[Bio-Bentall Procedure in Patients Over 65 Years of Age].

OBJECTIVE: This study aimed to review the results of the bio-Bentall procedure in patients over 65 years of age at our hospital. MATERIALS AND METHODS: Of the 65 aortic root replacement procedures performed at our hospital from October 2015 to January 2024, we reviewed 45 bio-Bentall procedures performed on patients 65 years of age or older. These patients consisted of 39 men and 6 women, with a mean age of 72 years. There were 5 patients with aortic dissection and 40 patients with non-dissection, and 6 patients had reoperation. There were 19 concomitant surgeries, including coronary artery bypass grafting, valve surgery, and aortic procedure. The bioprosthetic valves used were Magna EASE in 17 patients, Inspiris in 25 patients, Trifecta in 2 patients, and Avalus in 1 patient. All Valsalva grafts used were J Graft Valsalva. RESULTS: The mean intubation time was 19 hours, and the mean intensive care unit( ICU) stay was 6 days. The number of in-hospital deaths was 3 patients, and the mean length of hospital stay was 18 days. The remote mortality rate was 4( 1 heart failure, 2 lung cancer, and 1 pancreatic cancer). There have been no case of reoperation, structural valve deterioration (SVD), or thromboembolism to date, and the rates of freedom of reoperation, SVD, and thromboembolism were all 100%. The 1-, 3-, 5-, and 7-year survival rates were 91.1%, 86.4%, 83.6%, and 83.6%, respectively. CONCLUSION: The surgical and long-term outcomes of the bio-Bentall procedure in patients over 65 years of age were stable. In patients who may outlive the bioprosthetic valve life, it is important to perform an appropriate and durable Bentall procedure, including valve-in-valve, prioritizing the future of each patient.

Clinical outcomes of Najuta thoracic stent graft system for arch aneurysms.

Objectives: We aimed to elucidate the perioperative and short-term clinical outcomes of the Najuta thoracic stent graft system with fenestrations for supra-aortic vessels. Methods: We retrospectively investigated the perioperative and short-term clinical outcomes of 20 patients treated for arch or distal arch aneurysms using the Najuta thoracic stent graft system during the period from May 2019 to February 2023. Results: The technical success rate of the Najuta thoracic stent graft system was 95%. Of the 20 patients, 17 patients (85.0%) underwent concomitant extra-anatomical supra-aortic bypass. Postoperative CT revealed type Ia (n = 2) and type II (n = 3) endoleaks which disappeared on follow-up. The postoperative complications were stroke (n = 2, 10.0%), paraplegia (n = 1, 5.0%), and paraparesis (n = 1, 5.0%). In a very old patient, a blood transfusion was performed from the common iliac artery using the retroperitoneal approach. There were no aorta-related complications such as retrograde type A dissection or distal stent graft-induced new entry. Conclusions: We treated arch or distal arch thoracic aneurysms by inserting a tube-type stent graft as a scaffold on the peripheral site and placing the Najuta thoracic stent graft on the proximal site. By extending the landing zone to Zone 0 and using a low radial force, which is a feature of the Najuta thoracic stent graft system, postoperative bird-beak and aorta-related complications were avoided. The treatment of arch and distal arch aortic aneurysms using the Najuta thoracic stent graft system showed acceptable perioperative and short-term clinical outcomes. Thoracic endovascular aortic repair using the Najuta thoracic stent graft system may be a potential treatment option for arch and distal arch aortic aneurysms, warranting further studies.

Actual incidence of cerebral infarction after thoracic endovascular aortic repair: a magnetic resonance imaging study.

OBJECTIVES: The actual incidence of cerebral infarction (CI), including asymptomatic infarction, owing to thoracic endovascular aortic repair (TEVAR) has not been reported in detail. This study was performed to investigate the incidence of post-TEVAR CI by using diffusion-weighted magnetic resonance imaging (DW-MRI) and to determine the risk factors for both symptomatic and asymptomatic CI. METHODS: We examined 64 patients undergoing TEVAR at our institute between April 2017 and November 2020. Aortic atheroma was graded from 1 to 5 by preoperative computed tomography. Cerebral DW-MRIs were conducted 2 days after the procedure to diagnose postoperative CI. RESULTS: A total of 44 new foci were detected by post-interventional cerebral DW-MRI in 22 patients (34.4%). Only one patient developed a symptomatic stroke (1.6%), and TEVAR was successfully completed in all cases. Debranching of the aortic arch and left subclavian artery occlusion with a vascular plug was performed in 19 (29.7%) and 12 (18.8%) patients, respectively. The number of patients with proximal landing zones 0-2 was significantly higher in the CI group than in the non-CI group (68.2% vs 11.9%; P < 0.001). The following risk factors were identified for asymptomatic CI: aortic arch debranching (P < 0.001), left subclavian artery occlusion (P = 0.001) and grade 4/5 aortic arch atheroma (P = 0.048). CONCLUSIONS: Over one-third of the patients examined by cerebral DW-MRI after TEVAR were diagnosed with CI. High-grade atheroma and TEVAR landing in zone 0-2 were found to be positively associated with asymptomatic CI. CLINICAL TRIAL REGISTRATION: 02-014.

Successful treatment of chronic type B aortic dissection complicated by disseminated intravascular coagulopathy with recombinant human soluble thrombomodulin after thoracic endovascular aortic repair.

OBJECTIVES: We report a case of successful thoracic endovascular aortic repair (TEVAR) of chronic type B aortic dissection complicated by disseminated intravascular coagulopathy. METHODS: The patient suffered from chronic type B aortic dissection coexisting with a large false lumen and an intimal tear. He underwent TEVAR with left common carotid-left subclavian artery bypass. RESULTS: The following day, the patient exhibited a bleeding tendency and marked subcutaneous hemorrhage. He had a low fibrinogen level, a low platelet count, and high levels of fibrin dimer product and D-dimer. We diagnosed the condition as disseminated intravascular coagulopathy and administered recombinant human soluble thrombomodulin (rhTM). The patient recovered successfully from disseminated intravascular coagulopathy and was discharged on postoperative day 6. CONCLUSIONS: We successfully treated a patient with chronic type B aortic dissection with a large intimal tear complicated by postoperative disseminated intravascular coagulopathy using TEVAR followed by rhTM administration. rhTM may be considered in patients with large intimal tear and false lumen.

Surgical revision of failed MitraClip procedure for atrial functional mitral regurgitation.

The MitraClip system is used for patients with severe mitral regurgitation (MR) who are at high risk for open surgery. However, some patients need surgical revision for various complications. The acute outcome of MitraClip treatment for atrial functional MR (aFMR) is scarcely reported. Herein, we describe a rare case of an 80-year-old woman treated with a MitraClip for aFMR with mitral annular dilatation and failed leaflet adaptation. The patient suffered from single leaflet device attachment (SLDA) and posterior leaflet injury 3 days posttreatment. The patient successfully underwent mitral valve replacement. The postoperative pulmonary hypertension was markedly improved and the left atrial volume was reduced. A MitraClip should be carefully used for aFMR with mitral annular dilatation and failed leaflet adaptation as it may cause SLDA.

Native aortic valve thrombosis due to heparin-induced thrombocytopenia.

A 65-year-old man with unstable angina was transferred to our department for coronary artery bypass grafting (CABG). Preoperative computed tomography indicated a large thrombosis in the left coronary cusp (LCC). CABG concomitant thrombectomy was performed under cardiopulmonary bypass using unfractionated heparin. Although the LCC was filled with a large thrombus, the left coronary artery ostium was not obstructed. The platelet count decreased by 68%, 12 days after starting heparin in the previous hospital. There is a high probability that this patient had HIT which was not recognized before surgery.

Insertion of Impella CP following postcardiotomy cardiogenic shock concomitant with veno-arterial extracorporeal membrane oxygenation.

Postcardiotomy cardiogenic shock (PCCS) is associated with considerably high rates of mortality. In PCCS, veno-arterial extracorporeal membrane oxygenation has been used despite the high rates of complications and poor outcome. Since the introduction of Impella CP (Abiomed, Danvers, MA, USA), effective left-ventricular unloading and systemic perfusion could be maintained even in patients with severe PCCS. Herein, we describe the successful treatment of PCCS following combined heart surgery in a patient by Impella CP insertion.

Extended thoracic endovascular aortic repair for residual aortic dissection after type A aortic dissection repair.

OBJECTIVE: We investigated the outcomes of extended coverage of the descending thoracic aorta by thoracic endovascular aortic repair (TEVAR) for residual chronic type B aortic dissection after type A aortic dissection (TAAD) repair. METHODS: From November 2015 to August 2020, 36 patients underwent extended TEVAR for residual intimal tear after TAAD repair. We specifically investigated the methods and outcomes of this procedure. RESULTS: TEVAR consisted of isolated TEVARs (n = 29), single-vessel debranching TEVAR (6), and two-vessel debranching TEVAR (1). The mean time from TAAD repair to TEVAR was 27 ± 33 months (2-86 months). The TEVAR devices used were Valiant (28 cases), GORETAG (4), Relay plus (2), and TX2 (2). Technical success of TEVAR was 100%. The distal ends of the stent grafts were T 8 (1 case), T 9 (5), T 10 (6), T 11 (9), and T 12 (15), with an average of T 11 ± 1. The average length of hospital stay after TEVAR was 9 ± 3 days (5-17 days). There were no surgical/hospital deaths or complications. The average postoperative follow-up period was 21 ± 15 months without death or reintervention. CONCLUSIONS: The short-term outcomes of extended TEVAR for residual chronic type B aortic dissection after TAAD repair were acceptable without perioperative SCI. Aggressive descending thoracic aorta coverage may prevent aortic events, and extended TEVAR may be a preemptive treatment for the downstream aorta. Mid- to long-term results should be clarified.

Emergency Endografting for Spontaneous Thoracic Aortic Rupture.

Spontaneous rupture of the thoracic aorta is rare. We present a 76-year-old man who developed spontaneous rupture of the aortic arch associated with massive periaortic hematoma and hypovolemic shock. Because the site of rupture could not be identified, emergency hybrid endovascular aortic repair to shield a long segment of the aorta was performed according to the extent and density of periaortic hematoma on axial CT scans. His blood pressure improved just after deployment of the endograft. Rapid diagnosis by CT and prompt control of aortic hemorrhage by endografting salvaged this patient. Three-dimensional (3D) volume-rendered CT images are useful for identifying the site of aortic rupture, but may not be available in an emergency.

Effect of the Terminal Aortic Diameter on the Patency Rate of Iliac Limbs after Endovascular Aortic Repair.

Objective: Endograft limb occlusion (ELO) is a complication of endovascular aneurysm repair (EVAR). In this study, we investigated the mechanism and anatomical features of ELO. Materials and Methods: We retrospectively reviewed 227 consecutive patients with abdominal aortic aneurysm who underwent EVAR between 2007 and 2017. We then analyzed the preoperative risk factors and anatomical features of patients with ELO. Results: A total of nine patients had ELO (4.0%). The diameter of the terminal aorta was significantly smaller in patients with ELO than in patients without ELO (18.0 mm vs. 22.3 mm, p=0.039). We measured the diameter of each limb near the terminal aorta. The smaller limb (SL) was occluded in all patients with occlusion. The difference between the larger limb (LL) and the SL (LL-SL) was significantly larger in patients with ELO than in patients without ELO (4.0 mm vs. 1.7 mm, p<0.001). The following were considered risk factors for ELO: younger age, narrow terminal aorta, severe calcification at the terminal aorta, and use of an Endurant device. Conclusion: ELO occurs when the diameter of one side of the stent graft limb is small compared with the diameter of the other side owing to the narrow terminal aorta and calcification.

Antithyroid Drugs Inactivate TSH Binding to the TSH Receptor by their Reducing Action.

Backgroud and Objective: Antithyroid drugs (ATDs) [methylmercaptoimidazole (MMI) and propylthiouracil (PTU) ] are used to treat hyperthyroidism in Graves' disease. The effect of ATDs and reducing agents (mercaptoethanol, dithiothreitol and cysteine) on bovine (b) TSH binding to human (h) and porcine (p) TSH receptor (R) was examined. METHODS AND RESULTS: (1) ATDs was pre-incubated with hTSHR coated tube for 1- 4 h, washed free of ATDs, and then 125I-bTSH binding to hTSHR after 1 h incubation was examined. MMI (10-40 mM) decreased 125I-bTSH binding in a dose-dependent manner and binding decreased proportionally as preincubation time increased from 1 to 4 h. PTU (10mM) slightly decreased binding, When reducing agents were pre-incubated with hTSHR for 2 h, 125I-bTSH binding similarly decreased. (2) Porcine thyroid membrane was pre-incubated with both agents for 2 h. Then, the washed or unwashed membrane was incubated with 125I-bTSH for 1 h. 125I-bTSH binding in both methods decreased. (3) When the effect of ATDs or reducing agents on the biological activity of 125I-bTSH and thyroid stimulating antibody (TSAb) was examined after gel-filtration of 125I-bTSH- and TSAb- treated with both reagents for 1 h, no inactivation was observed. (4) ATDs showed similar reducing action as reducing agents because iodine (I+) was reduced to I- by ATDs. CONCLUSION: ATDs inactivate the TSH-binding site of TSHR by reduction, although ATDs do not inactivate bTSH and TSAb activity. This suggests that TSAb would not stimulate the thyroid due to the inactivation of the TSHR when ATDs are administered to patients with Graves' disease.

Open Conversion for Type A Ascending Aortic Dissection after Thoracic Endovascular Aortic Repair by the Chimney Graft Technique.

An 83-year-old man with aortic arch aneurysm underwent zone 0 thoracic endovascular aortic repair (TEVAR) by the chimney graft technique with two supra-aortic arch debranching grafts and developed subacute type A ascending aortic dissection. We performed emergency open conversion with circulatory arrest under deep hypothermia. The tip of the chimney graft (around the sino-tubular junction in the ascending aorta) was stiff, making it difficult to inspect the lumen and perform anastomosis. Deep hypothermic circulatory arrest and cutting the endograft stents to mobilize the graft were necessary for secure anastomosis.

Suture Line Dehiscence after Endovascular Aneurysm Repair in a Patient with Marfan Syndrome.

A 68-year-old man with Marfan syndrome developed de-novo leakage after endovascular aneurysm repair of a Dacron graft. Findings at subsequent reoperation suggested that the rebound force on the endograft generated by marked longitudinal deformation in the Dacron graft may have placed stress on the suture line, leading to partial dehiscence. The Dacron graft seemed to provide a stable proximal landing zone. However, the strong tendency of some endograft devices to return to their original shape may apply stress that affected weakened regions of the native aorta.

Modified 'candy-plug' technique for chronic type B aortic dissection with aneurysmal dilatation: a case report.

BACKGROUND: The original 'candy-plug' technique has been reported to be beneficial for the treatment of residual perfused false lumen in patients with aortic dissection. However, this technique is also associated with several problems, such as narrowing of the true lumen and damage to the flap or vessel wall. Therefore, we modified the procedure to overcome these problems. Here we report a case in which the patient was successfully treated using the modified procedure. CASE PRESENTATION: A 59-year-old man presented with chronic type B aortic dissection with aneurysmal dilatation. The patient had undergone prosthetic graft replacement of the ascending aorta for acute type A aortic dissection 3 years previously and replacement of the descending aorta for residual type B aortic dissection with aneurysmal dilatation 1 year previously. After these procedures, the residual false lumen aneurysm of the distal descending aorta expanded to 57-mm in diameter. Endovascular stent grafting was successfully performed using the modified 'candy-plug' technique with relining of the true lumen and occlusion of the false lumen. The patient was discharged 10 days after the procedure. Follow-up imaging at 1 year showed a completely thrombosed false lumen aneurysm. CONCLUSION: The modified 'candy-plug' technique is useful for treatment of residual type B aortic dissection with aneurysmal dilatation.

Thoracic Endovascular Aortic Repair Including Total Debranching on Femoral Artery for Arch Rupture.

A 94-year-old woman with rupture of a thoracic aortic aneurysm (rTAA) was referred to us. She previously underwent thoracic endovascular aortic repair and was considered to be at high risk for a conventional open operation. Therefore an endovascular procedure was planned. The proximal landing zone needed to be placed at the ascending aorta to seal a type 1a endoleak. A hybrid operation consisting of supraaortic total debranching on the common femoral artery and endovascular repair was performed. All debranched bypasses were patent and the aneurysm was excluded. The patient regained sufficient ambulatory strength and showed no symptoms of syncope.

[Cardiac Failure Developing Eleven Years after Coronary Artery Bypass Grafting;Report of a Case].

We report a rare case of cardiac failure for intrapericardial hematoma 11 years after coronary artery bypass grafting. A 59-year-old man was admitted to our hospital with cardiac tamponade. Echocardiography and computed tomography scan showed severe compression of the left ventricle(LV) by a large mass sized about 5×8 cm. Coronary angiography showed total occlusion at circumflex branch (Cx) #11. The mass was diagnosed with intrapericardial hematoma. We performed removal of hematoma in the pericardial cavity, and removed hematoma had 126 g. Considering that the patient had suffered from diabetes mellitus, the localized collection of the hematoma might be explained by possible slow oozing from LV free wall rupture after asymptomatic myocardial infarction at Cx area.

Postoperative Stroke after Debranching with Thoracic Endovascular Aortic Repair.

OBJECTIVES: This study aimed to analyze the perioperative stroke rate, stroke lesions, outcome, risk factors, and stroke prevention following debranching with thoracic endovascular aortic repair (TEVAR). DESIGN: Retrospective study. METHODS: Between February 2011 and February 2015, 74 consecutive patients underwent debranching with TEVAR at our institution. Of these, the TEVAR proximal landing zone was "zone 0" in 23 patients, "zone 1" in 28, and "zone 2" in 23. Left subclavian artery (LSA) occlusion with coil embolization, balloon occlusion, or vascular plugging was performed in 27 patients. Mean follow-up time was 19.2 months (range 2-52 months). RESULTS: The in-hospital mortality rate was 4.1%. Stroke developed in 7 patients (9.5%), zone 0 in 4 patients, zone 1 in 2, and zone 2 in 1. Six of these patients had stroke lesions arising from the vertebral/basilar artery. Univariate analysis revealed a significant increase in the risk of postoperative stroke in patients with intraluminal atheroma (P = 0.001), those who underwent prior percutaneous transluminal coronary angioplasty or coronary artery bypass graft (P = 0.002), and those with a long operative duration (P = 0.001). Additionally, LSA occlusion significantly decreased the incidence of stroke (P = 0.041). The postsurgical 1- and 2-year cumulative survival rates were 87.3% and 77.0%, respectively, in those without stroke, and 68.6% and 22.9%, respectively, in those with stroke (P = 0.012). CONCLUSIONS: Stroke after debranching with TEVAR was associated with a high mortality. To prevent stroke, careful patient selection and protection of the vertebral artery are important. Prophylactic LSA occlusion at the time of stent-graft deployment might reduce the risk of perioperative stroke.

Kinked Graft and Anastomotic Stenosis-Induced Hemolytic Anemia Requiring Reoperation.

We report a case of hemolytic anemia caused initially by narrowing of a proximal anastomotic site and subsequently by a kinked prosthetic graft after total aortic arch replacement. A 55-year-old man was diagnosed with acute type A aortic dissection by computed tomography (CT). After total aortic arch replacement, hemolytic anemia and renal dysfunction developed. CT detected narrowing of proximal anastomotic site of the graft. Removing the graft and ascending aortic replacement resolved the signs of hemolytic anemia. However, 50 days after the surgery, severe hemolytic anemia developed again. CT revealed a sharply kinked graft. Total arch replacement was again performed to resect the kinked graft. He was discharged on the 24th postoperative day without hemodialysis.

Repair of Acute Type B Aortic Dissection Complicated by Aortic Rupture with Debranching Thoracic Endovascular Aortic Repair and Left Subclavian Artery Occlusion Using Amplatzer Vascular Plug II.

An 88-year-old man with severe chest pain and syncope was admitted to our hospital. Contrast-enhanced computed tomography (CT) revealed acute type B aortic dissection with rupture. Considering age and operative risk, we performed emergency thoracic aortic endovascular repair with two-debranching of the left common carotid and left subclavian arteries. To prevent type II endoleak, we used Amplatzer Vascular Plug (AVP) II for left subclavian artery embolization. Postoperative contrast-enhanced CT showed no type II endoleak and rupture site exclusion. As postoperative persistent blood flow to the primary entry or rupture site causes re-rupture, AVP II was crucial in preventing type II endoleak.

A novel method for measuring TBAb activity in TSAb- and TBAb-positive serum.

We reported a conversion assay in which thyroid blocking antibody (TBAb) function as thyroid stimulating antibody (TSAb). TBAb-bound porcine thyroid cells (PTC) were made by incubating TBAb(+) serum and PTC for 1 hour. When these TBAb-bound PTC were incubated 4 h with rabbit anti-human (h) IgG antibody (Ab), cAMP production was high, but when incubated with normal rabbit serum (NRS) cAMP production was low. TBAb-Mnoclonal Ab (MoAb) (KI-70) showed similar conversion. However, when TSAb-MoAb(M22) was assayed, anti-hIgG Ab-produced cAMP was lower than NRS-produced cAMP. When a mixture of M22 and KI-70 was assayed, anti-hIgG Ab-produced cAMP was higher than NRS. Thus, it is possible to determine existence of TBAb in TSAb(+)serum when anti-IgG Ab-produced cAMP is higher than NRS-produced cAMP. In this assay TBAb activity in TSAb(+)serum was scored as positive, gray zone and negative when the difference [anti-hIgG Ab-produced cAMP(%)-NRS-produced cAMP(%)] was >100%, 50-100% and <±50%, respectively. In TSAb(+)sera of Graves' patients with no treatment or anti-thyroid therapy, positive TBAb was 9% (3/33 )and 6.9% (5/72), and gray zone was 18 % (6/33) and 25% (18/72), respectively. A low prevelance of TBAb and low TBAb activity (<200% as cAMP) was found in these Graves' patients. A radioisotope treated Graves' patient showed existence of both TSAb and TBAb at 5 months (NRS, 800% cAMP and anti-IgGAb,1,350% cAMP), and highly positive TBAb (NRS, 180% cAMP and anti-hIgG Ab, 3,200% cAMP) at 30 months. This conversion assay is useful principally for TBAb determination but is also useful for TBAb determination in TSAb(+)serum.