Clinical Features of Cardiac Calcified Amorphous Tumor: A Narrative Review.

A cardiac calcified amorphous tumor (CAT) is a non-neoplastic cardiac mass composed of calcified nodules surrounded by amorphous fibrous tissue in a context of degeneration and chronic inflammation. Although CAT cases are increasingly reported, its clinical manifestation remains unclear. We aimed to conduct a narrative review of CAT and identify its clinical characteristics. We conducted a comprehensive literature search using PubMed, with the keyword "Cardiac Calcified Amorphous Tumor" to identify relevant articles. A total of 113 articles published between 1997 and 2022 were retrieved. The clinical features allowing for assess patient background, differences with and without end-stage renal disease (ESRD), symptom-related factors, risk factors for embolism caused by CAT, and features of CAT, such as shape, location, mobility, pathology, and treatment, were statistically analyzed in 106 criteria-matched cases. The mean patient age was 60.2 ± 18.6 years, with 45 men and 61 women. Of the data collected from 21 countries, 52 patients were from Japan. Mobile CAT was more common in the chronic renal failure group. Linear, club-shaped, and spindle-shaped CAT tended to be mobile and more common in the ESRD group as well as located in the mitral valve region. The shape, mobility, location, and underlying mechanism of CAT depended on the presence or absence of ESRD. The risk of embolism was considered high because mobile CAT was more common in the ESRD group, and CAT originated in the mitral valve region. Hence, early diagnosis based on periodic examination in patients with ESRD and aggressive surgical treatment are necessary.

Removal of a frozen elephant trunk using a polyvinyl tube.

The increasing use of total arch replacement and frozen elephant trunk (FET) is expected to lead to an increase in the prevalence of graft infections requiring replacement involving an FET, which is generally a more invasive procedure than the initial surgery. Herein, we describe a novel method for FET removal using a polyvinyl tube as the storage device. The procedure is completed using the same median sternotomy approach as the initial surgery. We report on the outcomes for six patients. Our procedure is simple to perform and safe and caused no injury to the aorta in our case series.

Thoracoscopic infrared ablation to create a box lesion as a treatment for atrial fibrillation.

BACKGROUND: Creating a box lesion in the posterior wall of the left atrium from the epicardial side of the beating heart remains a challenge. Although a transmural lesion can be created by applying radiofrequency (RF) energy at clampable sites, it is still difficult to create a transmural lesion at unclampable sites because the inner blood flow in the unclampable free wall weakens the thermal effect on the outside. Our aim was to apply the newly developed infrared coagulator to create linear transmural lesions on the beating heart thoracoscopically to treat atrial fibrillation (AF). CASE PRESENTATION: A 71-year-old male was referred to our hospital with a diagnosis of hypertrophic cardiomyopathy and permanent atrial fibrillation. The patient was first diagnosed with atrial fibrillation 20 years before. Direct current cardioversion had been performed every few years a total of four times, but sinus rhythm restoration had always been temporary. On February 27, 2020, thoracoscopic PV isolation together with infrared roof- and bottom-line ablation to create a box lesion and left atrial appendage amputation (LAAA) were performed. The coagulator could be applied to clinical thoracoscopic surgery to successfully create a box lesion without any complication. The patient restored a regular sinus rhythm, it has been maintained for eleven months, and there have been no adverse events. CONCLUSIONS: The infrared coagulator might have enough potential to create transmural lesions on the beating heart in thoracoscopic AF surgery.

Long-term support by left ventricular assist device for arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heart muscle disorder characterized by right ventricular enlargement, right heart failure (HF), and ventricular arrhythmias which lead to sudden death especially in young adults. Current recommendations for management of patients with ARVC are antiarrhythmic medications, catheter ablation, and implantable cardioverter defibrillator therapy to prevent sudden cardiac death. However, despite these treatments, few patients suffer from recurrent ventricular arrhythmias or HF unresponsive to conventional management. Heart transplantation (HTx) is a preferred treatment for these cases, but because of a persistent donor heart shortage in Japan, ventricular assist device (VAD) support has become an important option for a management of the end-stage ARVC. Previous articles reported 4 cases of a successful management by left ventricular assist device (LVAD), but the longest interval of LVAD support was only 333 days. We present 3 cases of ARVC patients who were successfully managed by LVAD implantation for more than a year. These 3 cases are unconventional examples of ARVC patients, considering the nature of the disease. The novelty of these cases should be taken in the context of the extremely long waiting period for HTx in Japan.

Hemoptysis.

Hemoptysis is a rare complication of acute aortic dissection. A 77-year-old woman was admitted to our department with epigastralgia and hemoptysis. Computed tomography showed Stanford A acute aortic dissection and massive posterior mediastinal hematoma which extended along the right pulmonary artery. Hemoptysis is a lethal sign of aortic dissection, therefore, emergency ascending aortic replacement was performed with a good clinical outcome.

Axillofemoral Bypass Markedly Improved Acute Decompensated Heart Failure and Kidney Injury in a Patient with Severely Calcified Stenosis of Thoracoabdominal Aorta (Atypical Aortic Coarctation).

Atypical aortic coarctation (AAC) has been reported to occur anywhere along the aorta, except for the ascending aorta. The associated symptoms include hypotension in the lower half of the body, secondary hypertension in the upper half of the body, and heart failure. Here we present an 80-year-old Asian woman complaining of progressive exertional dyspnea. She was diagnosed with acute decompensated heart failure and kidney injury due to severely calcified stenosis of the thoracoabdominal aorta, the so called AAC. She received hemodiafiltration, and pulmonary congestion improved in part. Generally, surgical treatments are quite invasive in elderly patients. Endovascular stent graft placement is less invasive, however, fracture and rupture should be considered at severely calcified lesions like this case. Therefore, we selected extra-anatomical axillofemoral bypass. Her recovery after the surgery was remarkable. In a few days, she became free from hemodiafiltration, intravenous diuretics, and oxygen administration. We thought the contributive factors are the increase in kidney blood flow and the correction of afterload mismatch. The decrease in pulse pressure may reflect the reduction in systemic arterial compliance by axillofemoral bypass. The operative mortality of axillofemoral bypass was reported to be acceptable, although the patency of the axillofemoral bypass graft was not high enough. In conclusion, axillofemoral bypass is effective and feasible for elderly patients with acute decompensated heart failure and kidney injury due to AAC.

Left mammary artery bypass grafting rescued a patient with hypoplastic left heart syndrome with ascending aorta obstruction after norwood stage I procedure.

A three-month-old boy with hypoplastic left heart syndrome (mitral atresia, aortic atresia) and moderate tricuspid regurgitation developed ascending aorta obstruction two months after a Norwood stage I procedure. An emergent left mammary artery bypass grafting to the ascending aorta and extracorporeal membrane oxygenator support resulted in successful salvage. The patient subsequently underwent a bidirectional Glenn procedure and tricuspid valve repair at the age of five months. Follow-up at an outpatient clinic reveals no electrocardiographic evidence of ischemia, and echocardiography shows recovery of ventricular function.

Off-pump coronary artery bypass grafting with an aortic nonclamping technique may reduce the incidence of cerebral complications.

PURPOSE: Cerebrovascular accidents after coronary artery bypass grafting (CABG) remain a complication despite the advancements in techniques. Aortic partial clamping should be avoided to prevent this cerebral complication. We use pedicle arterial grafts (bilateral internal-mammary arteries and the right gastroepiploic artery) and saphenous vein graft with a proximal anastomosis device for off-pump CABG without aortic partial clamping. We call this technique the aortic nonclamping technique. METHODS: Between 2001 and 2007, a total of 468 patients underwent coronary bypass operations; 8 who were operated on with cardiopulmonary bypass were excluded from this study. Altogether, 451 patients underwent off-pump CABG using the aortic nonclamping technique. Among the procedures, 354 were performed using pedicle arterial grafts alone, and 99 were done using a saphenous vein graft with a proximal anastomosis device. Nine were performed with aortic partial clamping for any reason. Postoperative cerebral complications, especially cerebral infarction, were analyzed. RESULTS: Cerebral infarction occurred in two cases (0.47%) in the aortic nonclamping group. They were delayed in both cases, one occurring on the third day after operation and the other on the fourth day. One patient in the aortic clamping group had an intraoperative (early) cerebral infarction. CONCLUSION: The aortic nonclamping technique might reduce the incidence of cerebral complications and produce ideal bypass grafts using arterial grafts and saphenous vein grafts with a proximal anastomosis device.

Mechanism of pressure-overload right ventricular hypertrophy in infant rabbits.

Although pressure-overload right ventricular hypertrophy is a long-term risk in some congenital heart diseases such as tetralogy of Fallot, how it develops is unclear. The aim of this study was to investigate the mechanism of development of this right ventricular heart failure.Pulmonary artery banding in 10-day-old rabbits induced pressure-overload right ventricular hypertrophy as they grew. Comparisons were made with age-matched sham controls (n = 24 per group). In weekly serial echocardiography, the right ventricular contraction and diastolic function decreased from 3 weeks after surgery (P < 0.01), and the right ventricle became hypertrophic from 4 weeks after (P < 0.05). Pressure-overload increased cardiomyocyte apoptosis from 4 weeks postoperatively (TUNEL staining and Western blotting analysis, P < 0.05); and fibrosis occurred in the right ventricular cardiomyocytes at 8 weeks after operation (Masson's trichrome stain, P < 0.01). In our model, pressure-overload to the right ventricle caused the right ventricular disorder, hypertrophy, and fibrosis. Apoptosis of right ventricular cardiomyocytes was involved in progression. We have shown for the first time the mechanism whereby pressure-overload right ventricular hypertrophy develops in an infant rabbit model.