Aortic endograft infection by Mycobacterium abscessus subsp. massiliense with acquired clarithromycin resistance: a case report.

BACKGROUND: Mycobacterium abscessus subsp. massiliense (MMA) comprises a group of non-tuberculous, rapidly growing mycobacteria. Although MMA can cause pulmonary diseases, surgical site infections, and disseminated diseases, aortic endograft infection has not been reported. Here, we describe the first case of aortic endograft infection caused by MMA. CASE PRESENTATION: Two months after stent-graft insertion for an abdominal aortic aneurysm, an 85-year-old man was admitted with fever and abdominal pain and was diagnosed with aortic endograft infection. Despite 14 days of meropenem and vancomycin intravenous administration, periaortic fluid pooling increased as compared to that before antibiotic administration. The abscess was drained, and fluorescent acid-fast staining of the abscess fluid revealed bacilli. We conducted genetic tests on the genes hsp65, rpoB, and sodA, performed Whole Genome Sequencing (WGS), and identified the organism as MMA. Intravenous imipenem-cilastatin (IPM/CS), amikacin (AMK), and oral clarithromycin (CAM) were administered. After 2 months, oral CAM and sitafloxacin were administered because the abscess had decreased in size. However, after 6 weeks, the abscess increased in size again. Antimicrobial susceptibility testing of the drainage fluid from the abscess resulted in the isolation of an MMA strain that had acquired resistance to CAM. Intravenous IPM/CS, AMK, and oral linezolid were added to the treatment regimen along with oral CAM and STFX. However, he was not fully cured and died 6 months later. Neither the full-length erythromycin ribosome methyltransferase (erm)(41) gene nor the rrl or rpIV gene mutations were found by Sanger sequencing in the pre- and post-treatment strains. Whole-genome sequence analysis of the post-treatment strain revealed mutations in genes with no previous reports of association with macrolide resistance. CONCLUSIONS: Aortic endograft infection caused by MMA strain is extremely rare; nonetheless, MMA should be suspected as the causative microorganism when broad-spectrum antimicrobials are ineffective.

[Esophageal Perforation on Transesophageal Echocardiography in Open-heart Surgery:Report of a Case].

A 70-year-old woman, who was taking prednisolone to treat Takayasu arteritis, underwent surgery for aortic regurgitation and aneurysm of the ascending aorta. The probe of the transesophageal echocardiography (TEE) could not be inserted due to resistance during anesthesia induction and was inserted after starting cardiopulmonary bypass. The right pneumothorax was observed during surgery. After surgery, fever and a high C-reactive protein level continued, and a computed tomography (CT) examination revealed right thoracic empyema together with free air around the esophagus. The esophageal perforation diagnosis was confirmed by upper endoscopy. Esophageal leakage continued despite emergency esophageal repair and enterostomy. Although esophagectomy was performed 2 months later, the patient died 6 months after cardiac surgery due to sepsis. Thus, esophageal perforation related to TEE in open-heart surgery was considered to be associated with a poor prognosis.

A Case of Vascular Graft Infection Caused by Haemophilus parainfluenzae.

Haemophilus parainfluenzae is a gram-negative coccobacillus that is a part of the normal flora in the human upper airway and sometimes causes infective endocarditis. We present a case of a 68-year-old Japanese man who had vascular graft infection caused by H. parainfluenzae 4 years after surgery for chronic aortic dissection.

Degos disease complicated by constrictive pericarditis in remote phase: a case report.

BACKGROUND: Degos disease, also known as malignant atrophic papulosis, is characterised by cutaneous manifestations due to chronic thrombo-obliterative vasculopathy. There have been reports of the rare late-onset Degos disease complicated by constrictive pericarditis (CP). This study reports a case of CP caused by Degos disease that developed 20 years after diagnosis. CASE PRESENTATION: A 62-year-old woman who had been taking aspirin for 20 years for Degos disease was hospitalised for worsening of heart failure. The patient was diagnosed with CP and underwent pericardiectomy. Pathological findings suggested the involvement of Degos disease. The postoperative course was uneventful, and her heart failure and Degos disease did not worsen. CONCLUSIONS: The study findings suggests that Degos disease can cause long-term CP. Aspirin effectively inhibited the progression of Degos disease, and surgical treatment was necessary when heart failure due to CP was refractory to treatment.

Severe Heart Failure in a Young Cocaine User.

A 27-year-old Caucasian male traveler with well-controlled asthma was admitted to our hospital because of severe heart failure (HF). He had a history of cocaine use. Transthoracic echocardiography (TTE) showed severe diffuse hypokinesis of the left ventricle (LV) and a large mobile thrombus in the LV. He was treated with diuretics, inotropes and anticoagulants which led to small improvements in the HF and LV thrombus, however, he needed to undergo left ventricular assist device (LVAD) implantation and surgical removal of a residual LV thrombus due to inotrope-dependency.It is necessary to consider the possibility of cocaine or illicit drug use in a young individual with cardiovascular disease or sudden death even in Japan where cocaine and drugs are prohibited by law, as recreational drug use has been increasing in many countries around the world.

Prosthetic valve endocarditis presenting with back pain alone: A case report.

We report a case of a 64-year-old woman with a past medical history (PMH) of prosthetic valve replacement 7 months prior to admission, who presented with only right back pain. Physical examination revealed one conjunctival spot hemorrhage and a mild systolic murmur. Blood cultures were positive for methicillin-resistant Staphylococcus epidermidis. Trans-esophageal echocardiography revealed aortic valve vegetations; hence, a diagnosis of prosthetic valve endocarditis (PVE) was made. Clinical presentation of infective endocarditis varies and sometimes mimics that of polymyalgia rheumatica. The patient was diagnosed as PVE considering the whole clinical picture including the patient's PMH, physical examination, and blood cultures.

Endovascular Therapy for Chronic Type B Aortic Dissection.

Objectives: Endovascular repair of the thoracic aorta (TEVAR) represents a therapeutic option for type B aortic dissection. However, the optimal timing for TEVAR is controversial. We examined the outcomes of TEVAR for chronic type B dissection and reviewed aortic morphology using pre- and postoperative CT scan images. Methods: Between 2012 and 2017, 12 patients underwent TEVAR for chronic type B dissection at our institution. We retrospectively reviewed the clinical and operative data including CT scan images, comparing the values between early group (5 cases, 3 months to 1 year from initial dissection) and late group (7 cases, more than 1 year from initial dissection). Results: There were no paraplegia, stroke, and death in our cohort. There was no difference in degree of the aortic remodeling between two groups. Conclusions: Outcomes after TEVAR for chronic type B aortic dissection were favorable. Aortic remodeling could be obtained in selected patients by closing an entry with TEVAR procedure. (This is a translation of Jpn J Vasc Surg 2018; 27: 281-287.).

Novel surgical strategy for complicated pulmonary stenosis using haemodynamic analysis based on a virtual operation with numerical flow analysis.

OBJECTIVES: A novel surgical strategy using haemodynamic analyses based on virtual operations with computational simulations has been introduced for complicated pulmonary stenosis. We evaluated the efficacy of this strategy. METHODS: Six patients were enrolled. Before surgery, the optimal pulmonary arteries were constructed based on computational fluid dynamics using 3-dimensional computed tomography. Energy loss (EL, mW) and wall shear stress (WSS, Pa) were calculated. We compared the shapes of preoperative and optimal pulmonary arteries to determine the surgical strategy, including the incision line and the shape of the patch (virtual surgery). EL and WSS were compared between virtual and actual surgeries using flow analysis. RESULTS: In both the virtual and actual surgeries, postoperative EL tended to be lower than the preoperative EL, although there were no significant differences (P = 0.12 and P = 0.17, respectively). The mean WSS in the virtual surgery was significantly reduced from 112 ± 130 Pa to 25 ± 24 Pa (P = 0.028). After the actual surgery, the mean WSS was also significantly reduced to 30 ± 23 Pa (P = 0.047). There were no significant differences in the values for EL and WSS before and after surgery or between virtual and actual surgery (P = 0.94 and P = 0.85, respectively). CONCLUSIONS: Pulmonary artery plasty, using computational fluid dynamics based on virtual surgery, is an efficient surgical strategy. This novel strategy can easily and successfully provide an optimal pulmonary artery plasty equivalent to that using the conventional approach, which is based on the surgeon's personal experience and judgement.

Markers of peripheral perfusion during high-flow regional cerebral perfusion for aortic arch repair.

OBJECTIVES: High-flow regional cerebral perfusion (HFRCP) provides cerebral and somatic oxygen delivery through collateral vessels during aortic arch repair in small children; however, optimal flow conditions during HFRCP have not been established. We sought to identify markers of peripheral perfusion during HFRCP. METHODS: Between 2009 and 2016, in total 20 consecutive pediatric patients undergoing aortic arch repair with HFRCP were enrolled in this prospective, observational study. Median age was 20 days (range, 6-116 days); median body weight was 2.77 kg (range, 1.8-4.98 kg). Oxygen delivery ratio (Do2R) was calculated as the oxygen delivery during HFRCP divided by the oxygen delivery before HFRCP. Regional oxygen saturations on the forehead and on the thigh (rSo2T) were monitored during HFRCP, and postoperative creatinine kinase and lactate concentrations were measured as postoperative outcomes. Multivariate analyses were performed to clarify the effectiveness of Do2R and rSo2T as markers of peripheral perfusion during HFRCP. RESULTS: No deaths or neurologic impairments occurred. Multivariate analysis showed that the lowest rSo2T (P = .005) and cardiopulmonary bypass time (P = .012) predicted postoperative creatinine kinase concentration. Do2R was the only factor to predict postoperative lactate concentration (P < .001). Receiver operating characteristic analysis showed that Do2R less than 0.66 predicted risk of high postoperative lactate concentration (>5.0 mmol/L), with area under the curve of 0.95. CONCLUSIONS: For aortic arch repair in small children, rSo2T and Do2R during HFRCP are useful markers for predicting peripheral perfusion. Maintaining higher Do2R during HFRCP minimizes postoperative increases in lactate and creatinine kinase concentrations.

Early Extubation in the Operating Room after Congenital Open-Heart Surgery.

Early extubation in the operating room after congenital open-heart surgery is feasible, but extubation in the intensive care unit after the operation remains common practice at many institutions. The purpose of this study was to evaluate retrospectively the adequacy of our early-extubation strategy and exclusion criteria through analysis based on the Risk Adjustment in Congenital Heart Surgery method (RACHS-1).This retrospective analysis included 359 cases requiring cardiopulmonary bypass (male, 195; female, 164; weight > 3.0 kg; aged 1 month to 18 years). Neonates and preoperatively intubated patients were excluded. Other exclusion criteria included severe preoperative pulmonary hypertension, high-dose catecholamine requirement after cardiopulmonary bypass, delayed sternal closure, laryngomalacia, serious bleeding, and delayed awakening. The early-extubation rates were compared between age groups and RACHS-1 classes.Overall, 83% of cases (298/359) were extubated in the operating room, classified by RACHS-1 categories as follows: 1, 59/59 (100%); 2, 164/200 (84%); 3, 61/78 (78%); and 4-6, 10/22 (45%). The early extubation rate in categories 1-3 (86%, 288/337) was significantly higher than for categories 4-6 (45.5%, 10/22) (P < 0.001). Because they met one of the exclusion criteria, 61 patients (17%) were not extubated in the operating room. Eight patients (2.7%) required re-intubation after early extubation in the operating room, and longer operation time was significantly associated with re-intubation (P < 0.001).Extubation in the operating room after congenital open-heart surgery was feasible based on our criteria, especially for patients in the low RACHS-1 categories, and involves a very low rate of re-intubation.

Surgical strategy for aortic arch reconstruction after the Norwood procedure based on numerical flow analysis.

OBJECTIVES: Inefficient aortic flow after the Norwood procedure is known to lead to the deterioration of ventricular function due to an increased cardiac workload. To prevent the progression of aortic arch obstruction, arch reconstruction concomitant with second-stage surgery is recommended. The aim of this study was to determine the indications for reconstruction based on numerical simulation and to reveal the morphology that affects the haemodynamic parameters. METHODS: Fifteen patients who underwent the Norwood procedure or arch repair and Damus-Kaye-Stansel anastomosis were enrolled. The pressure gradient in aortic arch was 1.6 ± 3.9 mmHg (ranged from 0 to 12 mmHg) on catheter examination. Six patients who had prominent turbulent flow accompanied with a large flow energy loss index greater than 40 mW/m2 and high wall shear stress greater than 100 Pa underwent arch reconstruction. RESULTS: After arch reconstruction, the energy loss index significantly decreased from 88.5 ± 50.0 mW/m2 to 23.1 ± 10.4 mW/m2 (P = 0.026) and wall shear stress significantly decreased from 194.5 ± 87.4 Pa to 60.3 ± 40.5 Pa (P = 0.0062). There were 3 late deaths due to heart failure caused by progressive atrioventricular valve regurgitation during the follow-up period (60 months). The systemic ventricular function was preserved in the remaining patients without any pressure gradients in the arch. CONCLUSIONS: Determining the surgical strategy for arch reconstruction based on numerical flow analysis may effectively reduce the ventricular load even if no stenosis or pressure gradients are observed on catheter examination or echocardiography.

Direct True Lumen Cannulation ("Samurai" Cannulation) for Acute Stanford Type A Aortic Dissection.

In operations for acute Stanford type A aortic dissection, several cannulation options are available for cardiopulmonary bypass arterial perfusion. These are femoral, axillary, Seldinger ascending aortic, transapical, and transatrial, each of which has advantages and drawbacks. We describe our surgical technique of direct true lumen cannulation ("Samurai" cannulation), which represents an easy, safe, and practical option in operations for acute type A aortic dissection.

Transareolar Video-Assisted Approach to the Atrial Septal Defect and Tricuspid Valve.

Minimally invasive atrial septal defect closure and tricuspid annuloplasty in female patients are normally performed through a right submammary anterior minithoracotomy approach. However, when the aortic root is located higher, the direction of aortic cannulation becomes not ideal through the submammary incision. In such cases, transareolar approach is useful. Through this approach, aortic cannulation and tricuspid operation can be performed with endoscopic assistance, and ASD closure can be performed under direct vision.

Outcomes of patients who declined surgery for acute Stanford type A aortic dissection with patent false lumen of the ascending aorta.

OBJECTIVES: This study aimed to evaluate the outcomes of patients who did not undergo initial aortic surgery for acute Stanford type A aortic dissection with a patent false lumen of the ascending aorta. METHODS: Inpatient and outpatient records were retrospectively reviewed. RESULTS: We identified 195 patients with acute type A aortic dissection with a patent ascending false lumen between January 1998 and March 2016. Of these, 137 underwent aortic surgery, 16 died before surgery and 42 declined aortic surgery. The ages of the patients who underwent and those who declined aortic surgery were 60.0 ± 10.6 years and 72.3 ± 12.4 years, respectively. The mortality rate of those who underwent and those who declined aortic surgery was 15 and 62% at 30 days and 19% and 67 at 90 days, respectively ( P < 0.0001). In the 58 patients who did not undergo initial aortic surgery, the maximum aortic diameter was correlated with survival ( P = 0.0037). At follow-up (3.7 ± 4.5 years; range 0-16.4 years), survival at 1, 5 and 10 years in those who underwent and those who declined initial aortic surgery was 78, 68 and 49%, and 29, 24 and 12%, respectively ( P < 0.0001). CONCLUSIONS: In this study of patients with acute Stanford type A aortic dissection with a patent false lumen of the ascending aorta, the mortality of those who declined initial aortic surgery was 62% at 30 days and 67% at 90 days, respectively, and a smaller aortic diameter was significantly associated with better survival.

Energy dynamics of the intraventricular vortex after mitral valve surgery.

Mitral valve morphology after mitral valve surgery affects postoperative intraventricular flow patterns and long-term cardiac performance. We visualized ventricular flow by echocardiography vector flow mapping (VFM) to reveal the impact of different mitral valve procedures. Eleven cases of mechanical mitral valve replacement (nine in the anti-anatomical and two in the anatomical position), three bioprosthetic mitral valve replacements, and four mitral valve repairs were evaluated. The mean age at the procedure was 57.4 ± 17.8 year, and the echocardiography VFM in the apical long-axis view was performed 119.9 ± 126.7 months later. Flow energy loss (EL), kinetic pressure (KP), and the flow energy efficiency ratio (EL/KP) were measured. The cases with MVR in the anatomical position and with valve repair had normal vortex directionality ("Clockwise"; N = 6), whereas those with MVR in the anti-anatomical position and with a bioprosthetic mitral valve had the vortex in the opposite direction ("Counterclockwise"; N = 12). During diastole, vortex direction had no effect on EL ("Clockwise": 0.080 ± 0.025 W/m; "Counterclockwise": 0.083 ± 0.048 W/m; P = 0.31) or KP ("Clockwise": 0.117 ± 0.021 N; "Counterclockwise": 0.099 ± 0.057 N; P = 0.023). However, during systole, the EL/KP ratio was significantly higher in the "Counterclockwise" vortex than that in the "Clockwise" vortex (1.056 ± 0.463 vs. 0.617 ± 0.158; P = 0.009). MVP and MVR with a mechanical valve in the anatomical position preserve the physiological vortex, whereas MVR with a mechanical valve in the anti-anatomical position and a bioprosthetic mitral valve generate inefficient vortex flow patterns, resulting in a potential increase in excessive cardiac workload.

Epicardial Implantable Cardioverter-Defibrillator in a 2-Month-Old Infant.

We describe the implantation of an implantable cardioverter defibrillator (ICD) in a 2-month-old infant with frequent sustained ventricular tachycardia (VT) refractory to antiarrhythmic agents. An epicardial ICD shock coil lead and pacing leads were placed, as was a cumbersome device console that was stored in a pocket between the left external and internal oblique muscles. These methods were safe and feasible even for such a small infant, and possible adverse events were avoided.

Factors associated with a low initial cerebral oxygen saturation value in patients undergoing cardiac surgery.

Regional cerebral oximetry using near-infrared spectroscopy device, an INVOS 5100 C (Medtronic, Minneapolis, MN, USA), during cardiac surgery aims to avoid perioperative neurological impairment, especially during cardiopulmonary bypass. However, it is not uncommon to encounter critically low initial cerebral regional oxygen saturation or a low value unresponsive to intervention. Therefore, it is important to identify factors associated with low saturation value other than true cerebral hypoxia. We investigated the relationship between preoperative regional cerebral oxygen saturation and clinical variables during cardiac surgery. From January 2013 to May 2016, 462 patients underwent elective cardiac surgery. Patient's ≤12 years of age, with acute cerebral infarction, with previous intracranial hemorrhage or neurosurgery, with concomitant aortic surgery, and having off-pump coronary artery bypass surgery were excluded. The remaining 223 patients were monitored by intraoperative regional cerebral oximetry. Univariate analysis found that scalp-cortex distance, cerebrospinal fluid thickness, left ventricular ejection fraction, hemoglobin concentration, estimated glomerular filtration rate, and hemodialysis were significantly correlated with the initial regional oxygen saturation value. Multiple regression analysis revealed that scalp-cortex distance, left ventricular ejection fraction, hemoglobin, and hemodialysis remained as significant variables. A receiver operating characteristic analysis found that for a low initial regional oxygen saturation value of 40%, the thresholds of scalp-cortex distance, left ventricular ejection fraction, and hemoglobin concentration were 17.6 mm, 45.2%, and 7.5 g/dl, respectively. In conclusion, brain atrophy, poor left ventricular function, anemia, and hemodialysis were associated with low initial cerebral regional oxygen saturation values in adult cardiac surgery patients.

Synchronization of the Flow and Pressure Waves Obtained With Non-Simultaneous Multipoint Measurements.

The use of measured data as boundary conditions renders hemodynamic simulations more patient-specific. However, synchronized acquisition of data at multiple locations is often difficult in clinical practice. This study proposes a method for resynchronizing measured data for use as boundary conditions for flow simulations using frequency analyses, and discusses the optimal cut-off frequency for differentiating cardiac and respiratory variation in hemodynamic data during resynchronization. To demonstrate the utility of the method, a Fontan circulation, which is the final palliative result with single-ventricle physiology, was used. The results suggest that it is optimal to set a cut-off frequency that gives a local minimum in the power spectrum that is slightly lower than the peak frequency of the heartbeat. Additionally, the total energy loss depended on the cut-off frequency, although the overall flow patterns appeared to be similar. The method is applicable to cardiovascular systems other than the Fontan circulation, where hemodynamic data with multifactorial fluctuations are required at various locations but simultaneous measurements are not possible.

Two-stage operation for Stanford type A acute aortic dissection originating from Kommerell's diverticulum.

We report a rare case of Stanford type A acute aortic dissection involving an aberrant right subclavian artery and originating from Kommerell's diverticulum in a 52-year old man. Initially, as an emergency measure, total arch replacement and right axillary artery reconstruction were performed. However, due to the subsequent enlargement of the false lumen, thoracic endovascular aortic repair and right subclavian artery coiling were performed successfully 5 months after the first operation. Herein, we describe surgical management approaches for the treatment of a Stanford type A acute aortic dissection with aberrant right subclavian artery.