Reconstruction of right ventricular outflow tract with severe calcification: lantern procedure.

Right ventricular outflow tract reconstruction is repeatedly required after the Rastelli procedure. However, standard right ventricular outflow tract reconstruction using direct anastomosis on the posterior right ventricular outflow tract wall is unfeasible in cases with severe calcification. Herein, we present a novel technique called the "lantern procedure," which can fix the prosthetic pulmonary valve without anastomosis to the calcified right ventricular outflow tract wall.

Impact of sarcopenia on early and mid-term outcomes of surgery for acute type A aortic dissection in octogenarians.

OBJECTIVE: To determine the association between sarcopenia and surgical outcomes in octogenarians with acute type A aortic dissection. METHODS: We enrolled 72 octogenarians who had undergone type A aortic dissection surgery between April 2013 and March 2019. The psoas muscle index, an indexed area of the psoas muscle at the L3 level on preoperative computed tomography, was obtained as an indicator of sarcopenia. The study participants were divided into sarcopenia and non-sarcopenia groups based on the mean psoas muscle index. The postoperative outcomes were compared between the groups. RESULTS: The median age was 84 years (interquartile range 82-87 years), and 13 patients were male. The mean psoas muscle index was 3.53 ± 0.97 cm2/m2. Except for sex, no significant differences were observed in patients' baseline characteristics and operative data between the two groups. The 30-day mortality rates in the sarcopenia and non-sarcopenia groups were 14% and 8%, respectively (P = 0.71), and postoperative morbidity was similar in both groups. Postoperative all-cause mortality was significantly higher in the sarcopenia group (log-rank P = 0.038), especially in patients aged 85 years or older (log-rank P < 0.01). The sarcopenia group had a lower home discharge rate than the non-sarcopenia group (21% vs. 54%, P < 0.01), and home discharge was associated with longer survival (log-rank P = 0.015). CONCLUSIONS: All-cause mortality after emergency surgery for acute type A aortic dissection was significantly higher in octogenarians with sarcopenia than in those without, especially in patients aged 85 years or older.

Iatrogenic Arteriovenous Fistula of Subclavian Artery to Vertebral Vein with Perimedullary Vein Reflux.

Iatrogenic arteriovenous fistula (AVF) rarely develops around the proximal subclavian artery, although open surgical repair of this etiology is known to be complicated as deep dissection is required around the fistula surrounded by dilated veins. In this study, we present the case of a 64-year-old man, who was referred to our hospital, with AVF between the right subclavian artery and the right vertebral vein. He had a history of accidental puncture of the right subclavian artery. An endovascular repair using a covered stent was successfully performed, and the AVF disappeared. Thus, covered stent placement should be considered as the first-line treatment for a deeply developed AVF, if anatomically feasible.

A simple closure method for a mechanical aortic valve in left ventricular assist device implantation.

Because a mechanical aortic valve is a contraindication for the implantation of left ventricular assist device, complicated additional procedures such as a replacement with a bioprosthesis and a closure of the left ventricular outflow tract are required to implant the device. Among such procedures, a sandwich plug technique using vascular clips is one of the simple and feasible procedures. However, this technique requires an off-label use of vascular clips within the aorta that could be associated with a risk of dislodgement and embolization. Thus, we developed a modified sandwich technique without using vascular clips, where the valve leaflets were fixed in the closed position using felt patches and sutures instead of vascular clips. This modified technique is a simple and secure method to close the mechanical aortic valve with the minimum use of artificial materials.

Chunnel debranching for hybrid repair of thoracoabdominal aortic aneurysm.

Hybrid repair of a thoracoabdominal aortic aneurysm comprising thoracic endovascular aortic repair and total renovisceral debranching is a feasible alternative to open repair, especially for high-risk patients. However, transperitoneal debranching is a relatively complicated procedure that requires deep dissection around vital abdominal organs. Therefore, we developed a new debranching technique called Chunnel debranching, which was characterized by transaortic tunneling using a covered stent between the target artery and the prosthetic graft anastomosed on the aneurysmal wall using an inclusion technique. This procedure increases the feasibility of renovisceral debranching with fewer dissections than conventional transperitoneal debranching.

Reduction of tethering distance by papillary muscle tugging approximation with mitral valve replacement for non-ischemic functional mitral regurgitation induces left ventricular reverse remodeling.

BACKGROUND: Functional mitral regurgitation (FMR) is caused by left ventricular (LV) remodeling and subsequent tethering of the mitral valve (MV). If LV remodeling is irreversibly advanced, it could not be attenuated by the MV procedure alone, although the additional subvalvular procedure could induce LV reverse remodeling by forcibly reducing MV tethering. This study aimed to assess the anti-tethering effect of papillary muscle tugging approximation (PMTA) on LV reverse remodeling after mitral valve replacement (MVR) for non-ischemic FMR. METHODS: The study subjects were 19 patients who underwent MVR with and without PMTA [MVR + PMTA (n = 11) and MVR alone (n = 8), respectively] for non-ischemic FMR. The tethering distance (TD) and LV end-systolic volume (ESV) at the preoperative, postoperative, and follow-up periods were assessed in terms of their correlation and time-dependent changes. The intra-LV energy efficiency was also evaluated through vector flow mapping analysis. RESULTS: TD and ESV were comparable between both procedures preoperatively and did not change after MVR alone. In MVR + PMTA, however, a significant decrease was identified in TD and ESV at the early postoperative and follow-up periods, respectively [TD = 48, 30, and 31 mm (p < 0.001) and ESV = 159, 133, and 82 mL (p < 0.001) at the preoperative, postoperative, and follow-up periods, respectively]. Finally, at follow-up, the extent of change from the preoperative value in ESV significantly correlated with that in TD (ρ = 0.81, p < 0.001 for overall; ρ = 0.93, p < 0.001 for MVR + PMTA; ρ = 0.86, p = 0.011 for MVR alone). The ratio of TD to ESV was also significantly correlated with systolic energy loss to LV stroke work after MVR + PMTA (ρ = 0.81, p = 0.015). CONCLUSIONS: PMTA for non-ischemic FMR could induce LV reverse remodeling depending on the extent of postoperative TD reduction. A smaller TD to ESV was associated with a higher intra-LV energy efficiency after PMTA + MVR.

Refractory Right Ventricular Failure in a Patient with Emery-Dreifuss Muscular Dystrophy.

A 23-year-old man had progressive muscle weakness and Emery-Dreifuss muscular dystrophy (EDMD) due to a LMNA (lamin A/C) mutation. Congestive heart failure diagnosed at 19 years of age. Maximal drug treatment/cardiac resynchronization failed to improve the cardiac function. He was therefore hospitalized due to heart failure. Despite extracorporeal membrane oxygenation, he developed severe right heart dysfunction and died (multiple organ failure). A cardiac lesion's presence determines the prognosis of EDMD. While there are many arrhythmia reports, few reports on heart failure (particularly severe heart failure requiring cardiac transplantation) have been published. Right heart function monitoring and early ventricular-assist device use plus right heart support considering heart transplantation are important.

Perioperative changes of the slope in the preload recruitable stroke work relationship by a single-beat technique after mitral valve surgery in functional mitral regurgitation with non-ischemic dilated cardiomyopathy.

OBJECTIVES: The slope in the preload recruitable stroke work relationship is a highly linear, load-insensitive contractile parameter. However, the perioperative change of the slope has not been reported before. We examined the perioperative slope from a steady-state single beat in patients with functional mitral regurgitation and assessed the correlation with brain natriuretic peptide (BNP) levels. METHODS: The study included 16 patients with non-ischemic dilated cardiomyopathy and refractory heart failure: 10 patients underwent mitral valve plasty and left ventricular plasty (MVP + LVP group) and 6 patients who underwent mitral valve replacement and papillary muscle tugging approximation (MVR + PMTA group). The left ventricular ejection fraction was assessed by the modified Simpson method; the slope was assessed by the single-beat technique using transthoracic echocardiography. BNP levels were measured by chemiluminescent immunoassay. RESULTS: The left ventricular ejection fraction and slope did not significantly change from pre- to early post-surgery in the MVP + LVP group. Both the left ventricular ejection fraction and slope significantly increased 6 months after surgery in the MVR + PMTA group. Postoperative BNP level was low in the MVR + PMTA group. While the postoperative left ventricular ejection fraction did not correlate with BNP levels, the postoperative slope significantly correlated with BNP level after surgery in the MVP + LVP group and in the total functional mitral regurgitation group. CONCLUSIONS: The change of slope was dependent on surgical procedures. In functional mitral regurgitation, the slope may be a more sensitive parameter in reflecting the left ventricular contractile function than the left ventricular ejection fraction.

Increased Susceptibility to Allergic Asthma with the Impairment of Respiratory Tolerance Caused by Psychological Stress.

BACKGROUND: Bronchial asthma is characterized by type 2 T helper (Th2) cell inflammation, essentially due to a breakdown of immune tolerance to harmless environmental allergens. Etiologically, experiences of psychological stress can be associated with a heightened prevalence of asthma. However, the mechanisms underlying stress-related asthma development are unclear. In this study, we examined whether psychological stress increases susceptibility to allergic asthma by downregulating immune tolerance. METHODS: Female BALB/c mice were sensitized with ovalbumin/alum, followed by ovalbumin inhalation. Ovalbumin inhalation induced immune tolerance before sensitization occurred. Some mice were exposed to restraint stress during tolerance induction or sensitization. Asthma development was evaluated by airway responsiveness, inflammation, cytokine expression, and IgE synthesis. Sensitization was evaluated by measuring proliferation and cytokine production by splenocytes. The effects of stress exposure on the numbers and functions of dendritic cells and regulatory T (Treg) cells in bronchial lymph nodes and spleens were evaluated. To investigate the role of endogenous glucocorticoid in inhibiting immune tolerance after stress exposure, we examined the effects of (i) a glucocorticoid-receptor antagonist administered prior to stress exposure, and (ii) exogenous gluco-corticoid (instead of stress exposure). RESULTS: Asthmatic responses and Th2-biased sensitization, which were suppressed in tolerized mice, re-emerged in tolerized mice stressed during tolerance induction in association with decreased tolerogenic dendritic and Treg cell numbers. The effects of stress exposure on tolerized mice were abolished by administering a glucocorticoid-receptor antagonist and reproduced by administering exogenous glucocorticoid without stress. CONCLUSIONS: Our findings suggested that psychological stress can potentially increase allergic asthma susceptibility by inhibiting immune tolerance.

Severe Obstructive Calcification of the Descending Aorta: A Case Report of "Coral Reef Aorta".

An 82-year-old man suffering from lower back pain and dyspnea presented to our institute in a state of shock. Computed tomography showed subtotal occlusion of the descending aorta with massive atherosclerotic calcification. As the proximal portion of the superior mesenteric artery was obstructed, emergency bypass from the right axillary artery to the bilateral external iliac arteries was performed, but the patient died 2 days later. Autopsy revealed that reddish-brown and verrucous masses obstructed the descending aorta, and high-grade thickening of the intima and extensive deposits of calcium in the lumina and medial layer were detected in the descending aorta histologically.

[Disruption of Matsui-Kitamura Stent-graft Six Years after Treatment for Rupture of Thoracic Aortic Aneurysm].

Matsui-Kitamura stent-graft (MKSG) is a home-made device for thoracic endovascular aortic repair (TEVAR) developed in Japan. A 76-year-old man who had been treated by TEVAR (zone 3) with a MKSG for ruptured thoracic aortic aneurysm was diagnosed as having type Ia endoleak caused by suture disruption and aneurysmal sac expansion 6 years later. He underwent TEVAR (zone 1) with debranching and type Ia endoleak disappeared. MKSG had been the effective device especially for acute aortic emergencies in the descending thoracic aorta until the stent-grafts became commercially available, but careful observation and appropriate re-intervention is mandatory for the continued life-saving contribution.

[Early and Long Term Outcomes of Surgery for Acute Type A Aortic Dissection Complicated with Organ Malperfusion].

OBJECTIVE: The purpose of this study was to evaluate early and long term outcomes of surgery for acute type A aortic dissection complicated with organ malperfusion. METHOD: From January 2001 to October 2015, 336 consecutive patients (mean age 68.6±12.2, male 172) underwent surgery for acute type A aortic dissection at out center. Early and late outcomes were compared between patients accompanied with and without organ malperfusion. RESULTS: Preoperative organ malperfusion was observed in 76 patients( 22.6%). That consisted of 38 neurological systems, 13 coronary, 8 visceral, and 26 extremities. Nine patients had 2 organ malperfusion. In-hospital mortality was 22.4% and 6.5% in patients with and without organ malperfusion, respectively. Multivariate logistic analysis showed preoperative organ malperfusion was a significant risk factor for in-hospital mortality (Odds ratio 3.59, 95% confidence interval 1.56~8.28, p<0.01). Five year survival rate of hospital survivors were 84.5±5.5% and 80.9±3.3% with and without organ malperfusion (p=0.51). CONCLUSIONS: Although organ malperfusion is still associated with high mortality, however, acceptable long term outcomes could be obtained if organ malperfusion is treated appropriately. Ischemic organ oriented approach might be very important to improve surgical outcomes of these critically ill conditions.