A knot-pusher technique with hand-tying precision through a mini-thoracotomy.

This study documents the application of a knot-pusher technique via a mini-thoracotomy with the traditional one-handed knot-tying rationale using an existing long-shaft knot-pushing device. This technique achieved the typical hand-tying precision and secured tight knots in minimally invasive cardiac surgery.

Extensive aortic root endocarditis caused ventricular septal rupture.

A 79-year-old man was referred to us for severe cardiac decompensation. Chest radiography showed severe pulmonary edema, and transesophageal echocardiography revealed extensive vegetations on all aortic valve leaflets with severe aortic valve regurgitation, heterogeneous cavities adjacent to the aortic annulus, and ventricular septal rupture into the right-ventricular outflow tract. After extensive debridement of the aortic root (including the infected ventricular septum), the ventricular septum and aortic root were reconstructed using autologous and bovine pericardial patches, and a bioprosthetic stented valve was placed. The postoperative course was uneventful, and he remains recurrence-free 4 years after surgery.

Insulin and glucose infusion could prevent euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter 2 inhibitors.

Perioperative euglycemic diabetic ketoacidosis (euDKA) is a serious adverse effect of sodium-glucose cotransporter 2 inhibitor (SGLT2i) treatment. We observed perioperative euDKA immediately after discontinuing insulin infusion that was started during surgery in a patient with type 2 diabetes mellitus (T2DM) for whom empagliflozin could not be withdrawn before emergency off-pump coronary artery bypass grafting (OPCAB). Insulin infusion that was started during surgery unexpectedly prevented euDKA until its discontinuation. Therefore, we hypothesized that insulin and glucose infusion initiated at the start of emergency surgery in patients receiving SGLT2is prevents perioperative euDKA. We implemented this strategy during emergency OPCAB in another patient with T2DM who received empagliflozin 2 days before surgery and observed that the patient did not develop perioperative euDKA. With the increasing use of SGLT2is, surgeons may encounter more SGLT2i users who require emergency surgeries. The administration of insulin and glucose infusion in advance emergency surgery can prevent perioperative euDKA.

Myocardial ischemia due to radical resection of complex coronary fistulas with giant aneurysms: a case report.

A 56-year-old man underwent surgery for complex coronary artery fistulas with giant coronary aneurysms. This treatment resulted in complications and caused myocardial ischemia of the right ventricular outflow tract, resulting in repeated ventricular fibrillations. The irritability caused by this fetal arrhythmia was improved by the placement of an intra-aortic balloon pump. The case findings suggest that even careful resection of complex coronary fistulas could precipitate myocardial ischemia.

[Double Infectious Aortic Aneurysms Followed by Positron Emission Tomography/Computed Tomography for Evaluation of Infection Control after Simultaneous Thoracic Endovascular Aortic Repair and Endovascular Aortic Repair:Report of a Case].

An 81-year-old male was referred to our institute. His chief complaint was high fever. Computed tomography (CT) angiography demonstrated newly saccular aortic aneurysms at both thoracic and abdominal aorta. We used intravenous antibiotics( ceftriaxone 4 g/day) for seven days. Positron emission tomography (PET)/CT showed active inflammation sign at both chest and abdominal aneurysms. Open surgery for double aortic aneurysms seemed too invasive because of his past medical history. At eighth day after admission, we performed thoracic endovascular aortic repair( TEVAR) and endovascular aortic repair (EVAR) for preventing rupture of aortic aneurysms. After surgery, we continued intravenous antibiotics (ceftriaxone 4 g/day) for 15 days. We changed intravenous antibiotics to oral antibiotics( levofloxacin 500 mg/day). The postoperative course was uneventful. He was discharged at 19th day after surgery. Since surgery, no symptoms of reinfection have been observed at outpatient clinic. PET/CT was useful to evaluate the control of local infection in this case.

[Constrictive Pericarditis with Intractable Ascites after Aortic Valve Replacement;Report of a Case].

We report a 68-year-old man, who developed refractory ascites of unknown cause after aortic valve replacement. He was diagnosed with constrictive pericarditis because of "dip-and-plateau" waveform findings via cardiac catheterization and operated with cardiopulmonary bypass. Following waffle procedure, we incised pericardium for decompression, so that pericardial mobility and diastolic dysfunction was improved. Postoperative computed tomography (CT) image also showed decrease of ascites fluid. We concluded that pericardiotomy is an established surgical procedure and is excellent indication to constrictive pericarditis.

[Emergent Thoracic Endovascular Aortic Repair and Subxiphoid Pericardiotomy for Retrograde Type A Acute Aortic Dissection with Cardiac Tamponade;Report of a Case].

Type A acute aortic dissection has a high rate of mortality. Emergent surgical repair is the gold standard treatment, but some patients cannot tolerate the open surgery. Here, we report an 82-year-old patient with a history of cerebral infarction and cerebral bleeding who presented with a depressed level of consciousness and who was in a state of shock. A computed tomography (CT) scan showed cardiac tamponade associated with retrograde type A aortic dissection(RAAD), with a primary entry tear at a distal site of the left subclavian artery. We therefore performed emergent primary entry closure with stent grafting using the Conformable Gore Tag device and emergent drainage of the cardiac tamponade with subxiphoid pericardiotomy. Postoperative CT scan showed complete closure of the primary entry tear and a completely thrombosed false lumen. Primary entry closure with stent grafting could be an effective option for RAAD that meets anatomical criteria.

[Strategy of Thoracic Endovascular Aortic Repair for Uncomplicated Type B Aortic Dissection in Subacute and Chronic Phase;Interval From Onset and Maximum Diameter].

We classified 59 patients who underwent thoracic endovascular aortic repair for uncomplicated type B aortic dissection from April 2008 to April 2016 into 3 groups based on time from onset and maximum aortic diameter:SA (2weeks to 1 year since onset;n=29), C (>1 year since onset;n=17), and D(maximum aneurysm size≥60 mm;n=13). We used the Kaplan-Meier method tso analyze survival, major adverse cardiovascular event and the need for additional treatment. There was no significant difference in outcomes between the SA and C groups (p=0.998) or C and D groups (p=0.279), but the results in group D tended to be consistently inferior. The freedom from aneurysm rupture rate was inferior in this group, with a significant difference between groups C and D (p=0.044). The time from onset to the procedure and maximum aortic diameter were not significantly associated with the longterm outcomes;however, more aortic ruptures occurred in the group with maximum aortic diameter≥60 mm. Simultaneous treatment for re-entry closure or conventional surgical procedures should be considered for such cases.

[Quadricuspid aortic valve; report of two cases].

Quardicupid aortic valve( QAV) is a comparatively rare congenital anomaly, which presents with frequent aortic regurgitaion ( AR) due to sclerotic changes. We report 2 cases (a 67-year-old woman and a 53-year-old man) of QAV associated with AR. We made an definite diagnosis by preoperative transthoracic and intraoperative transesophageal echocardiography. Intraoperative findings showed type C QAV in case 1 and type B QAV in case 2 according to the Hurwitz classification. The left coronary ostia was slightly shifted to the aortic root in case 1. There were no other congenital anomalies, therefore only aortic valve replacement with mechanical prosthesis was performed in both cases. The postoperative courses were uneventful.

[Penetrating injury of the left ventricle caused by a nail gun; report of a case].

Penetrating cardiac injuries are life-threatening emergencies. We present a case of a 24-year-old construction worker who accidentally shot himself with a nail gun. Chest X-ray showed a 6 cm-long nail overlapping the cardiac shadow. A computed tomography (CT) scan revealed the nail penetrating the left ventricle and a large amount of pericardial effusion. Median sternotomy was performed and cardiopulmomary bypass was established. Then, the nail was removed and the left ventricular wound was repaired by 4-0 Prolene mattress sutures buttressed with felt-strips. He had an uncomplicated postoperative course and was discharged 7 days postoperatively.

[Papillary fibroelastoma attached to the underside of the aortic valve; report of a case].

We report a case of papillary fibroelastoma of the aortic valve. A 72-year-old man was referred to our hospital with cardiac tumor incidentally detected by transthoracic echocardiography. Transesophageal echocardiography showed a mobile tumor on the ventricular side of the aortic valve. We performed semi-emergency surgery and resected the tumor with a blade to prevent embolism. Pathologic findings revealed papillary fibroelastoma. The postoperative course was uneventful, and the patient was discharged 10 days arter surgery. Follow-up transthoracic echocardiography has not shown any evidence of local recurrence.

Is the mid-term outcome of free right internal thoracic artery with a proximal anastomosis modification inferior to in situ right internal thoracic artery?

BACKGROUND: We investigated the mid-term results of free right internal thoracic artery (RITA) grafts used in an aorto-coronary fashion with a modified proximal anastomosis. METHODS: The subjects were 214 patients who underwent coronary artery bypass grafting with anastomosis to the left circumflex arteries using the RITA as a free graft (Group A: 158 patients) or an in situ graft (Group B: 56 patients). In Group A, the proximal end of the free RITA was anastomosed onto the ascending aorta interposing free graft tissue or to part of its own tissue as a cuff. RESULTS: The number of RITA anastomoses was 1.38 ± 0.50 in Group A and 1.04 ± 0.19 in Group B (P < 0.001). The relationship between perioperative variables and mid-term outcomes was assessed using Cox proportional hazard models. Survival was not associated with the way the RITA graft was performed (Hazard Ratio 5.26, 95 % CI 0.52-53.1, P = 0.159), however, the number of cardiac events was decreased in Group A (Hazard Ratio 2.55, 95 % CI 1.03-6.33, P = 0.043). The graft patency was evaluated in 187 of 214 patients, and at 1, 3 and 5 years was 97.0, 97.0 and 97.0 % in Group A, and 97.9, 92.5 and 80.5 % in Group B (P = 0.378), respectively. CONCLUSION: By modifying the proximal anastomosis of the free RITA, cardiac events may be decreased, while survival and graft patency comparable with in situ RITA can be obtained, and a significantly larger number of targets can be revascularized.

Balloon occlusion of the ascending aorta without hypothermic circulatory arrest in valve surgery for patients with a porcelain aorta.

Severe calcification of the ascending aorta and the aortic arch complicates cardiac surgery. The optimal approach in such patients is unknown. Four valve surgeries were performed with balloon occlusion without hypothermic circulatory arrest. All patients had femoral arterial cannulation, and all 3 patients who required an aortotomy had right axillary artery cannulation as well. A balloon catheter was inserted just proximal to the brachiocephalic artery via a purse-string stitch. Good cardiac arrest was obtained in all cases, and a good bloodless field was obtained in all 3 aortic valve cases. There were no balloon-related complications. The patients all showed good postoperative courses. Balloon occlusion of the ascending aorta without circulatory arrest is effective for performing a rapid and less invasive surgery that is not significantly different from the usual valve surgery.

Use of an expanded polytetrafluoroethylene patch as an artificial leaflet in mitral valve plasty: an early experience.

PURPOSE: The purpose of this study was to examine the usefulness of polytetrafluoroethylene (PTFE) patches as artificial mitral leaflets in complex mitral valve plasty. DESCRIPTION: Nineteen patients (mean age, 66 +/- 9 years) who were in need of mitral valve replacement successfully underwent mitral valve plasty with enlargement of the basal anterior leaflet using a PTFE patch. EVALUATION: Operative and in-hospital mortality was 0%. Patients were followed-up by maintaining their history, physical examinations, and echocardiography. The mean follow-up period was 30 +/- 15 months (2 to 52 months) with one late mortality and one reoperation. A thin neointimal layer was observed on the explanted PTFE patch. The PTFE patch maintained its pliability with no signs of calcification, excessive thickening, or perforation for 4 years. Mean motion angle of the patch on echocardiography decreased from 41.1 +/- 10.6 to 35.2 +/- 12.5 degrees (p < 0.05) during 26.7 +/- 15.5 months of study (range, 6-46 months). The mean mitral valve area was 2.9 +/- 0.7 cm(2) at last follow-up. CONCLUSIONS: The PTFE patches may be a promising material for artificial mitral leaflets.

Edge-to-edge mitral valve repair for anterior leaflet prolapse associated with extensive calcification of the mitral annulus: Report of a case.

Extensive mitral annular calcification remains a technical challenge in mitral valve surgery. Decalcification and reconstruction of the mitral annulus is an established technique, but it is time consuming and technically demanding. This report presents the case of an 88-year-old diabetic female patient in whom edge-to-edge repair was completed quickly, with good early results thus being obtained.

Atherosclerotic arch aneurysm operations with perfusion toward the aortic valve.

BACKGROUND: The study objective was to investigate the efficacy of perfusion toward the aortic valve in patients who had undergone total arch replacement for atherosclerotic arch aneurysms. METHODS: Transesophageal echocardiography was used to measure the peak velocities of each perfusion method in the aortic arch. The latest 15 patients with perfusion toward the aortic valve in the arch procedure were compared with 15 patients with perfusion toward the aortic arch in other cardiac operations as controls. Between April 2005 and February 2009, 65 consecutive patients underwent total arch replacement for atherosclerotic aneurysms. Among them, 48 patients underwent operations with perfusion toward the aortic valve and were reviewed. RESULTS: The peak forward aortic flow velocities with perfusion toward the aortic valve were 48 +/- 26 cm/s before cardiopulmonary bypass and 29 +/- 13 cm/s on cardiopulmonary bypass. The velocities with perfusion toward the aortic arch were 67 +/- 28 cm/s before cardiopulmonary bypass and 226 +/- 114 cm/s on cardiopulmonary bypass (p < 0.001). Of the 48 patients with perfusion toward the aortic valve, postoperative temporary and permanent neurologic dysfunctions occurred in 4 (8.2%) and in 1 (2.0%), respectively. One (2.0%) hospital death occurred. CONCLUSIONS: Perfusion toward the aortic valve resulted in a significant decrease in peak forward aortic flow velocity in the aortic arch during cardiopulmonary bypass, which might reduce the risk of erosion or disruption of existing atheroma and ensuing embolic complications in patients with atherosclerotic aneurysm.

Foldback technique for aortic anastomosis of free right internal thoracic artery in coronary artery bypass grafting.

We herein report a new technique that we term "foldback plasty" for stenosis-free proximal anastomosis of free arterial grafts without using any other interposition materials. The arterial graft is first anastomosed to the aorta in side-to-side fashion, leaving 1 cm of remnant tissue at the proximal end. The reverse side of the graft is then opened longitudinally, starting at the proximal end, to just distal to the aortic anastomosis site. The new proximal graft flap is folded back and sutured onto the graft to close the longitudinal opening. The proximal anastomosis site is enlarged only by the graft tissue, and stenosis can be avoided even if the graft has a small caliber.

Transapical aortic cannulation via left lateral thoracotomy for descending thoracic and thoracoabdominal aortic surgery.

Two patients underwent surgery for a chronic type B dissection using a total cardiopulmonary bypass (CPB) with transapical arterial cannulation. At surgery, a total CPB was established by cannulating the left femoral artery and the ascending aorta via the ventricular apex. The patients were cooled to 30 degrees C. The proximal anastomosis was done after cross-clamping the aortic arch between the left carotid artery and the left subclavian artery in both cases. In the first case, the entire descending thoracic aorta was replaced, and two pairs of intercostal arteries were reconstructed. The other patient underwent replacement of the proximal descending thoracic aorta. Neither patient experienced any complications. Transapical aortic cannulation is a useful option during descending thoracic and thoracoabdominal aortic surgery. It can provide more stable circulation during the cross-clamping, more gentle manipulation of the aorta by nonpulsatile flow, and more liberty in temperature control.