Safety and outcomes of surgical treatment of atrial fibrillation in emergency surgery cases.

BACKGROUND: Recent developments in surgical devices, including left atrial appendage closure, have enabled surgeons to perform aggressive operations for atrial fibrillation (AF). However, the outcomes of AF surgery in emergent cases have not been extensively studied. OBJECTIVE AND METHODS: The present study aimed to investigate the effectiveness of AF surgery in emergency surgery cases associated with cardiovascular events. We enrolled 18 patients who underwent various types of AF surgery due to emergencies, including acute aortic dissection (n = 6), acute myocardial infarction (n = 5), bleeding due to perforation from radiofrequency catheter ablation (n = 4), acute mitral regurgitation (n = 2), and cardiac tumor (n = 1). Four and ten patients underwent the full maze procedure and pulmonary vein isolation, respectively. Ganglionated plexi ablation was also performed in three patients as part of a combined procedure. The left atrial appendage was solely closed in four patients. RESULTS: There was no surgical mortality or major adverse cardiac and cerebrovascular events in our patient series. The rates of freedom of recurrence of AF or atrial tachycardia at 1 and 3 years were 92.9% and 82.5%, respectively. After a mean follow-up period of 46.7 ± 25.8 months, no thromboembolism events were observed in the patients. Furthermore, no cardiovascular death was recorded. CONCLUSION: The surgical procedures for AF are safe and effective in cases requiring emergency surgery.

Electrophysiological and Histopathological Characteristics of Ventricular Tachycardia Associated With Primary Cardiac Tumors.

BACKGROUND: Ventricular tachycardia (VT) associated with primary cardiac tumors (PCTs) originating from the ventricles is rare, but lethal, in young patients. OBJECTIVES: This study aimed to clarify the mechanisms underlying primary cardiac tumor-related ventricular tachycardia (PCT-VT) and establish a therapeutic strategy for this form of VT. METHODS: Among 67 patients who underwent surgery for VT at our institute between 1981 and 2020, 4 patients aged 1 to 34 years, including 3 males, showed PCT-VT (fibroma, 2; lipoma, 1; and hamartoma, 1), which was investigated using a combination of intraoperative electroanatomical mapping and histopathological studies. RESULTS: All 4 patients developed electrical storms of sustained VTs refractory to multiple drugs and repetitive endocardial ablations. The VT mechanism was re-entry, and intraoperative electroanatomical mapping showed a centrifugal activation pattern originating from the border between the tumor and healthy myocardium, where fractionated potentials were detected during sinus rhythm. Histopathological studies of serial sections of specimens acquired from these areas revealed tumor infiltration into the surrounding myocardium with cell disorganization, exhibiting myocardial disarray. Several myocardia entrapped in the tumor edges contributed to the development and sustainment of re-entrant VT activation. In the 2 patients in whom complete resection was unfeasible, encircling cryoablation to entirely isolate the unresectable tumor was effective in suppressing VT occurrence. CONCLUSIONS: The mechanism underlying PCT-VT involves re-entry localized at the tumor edges. Myocardial disarray associated with tumor infiltration is a substrate for this form of VT. Cryoablation along the border between the tumor and myocardium is a promising therapeutic option for unresectable PCT-VT.

Surgery for ventricular tachycardia originating from the left ventricular summit.

OBJECTIVES: Ventricular tachycardia (VT) originating from the left ventricular summit region, the most superior region of the left ventricle surrounded by the major coronary arteries and veins, is frequently refractory to pharmacological therapies and endocardial and epicardial catheter ablation. METHODS: Eleven patients with an age from 31 to 79 (median 56) years old, underwent map-guided surgery for left ventricular summit VT. All patients had undergone 1-5 unsuccessful sessions of catheter ablation for incessant VT, preoperatively. Five patients had suffered VT storm and 1 had a history of cardiopulmonary resuscitation. Four patients had implanted with a defibrillator. Epicardium to endocardium transmural cryothermia was applied at the VT origin determined by intraoperative epicardial mapping with electro-anatomical mapping system. Harmonic scalpel was used to remove the epicardial fat and cryothermia was applied directly to the myocardium, avoiding thermal or mechanical injuries to the coronary vessels. Additional endocardial cryothermia at the VT origin was performed by a cryoprobe introduced into the left ventricular cavity through an aortotomy. RESULTS: There was no surgical mortality or long-term mortality related to VT during a median follow-up period of 60 months (interquartile range: 34-82). Five-year freedom from preoperatively documented left ventricular summit VT and non-documented VT was 91% and 73%, respectively. All the patients with postoperative VT underwent successful catheter ablation. Other patients were free from VT during the follow-up period. CONCLUSIONS: Epicardial to endocardial transmural cryothermia at the VT origin guided by intraoperative electro-anatomical mapping with a close collaboration with electrophysiologists was crucial in successful surgery for left ventricular summit VT.

Multiple cardiac surgical procedures in a case of an octogenarian with essential thrombocythemia.

BACKGROUND: Essential thrombocythemia (ET) is a chronic myeloproliferative disorder characterized by an elevation of platelet counts with a tendency for thrombosis and hemorrhage. The perioperative management of cardiovascular surgery of an ET patient is complicated. There is limited literature on the perioperative management of patients with ET undergoing cardiovascular surgery, particularly those requiring multiple procedures. CASE PRESENTATION: An 85-year-old woman with a history of essential thrombocythemia (ET), which resulted in an abnormally high platelet count, was diagnosed with aortic valve stenosis, ischemic heart disease and paroxysmal atrial fibrillation. She underwent aortic valve replacement, coronary artery bypass grafting, and pulmonary vein isolation. The postoperative course was uneventful, nor hemorrhage and thrombosis. CONCLUSIONS: We represent a case of perioperative management and successful treatment of three combined cardiac surgery for an octogenarian ET patient who is the oldest case ever reported.

On-pump beating-heart technique for managing a ruptured left coronary artery aneurysm.

We present the case of an 86-year-old woman with a ruptured left coronary artery aneurysm associated with coronary-pulmonary artery fistula. She was transferred to our hospital with complaints of chest discomfort. Echocardiography revealed cardiac tamponade, and subsequently, a bloody pericardial effusion was drained. Coronary angiography and computed tomography revealed a ruptured left coronary artery aneurysm originating from a branch of the proximal left anterior descending artery and a coronary-pulmonary artery fistula. In the emergency operation, under cardiopulmonary bypass, the inlet and outlet vessels were ligated, and the aneurysm was closed without arresting the heart. By utilizing cardiopulmonary bypass, the pulmonary trunk was easily decompressed, and dissection around the aneurysm and identification of the inlet and outlet vessels was facilitated without cardiac arrest. Thus, to conclude, an on-pump beating-heart technique should be considered in such cases.

A Case of Contained Rupture of the Common Iliac Artery with Idiopathic Retroperitoneal Fibrosis: Efficacy of Surgical Treatment and Immunosuppressive Therapy at 2-Year Follow-Up.

Rupture of inflammatory aortic aneurysm associated with retroperitoneal fibrosis (RF) is rare. We report a 62-year-old man with an inflammatory abdominal aortic aneurysm (IAAA) complicated with idiopathic RF, resulting in a contained rupture of the common iliac artery. The patient also presented with mild renal insufficiency due to urethral obstruction and left hydronephrosis. Surgical procedures including graft replacement and ureterolysis relieved the symptoms. Postoperative immunosuppressive treatment using corticosteroid and methotrexate successfully maintained clinical remission without signs of recurrence of RF and IAAA at the 2-year follow-up.

Case of left ventricular thrombus managed with thrombectomy with left ventricular reconstruction in a patient who had coronavirus disease 2019 infection.

BACKGROUND: Intracardiac thrombus is relatively rare in patients with coronavirus disease 2019 (COVID-19). However, if it occurs, thrombotic complications are likely to develop. In this case, we performed a successful thrombectomy on a patient who developed left ventricular thrombus after COVID-19 infection without complications. CASE PRESENTATION: A 52-year-old man sought medical care due to fever, dyspnea, and abnormalities in the taste and smell that persisted for 2 weeks. The patient was diagnosed with COVID-19 and was treated with remdesivir, baricitinib, and heparin. Three weeks after hospitalization, electrocardiogram revealed angina pectoris, and cardiac catherization showed left anterior descending coronary artery stenosis. In addition, global hypokinesis and a thrombus at the left ventricular apex were observed on echocardiography. Left ventricular reconstruction concomitant with coronary artery bypass grafting was performed. A thrombus in the left ventricle was resected via left apical ventriculotomy, and the bovine pericardium was covered and sutured on the infarction site to exclude it. The patient was extubated a day after surgery and was transferred to another hospital for recuperation after 20 days. He did not present with complications. CONCLUSIONS: Thrombotic events could be prevented via thrombectomy with left ventricular reconstruction using an intraventricular patch to exclude the residual thrombus.

Surgical Treatment of a Defect Recurring 22 Years after Closure of an Inferior Sinus Venosus Defect: A Case Report.

BACKGROUND: Residual shunt after closure of an inferior sinus venosus defect (ISVD) is a rare complication with a high rate of reintervention. CASE PRESENTATION: Here, we report a rare case of a recurrent defect identified 22 years after closure of an ISVD. The defect (25 × 10 mm) was located at the inferior vena cava-right atrial junction and was closed directly when the patient was 5 years of age. No residual shunt was detected and follow-up was discontinued at age 12 years. However, a residual atrial septal defect shunt was detected incidentally at age 27 years. During the second surgery, the lower end of the original defect was opened and then closed with an expanded polytetrafluoroethylene patch. CONCLUSIONS: Because of the high rate of reintervention for residual shunt after ISVD closure, patch closure was selected as a better option to reduce tension at the inferior-posterior border. Patients with this profile should be followed closely, at least during childhood, including by echocardiography.

Shunt and pace: a novel experimental model of atrial fibrillation with a volume-loaded left atrium.

BACKGROUND: Atrial fibrillation (AF) is frequently seen in patients with a volume-loaded left atrium (LA) such as mitral valve regurgitation (MR). Previous animal models have incomplete relevance to human AF associated with MR. METHODS: A novel experimental model with a combination of volume loading of LA by creating a shunt from the subclavian artery to pulmonary artery and electrical remodeling induced by continuous rapid LA pacing was designed and the electrophysiological effects were examined in 10 canines. Five weeks after the shunt surgery, the entire atrial epicardium was mapped during sustained AF with form-fitted electrode patches with 246 bipolar electrodes and a three-dimensional dynamic mapping system to characterize the induced AF. RESULTS: Three animals died of severe heart failure and pacing failure occurred in one. Remaining six animals were subjected to the analysis. The LA diameter increased progressively after the shunt surgery. Sustained AF was induced after 3 weeks of continuous rapid LA pacing in all animals. The activation maps revealed repetitive focal activations arising from the pulmonary veins, right or left atrial regions, and reentrant activations in the RA, which patterns of atrial activations are the same as those seen in human AF. CONCLUSION: The animal model with a combination of LA volume load and electrical remodeling was relevant to human AF associated with LA volume load. Studies using the present model may provide further knowledges of AF and may be useful in examining the effects of pharmacological and non-pharmacological therapies.

Surgical Management of Cardiac Implantable Electronic Device Complications in Patients Unsuitable for Transvenous Lead Extraction.

BACKGROUND: Although surgical approaches for infected or failing cardiac implantable electronic device (CIED) leads are more invasive than transvenous approaches, they are still required for patients considered unsuitable for transvenous procedures. In this study, surgical management with transvenous equipment for CIED complications was examined in patients unsuitable for transvenous lead extraction.Methods and Results: We retrospectively examined 152 consecutive patients who underwent CIED extraction between April 2009 and December 2021 at the Department of Cardiovascular Surgery, Nippon Medical School. Nine patients (5.9%; mean [±SD] age 61.7±16.7 years) who underwent open heart surgery were identified as unsuitable for the isolated transvenous approach. CIED types included 5 pacemakers and 4 implantable cardioverter-defibrillators; the mean [±SD] lead age was 19.5±7.0 years. Indications for surgical management according to Heart Rhythm Society guidelines included failed prior to transvenous CIED extraction (n=6), intracardiac vegetation (n=2), and severe lead adhesion (n=1). Transvenous CIED extraction tools were used in all patients during or before surgery. Additional surgical procedures with CIED extraction included epicardial lead implantation (n=4) and tricuspid valve repair (n=3). All patients were discharged; during the follow-up period (mean 5.7±3.7 years), only 1 patient died (non-cardiac cause). CONCLUSIONS: Surgical procedures and transvenous extraction tools were combined in the removal strategy for efficacious surgical management of CIED leads. Intensive surgical procedures were safely performed in patients unsuitable for transvenous extraction.

Surgical Treatment of a Giant Popliteal Venous Aneurysm and Arteriovenous Fistula on the Adjacent Femoral Vein and Its Postoperative Findings.

A case of a giant popliteal venous aneurysm that caused massive pulmonary thromboembolism with an arteriovenous fistula draining into the adjacent proximal femoral vein is reported herein. Deep veins in the lower leg were occluded by thrombi. The inlet and outlet orifice inside the aneurysm was closed and aneurysmorraphy was performed. The fistula was retained on the estimation that it would maintain the blood flow and prevent thrombus formation inside the femoral vein. The aneurysm was shrunk, the femoral vein was patent, and the fistula was not observed 1 year later, although it still existed 1 week after the operation.

Anaesthetic management of an abdominal aortic aneurysmorrhaphy in Klippel-Trenaunay-Weber syndrome: a case report.

BACKGROUND: Klippel-Trenaunay-Weber syndrome (KTWS) is a rare congenital malformation. Although there have been few reports on anaesthetic management of patients with KTWS, there is a lack of data on anaesthetic management for abdominal aortic aneurysm (AAA) surgeries in these patients. CASE PRESENTATION: A 74-year-old man (height, 160 cm and body weight, 51.5 kg) with KTWS was scheduled for AAA replacement. Abdominal computed tomography (CT) showed prominent tortuosity below the abdominal aorta with an infrarenal abdominal aortic aneurysm, right common iliac artery aneurysm, and right external iliac artery aneurysm. Moreover, a remarkably noted arteriovenous fistula had developed between the aneurysm and peripheral artery. General anaesthesia was induced. Furthermore, a central venous catheter and an 8.5 French sheath in the left internal jugular vein were inserted. During the operation, bleeding from a collateral vessel in the cross-clamped aorta led the surgeon to decide to perform aneurysmorrhaphy. Intraoperatively, blood loss was 1500 ml, and 20 units of red blood cell concentrate were used. CONCLUSIONS: Regarding AAA procedures in patients with KTWS, aortic cross-clamping may not sufficiently intercept blood flow due to collateral vessels. In these patients, the anaesthesiologist must be prepared to transfuse blood more rapidly and frequently than during normal AAA procedures.

Combined cardiac surgery in a Marfan syndrome patient with severe scoliosis via lower hemisternotomy: a case report.

BACKGROUND: Scoliosis is one of the symptoms manifested by patients with Marfan syndrome (MFS). Deformity of the thoracic cavity due to severe scoliosis may cause difficulty during cardiac surgery in terms of the surgical approach and instrument manipulation; however, only a few reports have been available regarding the surgical case of MFS with severe scoliosis. Here, we report a case of combined aortic valve replacement and left atrial appendage closure in a patient with MFS who had severe scoliosis using lower hemisternotomy. CASE PRESENTATION: A 62-year-old female with MFS was referred to our hospital after being diagnosed with severe aortic regurgitation and paroxysmal atrial fibrillation with a history of cerebral thromboembolism. The aortic valve showed severe insufficiency due to cusp prolapse, whereas the aortic root was moderately dilated (42 mm). Echocardiography revealed severe regurgitation with reduced left ventricular ejection function (32%) and massive left ventricular diastolic dimension (88 mm). Moreover, combined aortic valve replacement and left atrial appendage closure was indicated. However, the patient had chest deformity due to severe scoliosis. Thus, conventional full sternotomy or thoracotomy was considered an inappropriate surgical approach. Lower hemisternotomy was selected on the basis of three-dimensional reconstruction imaging of the aorta, left atrial appendage, sternum, and rib. Sternal elevation and rib retraction with the costal arch folded back provided enough surgical field for the combined procedures to be safely conducted. The postoperative course was uneventful, except for predicted prolonged mechanical ventilation with the assistance of intraaortic balloon pumping. Thereafter, the patient has been free from any cardiac and cerebrovascular event. CONCLUSIONS: Lower hemisternotomy can be useful for combined cardiac surgery in MFS with severe scoliosis.

Multicenter randomized study evaluating the outcome of ganglionated plexi ablation in maze procedure.

OBJECTIVE: The benefit of adding ganglionated plexi ablation to the maze procedure remains controversial. This study aims to compare the outcomes of the maze procedure with and without ganglionated plexi ablation. METHODS: This multicenter randomized study included 74 patients with atrial fibrillation associated with structural heart disease. Patients were randomly allocated to the ganglionated plexi ablation group (maze with ganglionated plexi ablation) or the maze group (maze without ganglionated plexi ablation). The lesion sets in the maze procedure were unified in all patients. High-frequency stimulation was applied to clearly identify and perform ganglionated plexi ablation. Patients were followed up for at least 6 months. The primary endpoint was a recurrence of atrial fibrillation. RESULTS: The intention-to-treat analysis included 69 patients (34 in the ganglionated plexi ablation group and 35 in the maze group). No surgical mortality was observed in either group. After a mean follow-up period of 16.3 ± 7.9 months, 86.8% of patients in the ganglionated plexi ablation group and 91.4% of those in the maze group did not experience atrial fibrillation recurrence. Kaplan-Meier atrial fibrillation-free curves showed no significant difference between the two groups (P = .685). Cox proportional hazards regression analysis indicated that left atrial dimension was the only risk factor for atrial fibrillation recurrence (hazard ratio: 1.106, 95% confidence interval 1.017-1.024, P = .019). CONCLUSION: The addition of ganglionated plexi ablation to the maze procedure does not improve early outcome when treating atrial fibrillation associated with structural heart disease.

4D Flow MR Imaging of the Left Atrium: What is Non-physiological Blood Flow in the Cardiac System?

Most cardiac diseases cause a non-physiological blood flow pattern known as turbulence around the heart and great vessels, which further worsen the disease itself. However, there is no consensus on how blood flow can be defined in disease conditions. Especially, in the left atrium, the fact that vortex flow already exists makes this debate more complicated. 3D time-resolved phase-contrast (4D flow) MRI is expected to be able to capture blood flow patterns from multiple aspects, such as blood flow velocity, stasis, and vortex quantification. Previous studies have confirmed that physiological vortex flow is predominantly induced by the higher-volume flow from the superior left pulmonary vein. In atrial fibrillation, 4D flow MRI reveals a non-physiological blood flow pattern, which information may add value to well-established clinical risk factors. Currently, the research target of LA analysis has also widened to lung surgeons, pulmonary vein stump thrombosis after left upper lobectomy. 4D flow MRI is expected to be utilized for many more variable diseases that are currently unimaginable.

Outcomes of abdominal aortic aneurysm repairs: Endovascular vs open surgical repairs.

BACKGROUND: Operative mortality after endovascular aneurysm repair (EVAR) has been reported as lower than open surgical repair (OSR) for abdominal aortic aneurysm (AAA) in randomized controlled trials. However, many cohort studies have demonstrated similar mortality rates for both procedures. We compared operative mortality between EVAR and OSR, at our institution. METHODS: All AAA operations from 2012 to 2017 were reviewed, and baseline characteristics were collected. Outcomes included 30-day mortality, operative data, complications, length of hospital stay (LOS), costs, re-intervention, and survival rates were compared. A multivariable analysis with unbalanced characteristics was performed. RESULTS: We had a total of 162 patients, 100 having OSR and 62 for EVAR. The EVAR group was older, with higher ASA classification. Thirty-day mortality rate did not significantly differ (0/100 for OSR and 2/62 (3%) for EVAR; p = 0.145), while the EVAR group had less blood loss, shorter operative times, and LOS, but higher re-intervention rates (adjusted hazard ratio 6.4 (95%CI: 1.4, 26.8)). Survival rates did not significantly differ between the groups. EVAR cost approximately 1-million yen more. CONCLUSIONS: OSR had low 30-day mortality rate in selected low-risk patients whereas EVAR had less blood loss, shorter operative times, LOS and could be done in high-risk patients with low 30-day mortality but with higher re-intervention rate.

Temporal and Microbiological Analysis of Cardiac Implantable Electrical Device Infections　- A Retrospective Study.

Background: Although the causative pathogens in cardiac implantable electronic device (CIED) infections are well known, the relationship between time after implantation and infection patterns has not been sufficiently investigated. This study investigated the microbiology and onset of CIED infections according to infection patterns. Methods and Results: This retrospective study included 97 patients who underwent CIED removal due to device-related infections between April 2009 and December 2018. After device implantation, infections peaked in the first year and declined gradually over 10 years. Most infections (>60%) occurred within 5 years. Staphylococcal infections, the predominant form of CIED infections, occurred throughout the study period. CIED infections were categorized as systemic (SI; n=26) or local (LI; n=71) infections according to clinical presentation, and as CIED pocket-related (PR; n=85) and non-pocket-related (non-PR; n=12) infections according to the pathogenic pathway. The main causative pathogen in SI was Staphylococcus aureus, whereas coagulase-negative staphylococci were mainly related to LI. Both SI and LI peaked in the first year after implantation and then decreased gradually. There was no significant microbiological difference between PR and non-PR infections. PR infections showed the same temporal distribution as the overall cohort. However, non-PR infections exhibited a uniform temporal distribution after the first year. Conclusions: The severity of CIED infections depends on the causative pathogen, whereas their temporal distribution is affected by the microbiological intrusion pathway.

Surgical retrieval of an entrapped stent and a stuck snare device during percutaneous coronary intervention.

A 69-year-old male patient with a history of percutaneous coronary intervention (PCI) to the proximal left anterior descending coronary artery (LAD) underwent another PCI to the stenosis of the medium LAD as part of therapy for angina pectoris. Interruption of stent delivery because of past stent led to stent entrapment and a stuck guidewire. A snare catheter device was applied to retrieve the stent; however, the device lost mobility. Surgical removal and coronary artery bypass grafting (CABG) were required. We herein report some surgical techniques for resolving this complication of PCI. .