Suturing Fenestration of the Left Subclavian Artery Orifice in Frozen Elephant Trunk Procedure.

The frozen elephant trunk (FET) procedure enables easier replacement of the entire aortic arch because it does not require reaching the distal part of the left subclavian artery (LSCA). However, it requires additional management for reconstruction of the LSCA, which is associated with bleeding events. However, the fenestrated FET technique confers a risk of endoleakage from the fenestration site. We report our unique novel technique in which the proximal side of the hybrid stent graft is cut into V-shape around the subclavian artery and sutured continuously around the orifice of the subclavian artery during aortic stump fixation.

Correction to: Thoracic and cardiovascular surgery in Japan in 2016 : Annual report by The Japanese Association for Thoracic Surgery.

In the original publication of the article, the values of the row "Norwood procedure", under "(3) Main procedure" in Table 3 were published incorrectly. The corrected part of the table is given in this Correction.

Efficacy of modified less invasive quick replacement using mild hypothermic arrest and partial retrograde cerebral perfusion for type A acute aortic dissection.

OBJECTIVE: We previously reported a unique technique called "less invasive quick replacement (LIQR)" for treating type A acute aortic dissection with moderate hypothermic arrest (28 °C). This study examines the modified LIQR using mild hypothermic arrest (30 °C) with partial retrograde cerebral perfusion (RCP). METHODS: 187 patients were divided into 2 groups: group L consisted of 130 patients underwent LIQR without any cerebral perfusion; group M consisted of 57 patients who were treated with modified LIQR. In modified LIQR, circulatory arrest was commenced under the 30 °C for open distal aortic stamp fixation. RCP was used during final half anastomosis of the prosthesis and then rapid re-warming was initiated. RESULTS: The incidence of additional valve or coronary surgeries was significantly higher in group M (28.1%) than in group L (9.2%). The average rectal temperature was significantly higher in group M (29.5 °C) than in group L (27.4 °C). The durations of brain ischemia (M 7.7 min; L 18.6 min), cardiopulmonary bypass (M 82.0 min; L 93.3 min), and overall operation (M 145.2 min; L 154.2 min) were significantly shorter in group M. The incidence of postoperative brain damage was 6 patients (4.6%) in group L, but none in group M. The hospital mortality rate was 3 patients in group L (2.3%). All group M patients were discharged from the hospital without any complications. CONCLUSION: Modified LIQR is safe and effective. It makes the surgery much quicker and is a less invasive procedure. The surgical outcome was also favorable.

Efficacy of a newly modified technique for distal limited open stenting in octogenarians with aortic arch aneurysm.

OBJECTIVE: We assessed the efficacy of distal limited open stenting procedure in octogenarians with distal aortic arch aneurysm. METHODS: During the last 5 years, 24 patients underwent distal limited open stenting. Mean patient age was 81.6 ± 2.5 years, ranging from 80 to 90 years. The hemicircumference of the anterior surface of the arch around the left common carotid artery was obliquely incised, and a J-Graft Open Stent (Japan Lifeline Co, Ltd, Tokyo, Japan) was inserted into the descending aorta. During open stenting, circulatory arrest was induced at a rectal temperature of 28°C without any cerebral perfusion. As soon as the proximal side of the stent graft and aortic incision were concomitantly sutured, rapid rewarming was initiated through heated blood perfusion. RESULTS: The durations of circulatory arrest, aortic crossclamping, cardiopulmonary bypass, the overall operation, postoperative mechanical ventilation, and hospital stay were 17.0 minutes, 27.8 minutes, 106.1 minutes, 167.6 minutes, 11.0 hours, and 13.9 days, respectively. The in-hospital mortality was 0%. There were no incidences of brain damage, renal failure, or respiratory failure. At the time of this study, 21 patients were doing well and visiting the outpatient clinic, and 19 scored more than 20 points on the Mini-Mental State Examination, indicating no development of dementia. The actuarial survival at 5 years was 82.4%. CONCLUSIONS: This unique technique is safe and effective. It is a very attractive procedure that can contribute to maintaining a good long-term quality of life for octogenarians with distal aortic arch aneurysm.

Efficacy of limited proximal arch replacement for type A acute aortic dissection with critical complications.

OBJECTIVE: We assessed the efficacy of limited proximal arch replacement for type A acute aortic dissection (AAD) with critical complications. METHODS: Sixty-four patients with average age of 64.5 ± 13.0 years, who were intubated prior to arriving at hospital due to cardiopulmonary arrest, cardiac tamponade, or vital organ mal-perfusion, were divided into two groups: group PA consisted of 52 patients undergoing proximal arch repair with mild hypothermic circulatory arrest; group TA consisted of 12 patients who underwent total arch replacement with moderate hypothermia and selective cerebral perfusion. RESULTS: The intimal tear on the distal side of the left subclavian artery was not excised in 11 patients (21.2 %) of group PA. The intimal tear was excised in all patients in group TA. The durations of cerebral protection (PA, 18.7; TA, 70.3 min), cardiopulmonary bypass (PA, 121.5; TA, 206 min), and overall operation (PA, 181.8; TA, 403.8 min) were significantly shorter in group PA. The incidence of postoperative brain damage was significantly lower in group PA (9.6 %) than in group TA (33.3 %). The mortality rate was significantly lower in group PA (5.8 %) than in group TA (58.3 %). Distal arch to descending aortic replacement was required in four patients of group PA during follow-up period. There were no complications or mortality during the reoperation. The actuarial survival rate at 10 years was significantly better in group PA (66.5 %) than in group TA (25 %). CONCLUSION: Limited proximal arch repair is suitable for high-risk patients with AAD, despite no excision of the intimal tear.

Less Invasive Quick Open Stenting using a J Graft Open Stent for Distal Arch Aneurysms.

A new device of aortic stent graft made in Japan has been available since July 2014. Here, we describe a novel, unique surgical technique named "less invasive quick open stenting" at a rectal temperature of 28°C without any cerebral perfusion for treating distal arch aneurysms. All 12 patients were discharged from the intensive care unit within 24 hours after surgery without any complications. This technique aids in the exclusion of atherosclerotic plaques on the aortic wall and shortens the duration of circulatory arrest; moreover, it represents a very attractive option to prevent recurrent nerve injury.

Complete occlusion of the left main trunk coronary artery by a cardiac papillary fibroelastoma in a hemodynamically unstable patient.

Papillary fibroelastomas are benign cardiac tumors with high embolic potential. The majority of cases of complete obstruction of the left main trunk (LMT) of the coronary artery are diagnosed via autopsy following sudden death; survival is rare in this setting. We present the case of a 60-year-old woman who underwent stent placement in the LMT three years prior to developing chest pain and cold sweats. On coronary arteriography, the catheter could not be advanced into the LMT due to resistance in the ostium. Insertion of the catheter was achieved after the resolution of resistance via catheterization of the LMT by means of an intra-aortic balloon pump drive system. The LMT was normal, and the patient's circulatory failure improved. The cause of the LMT embolism was a cardiac papillary fibroelastoma. Primary surgical excision is the recommended therapy for symptomatic cardiac papillary fibroelastoma. If the patient is hemodynamically stable, it may be possible to delay surgery. However, the patient in question developed cardiogenic shock secondary to two-vessel obstruction by the tumor. Therefore, even if the tumor had been removed using an intra-aortic balloon pump, the patient may not have survived until surgery. .

Outcomes of Open Surgical Repair for Type B Dissecting Aortic Aneurysm With Alternative Methods in the Endovascular Stent Era.

We assessed the midterm outcomes of 2 types of open surgical repair for type B dissecting aortic aneurysm (BDA). During the last 4 years, 86 patients with BDA (mean age, 68.5 ± 9.8 years; range: 41-87 years) underwent open repair. The average duration between the dissection onset and surgery was 51.5 ± 31.3 months. If the BDA was of open type with patent false lumen or the aneurysm extended for a long segment, descending or thoracoabdominal aortic repair was performed with left thoracotomy. If the BDA was of the closed type with thrombosed false lumen and the aneurysm was located around the distal arch, open stent implantation was performed with our unique technique using circulatory arrest with a rectal temperature of 28 °C without any cerebral perfusion. Left thoracotomy was performed in 68 patients. The durations of aortic clamping and cardiopulmonary bypass were 65.2 ± 16.9 and 78.5 ± 34.6 minutes, respectively. Open stent implantation was performed in 18 patients. The durations of circulatory arrest and cardiopulmonary bypass were 19.1 ± 5.1 and 86.2 ± 17.8 minutes, respectively. In the present study, 4 patients (4.7%) required reexploration for bleeding and 1 patient (1.2%) had a stroke, but none suffered paraplegia. The hospital mortality rate was 1.2% (1 patient), resulting from retrograde type A dissection. The actuarial aortic event-free survival rate, including operative death, was 96.4% at 3 years. Both open surgical procedures for BDA were relatively safe, with favorable early and midterm outcomes, and may be superior for avoiding neurologic complications.

Carperitide and atrial fibrillation after coronary bypass grafting: the Nihon University working group study of low-dose HANP infusion therapy during cardiac surgery trial for postoperative atrial fibrillation.

BACKGROUND: Occurrence of atrial fibrillation after cardiac surgery is associated with long-term mortality. We investigated whether infusion of human atrial natriuretic peptide (carperitide) could prevent postoperative atrial fibrillation. METHODS AND RESULTS: A total of 668 patients who underwent isolated coronary artery bypass grafting were randomized to receive infusion of carperitide or physiological saline from the initiation of cardiopulmonary bypass. Patients were monitored continuously for 1 week after surgery to detect atrial fibrillation. The risk factors were investigated by Cox proportional hazard model. Postoperative atrial fibrillation occurred in 41 of 335 patients (12.2%) from the carperitide group versus 110 of 333 patients (32.7%) from the placebo group (P<0.0001). Postoperative levels of angiotensin-II, aldosterone, creatine kinase MB isoenzyme, human heart fatty acid-binding protein, and brain natriuretic peptide were all significantly lower in the carperitide group. The risk factors for postoperative atrial fibrillation by the Cox proportional hazard model were an age ≥70 years, emergency surgery, preoperative aldosterone level >150 ng/mL, preoperative nonuse of angiotensin receptor antagonists, preoperative use of calcium antagonists, postoperative nonuse of ß-blockers, postoperative nonuse of aldosterone blockers, and nonuse of carperitide. CONCLUSIONS: -Perioperative carperitide infusion reduced the occurrence of postoperative atrial fibrillation. Accordingly, carperitide could be a useful option for preventing postoperative atrial fibrillation. CLINICAL TRIAL REGISTRATION: -URL: http://www.umin.ac.jp. Unique Identifier: UMIN000003958.

Incidence of drug interaction when using proton pump inhibitor and warfarin according to cytochrome P450 2C19 (CYP2C19) genotype in Japanese.

OBJECTIVES: The US Food and Drug Administration has suggested that proton pump inhibitors (PPIs) increase the international normalized ratio (INR) when used concomitantly with warfarin (WF) because of being metabolized by cytochrome P450 2C19 (CYP2C19). We assessed whether CYP2C19 genotypes and type of PPI accentuated the drug interaction. METHODS AND RESULTS: The study group was 82 patients who needed WF after surgery and had their CYP2C19 genotypes analyzed in advance. We randomly divided them into two groups: group I (n = 41) included patients who had lansoprazole 15 mg/day and group II (n = 41) included patients who had rabeprazole 10 mg/day. The dose of WF was controlled by the doctor in charge as a target INR of 1.6 to 2.6 during the 2 months after surgery. The maximum INR was significantly higher in group I (3.36 ± 0.98) than in group II (2.29 ± 0.55, p < 0.0001). The incidence of over-INR (> 3.5) was significantly higher in group I (15 cases) than in group II (2 cases, p = 0.0001). Several bleeding events complicated 10 patients in group I, but none in group II (p = 0.015). Logistic regression analysis revealed that over-INR (odds ratio [OR] 3.58, 95% confidence interval [CI]: 3.48-368.25, p < 0.0001), and pair of lansoprazole and CYP2C19 intermediate metabolizer (OR 2.39, 95% CI: 1.108-29.491, p = 0.0009) were independent predictors of bleeding events. CONCLUSION: If a patient has had the intermediate metabolizer CYP2C19 genotype and concomitant use of WF and a PPI after open heart surgery, lansoprazole intensifies the effects of WF and is associated with bleeding events.

Early results of human atrial natriuretic peptide infusion in non-dialysis patients with chronic kidney disease undergoing isolated coronary artery bypass grafting: the NU-HIT trial for CKD-II.

BACKGROUND: Chronic kidney disease (CKD) is an important risk factor for cardiac surgery. In the most recently reported NU-HIT trial for CKD with CKD patients underwent coronary artery bypass grafting (CABG) as subjects, carperitide was reported to be effective in terms of renal function. In the present study, a subanalysis was performed on patients registered in the NU-HIT trial for CKD from the standpoint of renin-angiotensin system, natriuresis and renal function. METHODS: 303 patients with CKD who underwent isolated CABG were divided into a group that received carperitide infusion and another group without carperitide. The renin activity, angiotensin-II, aldosterone, urine-sodium, urine- creatinine, fractional sodium excretion, renal failure index, and BNP levels. RESULTS: There were significant lower in hANP group than the placebo group, in angiotensin-II at one day postoperatively, and in aldosterone from 0 day to one month postoperatively. FENa was significantly lower in the hANP group at 3 day and one week postoperatively. CONCLUSIONS: In on pump isolated CABG patients with CKD, carperitide showed a potent natriuretic action and inhibited the renin-angiotensin system, suggesting that it prevented deterioration of postoperative renal function. Our findings raise new possibilities for the perioperative and postoperative management of patients undergoing surgery with cardiopulmonary bypass.

Case of sudden death from retrograde type A dissection two days after surgery for a type B dissecting aneurysm.

A 64-year-old man underwent a descending aortic replacement for a chronic type B dissecting aneurysm with left thoracotomy. The patient was weaned from the mechanical ventilator immediately after surgery without any neurological complications. However, on the second post-operative day, he suddenly suffered from cardiopulmonary arrest when talking with his family. Despite 6 hours of cardiopulmonary resuscitation, the patient died. The postmortem examination revealed a 1000 mL blood volume and huge hematoma in the pericardium owing to a retrograde type A dissection, which descended from an intimal laceration between the common carotid and left subclavian arteries that corresponded with aortic cross clamping. We here report a rare case of iatrogenic retrograde type A dissection caused by surgical clamping on the aortic arch 2 days post-surgery.

Optimal treatment strategy for type A acute aortic dissection with intramural hematoma.

OBJECTIVE: The management strategy for type A acute aortic dissection (AAD) with intramural hematoma (IMH) remains controversial. The aim of this study was to compare the outcomes of emergency surgery and medical treatment for patients with acute type A IMH. METHODS: One hundred seventy-one patients with acute type A IMH, whose average age was 69.4 years (range, 39-90 years) were divided into 3 groups: groups I and II consisted of 74 and 33 patients undergoing emergency surgery for complicated and uncomplicated type A IMH, respectively, and group III comprised 66 patients who were treated conservatively. We compared the 3 groups in terms of mortality and morbidity. RESULTS: In group I, postoperative hospital mortality was 5.4% (4 patients). In group II, all patients survived without any complications after surgery. On the other hand, in group III, 5 patients underwent emergency surgery within 7 days after onset owing to newly developed cardiac tamponade and 17 (25.8%) patients died in the hospital, which was a significantly higher rate than those in groups I and II. Furthermore, although the group III patients survived, 5 patients required mechanical ventilation owing to heart failure or pneumonia, and 4 patients had a stroke during the hospital stay. There was no difference in actuarial survivals at 10 years, which were 64.2% in group I, 64.9% in group II, and 68.7% in group III. CONCLUSIONS: Emergency surgery for patients with type A IMH showed favorable mortality rates because most of the patients were in hemodynamically stable condition preoperatively. On the other hand, several patients died suddenly during medical care. Emergency surgical treatment may provide a better outcome than medical treatment at the time of onset, even for patients with type A IMH.

Screening and management for ischemic heart disease in patients undergoing emergency surgery for a type A acute aortic dissection.

PURPOSE: We assessed the incidence of coronary artery disease (CAD) during hospitalization after emergency surgery for a type A acute aortic dissection. METHODS: A total of 123 patients underwent multi-slice computed tomography (MSCT) scans during an early stage after surgery. The patients were divided into two groups: group I consisted of 14 patients (11.4%) who had coronary artery stenosis of more than 75% on MSCT, and group II consisted of 109 patients (88.6%) who had no coronary lesions. RESULTS: The prevalence of diabetes, dyslipidemia and a smoking history was significantly higher in group I. Although the serum low-density lipoprotein cholesterol levels were similar, the high-density lipoprotein cholesterol (HDL) level was significantly lower in group I (36.4 ± 7.9 mg/dl) than in group II (49.6 ± 13.5 mg/dl, P = 0.0005). The maximum carotid intima-media thickness (IMT) was significantly thicker in group I (1.17 ± 0.37 mm) compared to group II (0.96 ± 0.33 mm, P = 0.0297). The logistic regression analysis detected that a carotid IMT over 1.1 mm (odds ratio 4.35, P = 0.0371) and HDL less than 40 mg/dl (odds ratio 3.90, P = 0.0482) were predictors for CAD. CONCLUSIONS: CAD screening should be recommended for patients with aortic dissection who have several atherosclerosis risk factors, even after emergency surgery.

Comparison of febuxostat and allopurinol for hyperuricemia in cardiac surgery patients (NU-FLASH Trial).

BACKGROUND: Febuxostat has been reported to have a stronger effect on hyperuricemia than allopurinol. METHODS AND RESULTS: Cardiac surgery patients with hyperuricemia (n=141) were randomized to a febuxostat group or an allopurinol group. The study was single-blind, so the treatment was not known by the investigators. The primary endpoint was serum uric acid (UA) level. Secondary endpoints included serum creatinine, urinary albumin, cystatin-C, oxidized low-density lipoprotein (LDL), eicosapentaenoic acid/arachidonic acid ratio, total cholesterol, triglycerides, LDL, high-density lipoprotein, high-sensitivity C-reactive protein, blood pressure, heart rate, pulse wave velocity (PWV), ejection fraction, left ventricular mass index (LVMI), and adverse reactions. UA level was significantly lower in the febuxostat group than the allopurinol group from 1 month of treatment onward. Serum creatinine, urinary albumin, cystatin-C and oxidized LDL were also significantly lower in the febuxostat group. There were no significant changes in systolic blood pressure, PWV, and LVMI in the allopurinol group, but these parameters all had a significant decrease in the febuxostat group. CONCLUSIONS: Febuxostat was effective for high-risk cardiac surgery patients with hyperuricemia because it reduced UA more markedly than allopurinol. Febuxostat also had a renoprotective effect, inhibited oxidative stress, showed anti-atherogenic activity, reduced blood pressure, and decreased PWV and LVMI.

Results of low-dose carperitide infusion in high-risk patients undergoing coronary artery bypass grafting.

BACKGROUND: This study investigated the efficacy of human atrial natriuretic peptide (hANP, carperitide) for high-risk patients undergoing coronary artery bypass grafting (CABG). METHODS: This was a randomized controlled trial of 367 high-risk patients (European System for Cardiac Operative Risk Evaluation above 6) undergoing CABG. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE). Secondary endpoints were (1) postoperative death, (2) MACCE + hemodialysis, and (3) serum creatinine and brain natriuretic peptide (BNP) levels. Logistic regression analysis was conducted to identify preoperative and perioperative factors related to early death and MACCE. RESULTS: There was no significant difference of survival between the hANP and placebo groups (p = 0.1651), but the MACCE-free rate was significantly higher in the hANP group than in the placebo group (p < 0.0001). No patient from the hANP group started hemodialysis after operation, but 7 patients did in the placebo group, and the dialysis rate was significantly lower in the hANP group (p = 0.0147). Serum creatinine and BNP were also significantly lower in the hANP group at 1 year postoperatively. MACCE were strongly associated with age 75 years or older, chronic kidney disease, hemodialysis, left ventricular dysfunction, and nonuse of carperitide. CONCLUSIONS: In the early postoperative period, carperitide has a cardiorenal protective effect that prevents postoperative MACCE and hemodialysis. Perioperative low-dose carperitide infusion may be useful in high-risk patients undergoing on-pump CABG.

Long-term results of dialysis patients with chronic kidney disease undergoing coronary artery bypass grafting.

PURPOSE: Recently, coronary atrial bypass grafting (CABG) for dialysis patients increase, but the mortality is still high. Additionally, many patients show major adverse cardiovascular and cerebrovascular event (MACCE) after discharge and long-term results are not satisfactory. METHODS: Ninety patients underwent CABG for dialysis patients. Logistic regression analysis was conducted using preoperative and intraoperative factors in relation to the early death and MACCE. RESULTS: The operative mortality rate was 8.9% (isolated CABG: 6.9%, concomitant surgery: 16.7%). All death patients having isolated CABG were emergent cases. The postoperative survival rate was 81.5 ± 18.5% at 1 year, 72.0 ± 28.0% at 5 years and 68.4 ± 31.6% at 8 years. The postoperative MACCE-free rate was 70.3 ± 29.7% at 1 year, 61.8 ± 38.2% at 5 years, and 58.6 ± 41.4% at 8 years. We identified acute myocardial infarction, age ≥75 years, preoperative intra aortic balloon pumping assist (IABP), concomitant surgery, and non-use carperitide as risk factors for early death and ejection fraction <40%, preoperative IABP assist, and non-use of carperitide as risk factors for postoperative MACCE. CONCLUSIONS: The present study suggested that surgical outcome of CABG in dialysis patients was not satisfactory. Especially, patients with preoperative left ventricular dysfunction, IABP assist, and concomitant surgery were resulted in poor outcome. It is suggested that dialysis patients need not only surgery but also multidisciplinary therapy.