[The Long Outcome of the Left Atrial Appendage Preserving Maze Procedure].

We retrospectively study the outcome of left atrial appendage (LAA) preserving maze procedure, focus on thrombus formation in left atrium( LA), postoperative stroke, and LA function. PATIENTS AND METHODS: We studied 131 patients (mean age, 68.2y;77 men and 54 women) who underwent maze procedure for atrial fibrillation( Af) between 2008 and 2020. Full maze was performed for 116 patients with long-standing persistent Af or persistent Af. Pulmonary vein isolation alone was performed for 15 patients with paroxysmal Af. The mean follow-up period was 2.9( 10.1-0.4) years. RESULTS: In perioperative results, there were no death, cerebral infarction, and reoperation in this series. At discharge, 1 year, 3 years, 5 years, and 10 years after the surgery, sinus rhythm was maintained in 92%, 87%, 83%, 77%. Pacemaker was implanted in 8( early 3, late 5) patients. Despite adequate anticoagulant therapy, one patient developed cerebral infarction a month postoperatively. In other patients, there was no cerebral infarction in short-term nor long-term. CONCLUSIONS: The LAA preserving maze procedure was not a risk factor of cerebral infarction under appropriate medication. However, close follow-up is essential.

A case of primary cardiac angiosarcoma with surgical resection and reconstruction.

We report a 52-year-old man with primary cardiac angiosarcoma. He was referred to our hospital with a 3-month history of facial swelling and peripheral edema. Echocardiography and chest computed tomography revealed massive pericardial effusion and a right atrial tumor with a broad base at atrial septum which was extended into superior vena cava. We performed complete resection of the tumor and reconstruction of left atrium, atrial septum, right atrium, and superior vena cava with autologous pericardium and bovine pericardium. Histological examination exhibited angiosarcoma and a sign of radical excision. The patient, who made an uneventful recovery, was given postoperative radiotherapy and chemotherapy for liver metastasis 4 months postoperatively. The patient remains well without any signs of other metastasis for 2 years. We consider that an aggressive approach to resection with extensive reconstruction and multidisciplinary treatment can improve survival. Learning objective: Primary cardiac angiosarcoma is the most common primary malignant heart tumor with poor prognosis. We report a case of a 52-year-old man with primary cardiac angiosarcoma. We performed complete resection of the tumor and reconstruction of left atrium, atrial septum, right atrium, and superior vena cava with autologous pericardium and bovine pericardium. We think aggressive surgical resection with reconstruction is a feasible option.>.

Concomitant Mitral Regurgitation in Severe Aortic Stenosis　- A Report From the CURRENT AS Registry.

BACKGROUND: The clinical significance of concomitant mitral regurgitation (MR) has not been well addressed in patients with severe aortic stenosis (AS).Methods and Results:We analyzed 3,815 patients from a retrospective multicenter registry of severe AS in Japan (CURRENT AS registry). We compared the clinical outcomes between patients with moderate/severe MR and with none/mild MR according to the initial treatment strategy (initial aortic valve replacement [AVR] or conservative strategy). The primary outcome measure was a composite of aortic valve-related death or heart failure hospitalization. At baseline, moderate/severe MR was present in 227/1,197 (19%) patients with initial AVR strategy and in 536/2,618 (20%) patients with a conservative strategy. The crude cumulative 5-year incidence of the primary outcome measure was significantly higher in patients with moderate/severe MR than in those with none/mild MR, regardless of the initial treatment strategy (25.2% vs. 14.4%, P<0.001 in the initial AVR strategy, and 63.3% vs. 40.7%, P<0.001 in the conservative strategy). After adjusting confounders, moderate/severe MR was not independently associated with higher risk for the primary outcome measure in the initial AVR strategy (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.67-1.83, P=0.69), and in the conservative strategy (HR 1.13, 95% CI 0.93-1.37, P=0.22). CONCLUSIONS: Concomitant moderate/severe MR was not independently associated with higher risk for the primary outcome measure regardless of the initial treatment strategy.

Pulmonary vein reconstruction for pulmonary vein stenosis and occlusion after surgical ablation.

Acquired pulmonary vein (PV) stenosis (PVS) is a complication following cardiac catheter intervention. However, very few cases of PVS after surgical ablation have been reported. We herein report a case of stenosis and occlusion at the left atrium to each pulmonary vein after surgical ablation. A 73-year-old woman who had received aortic valve replacement and pulmonary vein isolation 10 months earlier was diagnosed with congestive heart failure accompanied by pulmonary hypertension. Contrast-enhanced computed tomography revealed stenosis and complete occlusion of the left atrium to all four pulmonary veins. Surgical repair was performed via pericardial patch reconstruction of the left atrium to each PV. Treating multiple PV lesions with involvement of the left atrium wall requires tailored methods. However, there have been few reports concerning such methods of reconstruction. We herein report a method of reconstructing the left atrium and pulmonary veins at the same time.

Early detection of large-vessel occlusion stroke after cardiac surgery using CT angiography leading to early recanalization with endovascular thrombectomy.

CT angiography may be useful for early diagnosis of ischemic stroke after cardiac surgery. When patients diagnosed with large-vessel occlusion, endovascular thrombectomy may be a therapeutic option and may improve their neurological complications.

Cardiac blood cyst with concomitant papillary fibroelastoma.

Cardiac blood cyst in adults is a rare benign tumor. Cardiac blood cyst concomitant with another type of cardiac tumor has never been reported. We report a case of a 77-year-old woman with cardiac blood cyst and papillary fibroelastoma. We performed resection of both tumors. An encapsulated mass (15 mm in diameter) with short stalks was identified in the right atrium, and a soft 1-cm mass was found adhering to a large part of the aortic valve noncoronary cusp without stalks. Postoperative course was uneventful. .

Infected thoracoabdominal aortic aneurysm related to an implanted long-term arterial catheter for chemotherapy: a case report.

BACKGROUND: An infected aortic aneurysm is a rare and life-threatening vascular condition with a high incidence of arterial rupture and recurrence even after treatment. One of the most common causes of an infected aortic aneurysm is catheter-related bloodstream infection. Although infection due to indwelling catheters is possible, the incidence of this is rare, especially for long-term implanted arterial catheters. CASE PRESENTATION: A 78-year-old Japanese man with a past medical history of rectal cancer with metastasis to the liver presented to our hospital as a result of low back pain. Remission had been achieved following surgery and adjuvant chemotherapy via an implanted catheter for arterial infusion. However, the original catheter that was inserted from the femoral artery to the hepatic artery via the celiac artery was still present more than 10 years after diagnosis, without being replaced, in case of a recurrence. On the day of admission, computed tomography scan of the chest and abdomen with contrast revealed an irregularly shaped aortic aneurysm at the origin of the celiac artery and a partially expanded common hepatic artery with disproportionate fat stranding along the implanted arterial catheter without extravasation. Although the initial impression was an impending rupture of the acute thoracoabdominal aortic aneurysm, a catheter-related infection was considered as a differential diagnosis. Surgery was performed, which revealed a catheter-related infected aortic aneurysm based on images along the catheter, pus cultures, and tissue pathology examination results. CONCLUSIONS: This is an extremely rare case of an infectious aneurysm caused by prolonged implantation of an arterial catheter for chemotherapy. It should be noted that an indwelling arterial catheter not only causes bloodstream infections but can also cause an infection of a thoracoabdominal aortic aneurysm.

Long-term results of the maze procedure with GP ablation for permanent atrial fibrillation.

OBJECTIVES: We investigated the effect of the maze procedure with intensive pulmonary vein isolation (PVI) guided by ganglionated plexus (GP) mapping (the Maze with GP ablation group) on a long-term postoperative maintenance of sinus rhythm in patients with permanent atrial fibrillation (AF) and compared with that in patients undergoing the maze procedure with the conventional PVI (the Maze group). METHODS AND RESULTS: We investigated 48 patients who underwent the maze procedure with GP ablation for persistent AF and 43 patients who underwent the maze procedure. The Maze procedure was conducted by the endocardial application of bipolar radiofrequency ablation and cryoablation. Conventional PVI was applied three times for the entrance of right and left PVs, respectively. Intensive PVI for GP ablation was repeated six-to-eight times for both sides of PVs to cover the bilateral GP regions identified by GP mapping. The duration of permanent AF, the prevalence of concomitant primary heart diseases, and the postoperative follow-up period were comparable between the two groups. At discharge, 1 year, 5 years after the surgery, sinus rhythm was maintained in 74.4%, 61%, and 40.5% of the Maze group. In contrast, it was maintained in 93.7%, 88.9%, and 75.7% of the Maze with GP ablation group. The cumulative freedom rate from AF at 10 years after surgery was significantly higher in the Maze with GP ablation group. CONCLUSIONS: More intense PV isolation including adjacent GP may improve long-term results of maze procedure in patients with permanent AF.

Extremely short setting of optimal sensed atrioventricular interval in patients after Fontan procedure with implanted dual-chamber pacemaker.

BACKGROUND: Atrioventricular interval optimisation is important in patients with dual-chamber pacing, especially with heart failure. In patients with CHD, especially in those with Fontan circulation, the systemic atrial contraction is supposed to be more important than in patients without structural heart disease. METHODS: We retrospectively evaluated two patients after Fontan procedure with dual-chamber pacemaker with a unique setting of optimal sensed atrioventricular interval. RESULTS: The optimal sensed atrioventricular interval determined by echocardiogram was extremely short sensed atrioventricular interval at 25 and 30 ms in both cases; however, the actual P wave and ventricular pacing interval showed 180 and 140 ms, respectively. In both cases, the atrial epicardial leads were implanted on the opposite site of the origin of their own atrial rhythm. The time differences between sensed atrioventricular interval and actual P wave and ventricular pacing interval occurred because of the site of the epicardial atrial pacing leads and the intra-atrial conduction delay. CONCLUSION: We need to consider the origin of the atrial rhythm, the site of the epicardial atrial lead, and the atrial conduction delay by using electrocardiogram and X-ray when we set the optimal sensed atrioventricular interval in complicated CHD.

Impact of concomitant tricuspid regurgitation on long-term outcomes in severe aortic stenosis.

AIMS: Tricuspid regurgitation (TR) has been reported to be associated with worse survival in various heart diseases, but there are few data in aortic stenosis (AS). METHODS AND RESULTS: In the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) Registry enrolling 3815 consecutive patients with severe AS, there were 628 patients with moderate or severe TR (TR group) and 3187 patients with no or mild TR (no TR group). The study patients were subdivided into the initial aortic valve replacement (AVR) stratum (n = 1197) and the conservative stratum (n = 2618) according to treatment strategy. The primary outcome measure was a composite of aortic valve-related death or hospitalization due to heart failure. The 5-year freedom rate from the primary outcome measure was significantly lower in the TR group than in the no TR group (49.1% vs. 67.3%, P < 0.001). Even after adjusting for confounders, the excess risk of TR relative to no TR for the primary outcome measure remained significant [hazard ratio (HR): 1.25, 95% confidence interval (CI): 1.06-1.48; P = 0.008]. The trend for the excess adjusted risk in the TR group was consistent in the initial AVR and the conservative strata (HR 1.55, 95% CI: 0.97-2.48; P = 0.07; HR 1.22, 95% CI: 1.02-1.46; P = 0.03, respectively). In the initial AVR stratum, the 5-year freedom rate from the primary outcome measure was not different between the two groups with (n = 56) or without (n = 91) concomitant tricuspid annuloplasty (61.5% vs. 72.1%, P = 0.48). CONCLUSION: The presence of clinically significant TR concomitant with severe AS is associated with a poor long-term outcome, regardless of the initial treatment strategy.

Three-step method for transesophageal echocardiography-guided implantation of the frozen elephant trunk: how to prevent spinal cord injury.

Total aortic arch replacement using the frozen elephant trunk (FET) procedure has widely spread all over the world with more sophisticated devices. However, spinal cord injury is one of the most important complications, which limits the use of FET. In our hospital, 80 patients treated with FET had no spinal cord injury. There are three key points to avoid spinal cord injury, (1) The distal end of stent graft should be positioned up to the eighth thoracic vertebrae level; (2) the time for selective left subclavian artery perfusion and distal body circulatory arrest should be shortened within 60 min; and (3) mean blood pressure should be maintained above 70 mmHg. Especially, Key point (1) is the most important. The level of aortic valve, which locates around the seventh thoracic vertebrae level, is an appropriate benchmark. We implanted the stent graft with the use of transesophageal echocardiography guided three-step method.

Is TEVAR with Full Petticoat Technique Effective for Complicated Acute Type B Dissection Cases?

Treatment by thoracic endovascular aortic repair (TEVAR) for type B dissection has improved outcomes. We tried the procedure named "Full Petticoat technique" in which the proximal entry tear was excluded with a covered stent and extended bare metal stents were placed to the aortic bifurcation for three complicated type B dissection cases with dynamic obstruction of the common iliac artery. Follow-up computed tomography revealed favorable aortic remodeling in which the true lumen was expanded. The short-term result of this procedure has shown acceptable aortic remodeling. The significance of this procedure is still unknown in the long term; hence long-term follow-up is necessary to completely understand the usefulness of this technique.

Subacute aortic regurgitation due to traumatic tear in the aortic wall.

A 37-year-old man presented with heart failure caused by severe aortic regurgitation (AR). He had a history of being involved in a traffic accident 3 months earlier. Imaging tests at admission detected no abnormalities in the aortic valve or aortic wall; however, the left coronary cusp prolapsed slightly on transthoracic echocardiography. He underwent aortic valve replacement because of uncontrolled heart failure and severe AR. Intraoperatively, the intima of the aortic wall just above the commissure of the left and right coronary cusps was torn to the short axial direction. Local aortic tear was the final diagnosis for the subacute AR. .

Early Surgery vs. Surgery After Watchful Waiting for Asymptomatic Severe Aortic Stenosis.

BACKGROUND: There is no large-scale study comparing postoperative mortality after aortic valve replacement (AVR) for asymptomatic severe aortic stenosis (AS) between initial treatment with AVR vs. eventual AVR after conservative management. Methods and Results: We analyzed data from a multicenter registry enrolling 3,815 consecutive patients with severe AS. Of 1,808 asymptomatic patients, 286 patients initially underwent AVR (initial AVR group), and 377 patients were initially managed conservatively and eventually underwent AVR (AVR after watchful waiting group). Mortality after AVR was compared between the 2 groups. Subgroup analysis according to peak aortic jet velocity (Vmax) at diagnosis was also conducted. There was no significant difference between the 2 groups in 5-year overall survival (OS; 86.0% vs. 84.1%, P=0.34) or cardiovascular death-free survival (DFS; 91.3% vs. 91.1%, P=0.61), but on subgroup analysis of patients with Vmax ≥4.5 m/s at diagnosis, the initial AVR group was superior to the AVR after watchful waiting group in both 5-year OS (88.4% vs. 70.6%, P=0.003) and cardiovascular DFS (91.9% vs. 81.7%, P=0.023). CONCLUSIONS: Asymptomatic severe AS patients who underwent AVR after watchful waiting had a postoperative survival rate similar to those who initially underwent AVR. In a subgroup of patients with Vmax ≥4.5 m/s at diagnosis, however, the AVR after watchful waiting group had worse postoperative survival rate than the initial AVR group.

Editorial comment regarding "Total aortic arch replacement using the frozen elephant trunk technique with J Graft Open Stent Graft for distal aortic arch aneurysm".

Total aortic arch replacement using the frozen elephant trunk (FET) technique has gained worldwide popularity, because it has simplified the treatment of complicated thoracic aortic lesions. The most effective use of FET has been total arch repair for acute-type A aortic dissection because of its particularly favorable prognosis. However, the use rate for true aneurysm in 2016 was half of the total 2150 cases using FET. The widespread use of FET is attributable to its ease of use. The incidence of FET-related paraplegia has decreased with the use of total aortic arch replacement but is still higher than in classic total arch replacement with distal arch anastomosis. A prospective multicenter study for FET is necessary.

[Successful Echo-guided Deployment of Stent Graft for Intraoperative Retrograde Aortic Dissection and Rupture;Report of a Case].

We report a case of chronic dissecting thoracoabdominal aneurysm with intraoperative retrograde aortic dissection and rupture at proximal descending aorta, which was successfully treated by echoguided stent-graft insertion. An 82-year old male underwent thoracoabdominal aortic replacement for dilatation of infra-diaphragmatic aorta. Under F-F bypass, his thoracoabdominal aorta was replaced by a Dacron graft with 4-branches. After he weaned from F-F bypass, we found massive bleeding from proximal descending aorta. Trans-esophageal echocardiography (TEE) showed aortic dissection from the clamp site to the distal anastomotic site of the former total arch replacement. We temporary got hemostasis by suture and surgical glue, and anastomosed a 10 mm-graft to the thoracoabdominal main graft as conduit, then inserted and deployed 2 pieces of stent-graft. Direct echo and TEE contributed to the accurate positioning of them. Bleeding was completely controlled. He well recovered without paraplegia. Post-operative computed tomography (CT) showed good positioning and dilatation of the stentgraft and the perfect reverse remodeling of thoracic aorta.

Reexpansion Pulmonary Edema After Atrial Septal Defect Closure Through Right-Sided Minithoracotomy.

We describe a patient with reexpanded pulmonary edema after atrial septal defect closure through a right-sided minithoracotomy. After reexpansion of the right lung after weaning from cardiopulmonary bypass, a large amount of serous slight-hemorrhagic bronchial secretions spilled out from the right bronchus. Positive pressure ventilation and differential ventilation were used. We found no bleeding and decreased secretions 24 hours after the onset of reexpanded pulmonary edema. The patient was extubated 42 hours after the operation. To the best of our knowledge, this is the first case report of the development of reexpansion pulmonary edema during a routine minimally invasive operation for atrial septal defect.

Diagnostic accuracy of the Embolic Risk French Calculator for symptomatic embolism with infective endocarditis among Japanese population.

BACKGROUND: Recently, the Embolic Risk French Calculator (ER-Calculator) was designed to predict symptomatic embolism (SE) associated with infective endocarditis (IE), but external validation has not been reported. This study aimed to determine predictors of SE and the diagnostic accuracy of the ER-Calculator in left-sided active IE among a Japanese population. METHODS: This retrospective cohort study included 166 consecutive patients with a definite diagnosis of left-sided IE from 1994 to 2015 in our institution. SE during the period after initiation of antibiotic therapy was defined as new SE and embolism during the period before initiation of antibiotic therapy was defined as previous embolism. The primary endpoint was new SE. RESULTS: The mean age of patients was 63±17 years. New SE occurred in 23 (14%) patients at a median of 6 days (interquartile range: 2.5-12.5 days) after initiation of antibiotic therapy. The cumulative incidence of new SE at 12 weeks was 18.2%. The 2-week probability by the ER-Calculator as well as previously reported predictors, such as previous embolism, vegetation length (>10mm), and their combination, were associated with a high risk of new SE. By receiver operating characteristic analysis, the area under the curve of the 2-week probability by the ER-Calculator for prediction of new SE was 0.75 and the optimal cut-off value was 8%. A 2-week probability >8% by the ER-Calculator was the most useful predictor of new SE (hazard ratio 3.63, 95% confidence interval 1.50-8.37; p=0.006), which was more remarkable for fatal embolic events (hazard ratio 13.9, 95% confidence interval 3.19-95.4; p=0.004). CONCLUSIONS: The ER-Calculator is a useful predictor of new SE. Predictive ability is more remarkable for critical embolic events.