicated operation is increasing in recent years, use of CS graft may simplify a Bentall operation.

[Single-stage procedure for multiple dissected aortic aneurysms with coagulopathy in an elderly patient].

An 86-year-old man was admitted for abdominal pain. Dissected descending thoracic aortic aneurysm and infrarenal abdominal aortic aneurysm were observed under computed tomographic (CT) scan. Hematologic studies revealed low platelet count and an increase in fibrin degradation products (FDP), and disseminated intravascular coagulation( DIC) associated with dissecting aortic aneurysm was highly suspected. Platelet transfusion was performed and gabexate mesilate was administered, however, no improvement of DIC could be obtained. An increase in aortic diameter was observed under CT scan and surgery was performed. The infrarenal aneurysm was replaced with a bifurcated prosthetic graft under open repair. Simultaneously, an endovascular stent-graft was delivered from the left limb of the abdominal graft and implanted into the descending thoracic aorta. The postoperative recovery was uneventful but platelet count did not improve in this case.

Evolving J waves prior to ventricular fibrillation postoperative coronary bypass.

A 74-year-old man without history of ventricular arrhythmias underwent coronary bypass surgery for 3-vessel disease. On the 4th postoperative day, he developed ventricular fibrillation (VF). His monitored ECG showed no elevation of the ST-segment and no prolongation of QT interval, but evolving J waves prior to VF were shown. These J waves gradually decreased after defibrillation. The subsequent angiography revealed patent grafts and normal left ventricular function. J waves reappeared in inferior leads when contrast medium was injected into the coronary artery. Therefore, evolving J wave can be a marker of latent ischemia and a predictor of VF.

A modified infarct exclusion repair of posterior postinfarction ventricular perforation: triple-patch technique for postinfarction ventricular septal perforation in 2 female patients.

We describe a new technique for the early surgical repair of a posterior postinfarction ventricular septal perforation (VSP) in two consecutive female patients. The occurrence of a posterior VSP is rare, and its repair is technically difficult because the posteromedial papillary muscle is located adjacent to the intraventricular septum. This modification appears to prevent leaks to the right ventricle through the VPS with a single direct patch and the use of two equine pericardial patches to form a single endocardial pouch. The women were 77 and 62 years old, and the time between the onset of acute MI and surgery was 3 and 6 days. On preoperative catheterization, Qp/Qs was 4.18 and 4.01. Neither operative death nor residual shunting was observed.

A case of abdominal aortic aneurysm associated with L-shaped crossed-fused renal ectopia.

Genitourinary anomalies are a tremendous challenge for the vascular surgeon, especially when dealing with an abdominal aortic aneurysm. We report a case of crossed-fused renal ectopia, a rare anomaly accompanied by abdominal aortic aneurysm. Bilateral renal arteries and one aberrant artery from the right common iliac artery supply the ectopic kidney. Because renal ischemia during aortic reconstruction can be a serious problem, we reconstructed a temporary right axillo-left renal artery bypass graft first, then reimplanted the aberrant renal artery. When choosing the procedure for renal preservation, preoperative multidetector-row computed tomography was useful to plan the operative strategy.

[Assessment of pulse wave velocity as a marker of post-operative cardiovascular risk in off-pump coronary artery bypass grafting patients].

OBJECTIVE: Pulse wave velocity is widely used as an index of arterial stiffness. The aim of this study is to assess the usefulness of pulse wave velocity as a risk factor in patients who underwent off-pump coronary artery bypass grafting (CABG) [OPCAB]. METHODS AND RESULTS: Arterial stiffness was measured by brachial-ankle pulse wave velocity (baPWV) and the ratio of patient's baPWV to age-matched normal value was calculated in 90 OPCAB patients. The mean age and male/female ratio were 69.1 years old and 68/22, respectively. baPWV was higher in CABG patients (1,891 +/- 511 cm/s) than that in age-matched normal value (p<0.01). Preoperatively, baPWV ratio did not correlate to the severity of coronary artery diseases. There were 1 (1.1%) in-hospital death and 48 incidences of postoperative complication in 38 patients. The baPWV ratio in the group with postoperative major complications except atrial fibrillation tended to be higher than that in the non-complication group (1.38 +/- 0.36 vs 1.26 +/- 0.30, p = 0.09). CONCLUSION: The elevated baPWV may be a useful predictor of operative risk in patients who undergo CABG.

Severe aortic regurgitation resulting from a downward displacement of anterior aortic annulus and fibrous strands in the bicuspid aortic valve.

Aortic regurgitation is occasionally caused by fibrous strands and more rarely by downward displacement of the aortic annulus. The present report describes an 18-year-old man with aortic regurgitation resulting from an anterior-posterior type of bicuspid aortic valve with fibrous strands and downward displacement of the anterior aortic annulus. A pair of fibrous strands at the anterior cusp of the bicuspid valve lifted the free margin of the cusp, and the anterior cusp originated from the intraventricular septum. We considered that the aortic regurgitation was due to poor coaptation of the cusps because of these two conditions. After resection of the cusps and the strands, the aortic valve was replaced at the intra-annular position.

[Exposure for harvesting gastroepiploic artery graft].

We present out technique for harvesting the gastroepiploic artery (GEA). We use a Universal Stabilizer Arm and an assistant attachment to push the liver against the diaphragm, giving en enough working space to harvest the graft. Between January and December 2007, 99 isolated coronary artery bypass grafting (CABG)s were performed, and in 36 (36.4%) patients the GEA was harvested using this technique. The mean operation time was 251.1 +/- 40.5 minutes and the mean number of distal anastomosis was 3.6 +/- 0.8. The early patency rate of the GEA graft was 95%. Combined use of a Universal Stabilizer Arm and an assistant attachment provide good exposure for harvesting the GEA.

Large saphenous vein graft aneurysm with a fistula to the right atrium.

We report on a case of a 65-year-old man who was admitted for anterior chest pain on effort. He had received coronary artery bypass grafting (CABG) surgery 20 years ago with saphenous vein grafts (SVGs) to the left anterior descending artery (LAD) and right coronary artery (RCA). An angiography demonstrated large aneurysmal dilatation of both grafts and a fistulous communication between the middle portion of the right SVG and the right atrium (RA). The aneurysm was excised surgically, and the fistula was closed with the right atrial wall with additional bypass grafts of the left internal thoracic artery (LITA) and gastroepiploic artery (GEA).

[Off-pump versus conventional coronary artery bypass grafting in octogenarians].

Coronary artery bypass grafting (CABG) in elderly patients is becoming increasingly common. From January 1996 to February 2002, 836 patients underwent CABG in our hospital, of whom 33 patients (3.9%) were aged 80 years or older. We evaluated the clinical and short-term results of 7 cases of off-pump CABG (OPCAB) and 26 cases of conventional CABG (C-CABG). Mean patient age and preoperative risk factors were similar in both groups. The OPCAB group had significantly decreased operation time (218 versus 281 minutes, p<0.05), and the number of distal anastomoses was significantly fewer in the OPCAB group than in the C-CABG group (1.9 versus 3.8, p<0.05). The frequency of complete revascularization in C-CABG was significantly higher than that of the OPCAB group (84.6% versus 42.9%, p<0.05), and there were no differences in the incidence of major postoperative complications between the groups. There was no hospital death in either group. Cumulative cardiac event free rates were 75% at 1 year and 75% at 3 years in the OPCAB group and 100% at 1 year and 84.6% at 3 years in the C-CABG group (p<0.05). In conclusion, CABG is safe and effective for myocardial revascularization in octogenarians. Except for high-risk cases, complete revascularization with OPCAB or C-CABG should be performed, because favorable outcomes can be expected even in the elderly patients.

Choledochal cyst and duodenal atresia: a rare combination of malformations.

A rare case of congenital duodenal atresia (DA) associated with a choledochal cyst (CC) is reported. At 38 weeks of gestation, a 1,610-g girl was born by cesarean section with a prenatal diagnosis of congenital DA. After the disease was confirmed by radiographs, she underwent a duodenoduodenostomy for complete separation of the duodenum with an annular pancreas. Thirty-two months after the initial operation, she developed upper abdominal pain and acholic stools. Abdominal ultrasonography demonstrated a CC and dilated intrahepatic bile ducts. Magnetic resonance cholangiopancreatography showed an anomalous arrangement of the choledochus and the main pancreatic duct. A diffusely dilated extrahepatic bile duct was resected, and a hepaticoduodenostomy was performed after a cholecystectomy. The patient was discharged without complications. We could not find a similar case report in the English literature. Although it is not reported that there is a close relation of DA and CC in embryologic development, the presence of this combination should be considered.

Adventitial cystic disease of the femoral vein: report of a case.

Adventitial cystic disease (ACD) of the veins is a rare phenomenon, and ACD of the femoral vein is particularly difficult to diagnose due to the similarity in symptoms to those of deep vein thrombosis. We report a case of ACD of the femoral vein, which was initially misdiagnosed as deep vein thrombosis, in a 48-year-old woman who presented with a painless swelling in her right lower leg. The extensive cystic involvement of the femoral vein was completely resected and reconstructed with an 8-mm ringed polytetrafluoroethylene vascular graft with good results.