Critical Circulatory Failure Accompanied With the aVR Sign Caused by Severe Graft Kinking Related to Acute Pseudoaneurysm Formation After Type A Acute Aortic Dissection Repair.

The aVR sign characterized by ST-segment elevation in lead aVR and diffuse ST-segment depression on the electrocardiogram indicates potential life-threatening conditions. We report the case of a 53-year-old male with a history of ascending aortic replacement for acute aortic dissection, who presented to our institution in shock. The initial electrocardiogram revealed the aVR sign, consisting of ST-segment elevation in lead aVR and ST-segment depression in leads II, III, aVF, and V3-6, leading to the initiation of salvage veno-arterial extracorporeal membrane oxygenation (ECMO) due to deteriorating hemodynamics. The aVR sign resolved shortly after ECMO initiation, and hemodynamics stabilized even with reduced ECMO flow. Subsequent coronary angiography showed no impaired coronary perfusion, whereas contrast-enhanced CT revealed severe supra-valvular stenosis due to pseudoaneurysm-induced graft kinking. The patient was then managed with emergency surgery for the pseudoaneurysm. In this report, we encountered a salvaged case of critical circulatory failure presenting with the aVR sign due to severe graft kinking caused by pseudoaneurysm formation.

Clinical Outcome of the Type A Acute Aortic Dissection Repair Using the "Tailored Stand-Up Collar" Technique.

PURPOSE: Achieving a secure anastomosis and complete hemostasis is essential for surgically treating type A acute aortic dissection (TAAAD). This study assessed the clinical feasibility of "tailored stand-up collar (TSC)" technique for constructing the distal stump. METHODS: We enrolled 68 patients who underwent ascending aortic repair for TAAAD. Patients were categorized according to the technique for distal stump construction: conventional (C) group using only a felt strip (32 cases); post-aortotomy (P) group, with a Hydrofit-felt strip attached after aortotomy (18 cases), and TSC group, where a Hydrofit-felt strip attached during cooling (18 cases). Pre-operative characteristics, procedural profiles, and post-operative outcomes were evaluated. RESULTS: The pre-operative characteristics were identical among the groups. The durations of cardiopulmonary bypass, hemostasis, and surgery were significantly shorter in the P and TSC groups. The duration of open distal in the TSC group (21 min) was significantly shorter than the other two groups. Post-operative additional procedures were not required for the TSC group and their post-operative hospital stay was significantly shorter (47.1% of patients were discharged within 2 weeks). CONCLUSION: The TSC technique would be practical because of its high reproducibility in terms of ease of use, shorter anastomotic time, and secure hemostasis.

First Experience With the Triolifter, a Novel Device for Organ Fixation Used as a Heart Positioner in Cardiac Surgery.

We describe our first experience with the Triolifter (Fuji Systems, Yokohama, Japan) in cardiac surgery. The Triolifter is a less expensive, novel organ fixation device developed as a fixation indenter mainly for traction of the lung under video-assisted surgery and is now available in Japan. An 84-year-old man diagnosed with unstable angina pectoris underwent emergency coronary artery bypass grafting (CABG) under cardiac arrest. Following the declamping of the aorta and the resumption of the beating heart, bleeding from the left anterior descending artery (LAD) anastomosis site was observed. The Triolifter was used as a heart positioner to expose the anastomosis site for hemostasis in the setting of an on-pump beating heart. Hemostasis of the posterior descending artery (PDA) anastomosis site could also be confirmed by traction of the right ventricular anterior wall using the Triolifter. It could be effectively and safely used with neither significant subepicardial hematoma nor epicardial injury. In Japan, the Triolifter might be used as one of the insurance-covered devices in off-pump CABG in the future, but globally, it could also be used in on-pump CABG without hesitation because it is so inexpensive.

Evaluation of the Factors Affecting Higher Hospitalization Cost of Lung Resection for Primary Lung Cancer: A Retrospective Cohort Study.

PURPOSE: This study aims to evaluate the factors associated with the higher hospitalization cost of lung resection for primary lung cancer to contribute to the reduction of healthcare spending. METHODS: A total of 435 consecutive primary lung cancer patients who underwent lung resection by a single surgeon at a single institution were enrolled. Baseline patient characteristics, operative procedures, postoperative complications, and postoperative courses were analyzed in relation to the hospitalization cost. Patients with higher costs (exceeding the third quartile [TQ]) were compared with patients with lower costs (less than TQ). RESULTS: Median and TQ medical costs for overall cases were 11177 US dollars (USD) and 12292 USD, respectively. Smoking history, history of coronary artery disease, previous thoracotomy, multiple sealant material use, transfusion, tumor factor T3 or higher, squamous cell carcinoma, postoperative complications, and longer postoperative hospital stay (>10 POD) were significant risk factors for increased hospitalization cost in multivariate analysis. The 5-year survival rate was significantly lower in the higher hospitalization cost group. CONCLUSION: In addition to postoperative complications and prolonged hospitalization, patient background, histological types, and intraoperative factors were also considered as the risk factors for higher medical costs.

[Successful Staged Repair of Double Rupture after Acute Myocardial Infarction:Report of a Case].

Double rupture is a very rare, and life-threatening complication after acute myocardial infection (AMI), which defined as the coexistence of any two of the three types of rupture include left ventricular free wall repture (LVFWR), ventricular septal perforation (VSP) and papillary muscule repture (PMR). We report here a case of successful staged repair of double rupture combined LVFWR and VSP. A 77-year-old woman with diagnosis of AMI in the anteroseptal area fell into cardiogenic shock suddenly just before starting coronary angiography. Echocardiography showed left ventricular free wall rupture, then an emergent operation was performed under intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) assistance using bovine pericardial patch and felt sandwich technique. Intraoperative transesophageal echocardiography revealed ventricular septal perforation on the apical anterior wall. Her hemodynamic condition was stable, therefore we selected a staged VSP repair to avoid surgery on freshly infarcted myocardium. Twenty-eight days after the initial operation, VSP repair was performed using the extended sandwich patch technique via right ventricle incision. Postoperative echocardiography revealed no residual shunt.

[Stanford Type A Acute Aortic Dissection after Coronary Artery Bypass Grafting using Automated Proximal Anastomotic Device].

Stanford type A acute aortic dissection after off-pump coronary artery bypass grafting( OPCAB) is a rare but potentially fatal complication. A 61-year-old man with subacute Stanford type B aortic dissection underwent a triple OPCAB using an automated proximal anastomotic device. On postoperative day 4, he had a sudden syncope. An enhanced computed tomography (CT) scan revealed Stanford type A acute aortic dissection. He underwent emergent total aortic arch replacement along with an open stent graft deployment. The entry of the dissection was located at the proximal anastomosis site of the vein graft. This case demonstrates that this device should be used carefully in patients with a history of Stanford type B aortic dissection.

[Stanford Type A Acute Aortic Dissection with Persistent Left Superior Vena Cava in a Turner Syndrome Patient:Report of a Case].

A 48-year-old woman who was diagnosed with Turner syndrome in her childhood presented with sudden onset of low back pain and respiratory discomfort. Contrast enhanced computed tomography scan revealed Stanford type A acute aortic dissection with persistent left superior vena cava (PLSVC). Emergency ascending aortic replacement was performed. After cardiopulmonary bypass was established through cannulating right femoral artery and right superior vena cava, inferior vena cava, another venous cannula was directly placed into the left superior vena cava. After core cooling, the right atrium was incised for retrograde cardioplegia. At a tympanic temperature of 25 ℃, circulatory arrest was started and retrograde cerebral perfusion was performed through right and left superior vena cava. Her postoperative course was uneventful.

[Passive Orthostatism Using Tilt Table in Critical Patients after Cardiovascular Surgery].

Previously, we performed passive orthostatism using a tilt table for the purpose of early mobilization in intensive care unit patients after cardiovascular surgery. In this study, we introduced VitalGo Total Lift Bed( TLB), which does not require patient-transfer before passive orthostatism, to reduce the burden on patients and medical staff. No obvious adverse events were found throughout the study. In the TLB group, number of medical staff required to perform the passive orthostatism was significantly less compared to the conventional tilt table group.

[Non-anastomotic Pseudoaneurysm of a Prosthetic Graft with Sternal Erosion after Total Aortic Arch Replacement].

An 82-year-old man underwent total aortic arch replacement with a 24 mm Triplex four-branched graft for aortic arch aneurysm. After two years, he was diagnosed with pseudoaneurysms due to bleeding from a non-anastomotic site of the branch graft to the left common carotid artery and minor leakage from a distal anastomotic site of the main graft. A self-expandable Fluency covered stent and cTAG thoracic endograft were used for the aneurysm. After four years, he was referred to our hospital with a complaint of pulsatile swelling of the anterior chest wall. Contrast enhanced computed tomography (CT) revealed a pseudoaneurysm arising from a non-anastomotic site of the branch graft to the left common carotid artery, which extended into the anterior chest wall and the skin through the sternum. He underwent emergency endovascular repair using a Niti-S ComVi covered stent. The postoperative course was uneventful. Postoperative CT showed shrinkage of the pseudoaneurysm. The patient was discharged and required no reintervention during the follow-up.

Successful surgical treatment of a long ingrowing intra-coronary septic vegetation.

A 39-year-old man was referred to our hospital as infective endocarditis with multiple organ failure and disseminated intravascular coagulation syndrome. Transoesophageal echocardiography and coronary computed tomography angiography revealed a long ingrowing vegetation into the right coronary artery. Emergency surgical resection of the vegetation and aortic valve replacement was performed successfully without distal embolism of the vegetation.

[Passive Orthostatism Using a Tilt Table in Patients with Impaired Oxygenation after Cardiovascular Surgery].

Passive orthostatism using a tilt table was introduced in patients with impaired oxygenation [Pao2/Fio(2 P/F) ratio < 300] after cardiovascular surgery. Our passive orthostatism protocol was as follows. Patient was transferred to a tilt table under endotracheal intubation with pulmonary artery catheter monitoring, and rested for 10 minutes in a supine position, followed by 45-degree tilt for 5 minutes, and then passive orthostatism at 60-degree for 25 minutes. P/F ratio was significantly improved during passive orthostatism. Improvement in P/F ratio was confirmed even 1 hour after completion of the protocol. No obvious adverse events were found throughout the protocol. On average, 15 hours (2~72 hours, median 4 hours) after the introduction of passive orthostatism, weaning from respirator was achieved.

Endovascular Repair for Abdominal Aortic Rupture Caused by Periaortic Mantle Cell Lymphoma.

A 72-year-old man was referred to our hospital for the suspicion of ruptured abdominal aortic aneurysm. Before admission, he was suspected of having a malignant lymphoma and underwent excisional biopsy in his right groin. A contrast enhanced computed tomography scan revealed a massive retroperitoneal hematoma with an extravasation arising from the infrarenal abdominal aorta coexisting with an extensive retroperitoneal mass surrounding the aorta. An emergency endovascular aneurysm repair was performed and the postoperative course was uneventful. After the treatment, histological examination of the previous biopsy confirmed the diagnosis of mantle cell lymphoma.

[Thoracentesis under Standing with Assistance of a Tilt Table in Critical Patients after Cardiovascular Surgery].

For safe and effective drainage in patients with pleural effusion after cardiac surgery, ultrasound-guided thoracocentesis was carried out under standing with assistance of a tilt table. Thoracocentesis was performed in 5( 11%) of the 44 patients who were treated under passive orthostatism using a tilt table. Four cases were under intubated-ventilator assist, and 2 cases were under intraaortic balloon pumping( IABP). No adverse events occurred. Thoracocentesis under standing with assistance of a tilt table can be safely performed.

Our tips for bronchoplasty using suture holder and tourniquet.

Bronchial anastomosis is an important part of successful bronchoplasty, but it takes time to achieve stable results because of few opportunities to do it. To ensure a stable outcome, we have applied some tips for bronchial anastomosis. One of the tips is the use of a suture holder to obtain appropriate suture pitches, adjusting the discrepancy of the bronchial diameter, and another one is the use of a tourniquet to obtain an adequate tension upon tying the knots, ensuring good operative view.

Bioprosthetic mitral valve dysfunction due to native valve preserving procedure.

Mitral valve replacement with preservation of the mitral leaflets and subvalvular apparatus is considered to maintain left ventricular geometry and function and reduce the risk of myocardial rupture. However, the routine use of this technique may lead to early complications such as left ventricular outflow tract obstruction and even mitral inflow obstruction, requiring reoperation. We describe a rare case of bioprosthetic mitral valve dysfunction caused by a native valve preserving procedure.

[Postoperative Superior Mesenteric Artery and Cerebral Infarction Possibly due to the Thrombus at the Left Superior Pulmonary Vein Stump].

Pulmonary vein stump thrombus (PVST) was thought to be a rare complication after lung resection. Several cases of embolism due to PVST were reported previously. However, in recent paper, PVST was reported to be found in 13.5% of patients after left upper lobectomy ( LUL). We experienced a case of PVST that induced acute embolism of the superior mesenteric artery at 2 weeks after LUL. After discontinuation of anticoagulation therapy, development of PVST was confirmed by computed tomography scan at 12 months after LUL resulting in cerebral infarction.

[Emergency coronary artery bypass grafting for acute myocardial infarction presenting as cardio-pulmonary arrest during a marathon race; report of a case].

We report a case of coronary artery bypass grafting for acute myocardial infarction which presented as cardio-pulmonary arrest during a marathon race. A 57-year-old man collapsed at the 18-km point in the Toyohashi half marathon. He was treated with an automated electrical defibrillator( AED) for ventricular fibrillation in an ambulance. Immediately after arriving at our emergency department, he was diagnosed with acute myocardial infarction by electrocardiography. Emergency coronary angiography revealed severe stenosis of the left anterior descending artery. Percutaneous coronary intervention was tried, but it was given up because calcification of the stenotic lesion was severe. He was then referred to our department for emergency coronary artery bypass grafting. Complete re-vascularization was accomplished and the patient has been doing well with no signs of angina.

[Reconstruction of the superior vena cava for invasive thymoma under monitoring of regional cerebral saturation of oxygen].

A 63-year-old man was referred to our department for surgical resection of invasive thymoma (type B3)after 2 courses of chemo-therapy resulted in stable disease. Resection of the tumor was done through a median sternotomy under monitoring of regional cerebral saturation of oxygen (rSo2) using near-infrared spectroscopy (NIRS). The tumor invaded to the right upper lobe (S3), the right phrenic nerve, the superior vena cava (SVC), and the bilateral brachiocephalic vein (BCV). Although bilateral clamping of the BCVs induced significant decrease in rSo2, unilateral clamping of the BCV did not. Therefore, reconstruction of the SVC by sequential reconstruction of BCVs was carried out, and the tumor was successfully and safely excised with the SVC and a part of the right upper lobe.

[Double-patch technique through right ventriculotomy for residual shunt after infarct exclusion technique for post-infarction ventricular septal perforation].

We report a case in which the double-patch technique was used to repair residual shunt after infarct exclusion technique for post-infarction ventricular septal perforation (VSP). A 68-year-old man was diagnosed with post-infarction VSP and surgical interveniton was performed by infarct exclusion technique through left ventriculotomy. Residual shunt was observed by left ventriculography, and he developed cardiac failure in spite of medical therapy. Additional surgery for residual shunt was performed 5 months after the initial operation. The VSP was closed with 2 pericardial patches onto both sides of the septum through right ventriculotomy. Complete closure of the defect was accomplished, and no residual shunt was observed by post-operative left ventriculography. The patient has been doing well with no signs of cardiac failure.