[Aortic Remodeling in Uncomplicated Stanford Type B Aortic Dissection Stratified by The Timing of Thoracic Endovascular Aortic Repair:A Retrospective Cohort Study].

PURPOSE: We investigated the relationship between aortic remodeling and timing of thoracic endovascular aortic repair( TEVAR) in patients with uncomplicated Stanford type B aortic dissection. METHODS: 29 patients with sub-acute and early chronic uncomplicated Stanford type B aortic dissection underwent TEVAR between February 2019 and August 2022 in our hospital. We retrospectively compared aortic remodeling between 19 patients in the sub-acute( SA) group( 15-90 days from onset) and 10 patients in the early chronic( ECh) group( 91-365 days from onset) using the false luminal area reduction rate using computed tomography imagings. RESULTS: The false lumen area reduction rates at the level of the carina in the SA and ECh groups were 21.9±13.5% and 7.0±21.2% (p=0.04) around 3-8 days after TEVAR, 91.8±13.8% and 62.6±48.4 % (p=0.26) at 6 months, 96.6±7.2% and 68.7±42.5% (p=0.14) at 12 months, and 96.2±10.0% and 79.2±37.6% (p=0.62) at 18 months respectively. There were no significant differences between the two groups regarding any complication. CONCLUSION: Preemptive TEVAR for sub-acute and early chronic uncomplicated Stanford type B aortic dissection resulted in good remodeling and it may provide a good prognosis, especially in the subacute stage.

Late-onset spinal subdural hematoma following cerebrospinal fluid drainage tube removal.

Cerebrospinal fluid drainage is recommended for high-risk patients to prevent spinal cord ischemia during aortic surgery; however, it is associated with complications. We report a case of a late-onset spinal subdural hematoma that developed after removal of the cerebrospinal fluid drainage tube from a patient who undergon thoracic endovascular aortic repair. Spinal hematoma usually develop 2 to 3 days after tube removal; however, in our patient's case, it developed after 7 days. Therefore, a spinal subdural hematoma can occur ≤1 week after drainage tube removal, necessitating prompt magnetic resonance imaging for patients with lower limb weakness or back pain.

[Mobile Thrombus in the Ascending Aorta Detected Incidentally in the Patient with Fever before Surgery for Esophageal Cancer:Report of a Case].

A mobile thrombus in the ascending aorta is extremely rare. A 57-year-old man was referred to our hospital with suspected esophageal cancer. Following thorough evaluation, he was diagnosed with esophageal cancer( UtMt type0-Ⅱa T1b, Mt type0-Ⅱc T1a N0M0 cStageⅠ) and tongue cancer in situ. He was administered preoperative chemotherapy comprising fluorouracil and cisplatin. The patient developed fever on day four of the first course of the chemotherapy. Contrast-enhanced chest and abdominal computed tomography revealed a mobile thrombus in the ascending aorta with bilateral partial renal infarction. We initiated intravenous unfractionated heparin and oral warfarin as anticoagulant therapy. The thrombus did not disappear despite ten-day treatment;therefore, he underwent aortic thrombectomy under hypothermic circulatory arrest with retrograde cerebral perfusion. Intraoperatively, we detected a pedunculated mobile thrombus attached to the aorta. His postoperative course was uneventful and he was treated at discharge with warfarin. He underwent video-assisted thoracoscopic esophagectomy postoperatively and was discharged without any complication. Currently, he showed no recurrent thrombus or cancer.

[Thoracic Endovascular Aortic Repair for Idiopathic Aortic Rupture].

Idiopathic aortic rupture is a rare but often fatal condition that requires urgent attention and repair. I have performed thoracic endovascular aortic repair ( TEVAR) in two cases of idiopathic aortic rupture and have achieved positive results. It can be difficult to identify the site of rupture in these cases. Therefore, it is necessary to lengthen treatment and to determine the potential for spinal cord ischemia and associated paralysis of the lower extremities. Given its association with a favorable postoperative recovery, TEVAR can be considered as a minimally-invasive option that can be used early to treat this condition, including those associated with hemodynamic instability and in patients who are at high risk for complications.

[Hybrid Coronary Revascularization of Minimally Invasive Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in a Patient with Left Main Coronary Stenosis].

We report a successful case of hybrid coronary revascularization of minimally invasive coronary artery bypass grafting( MICS-CABG) and percutaneous coronary intervention(PCI). The patient was a 78-year-old man with angina pectoris due to left main trunk (LMT) lesion, and had a history of repeated PCI to the left anterior descending artery (LAD) and the left circumflex artery (LCX) for angina pectoris. He presented with a chest pain on effort in June, 2015. A coronary angiogram showed a severe stenosis in the LMT extending to LAD and LCX. We performed hybrid therapy of CABG to LAD, and PCI to LMT and the proximal portion of LCX because the lesion was technically and suitable for PCI. CABG to LAD was performed via left mini thoracotomy using the left inter mammary artery (LIMA). LIMA was harvested under 3-dimentional endoscope. On the 5th post-operative day, PCI was performed to LMT and LCX. The postoperative course was uneventful and he was discharged on the 11th post-operative day. This case suggests that hybrid coronary revascularization is less invasive and feasible for selected patients with multi-vessel disease.

[Suspended Ventricular Septal Defect Closure Due to Heparin Resistance;Report of a Case].

We present a case of heparin resistance whereby open heart surgery was discontinued. A 53-year-old woman who was diagnosed with ventricular septal defect and atrial septal defect was scheduled for intracardiac repair. However, after intravenous heparin (400 U kg-1) supplementation, the activated clotting time (ACT) increased only to seconds. The operation was discontinued because the addition of heparin( 200 U kg-1) did not show sufficient prolongation of ACT, fully indicative of heparin resistance. Additional antithrombin III concentrate was also ineffective. Postoperative study of the administration of heparin in vitro to the patient's serum showed the probability of transient heparin resistance arising from the stress of surgery.

Transcatheter aortic valve implantation in a patient with aplastic anemia.

Aplastic anemia is a syndrome involving pancytopenia caused by bone marrow insufficiency. Pancytopenia increases the surgical risk of bleeding and infection. Here, we report a successful transcatheter aortic valve implantation (TAVI) in a patient with aplastic anemia. The patient was a 76-year-old woman who was admitted to our hospital with syncope. Laboratory testing showed pancytopenia, and echocardiography revealed severe aortic valve stenosis. Although the log.EuroSCORE and STS Score were not overly high, because of the presence of pancytopenia, surgical aortic valve replacement was considered too high risk, making her a candidate for TAVI. In this case, the patient's pancytopenia was so severe that even TAVI without preparation was considered high risk. In light of this, we carried out a two-day preoperative administration of granulocyte colony-stimulating factor and transfused packed red blood cells and platelet concentrates. TAVI was performed via the left femoral artery using the cut-down procedure under general anesthesia. The postoperative course was uneventful, and she was discharged on the sixth postoperative day. With adequate preoperative preparation, TAVI may be performed safely in high-risk patients with hematologic disorders. .

Aortic root replacement for annuloaortic ectasia with a single coronary artery.

A single coronary artery, arising from the left sinus of Valsalva, associated with a bicuspid aortic valve and annuloaortic ectasia, is very rare. We report on a surgical case of bicuspid aortic valve regurgitation, annuloaortic ectasia, and dilation of the ascending aorta to the aortic arch in a patient with a single coronary artery. We successfully performed aortic root replacement with reimplantation of the single coronary artery and total arch replacement. The reimplantation of the coronary orifice required particular attention. Postoperative CT demonstrated the expected contours from the aortic annulus to the aortic arch with a patent implanted coronary artery.

[Midterm Outcomes of Root Replacement Using Homograft for Aortic Valve Infective Endocarditis].

From August 2003 to June 2013, 9 patients with aortic valve endocarditis underwent aortic root replacement using homografts which were harvested and preserved in our institute. The median patient age was 62 years (range 46~84) and 5 patients were men. Four cases were prosthetic valve infections. The in-hospital mortality was 0%. In 8 of 9 cases were evaluated on midterm outcomes. At a median of 52 months (range 19~156), overall survival was 100%, freedom from cardiovascular events was 87.5%. The peak aortic pressure gradient was 9.04 ± 4.2 mmHg. Aortic regurgitation was less than 2 of 4 in all cases.

[Full root replacement with a Freestyle bioprosthesis for prosthetic valve endocarditis complicated by aortic-root pseudoaneurysm after subcoronary technique; report of a case].

We report a surgical case of prosthetic valve endocarditis( PVE) after aortic valve replacement with a Freestyle stentless bioprosthesis, which was successfully treated with full root replacement using a Freestyle valve. A 80-year-old man underwent aortic valve replacement with a Freestyle stentless bioprosthesis, using subcoronary technique for aortic stenosis in 2004. Three years later he had late PVE, and we found the aortic-root pseudoaneurysm. Although homografts are the optimal for cases of severe aortic annular destruction, availability of these are limited in Japan. We chose a Freestyle valve with full root technique, which fitted well to the destroyed annulus. The postoperative course was uneventful. Freestyle stentless bioprosthesis can be useful option for PVE, meanwhile care should be taken to dead cavity between prosthesis and aortic wall in the subcoronary technique.

[On pump beating heart mitral and tricuspid valve annuloplasty via right mini thoracotomy approach in a patient who had undergone cardiac surgery 3 times].

The patient was an 84-year-old man. He had a history of 3-time median sternotomy with a functioning coronary bypass graft. Because of his dependence on inotropic agents caused by a progressing mitral and tricuspid valve insufficiency, we decided to perform surgery. To avoid heart damage and injury to the bypass graft by adhesiotomy, we performed on-pump beating heart mitral and tricuspid valve annuloplasty via right mini-thoracotomy approach. He was discharged 16 days after surgery. The on-pump beating heart valve repair via right mini-thoracotomy approach was useful in a selected case with multiple surgeries.

A newly designed holder for grafts with four side branches used in total arch replacement.

Grafts with four presewn side branches have proven very useful for total aortic arch replacement worldwide. However, the four side branches often obscure the surgeon's view of the distal anastomotic site. Thus, we designed a holder for this graft, which sheaths and hides the graft body and branches, allowing the surgeon a better view of the distal anastomosis. By using this device, distal anastomosis can be achieved early and quickly without obstruction of the surgeon's view, resulting in reduced cardiac ischemic time in aortic arch surgery.

Transapical aortic cannulation using a deep hypothermic procedure through a left thoracotomy for acute traumatic aortic rupture.

We describe a transapical aortic cannulation procedure through a left thoracotomy for a case of acute traumatic aortic rupture. A 26-year-old man was involved in a motor vehicle accident and admitted in a state of hypovolemic shock. Chest computed tomography findings revealed a rupture of the proximal portion of the descending aorta and a massive hematoma around the aorta extending into the thoracic cavity. Under hypothermic circulatory arrest, he underwent an emergency graft replacement through a left thoracotomy. We used transapical aortic cannulation together with femoral cannulation, in order to avoid malperfusion of the brain and upper body that can occur as a result of retrograde perfusion. The postoperative outcome was favorable. Transapical cannulation is a useful alternative for hypothermic aortic operations through a left thoracotomy.