Effectiveness of Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury.

PURPOSE: Blunt thoracic aortic injury (BTAI) has a high mortality rate, and the occurrence of clinical complications is high. Several studies have reported the efficacy of thoracic endovascular aortic repair (TEVAR) for BTAI. This study aimed to clarify the use of TEVAR for BTAI. METHODS: We analyzed 10 cases of TEVAR for BTAI from July 2011 to December 2020 at our hospital. Five of 10 cases of BTAI were caused by road traffic accidents, while five were caused by falls from a height. RESULTS: The mean patient age was 59.3 years. When arriving at our hospital, seven of 10 patients were in shock. Nine of 10 cases of BTAI were at the aortic isthmus. With respect to BTAI severity, five of 10 patients were categorized as grade IV. Ps of non-survivors were extremely low. All patients underwent TEVAR. The mean surgical duration and volume of intraoperative blood loss were 77.5 minutes and 234 ml, respectively. CONCLUSION: The results of TEVAR for BTAI at our institution support previous reports, which show excellent clinical results. To further improve the outcomes, we must clarify the adaptation of nonoperative management (delayed repair), the optimal timing of invasive treatment, and the importance of long-term follow-up.

[A case of recurrent cerebral embolism associated with Lambl's excrescence].

A 75-year-old female had a history of prior ischemic stroke with aphasia and right hemiplegia. Magnetic resonance angiography showed left internal carotid artery occlusion. She was successfully treated with intravenous recombinant tissue plasminogen activator (IV t-PA) and underwent endovascular thrombectomy (EVT). She was diagnosed with cardioembolic stroke due to the presence of atrial fibrillation and mitral valve stenosis, and warfarin was administered. However, she experienced large vessel occlusion twice within 2 years. Upon further analysis, transesophageal echocardiography revealed a mobile hyperechoic structure on the aortic valve, which was assumed to be an embolic source. Thus, we decided to perform mitral and aortic valve replacement. The excised aortic valve structure was suggested to be an example of Lambl's excrescence, histopathologically. After surgery, the patient had no recurrence for 3 years. Several cases of ischemic stroke associated with Lambl's excrescence have been reported, but definitive guidelines for managing patients with Lambl's excrescence do not currently exist. Surgical intervention for Lambl's excrescence with recurrent ischemic events may be important for preventing further recurrence.

[Self-made Bovine Pericardial Roll Graft Replacement of Infected Aneurysm Following Thoracic Endovascular Aortic Repair;Report of a Case].

A 72 years-old man was admitted with fever and cough. He had undergone aortic arch graft replacement with elephant trunk and endovascular stent graft for distal arch aortic aneurysm 1 year ago. Additionally, he had treated type I endoleak with an endovascular stent graft 3 month previously. Computed tomography showed soft tissue around the aneurysm and visible gas bubble within intramural thrombus, and he was diagnosed with stent graft infection. The stent graft was removed and aortic reconstruction was performed using bovine pericardial roll grafts. The grafts were covered with the greater omentum. He was discharged on the 48th postoperative day, and was alive and well 4 years after the operation.

[Migration of a Temporary Epicardial Pacing Wire into the Aorta Following Open Heart Surgery].

The patient was a 76-year-old female. An epicardial pacing wire was inserted in an open heart surgery. As there was some resistance when extracting it, it was cut off at the cutaneous level. Ten months after discharge, she was referred to our hospital for further examination due to a flap found in the left external carotid artery by the carotid echography. The remaining wire was found between the ascending aorta and the left external carotid artery by computed tomography (CT). It was considered that the wire, with no resistance after being cut off, became isolated, pierced the ascending aorta, moved further by the heart beat, and reached the left external carotid artery. Surgery was performed via median re-sternotomy and left common carotid artery incision, since the proximal edge of the wire remained in the mediastinal space. It is quite rare for a remaining pacing wire to migrate into the aorta.

[Surgical Outcomes for Aortic Root Repair in Patients Undergoing Type A Acute Aortic Dissection].

We evaluated retrospectively 11 consecutive patients who underwent emergent aortic root operations for acute aortic dissection from April 2012 to March 2017. We underwent Bentall operation in 6 patients and Florida Sleeve repair in 3 patients and aortic root replacement with a Freestyle stentless porcine valve in 2 patients. The 30-day mortality of emergent aortic root operations was 9.1%(1 of 11), and the hospital mortality was 18.2%(2 of 11). The Overall survival at 5 years was 90.0%. In conclusion, the aortic root repair can be performed safely in acute aortic dissection.

Four-stitch side-to-side anastomosis for sequential coronary artery bypass grafting.

Sequential bypass (SB) is an effective method of implementing complete myocardial revascularization of complex coronary stenoses. The SB allows a single graft to be used for bypass in several locations, which facilitates multi-branch revascularization. We have developed a simple SB technique, four-stitch side-to-side anastomosis, and report its clinical effectiveness in 428 patients.

Safety and efficacy of an ultrashort-acting ß1-blocker on left ventricular dysfunction.

Landiolol hydrochloride, an ultrashort-acting ß1-selective blocker, is a highly regulated drug. This study evaluated the safety and efficacy of this drug for cases of coronary artery bypass grafting (CABG) with left ventricular dysfunction. Between September 2006 and August 2009, 32 patients with a left ventricular ejection fraction of <40% underwent CABG. Two groups of patients, a group administered landiolol hydrochloride and a control group not administered this drug, were compared. The administration of landiolol hydrochloride was initiated at 1 µg/kg per minute (γ) after cardiopulmonary bypass in on-pump cases and after completion of all the distal anastomoses in off-pump cases. We observed no significant differences between the groups with respect to preoperative patient background or incidences of complications, except for postoperative atrial fibrillation. The heart rate decreased significantly 30 minutes after landiolol hydrochloride administration, but no change was observed in arterial pressure. No change was observed in other parameters; the hemodynamics were stable. The occurrence of atrial fibrillation during the intensive care unit stay (during landiolol hydrochloride administration) was significantly lower in the administration group. The difference remained significant after multiple logistic regression analysis; landiolol hydrochloride was the sole inhibitory factor.

Histopathologic Characteristics of a Coronary-pulmonary Artery Fistula with a Coronary Artery Aneurysm.

Here, we report a case of a 59-year-old woman with a coronary-pulmonary artery fistula with a concomitant coronary artery aneurysm, which comprised an anomalous coronary artery originating at the right coronary cusp, an aberrant branch of the left anterior descending artery, and a coronary artery aneurysm draining into the main pulmonary artery. Histopathologically, non-dilated anomalous coronary artery showed the preservation of internal elastic lamina and medial smooth muscle cell phenotype which lacked in the aneurysmal wall. Thus, the disrupted internal elastic lamina and phenotypic change of medial smooth muscle cells might contribute to aneurysm formation in a coronary-pulmonary arterial fistula.

Efficacy of propafenone hydrochloride in preventing postoperative atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Atrial fibrillation (AF) is one of the most common complications after coronary artery bypass grafting (CABG), and the incidence of postoperative AF (PAF) is estimated to range from 10% to 40%. PAF is a serious complication that is related to unstable hemodynamics, development of embolisms, patient discomfort, and increased medical costs associated with the prolongation of hospital stay. Sometimes, immediate attention is also necessary. In this study, we assessed the efficacy of treatment with the antiarrhythmic drug propafenone hydrochloride, which was administered in the early postoperative period, in preventing the development of PAF, and we attempted to identify risk factors for PAF. MATERIALS AND METHODS: The subjects were 78 patients who underwent isolated off-pump CABG between July 2007 and October 2008. We conducted the study by dividing the patients into 2 groups, a group of 26 patients who received propafenone hydrochloride (P group) and a control group of 52 patients who did not receive this drug (C group). The patients in the P group were given propafenone hydrochloride (150-450 mg/day orally) for 10 days, starting on the day after surgery, and were observed for the development of AF by means of continuous 12-lead electrocardiographic monitoring. Development of AF was defined as AF that lasted

Right ventricular rupture induced by cardiopulmonary resuscitation.

Right ventricular rupture is a rare complication of cardiopulmonary resuscitation and could be fatal. We report a survival case of right ventricular rupture induced by cardiopulmonary resuscitation in a patient with acute myocardial infarction. A 57-year-old man was admitted to our hospital with ventricular fibrillation. Although chest compression and defibrillation were performed, ventricular fibrillation continued. We inserted a percutaneous cardiopulmonary system and performed coronary angiography, which revealed occlusion of the left anterior descending artery. After coronary stenting and intra-aortic balloon pumping, we succeeded in defibrillation and vital signs became stable. Twenty hours after the intervention, systolic blood pressure dropped to 60 mmHg. Ultrasonic cardiogram at that time revealed massive pericardial effusion. We diagnosed cardiac tamponade, and 8Fr drainage tube was placed in the pericardial space. We determined that emergent operation was necessary because we suspected left ventricular rupture due to acute myocardial infarction or coronary rupture induced by percutaneous coronary intervention. However, operative findings revealed right ventricular free wall rupture, which could have been induced by chest compression. In these cases, we should consider the possibility of not only the rupture of left ventricle and coronary artery but also the rupture of right ventricle induced by cardiopulmonary resuscitation.

Endoscopic radial artery harvesting for coronary artery bypass grafting: the initial clinical experience and results of the first 50 patients.

BACKGROUND: The radial artery (RA) is a commonly used arterial conduit in coronary artery bypass grafting (CABG). Traditional open-vessel harvest often leads to postoperative wound complications and cosmetic problems. Endoscopic RA harvesting (ERAH) has been widely used to prevent these problems. The purpose of this study was to assess these problems and graft patency in the first 50 patients who underwent ERAH. METHODS: Between February 2006 and October 2007, 50 patients underwent ERAH with the VasoView system (Boston Scientific). These patients were compared with 50 patients who underwent the traditional open technique. RESULTS: The mean age was 62.8 years in both groups. All RAs were successfully harvested. No conversion was made from ERAH to the traditional open technique. The mean harvesting time (forearm ischemic time) was 27.4 + or - 6.5 minutes, and the mean length of the RA in the ERAH group was 18.5 cm. Neither wound complications, such as wound infection and skin necrosis, nor severe neurologic complications were recorded. The patency rate was 95.9% (95/99) in the ERAH group and 94% (94/100) in the open group. CONCLUSION: ERAH can be performed safely, and the early results are satisfactory. Endoscopic vessel harvesting is therefore recommended as the technique of choice for RA harvesting.

New method of thermal coronary angiography for intraoperative patency control in off-pump and on-pump coronary artery bypass grafting.

BACKGROUND: We evaluated the effectiveness of a new thermal coronary angiogram system using intraoperative imaging with an infrared camera for coronary artery bypass grafting. METHODS: The thermal coronary angiograms of 51 patients who underwent a total of 107 coronary artery bypass grafts were evaluated. Thermal coronary angiograms were obtained after completing distal anastomoses by the injection of cold saline solution into the vein grafts or free arterial grafts or by reperfusion with warmer blood in the internal thoracic artery grafts. Temperature differences of greater than 0.1 degrees C between the injectant and the epimyocardium resulted in high-contrast images. RESULTS: Thermal coronary angiograms were obtained from 107 coronary artery bypass grafts; 103 grafts were patent (96.3%), and 2 internal thoracic artery grafts were occluded. After reanastomoses, thermal coronary angiograms were again obtained, and all grafts appeared to be patent. Four grafts did not clearly show hemokinesis because of an intramyocardial segment or circumferential fat surrounding the artery. CONCLUSIONS: Thermal coronary angiograms cannot show hemokinesis clearly in cases with an intramyocardial arterial segment or in patients in whom the grafts are surrounded by fat. Therefore, thermal coronary angiograms are considered to play a valuable role in confirming the success or failure of myocardium revascularization because this diagnostic modality does not interfere with the surgical procedures, is noninvasive, and can be both quickly and easily performed.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa following infective endocarditis in a patient with acute heart failure: a case report.

A 22-year-old male presented with infective endocarditis and aortic regurgitation with congenital bicuspid aortic valve. Echocardiography revealed vegetation on the aortic valve and a pseudoaneurysm in the region of the mitral-aortic intervalvular fibrosa (MAIVF) with severe aortic and mitral regurgitation. His clinical condition, acute heart failure due to severe aortic and mitral regurgitation, became worse. Since the MAIVF complication indicates advanced disruption of tissue at the MAIVF, urgent cardiac surgery was indicated because of the evidence of pseudoaneurysm. He received successful aortic valve replacement and restoration of normal mitral-aortic continuity. Pseudoaneurysm of the MAIVF is a relatively rare complication of infective endocarditis, but should be considered in patients who are suspected to have vegetation because echocardiography can easily establish the correct diagnosis.

Coronary artery bypass grafting in DES era.

Coronary artery bypass grafting (CABG) has played an important role in the treatment of ischemic heart disease. Recently, the introduction of a drug-eluting stent (DES) has decreased the incidence of restenosis after percutaneous intervention (PCI). PCI with a DES is being increasingly performed, whereas the number of patients for whom CABG has been indicated has decreased over the last few years in Japan and the United States. According to a report, the number of patients undergoing CABG will not decrease in the future due to its usefulness in the treatment of multi-vessel lesions. We have also reviewed how CABG should be improved. For this purpose, it may be important to carry out less invasive CABG by the off-pump method and to improve the long-term results obtained by CABG with an internal thoracic artery graft and complete revascularization. Hence, CABG may achieve better long-term results compared with PCI and continued future application of CABG.

Left ventricular pseudoaneurysm following acute myocardial infarction.

We describe a case of 57-year-old man who presented with acute myocardial infarction (AMI) and heart failure with rapid progression of cardiomegaly. Cardiac multislice computed tomography and echocardiography showed the ventricular pseudoaneurysm, probably due to cardiac free wall rupture caused by AMI. Cardiac CT is another useful tool for the non-invasive diagnosis of cardiac rupture.

Application of a new suture material called the U-Clip for composite and sequential grafting with off-pump coronary bypass surgery.

BACKGROUND: The U-Clip was found to facilitate the interrupted anastomosis of coronary artery bypass grafts (CABG). This device may be beneficial especially in multivessel off-pump CABG (OPCAB) using composite grafts or sequential anastomosis. The aim of this study was to evaluate our early clinical experience using the U-Clip in OPCAB cases. METHODS: This retrospective study included 118 patients who underwent off-pump CABG between 2001 and 2004. The mean age of the 91 men and 27 women was 69.5 +/- 8.0 years (range, 47-85). The U-Clip was adopted for sewing 73 proximal ends of the free graft to the side or end of the inflow conduit to prepare the composite graft. The U-Clip was also applied to 112 distal anastomoses, especially to the side-to-side anastomosis of the sequential graft. RESULTS: Hospital mortality rate was 0.8% (1/118). The early patency rate of distal anastomoses using the U-Clip was 95% (96/101). The early patency rate of proximal anastomoses using the U-Clip was 98.4% (62/63). Interim angiography was performed in 12 patients (range, 3.8-42 months; average, 16 months). In these 12 patients, a total of 8 proximal anastomoses of conduits using the U-Clip were all patent without stenosis. The patency rate of a total of 10 distal anastomoses in the 12 patients using the U-Clip was 100%. CONCLUSIONS: The U-Clip-interrupted anastomosis enables a safe, definite, and rapid end-to-end or end-to-side connection of arterial grafts. We therefore consider the U-Clip to be a useful suture material especially for multivessel OPCAB using multiple arterial grafts.

[Surgery for acute myocardial infarction].

We discuss the current status and outcome of surgery for acute myocardial infarction (AMI). The optimal timing of surgical revascularization following AMI is a matter of controversy. Early surgery after an AMI involves high risk If elective surgery is possible under mechanical cardiac support cardiac artery bypass grafting (CABG) can be performed with acceptable mortality rates early after AMI. On-pump beating heart revascularization is efficacious in patients in cardiogenic shock or with unstable hemodynamics early after AMI. For postinfarct ventricular septal perforation, an infarct exclusion technique is a standard surgical procedure. For an oozing-type postinfarction left ventricular free wall rupture, a sutureless technique is effective. For papillary muscle rupture, emergent mitral valve replacement concomitant with CABG is recommended.

Central arterial cannulation and the arch first method for aortic arch aneurysm repair.

BACKGROUND: We investigated whether the axillary artery or ascending aorta cannulation combined with the arch first method decreases the risk of stroke during total arch replacement. PATIENTS AND METHODS: From January 2002 to January 2006, 35 total arch replacements were performed with the arch first method and central arterial cannulation. The mean age was 66+/-10 years. The cannulation sites were the axillary artery in 19 and the ascending aorta in 16. The arch first method (a short period of deep hypothermic circulatory arrest with retrograde cerebral perfusion and then subsequent antegrade cerebral perfusion) was used in all patients. RESULTS: The mean retrograde cerebral perfusion time was 29+/-7 min. The incidence of the permanent neurological dysfunction related to the surgical procedures was 2.9% (1/35). Hospital mortality was 5.7% of patients (2/35). There was no difference in the operative outcome between the 2 arterial inflow sites. CONCLUSION: At the time of total arch replacement, the use of central arterial cannulation and the arch first method are effective methods for preventing permanent brain injury. Cannulation of the ascending aortic using Dispersion cannula perfusing toward the aortic valve is considered to be a safe and favorable method for central arterial cannulation.

Higher small arterial elasticity in hypertensive patients treated with angiotensin II receptor blockers.

Although evidence from basic research suggests the involvement of angiotensin II (Ang II) in the progression of arteriosclerosis, the clinical data are limited. In the present study, hypertensive outpatients who were well controlled with antihypertensive medication and had similar blood pressure levels were studied, and arterial elasticity was compared between those receiving Ang II receptor blockers (ARBs) and those treated with other antihypertensive agents. The effects of HMG-CoA reductase inhibitors (STs) on arterial elasticity were also evaluated. The study enrolled 298 outpatients who had been diagnosed with essential hypertension whose blood pressure was controlled to 150/95 or less by antihypertensive treatment (excluding angiotensin converting enzyme [ACE] inhibitors) for at least 2 months. The small artery elasticity index (SAEI) was determined for each patient from the radial artery pulse waves using a non-invasive pulse wave analysis system CR-2000. The mean of two blood pressure measurements taken from subjects lying in a recumbent position during SAEI analysis was used for the data analysis. The patients were grouped according to the use of ARBs and STs, and two-way analysis of variance (ANOVA) was used for statistical comparisons. A backward stepwise multiple regression analysis was carried out to identify factors contributing to the SAEI. Hypertensive patients receiving ARB treatment had a significantly higher SAEI compared to those not receiving ARBs, despite the similar blood pressure levels of both groups. No significant effects of ST treatment on the SAEI were observed (two-way ANOVA). A backward stepwise multiple regression analysis for the SAEI suggested that ARB treatment was an independent determinant of the SAEI after the adjusting of age, gender, total cholesterol, high density lipoprotein cholesterol, smoking and systolic blood pressure. Our results suggested that while providing blood pressure control similar to that of other antihypertensive agents, ARBs may also increase vascular elasticity and thereby delay the progression of arteriosclerosis.