Emergency Open Surgical Repair for Ruptured Abdominal Aortic Aneurysm in Octogenarians and Nonagenarians: A Single-Center Retrospective Observational Study.

BACKGROUND: In the endovascular aneurysm repair era, open surgical repair (OSR) is performed for ruptured abdominal aorta aneurysm (RAAA) in patients with complex aneurysm neck and technical difficulties. Understanding the risk factors of OSR is essential for the clinical selection of the ideal surgical procedure. We aimed to re-evaluate the outcomes of OSR and treatment options for RAAA. METHODS: Patients who underwent OSR for RAAA between January 2010 and December 2022 were enrolled in this single-center retrospective observational study. Preoperative status, operative findings, and postoperative course were retrospectively reviewed. The Cox proportional hazards model was used to evaluate the association between age and early postoperative mortality. RESULTS: Among 142 patients, 43 (30.3%) and 99 (69.7%) were aged ≥80 and <80 years, respectively. Postoperative mortality within 30 days occurred in 24 (16.9%) patients (11/43 [25.6%] and 13/99 [13.1%] patients aged ≥80 and <80 years, respectively; hazard ratio = 1.95; P = 0.069). In a multivariable analysis, increased postoperative mortality within 30 days was associated with age ≥80 years (adjusted hazard ratio, aHR = 2.36; P = 0.049), the presence of preoperative or intraoperative cardiopulmonary arrest (aHR = 12.0; P < 0.001), and postoperative gastrointestinal disorder (aHR = 4.42; P = 0.003). CONCLUSIONS: Endovascular aneurysm repair may be preferable in older people; however, its use in cases of preoperative or intraoperative cardiopulmonary arrest or perioperative gastrointestinal disorders remains controversial, and a careful discussion on the surgical indications is needed in such cases.

Temporary Epicardial Pacing Wire Migration to the Pulmonary Artery in the Early Postoperative Stage.

Temporary epicardial pacing wires (TEPWs) are widely used during open heart surgery to treat postoperative bradycardia or arrhythmia. They are usually removed, but the wire is cut at the skin entrance site if there is resistance upon removal. Residual TEPWs have risks of complications such as infection, but they rarely migrate to distant organs. We report a case of TEPW migration from the right ventricle to the pulmonary artery during the early stage after acute type A aortic dissection surgery. Residual TEPW migration was detected incidentally during follow-up imaging for aortic dissection, and no other complications, such as residual wire infection or thrombus, were noted. The residual TEPW was safely treated using catheter therapy. This case report utilized existing patient information without intervention for research purposes, and the requirement for obtaining written patient consent was waived.

Pulmonary Tumor Thrombotic Microangiopathy Suspected to be COVID-19 Vaccine-Related Myocarditis: A Case Report.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a very rare condition that can lead to acute severe pulmonary hypertension and circulatory failure. It is caused by tumor cell microvascular obstruction and is usually difficult to diagnose; in fact, it is often diagnosed after death. We report the case of a patient who experienced a sudden cardiac arrest and developed severe pulmonary hypertension two days after receiving the coronavirus disease (COVID-19) vaccine. The patient was initially diagnosed with vaccine-associated myocarditis, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) implantation with median sternotomy was performed. The patient survived for more than two weeks. PTTM was later diagnosed during a pathological autopsy.

Early mortality of emergency surgery for acute type A aortic dissection in octogenarians and nonagenarians: A multi-center retrospective study.

OBJECTIVES: The clinical data on postoperative mortality and central nervous system (CNS) complications in older adults who underwent acute type A aortic dissection are limited. Thus, in this study we aimed to evaluate the association between age and early postoperative mortality and occurrence of CNS complications. METHODS: This multicentric retrospective cohort study included 5 tertiary hospitals in Japan. All patients who underwent emergency surgery for acute type A aortic dissection between October 1998 and December 2019 were enrolled. The multilevel Cox proportional hazards model, which considered years as level 1, institutions as level 2, and surgeons as level 3, was used to evaluate the association between age and early postoperative hospital mortality and occurrence of CNS complications. RESULTS: Of the 1037 patients, 227 (21.9%) were ≥80 years old and 810 (78.1%) were <80 years old. Overall, 134 patients (12.9%) died within 30 days postoperatively; among them, 42/227 (18.5%) and 92/810 (11.4%) were aged ≥80 and <80 years, respectively (hazard ratio [HR], 1.63; P = .0046). CNS complications within 30 days postoperatively occurred in 140/1037 (13.5%) patients; among them, 42/227 (18.5%) and 98/810 (12.1%) were aged ≥80 and <80 years, respectively (HR, 1.63; P = .011). In multivariate analysis, age ≥80 years was associated with mortality within 30 days postoperatively (adjusted HR, 2.37; 95% CI, 1.23-4.57; P = .01) but not with CNS complications (adjusted HR, 1.58; 95% CI, 0.93-2.69; P = .091). CONCLUSIONS: The early postoperative mortality in older patients was approximately 50% higher than in the younger population. A thorough discussion regarding the surgical indications should be done.

Post-Coronavirus Disease 2019 Syndrome in Japan: An Observational Study Using a Medical Database.

Introduction: In Japan, the clinical information on post-COVID-19 syndrome, including nursing care requirements, is limited. The present study investigated the incidence of acute and post-COVID-19 symptoms, including nursing care requirements, when different SARS-CoV2 strains were prevalent and vaccination statuses changed to mass vaccination programs in Japan. Methods: Electronic health records of 122,045 patients diagnosed with COVID-19 between January 1, 2020, and June 30, 2022, were obtained from the Tokushukai Group Medical Database. Patient data was divided into three observation periods. Using the International Statistical Classification of Diseases and Related Health Problems 10 codes, typical symptoms of acute (within two weeks after diagnosis) and post-COVID-19 (2-12 weeks after diagnosis) were extracted. Moreover, the nursing care requirements of patients who visited the hospital before and after the COVID-19 diagnosis were examined. Results: Original and alpha strains were prevalent in Period 1, wherein most of the population was unvaccinated. The delta strain was prevalent in Period 2, wherein approximately 70% of the population was vaccinated. The omicron strain was prevalent in Period 3, wherein approximately 70% of the population completed the two vaccination doses. Headache, malaise/fatigue, depression, and disuse syndrome were detected in acute and post-COVID-19. The incidence of depression and disuse syndrome in post-COVID-19 increased with age, with the highest incidence in the 60-85-year group. Moreover, increased high-level nursing care requirements were observed after COVID-19 in the 60-85-year-age group. Conclusions: A lower incidence of acute and post-COVID-19 symptoms in Japan is linked to increased population vaccination coverage. However, differences in viral strains may be involved. Moreover, a reduction in long-term quality of life exists in older adult patients after COVID-19. These data provide fundamental information for preventing and treating post-COVID-19 syndrome in Japan.

Experiences in Emergency Cardiac Surgery of COVID-19-Positive Patients: A Case Series.

The coronavirus disease-2019 (COVID-19) pandemic has placed many restrictions on medical care. The timing of surgical treatment has been particularly affected, with patients experiencing delayed operation dates. This report describes three patients with preoperative COVID-19-positive diagnoses, tested with reverse transcription-polymerase chain reaction, who were urgently treated surgically with excellent results. Case 1 involved an 89-year-old woman with a left ventricular rupture after a myocardial infarction. Case 2 involved a 52-year-old male patient with an acute type A aortic dissection. Case 3 involved a patient with an occlusion of an autologous dialysis shunt. All patient conditions were either life-threatening or overwhelmed hospital beds without surgical treatment. In Japan, we still experience cases where surgery is refused because of COVID-19 positivity, even if emergency surgery is necessary. This report describes three cases where standard precautions were taken, postoperative management was devised, and good results were achieved.

Utility of cardiac magnetic resonance imaging for pre-operatively evaluating the degree of caseous calcification of the mitral annulus infiltration within the left ventricular myocardium: a case report.

Background: Depending on the degree of infiltration of dry mitral annulus calcification (MAC) into the left ventricular myocardium, calcification removal may cause thinning of the left ventricular wall and increase the risk of post-operative left ventricular rupture. Therefore, the degree of pre-operative infiltration into the left ventricular myocardium should be assessed as accurately as possible. We report a case of caseous calcification of the mitral annulus (CCMA), a subtype of MAC, in an 84-year-old woman; cardiac magnetic resonance imaging (MRI) was useful in assessing the degree of left ventricular infiltration of calcification. Case summary: The patient was referred to our hospital for surgery due to respiratory distress and severe mitral insufficiency. Echocardiography revealed a mass under the posterior mitral annulus adjacent to the mitral valve ring, suspected to be a CCMA. Cardiac MRI was performed to assess the risk of left ventricular rupture. Pre-operatively, no valve ring or left ventricular myocardium infiltration was confirmed. Surgical caseous calcification removal and artificial valve implantation within the preserved valve annulus were then performed. The patient had an uneventful post-operative course and was discharged without complications on the 21st post-operative day. Discussion: In this CCMA case, a pre-operative cardiac MRI was useful for evaluating the degree of the valve annulus and left ventricular myocardial involvement and estimating the risk of left ventricular rupture.

Effect of waiting time for COVID-19 screening on postoperative outcomes of type A aortic dissection: An institutional study.

BACKGROUND: Since November 2020, all patients undergoing emergency surgery at our hospital have been subjected to preoperative reverse transcription polymerase chain reaction (RT-PCR) screening to prevent nosocomial COVID-19 infection, with admission to the operating room requiring a negative result. Herein, we compared the pre- and postoperative outcomes of acute type A aortic dissection surgery before and after implementing the RT-PCR screening for all patients. METHODS: We compared the postoperative results of 105 patients who underwent acute type A aortic dissection emergency surgery from January 2019 to October 2020 (Group I) and 109 patients who underwent the surgery following RT-PCR screening from November 2020 to March 2022 (Group II). RESULTS: The average waiting time from arrival at the hospital to admission to the operating room was 36 and 81 min in Groups I and II, respectively. Ruptured cardiac tamponade was observed preoperatively in 26.6% and 21.1% of Groups I and II patients, respectively. The preoperative waiting time due to RT-PCR screening did not contribute to the cardiac tamponade. Surgical complications such as bleeding (reopened chest), respiratory failure, cerebral neuropathy, or mediastinitis did not increase significantly. The number of deaths 30 days after surgery (Group I = 13 and Group II = 3) showed no significant difference between the groups. There were no cases of nosocomial COVID-19 infections. CONCLUSIONS: Preoperative COVID-19 screening is an important method to prevent nosocomial infections. The associated waiting time did not affect the number of preoperative ruptures or affect postoperative complications or mortality.

[Feasibility and Clinical Benefit of Robot-assisted Minimally Invasive Direct Coronary Artery Bypass Surgery].

In minimally invasive direct coronary artery bypass surgery (MIDCAB), internal mammary artery harvesting is not so easy because of small exposure and difficult maneuver for long distant target vessel. To expose and harvest left internal mammary artery (LIMA) we should lift thoracic wall and thoracic ribs which might cause rib fracture and wound pain. To overcome these disadvantages we started da Vinci robotic endoscopic LIMA harvesting for selected patients with standard sternotomy operation followed by robot-assisted MIDCAB. da Vinci robotic endoscopic LIMA harvesting is feasible and safe with less bleeding and less pain. Further learning experience might improve time and easy of operation even further.

A rare case of asymptomatic right coronary artery ectasia associated with giant aneurysm.

A rare case of giant coronary artery ectasia associated with coronary artery aneurysm was recognized. A 69-year-old woman presented with an ischemic electrocardiogram changes during a medical check-up. Coronary computed tomography angiography showed right coronary artery (RCA) ectasia associated with a giant aneurysm originating from the distal RCA. She was asymptomatic and exhibited no risk factors, including Kawasaki disease, hypertension, diabetes mellitus or family history. The patient underwent surgery for giant coronary aneurysms to prevent rupture. The aneurysm was on the peripheral side of the right coronary artery; hence, coronary artery bypass was not performed. The patient's postoperative course was uneventful. Histopathological examination of the aneurysm revealed degeneration due to atherosclerosis. She was prescribed warfarin and aspirin for thrombus prevention.

[Four Times Aortic Valve Replacement for Recurrent Aortic Annulus Destruction Due to Behçet's Disease:Report of a Case].

Surgical results of aortic regurgitation with Behcet's aortitis is associated with high morbidity and mortality due to risk of annular dehiscence. Here we describe a case of severe aortic regurgitation with Behcet's disease in 51-year-old man who underwent aortic valve replacement and subannular patch reconstruction for suspected infectious endocarditis with severe aortic regurgitation and subannular abcess. Then we performed three times aortic valve replacement for recurrent prosthetic valve dehiscence. Before the fourth operation, the patient was diagnosed with Behcet's disease and given immunosuppressant. Postoperative course was uneventful and he was discharged on postoperative day 59th, and doing well.

Hybrid treatment of a giant coronary artery aneurysm in a patient with immunoglobulin G4-related disease.

A 62-year-old man was diagnosed with a giant coronary artery aneurysm associated with immunoglobulin G4 (IgG4)-related disease. He had previously undergone two thoracic operations with sternotomies and abdominal aortic aneurysm repair for IgG4-related aortopathy. We opted for hybrid open and endovascular repair to reduce risk and avoid complications of a resternotomy and extracorporeal circulation. This first successful case of hybrid repair of a giant coronary artery aneurysm shows that the procedure is safe and feasible in patients with IgG4-related vasculopathy. It is critical to carefully monitor these patients for the occurrence of new IgG4-related aneurysms and other manifestations of vasculopathy.

Post-myocardial infarction left ventricular septal dissecting aneurysm: a case report.

BACKGROUND: Post-infarction perforation of the ventricular septum is recognized as a major complication of post-myocardial infarction. However, post-infarction ventricle dissection is seldom reported, as the ventricular shunt often accompanying this condition is a significant cause of cardiogenic shock. We encountered a rare case of ventricular dissection unaccompanied by a shunt, which caused a state of shock. CASE PRESENTATION: A 67-year-old man was diagnosed with acute myocardial infarction with a left ventricular oozing rupture. The occlusion of the left anterior descending artery was aspirated, followed by drainage of the pericardial bleeding and hemostasis of the left ventricle. After 15 h, he presented with sudden cardiogenic shock requiring extra-corporeal membrane oxygenation. The transesophageal echocardiogram showed a left ventricular septal aneurysm. Five days later, he underwent an operation, in which a ventricular septal wall dissection with a tear-forming large pseudoaneurysm was found. The tear was closed with a patch. He was weaned off extra-corporeal membrane oxygenation the next day. Αfter 4 months, he was discharged in a stable condition. CONCLUSIONS: Recognizing and identifying the cause of cardiogenic shock after myocardial infarction is crucial to provide the best treatment and surgical approach. Ventricular septal dissection should be considered, in addition to the usual complications, such as possible papillary muscle rupture, cardiac rupture, and perforation of the interventricular septum.

[Successful Use of Percutaneous Left Ventricular Assist Device( Impella) and Veno Artery Extracorporeal Membrane Oxygenation( VA-ECMO) for Ischemic Cardiogenic Shock;Report of a Case].

A 73-year-old male was referred to our hospital for acute congestive heart failure. His cardiac and respiratory conditions were worsening with cardiogenic shock requiring intubation. Coronary angiography revealed severe triple vessel disease, and echocardiography showed severe left ventricular dysfunction. Therefore, he underwent veno artery extracorporeal membrane oxygenation (VA-ECMO) followed by percutaneous left ventricular assist device (Impella). His cardiac condition improved and VA-ECMO and Impella were removed on the 2nd day and the 4th day after surgery, respectively. He underwent off-pump coronary artery bypass grafting (OPCAB) without any complication on the 36th day. Postoperative course was uneventful and he was discharged on postoperative day 30. Concomitant use of Impella and VA-ECMO (Ecpella) remarkably improved ischemic cardiogenic shock by unloading the left ventricle and increasing the cardiac output.

Fistula between the Thoracic Duct and an Unusual Vessel Aneurysm Branching Off the Abdominal Aorta Revealed by Aneurysm Rupture: A Case Report.

Fistulas between an aneurysm branching off the abdominal aorta and the thoracic duct are rare. We report a case of aneurysmal-thoracic duct fistula diagnosed by angiography when aneurysm ruptured, and we successfully treated by catheter embolization. A 42-year-old man was referred to our hospital with a chief complaint of sudden back and chest pain. Computed tomography showed both post-mediastinal and retroperitoneal hematomas, with the aneurysm from the aorta being connected to the thoracic duct. After confirming the aneurysmal-thoracic duct fistula by angiography, we performed embolization of the aneurysm. The patient has remained well for 3 postoperative months, to date.

Predictors of patent false lumen of the aortic arch after hemiarch replacement.

BACKGROUND: Hemiarch replacement for acute type A aortic dissection is less invasive than total arch replacement but involves increased risk of late aortic arch dilation because of patent false lumen of the aortic arch. If we can predict this risk, it may be a valuable prognostic indicator for selecting surgical procedures for acute type A aortic dissection. METHODS: We reviewed our surgical experience to predict patent false lumen. From January 2009 to November 2014, we performed 108 hemiarch replacement procedures for acute type A aortic dissection that had patent false lumen of the ascending aortic arch. We identified 56 patients who had preoperative and postoperative contrast-enhanced computed tomography. Patients' preoperative characteristics, preoperative and postoperative contrast-enhanced computed tomography findings, intraoperative findings and postoperative course were investigated. RESULTS: Of the 56 patients, 32 (57.1 %) were men and their mean age at surgery was 63.7 ± 11.8 years. Overall in-hospital mortality rate was 7.1 % (4 patients). According to postoperative imaging findings, 56 patients were classified into two groups: group A (39 patients), with patent false lumen, and group B (17 patients), with thrombosed false lumen. Logistic regression analysis revealed that brachiocephalic artery dissection and no tear resection contributed to postoperative patent false lumen of the aortic arch more strongly than did other factors. CONCLUSIONS: Brachiocephalic artery dissection and no tear resection are potential predictors of patent false lumen of the aortic arch after hemiarch replacement.

Emergency Pulmonary Embolectomy Using Minimally Invasive Cardiac Surgery.

A 78-year-old man who had undergone operation for acute type A aortic dissection presented with dyspnea and shock. Chest computed tomography revealed pulmonary embolism. Minimally invasive cardiac surgery was performed through a right fourth intercostal skin incision using cardiopulmonary bypass through the right femoral artery and vein. The right pulmonary artery below the superior vena cava was incised vertically, and the thrombus was extracted directly by balloon catheter. The patient was weaned off cardiopulmonary bypass uneventfully. The postoperative course was also uneventful. In redo cardiac surgery, pulmonary embolectomy through minimally invasive right thoracotomy can be easily performed, with quick recovery.

Oblique venotomy with parallelogram anastomosis in sequential bypass grafting.

The proximal vein graft is incised obliquely and anastomosed to the coronary artery to ensure that the proximal rim of the vein incision is adjusted to the lateral side of the coronary artery incision adjacent to the proximal rim. So the vein graft can be placed perpendicular to the coronary artery without kinking, and the anastomosis orifice can be made wider than those made with diamond anastomosis. Oblique venotomy with parallelogram anastomosis provides sufficient anastomotic flow, allows long incisions, and prevents kinking.