Effect of False Lumen Occlusion Treatment With AFX VELATM, Candy-Plug Technique for Chronic Aortic Dissection.

INTRODUCTION: We sought to examine midterm results and remodeling effect of false-lumen occlusion treatment using AFX VELA in case of chronic dissection repair. MATERIAL AND METHODS: From June 2019 to May 2022, we performed false lumen occlusion treatment using a modified Candy-Plug technique with AFX VELA on 8 chronic aortic dissection patients with a patent false lumen. We collected operative data, short-term clinical outcomes, mid-term clinical outcomes and imaging test results. We conducted follow-up examinations at postoperative, 6-month and 1-, 2- and 3-year intervals, including contrast-enhanced computed tomography to evaluate the diameter, false lumen thrombosis and any events. RESULTS: The average time from the symptom onset to the thoracic endovascular repair was 81.5 (35-155) months. The aorta showed aneurysmal dilation with an average maximum short-axis diameter of 58.9 (41-91) mm. Two cases needed emergency surgery due to rupture and impending rupture. There were no postoperative deaths. Complete thrombosis within the false lumen was achieved in 6 cases (75%), but 2 cases had incomplete thrombosis, requiring additional treatment. The mean maximum diameter showed a significant decrease at 6 months, 1 year and 2 years postoperatively compared to preoperative measurements (P < .05). CONCLUSION: We showed the results of false lumen occlusion treatment using the AFX VELA cuff. We observed favorable clinical outcomes and remodeling effects. While the long-term durability and efficacy of this technique in aortic remodeling will need to be monitored with further observation, the use of this cuff is considered a reliable approach to false lumen occlusion treatment.

Direct Coronary Artery Reimplantation of Anomalous Aortic Origin of the Right Coronary Artery: A Case Report.

Anomalous aortic origin of the coronary artery (AAOCA) is a rare congenital cardiac abnormality. Although AAOCA can cause angina, syncope, palpitations, and sudden cardiac death, most patients remain asymptomatic. A 60-year-old woman experienced occasional chest discomfort. A coronary computed tomography (CT) showed that the right coronary artery (RCA) originated from the left sinus of Valsalva, indicating AAORCA. Exercise myocardial scintigraphy revealed ischemia in the inferior wall. Cardiac catheterization showed stenosis in the ostium of the RCA. Therefore, direct reimplantation of the RCA into the right sinus was performed under cardiopulmonary bypass. The patient recovered uneventfully, postoperatively. Postoperative coronary CT showed no evidence of bending or stenosis in the RCA. Moreover, exercise scintigraphy showed no ischemic changes. The patient was discharged on postoperative day 18 after the resolution of chest discomfort and remained healthy for the following one year. AAORCA is a rare congenital abnormality that could lead to sudden cardiac death. Appropriate imaging studies and surgery should be performed in symptomatic patients with AAORCA who have inter-arterial paths between the ascending aorta and pulmonary artery with right coronary ostial stenosis. Reimplantation of the RCA directly into the right coronary sinus with adequate mobilization of the RCA is a simple procedure that can return the anatomic and biophysiologic status of AAORCA patients to normal and resolve most morphologic abnormalities.

[Tricuspid Valve Replacement for Isolated Tricuspid Valve Infective Endocarditis without Risk Factor].

A 78-year-old Japanese male with previous gastric cancer and untreated diabetes mellitus was admitted to hospital for persistent fever and leg edema. Blood culture was positive for Streptococcus angino'sus, and echocardiography showed isolated tricuspid valve infective endocarditis. Infection was controlled with intravenous antibiotics, but surgery was indicated because of persistent severe regurgitation and large vegetation of 15 mm in size. As the tricuspid valve anterior leaflet was extensively damaged, he underwent valve replacement using a bioprosthetic valve. The patient was discharged 25 days postoperatively with additional antibiotics, and he has been free from recurrent endocarditis for 6 months.

Refractory diffuse coronary artery spasm post aortic valve replacement.

Postoperative coronary artery spasm occurs rarely after valve replacement surgery. We report the case of a 64-year-old man with normal coronary arteries who underwent aortic valve replacement. Nineteen hours postoperatively, his blood pressure plummeted with an elevated ST-segment. Coronary angiography demonstrated a 3-vessel diffuse coronary artery spasm, and direct intracoronary infusion therapy was performed with isosorbide nitrate, nicorandil and sodium nitroprusside hydrate within 1 h of onset. Nonetheless, there was no improvement, and the patient was resistant to treatment. The patient died due to prolonged low cardiac function and pneumonia complications. Prompt intracoronary vasodilator infusion is considered effective. However, this case was refractory to multi-drug intracoronary infusion therapy and was not salvageable.

Complete Resection of Phosphoglyceride Crystal Deposition Disease After Cardiac Surgery.

Phosphoglycerides are the major lipid component of all cell membranes. Phosphoglyceride crystal deposition disease (PCDD) is defined as the deposition of phosphoglyceride crystals and is considered a lipid metabolic disorder. It predominantly involves injured soft tissues, ultimately forming foreign body granulomas. We present a case of complete resection of PCDD in a 48-year-old woman, in whom the PCDD originated from a myocardial wound created at the time of surgical repair of a ventricular septal defect 40 years ago. We underscore that familiarity with this disease entity will help to stimulate accurate diagnosis and timely treatment.

Single-stage hybrid procedure for ruptured calcified thoracic aortic aneurysm caused by Takayasu's arteritis.

A 68-year-old woman was referred to our hospital because of ruptured severely calcified thoracic aortic aneurysm on chest computed tomography. She was diagnosed with Takayasu's arteritis ~ 30 years ago and was treated with oral steroids daily. We performed total arch repair using uncalcified ascending aorta with open stent-grafting technique, and additional thoracic endovascular aortic repair immediately after open surgery to avoid type Ib endoleak. Continuous hemodiafiltration was needed owing to postoperative transient acute renal failure, following which the patient recovered. She was referred to another hospital 50 days after surgery. A single-stage hybrid procedure for ruptured severe calcified thoracic aortic aneurysm caused by Takayasu's arteritis was required in this case.

Ventilatory Efficacy After Transcatheter Aortic Valve Replacement Predicts Mortality and Heart Failure Events in Elderly Patients.

BACKGROUND: We aimed to clarify the predictors of death or heart failure (HF) in elderly patients who undergo transcatheter aortic valve replacement (TAVR).Methods and Results:We prospectively enrolled 83 patients (age, 83±5 years) who underwent transthoracic echocardiography (TTE) and cardiopulmonary exercise testing (CPET) with impedance cardiography post-TAVR. We investigated the association of TTE and CPET parameters with death and the combined outcome of death and HF hospitalization. Over a follow-up of 19±9 months, peak oxygen uptake (V̇O2) was not associated with death or the combined outcome. The minimum ratio of minute ventilation (V̇E) to carbon dioxide production (V̇CO2) and the V̇E vs. V̇CO2slope were higher in patients with the combined outcome. After adjusting for age, sex, Society of Thoracic Surgeons score and peak V̇O2, ventilatory efficacy parameters remained independent predictors of the combined outcome (minimum V̇E/V̇O2: hazard ratio, 1.108; 95% confidence interval, 1.010-1.215; P=0.031; V̇E vs. V̇CO2slope: hazard ratio, 1.035; 95% confidence interval, 1.001-1.071; P=0.044), and had a greater area under the receiver-operating characteristic curve. The V̇E vs. V̇CO2slope ≥34.6 was associated with higher rates of the combined outcome, as well as lower cardiac output at peak work rate during CPET. CONCLUSIONS: In elderly patients, lower ventilatory efficacy post-TAVR is a predictor of death and HF hospitalization, reflecting lower cardiac output at peak exercise.

Comparison of the Long-Term Outcomes of Mechanical and Bioprosthetic Aortic Valves　- A Propensity Score Analysis.

BACKGROUND: The aim of this study was to assess the long-term outcomes of aortic valve replacement (AVR) with either mechanical or bioprosthetic valves according to age at operation.Methods and Results:A total of 1,002 patients (527 mechanical valves and 475 bioprosthetic valves) undergoing first-time AVR were categorized according to age at operation: group Y, age <60 years; group M, age 60-69 years; and group O, age ≥70 years). Outcomes were compared on propensity score analysis (adjusted for 28 variables). Hazard ratio (HR) was calculated using the Cox regression model with adjustment for propensity score with bioprosthetic valve as a reference (HR=1). There were no significant differences in overall mortality between mechanical and bioprosthetic valves for all age groups. Valve-related mortality was significantly higher for mechanical valves in group O (HR, 2.53; P=0.02). Reoperation rate was significantly lower for mechanical valves in group Y (HR, 0.16; P<0.01) and group M (no events for mechanical valves). Although the rate of thromboembolic events was higher in mechanical valves in group Y (no events for tissue valves) and group M (HR, 9.05; P=0.03), there were no significant differences in bleeding events between all age groups. CONCLUSIONS: The type of prosthetic valve used in AVR does not significantly influence overall mortality.

Twenty-year outcome of aortic valve replacement with St. Jude Medical mechanical valves in Japanese patients.

BACKGROUND: Bioprostheses have become increasingly popular for aortic valve replacement (AVR) in recent years, but mechanical valves are still the standard choice, especially for younger patients. The aim of this study was to assess the very long-term outcomes in Japanese patients who underwent AVR with St. Jude Medical (SJM) mechanical valves. METHODS AND RESULTS: From 1991 to 2001, a total of 816 patients underwent AVR with SJM mechanical valves in 5 hospitals. Of these, 801 patients (mean age, 58.3±11.7 years) were analyzed in this study. There were 24 in-hospital deaths (3.0%). Mean follow-up duration was 11.6±6.7 years and the 10-year follow-up rate was 84.1%. Freedom from valve-related death at 5, 10, 15, and 20 years was 96.2%, 92.7%, 88.8%, and 86.6%, respectively. The linearized ratio of major bleeding events and thromboembolic events was 1.1% per patient-year and 1.0% per patient-year, respectively. Freedom from reoperation for the aortic prosthesis was 98.0% and 94.8% at 10 and 20 years, respectively. CONCLUSIONS: The SJM mechanical valve provided excellent long-term freedom from valve-related death and reoperation in patients undergoing AVR. Therefore, this valve should be recommended to younger patients who wish to avoid reoperation.

[Valve Replacement for Tricuspid Valve Regurgitation due to Pacemaker Lead Adherence;Report of Two Cases].

We experienced tricuspid valve regurgitation (TR) due to pacemaker lead adherence in an 81-year-old woman and in a 68-year-old woman, who both had right heart failure. The cause of TR was deformation of the tricuspid valve by pacemaker leads. Because of strong adherence between the lead and the leaflet or the tendinous cord, lead extraction and valve replacement were performed. The living lead was preserved by fixation at the septum wall outside the valve cuff in 1 patient. In the other patient, the epicardial lead was used for implantation because it was easier compared to intravenous lead implantation. The heart failure and TR improved after the operation in both patients.

[Infectious endocarditis complicated with preoperative infectious intracranial aneurysm;report of a case].

A 44-year-old man was admitted with the diagnosis of active infective endocarditis( IE) due to Streptococcus mitis, complicated with infectious intracranial aneurysm. Preoperative echocardiography showed mobile vegetation on the mitral leaflet, size of which was 20 mm. The magnetic resonance imaging( MRI) demonstrated that the size of aneurysm was increasing, and infectious intracranial aneurysm was treated surgically. Twenty one days after the operation, the mitral valve plasty was performed. He was discharged on foot without any neurological findings. The duration between the brain surgery and the cardiac surgery was thought to be important to prevent the new neurological complication.

[Restenosis following descending aortic replacement for coarctation of the aorta; report of a case].

We report a case of a 44-year-old man with restenosis of coarctation of aorta (CoA). He had a history of descending aortic replacement for CoA using a graft 14 mm in diameter at 29 years ago. He had reoperation because of pressure gradient of 61 mmHg across the graft and intermittent claudication. Reoperation was done under unilateral lung ventilation with lung collapsed, through 3th and 5th interspace thoracotomy. Left lung adhesion was carefully released with an ultrasonically vibrating scalpel. After full heparinization, femoro-femoral bypass was started and descending aorta was clamped. The old graft was excised, and descending aortic replacement was done with a new graft of 26 mm in a diameter. His postoperative course was uneventful. The intermittent claudication disappeared.

Postoperative hyperglycemia and atrial fibrillation after coronary artery bypass graft surgery.

BACKGROUND: Postoperative atrial fibrillation (AF) is a common complication following coronary artery bypass grafting (CABG). We investigated the risk factors for postoperative AF and analyzed the relationship between blood sugar concentration (BS) and AF after CABG. METHODS AND RESULTS: A total of 199 consecutive patients who underwent isolated CABG were retrospectively examined and classified according to the presence (n=95) or absence (n=104) of postoperative AF. On univariate analysis mean postoperative BS (P<0.001), postoperative drainage volume (P<0.001), age (P=0.034), presence of diabetes mellitus (DM; P=0.004), and postoperative estimated glomerular filtration rate (P=0.032) were significant risk factors for postoperative AF. On multivariate analysis mean postoperative BS (OR, 1.041; 95% CI: 1.008-1.079; P<0.001), postoperative drainage volume (OR, 1.003; 95% CI: 1.001-1.006; P=0.001), and age (OR, 1.040; 95% CI: 1.002-1.083; P=0.041) were significant risk factors for postoperative AF. Postoperative AF often occurred in patients with high postoperative BS, irrespective of DM. The BS cut-off that predicted postoperative AF occurrence was 180 mg/dl. A strong positive correlation existed between the time of the maximum postoperative BS and AF onset time (ρ=0.746). CONCLUSIONS: Mean postoperative BS and postoperative drainage volume are risk factors for AF after CABG. AF was strongly associated with maximum postoperative BS. Intensive glycemic control could reduce AF occurrence after CABG.

[Graft replacement under percutaneous cardiopulmonary system for traumatic aortic rupture with multiple injuries].

We report a case of traumatic aortic rupture with multiple injuries. A 20-year-old man was transferred to our hospital. He was suffering from traumatic thoracic aortic rupture with multiple injuries (femoral fracture, pelvis fracture and so 4th) due to a traffic accident. Enhanced computed tomography revealed leakage from the aortic isthmus and hematoma in the surrounding area. Emergency operation was performed. The left 4th intercostal thoracotomy was performed and a lacerated foramen was observed across the lesser curvature of the aortic isthmus. The affected site was replaced by a prosthetic graft under percutaneous cardiopulmonary system. He was treated with open fixation of the right femur 11 days after the 1st operation. The postoperative recovery was generally uneventful and he was discharged on the 51st hospital day.

[Successful excision of a left ventricular fibroma in an adult patient; report of a case].

A 55-year-old man was referred with a diagnosis of a left ventricular thrombus. Echocardiography revealed that he had a thrombus in the free wall of the left ventricle. Under cardiopulmonary bypass, we removed the intramural tumor. After the removal, the defect was repaired by Dor operation. Pathological examination revealed the tumor was a cardiac fibroma. He is doing well without any troubles 3 years after the operation.

[Thoracic endovascular stent graft for late pseudoaneurysm formation after patch aortoplasty; report of a case].

We report a case of a 51-year-old man presenting with pseudoaneurysm associated with a knitted Dacron patch used to repair coarctation of the aorta. At the age of 15 years, he underwent patch angioplasty for coarctation of the aorta. However the computed tomography( CT) scan, taken after 36 years, demonstrated pseudoaneurysm of the thoracic aorta at the anastmotic site. He was treated by endovascular stent graft using Gore-TAG 3115. His postoperative course was uneventful. Follow-up CT scan demonstrated no recurrence of pseudoaneurysm.

[Extended aortic arch replacement through gull-wing approach to Kommerell's diverticulum and aneurysmal right-sided aortic arch with aberrant left subclavian artery].

The patient was a 76-year-old man. He was referred to our hospital to treat Kommerell's diverticulum and aneurysmal right-sided aortic arch with aberrant left subclavian artery. We performed extended aortic arch replacement using gull-wing approach. He was discharged uneventfully without any complication. Gull-wing approach method has an advantage of wide surgical field and may be useful for extensive thoracic aortic disease.

[Simultaneous coronary artery bypass grafting and the ascending aorta to bifemoral bypass].

OBJECTIVE: Coronary artery disease and arteriosclerosis obliterans (ASO) frequently coexist. Concomitant revascularization procedures may be required because harvest of the internal thoracic artery (ITA) in patients with ASO carries a risk of leg ischemia. This study reports our experience with combined coronary and femoral revascularization using the ascending aorta to bifemoral bypass. PATIENTS: Seven male patients (including 4 high aortic occlusions) underwent concomitant aorto-femoral bypass and coronary revascularization between 1990 and 2007. Mean age was 66 years old. RESULTS: Coronary artery bypass grafting (CABG) was performed on-pump in 5 cases and off-pump in 2 cases. The number of bypass grafts were 2.4 +/- 0.9. We harvested ITA in all cases. The prosthetic tube graft was positioned behind the muscles of the abnominal wall. One hospital death was related to mediastinitis. Perfect patency of the aorta-femoral grafts was obtained in all cases. CONCLUSIONS: The ascending aorta is a good source of inflow to femoral arteries and the ascending aorta to bifemoral bypass did not require an intraperitoneal procedure. Therefore the simultaneous operation can be performed in shorter time, and it is an interesting alternative in cases with ischemic heart disease and leg ischemia.