Repair of a right coronary artery rupture with perforated right ventricle following spontaneous pseudoaneurysm: a case report.

BACKGROUND: Following the rupture of a coronary artery, a patient's condition usually deteriorates rapidly due to cardiac tamponade. A pseudoaneurysm due to a coronary artery rupture is rare; however, when a spontaneous coronary artery pseudoaneurysm occurs without tamponade, it creates a fistula in the right ventricle, often requiring surgical repair. CASE PRESENTATION: This report describes the case of a 68-year-old man who presented with chest discomfort after a 12-day course of antibiotic treatment for bacteremia. Following coronary angiography, echocardiography, and enhanced computed tomography, he was diagnosed with a right coronary artery pseudoaneurysm accompanied with perforation of the right ventricle. Severe adhesions were observed during emergency surgery surrounding the entire heart. The patient presented with risk factors for coronary artery disease, including hypertension and smoking history. His coronary artery was severely calcified due to end-stage renal failure requiring dialysis; thus, a covered stent could not fit inside the arterial lumen. Consequently, coronary artery bypass grafting to the right coronary artery and right ventricle repair were performed. Unfortunately, the patient died postoperatively due to sepsis from intestinal translocation. This rare development was hypothesized to be an incidental result of the combination of severe post-inflammatory adhesions, extensive coronary artery calcification, and rupture of the calcification crevices. CONCLUSIONS: In the case of a severe post-inflammatory response, shock without cardiac tamponade may require further scrutiny by assuming the possibility of inward rupture. For patients in poor condition, two-stage surgical treatment might be considered after stabilization with a covered stent.

Relationship between false lumen morphology and entry tear in acute type A aortic dissection.

OBJECTIVES: This study aimed to investigate the relationship between false lumen morphology and the size, aortic segment and position of the entry tear for acute type A aortic dissection. METHODS: The records of patients who underwent emergency operation for acute type A aortic dissection in our institution between April 2011 and May 2022 were examined. Data regarding size, location and position of the entry tear and preoperative computed tomography findings were reviewed. The relationship of these variables with false lumen morphology was examined and retrospectively compared according to tear size. RESULTS: Of 243 cases, characteristics of the entry tear, visualized during surgery, were confirmed in 134 cases (age = 70.9 ± 12.6 years, male = 45.5%). Tear sizes at different aortic segments were not significantly different (P = 0.376). Tears posterior to the lesser curvature were significantly smaller than those anterior to the greater curvature (P = 0.004). A thrombosed false lumen was associated with a significantly smaller tear size and position on the posterior to the lesser curvature side in aortic cross-section (all P < 0.001). Multivariate analysis showed that tear size, the presence of re-entry and tear position anterior to the greater curvature were independent predictors of a patent false lumen. CONCLUSIONS: In acute type A aortic dissection, larger tear size, the presence of re-entry and tear position anterior to the greater curvature are risk factors for a patent false lumen. Although the results of this study are valid only for patients in whom intimal tears were detected during aortic surgery, this trend may provide information for pathophysiology of the disease.

Benefits and Risks of Delayed Surgery for Ventricular Septal Rupture after Acute Myocardial Infarction.

The timing of surgery for ventricular septal rupture (VSR) after acute myocardial infarction (AMI) remains controversial. This study investigated the benefits and risks of delayed surgery for post-AMI VSR and examined differences in echocardiographic findings between early and delay groups.A total of 38 consecutive patients with post-AMI VSR who underwent surgery at our hospital between May 2003 and November 2020 were retrospectively analyzed. Our strategy was to delay surgery until 2 weeks after AMI. If patients demonstrated organ dysfunction, we considered early surgery. Patients were divided into early (n = 20; 53%) and delay (n = 18; 47%) groups. Risks and benefits were investigated based on echocardiographic findings during the waiting period. The delay group had more preoperative intravenous catheter infections (P = 0.008) but fewer reoperations (P = 0.02) and lower operative mortality (P = 0.04) than the early group. The VSR defect diameter and total pulmonary blood flow to total systemic blood flow (Qp/Qs) increased in both groups while waiting. Nevertheless, the early group had a significantly higher Qp/Qs change rate than the delay group (P = 0.05). The 30 day and hospital mortality rates were 5.3% and 13.2%, respectively.The VSR defect diameter and Qp/Qs in both groups increased with time and can therefore become risk factors. Nonetheless, the benefit of waiting exceeded the risk because our outcomes were better than those previously reported.

Risk Factors for Sternal Wound Infection after Coronary Artery Bypass Grafting in Patients with and without Diabetes.

Diabetes mellitus (DM) is a well-known risk factor for sternal wound infections (SWIs). However, SWIs are also known to occur in patients without DM. This study aimed to examine the difference in risk factors for SWIs after coronary artery bypass grafting (CABG) between non-diabetic and diabetic patients.We conducted a retrospective observational study including 6,697 patients who underwent CABG at our hospital from 2015-2018. The patients were assigned to the non-diabetic (group N, n = 2,930) or diabetic (group D, n = 3,767) group. A total of 24 potential risk factors were evaluated using univariate and multivariate analyses. Differences between superficial and deep SWIs were also examined.A total of 209 (3.1%) CABG patients, comprising 47 (22.5%) and 162 (77.5%) in groups N and D, respectively, required surgical treatment for SWIs. Univariate analyses indicated that a body mass index (BMI) > 25 kg/m2 was uniquely associated with superficial SWIs in group N. Moreover, married status may have lowered the risk of deep SWIs in group D. Renal failure, intra-aortic balloon pump (IABP) use, and reopening in group N, as well as female sex, emergency admission, and reopening in group D, were independent predictors of SWI in the multivariate analysis.In this study, reopening was a common risk factor associated with SWIs in patients who underwent CABG with and without DM. Female sex and emergency admission were independent predictors of deep SWIs in patients with DM, whereas renal failure and IABP use were independent predictors of deep SWIs in patients without DM.

Intensity Interference in a Coherent Spin-Polarized Electron Beam.

We investigate the intensity interference between pairs of electrons using a spin-polarized electron beam having a high polarization and a narrow energy width. We observe spin-dependent antibunching on the basis of coincident counts of electron pairs performed with a spin-polarized transmission electron microscope, which could control the spin-polarization without any changes in the electron optics. The experimental results show that the time correlation was only affected by the spin polarization, demonstrating that the antibunching is associated with fermionic statistics. The coherent spin-polarized electron beam facilitates the extraction of intrinsic quantum interference.

Secondary Aortoesophageal Fistula Treated by Covered Esophageal Stent and Muscle Wrapping.

Secondary aortoesophageal fistula is rare but is associated with serious complications and high mortality. We devised a treatment strategy involving a covered esophageal stent, instead of esophageal resection, and placing the latissimus dorsi muscle around the infected aorta without removing the aorta and the stent graft. A 72-year-old man with a history of total arch replacement with a frozen elephant trunk for a thoracic dissecting aneurysm developed aortoesophageal fistula and underwent surgical treatment using our strategy. He recovered well, with no evidence of reinfection 6 months after surgery. This strategy may be a less invasive surgical option.

Surgical Treatment for Primary Mycotic Aneurysms Using Endovascular Therapy, Focusing on Patient Selection: Single-Center Experience.

Background: Mycotic aneurysms (MAs) are relatively rare but life-threatening. Some recent reports have described the use of endovascular therapy for their treatment; however, this still is a controversial treatment, and a definite target population has not been determined. Methods: We performed surgery on 34 patients with MAs from March 2005 to March 2019. Twenty patients who underwent open surgery (OS) first comprised the OS group, and 14 patients who underwent endovascular therapy first comprised the stent-graft (SG) group. We analyzed between-group differences, long-term outcomes, and risk factors for death retrospectively. Patients in the OS group had a higher initial white blood cell count than those in the SG group (p = 0.047). The SG group had more patients with a low albumin concentration (≤2.0 mg/dL) than did the OS group (p = 0.026). Results: There were no significant differences in the operative mortality rates between the groups (p = 0.773). Additional procedures were required more often in the SG than the OS group (p = 0.0013). The overall survival rate as estimated by the Kaplan-Meier method was 88% at 1 month, 67% at 1 year, 57% at 3 years, and 45% at 10 years. In the univariable analysis, chronic obstructive pulmonary disease (COPD) was a risk factor for death (p = 0.003). Conclusions: Endovascular therapy for MAs produced reasonable outcomes when patient selection was based on the activity level, nutritional condition, and degree of inflammation. Endovascular therapy may become an option for patients with a low albumin concentration or COPD despite the fact that additional procedures may be needed.

Ruptured sinus of Valsalva aneurysm with ventricular septal defect complicated by preoperative cardiogenic shock, cardiac arrest, and multiple organ dysfunction: a rare survivor and review of contemporary literature.

Sinus of Valsalva aneurysm (SVA) is a relatively rare cardiac condition, in which the patient is usually asymptomatic. However, once this aneurysm ruptures, patients present with acute symptoms of heart failure. Timely surgical intervention is essential. We present the case of a 27-year-old woman, who had a ruptured SVA with a ventricular septal defect (VSD). The patient collapsed before the emergency operation and needed cardiopulmonary resuscitation. The patient required preoperative high inotoropic support and postoperative management was difficult because of multiple organ dysfunction. However, the patient recovered after using inhaled nitric oxide and veno-venous hemofiltration and tracheostomy, and was discharged with no further complications. To the best of our knowledge, no such case of a ruptured SVA with VSD, complicated by preoperative cardiac arrest and multiple organ dysfunction that culminated in a successful recovery, has been reported to date.

Influence of Luminal Communication on Aortic Enlargement after Hemiarch Replacement for Acute Type A Aortic Dissection.

BACKGROUND: Aortic enlargement after hemiarch replacement (HAR) for acute type A aortic dissection (AAAD) is a serious problem. We reviewed our experience and analyzed the risk factors for aortic enlargement. METHODS: During April 2005 to December 2017, 364 patients underwent HAR for AAAD. Seventy-three patients fulfilled the inclusion criteria. We analyzed the change in aortic diameter, aortic growth rate, and major adverse aortic events (MAAEs) and their association with luminal communication of the aortic arch. RESULTS: Anastomotic communication, supra-aortic communication (SAC), and distal aortic communication were found in 34 (46.6%), 28 (38.4%), and 20 (27.4%) patients, respectively. The aortic growth rate was high because of the presence of SAC, distal aortic communication, and the number of coexisting aortic communication. Univariate analysis showed that the presence of SAC and an initial aortic diameter > 35 mm at 20 mm distal to the left subclavian artery and at the pulmonary artery bifurcation (PAB) were risk factors for MAAEs. Multivariate analysis showed that SAC and an initial aortic diameter > 35 mm at the PAB were independent risk factors for MAAEs. CONCLUSION: SAC, distal aortic communication, and the number of coexisting aortic communication are significant risk factors for aortic enlargement after HAR for AAAD. SAC and an initial aortic diameter > 35 mm at the PAB are independent risk factors for MAAEs after this procedure.

Successful Surgical Treatment of an Infected Thoracoabdominal Aneurysm Accompanied with Leriche Syndrome.

A 56-year-old man presenting with massive melena and loss of consciousness was diagnosed with an infected thoracoabdominal aneurysm, an aortoduodenal fistula, and Leriche syndrome following an evaluation by computed tomography. Emergency surgery for uncontrolled infection included the reconstruction of the superior mesenteric and bilateral renal arteries using a four-branched graft. The aortoduodenal fistula was resected after omental filling, and an enterostomy was performed for feeding. Intestinal reconstruction was performed in two stages. The patient was discharged on postoperative day 48 and was without evidence of recurrence at 23 months postoperatively.

Distal Neo-Neck Formation for Chronic Type B Dissection: False Lumen Closure After TEVAR.

OBJECTIVES:: Patients with chronic aortic dissection often require repeat interventions due to enlargement of the pressurized false lumen or disseminated intravascular coagulation even after additional thoracic endovascular aortic repair (TEVAR) to occlude the entry tear. Residual false lumen flow can persist even after performing the candy-plug technique or branched stent-graft placement in some cases. We have devised a new method for false lumen closure. METHODS:: From December 2010 to May 2017, 5 patients (mean age: 57 [13] years, range: 43-77 years) with chronic dissection at the aortic arch and descending aorta, who underwent initial TEVAR, required additional treatment. Using an open surgical approach, the endograft was fixed with an outer felt under cardiopulmonary bypass after the endograft with stent was expanded by fenestration. The false lumen was closed using this procedure, and the aortotomy was repaired by direct closure in 2 cases and by graft replacement in 3 cases. RESULTS:: No major operative complications occurred, such as respiratory failure or paraplegia. Postoperative enhanced computed tomography (CT) images showed that the false lumen flow disappeared in all cases. All patients were discharged under normal conditions. They were all followed up and their CT did not indicate any complications for a mean of 33.6 (20.3) months. CONCLUSIONS:: Our combined procedure was effective and provided a higher success rate compared with endovascular therapy alone. This staged treatment approach, using a combination of TEVAR and false lumen closure, is less invasive compared with open surgery alone and may represent a valid treatment option for chronic type B dissection.

Graft-Sparing Strategy for Thoracic Prosthetic Graft Infection.

OBJECTIVE: Thoracic prosthetic graft infection is a rare but serious complication with no standard management. We reported our surgical experience on graft-sparing strategy for thoracic prosthetic graft infection. METHODS: This study included patients who underwent graft-sparing surgery for thoracic prosthetic graft infection at Matsubara Tokushukai Hospital in Japan from January 2000 to October 2017. RESULTS: There were 17 patients included in the analyses, with a mean age at surgery of 71.0 ± 10.5 years; 11 were men. In-hospital mortality was observed in five patients (29.4%). CONCLUSIONS: Graft-sparing surgery for thoracic prosthetic graft infection is an alternative option particularly for early graft infection after hemiarch replacement.

Resternotomy Plus Left Thoracotomy Surgery after Previous Acute Type A Aortic Dissection Repair.

BACKGROUND: As the results of acute type A aortic dissection repair have improved, late reoperation for residual dissection has become increasingly important. We report our experience of graft replacement via extended approaches after a previous acute type A aortic dissection repair. METHODS: From April 2003 to September 2016, 17 patients underwent reoperation via extended (repeat median sternotomy plus left thoracotomy) approaches after a previous repair of an acute type A aortic dissection at the Matsubara Tokushukai Hospital in Japan and were included in the analyses (males, 16; mean age at surgery, 60.0 ± 9.3 years). RESULTS: The postoperative stroke and in-hospital mortality rates were 0 and 5.9%, respectively. CONCLUSION: Extended approach after a previous acute type A aortic dissection repair showed acceptable outcomes.

Strategy of delayed surgery for ventricular septal perforation after acute myocardial infarction.

BACKGROUND: The timing of surgical repair for ventricular septal perforation (VSP) is important because patients are susceptible to bleeding from fragile myocardial tissue or residual shunt during the acute phase of acute myocardial infarction (AMI). This study aimed to assess the results of delayed surgery for VSP performed 2 weeks after AMI. METHODS: In total, 24 consecutive postinfarction patients with VSP (mean age: 72.6±10.4 years; 13 males) underwent operation between May 2003 and June 2016. We postponed surgery during the acute phase and performed an elective surgery if the patient could wait for 2 weeks with support from intra-aortic balloon pumping (IABP) and respiratory management. If we could not control heart failure and organ function worsened during that period, we performed emergency surgery. Postoperative outcomes included complications, 30-day mortality rate, long-term hospital death, reoperation rate, and risk factors for hospital mortality. We examined whether organ function was maintained by delaying the surgery. RESULTS: Of the 24 patients, 11 (45.8%) required emergency surgery, and 13 (54.2%) could wait 2 weeks for surgery. The average time from AMI onset to diagnosis of VSP was 4.5±1.6 days, and the average time from VSP diagnosis to surgery was 9.0±6.0 days; 5 patients (20.8%) required resurgery for VSP due to residual shunt, recurrent VSP, or pseudoaneurysm of the left ventricle. The 30-day mortality rate was 4.2% (1 patient), and long-term hospital mortality rate was 12.5% (3 patients). Organ function was maintained in 10 patients (76.9%) who underwent elective surgery, and organ dysfunction was not advanced by delaying the surgery. CONCLUSIONS: We could delay surgery for an average of 9 days from VSP onset by means of IABP or respiratory management without the deterioration of organ function. The 30-day mortality and long-term outcome were favorable.

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.

Mitral and tricuspid valve surgery for Coffin-Lowry syndrome.

Coffin-Lowry syndrome is a rare X-linked disorder characterized by craniofacial and skeletal abnormalities, mental retardation, short stature, and hypotonia. An 18-year-old man with morphologic features characteristic of Coffin-Lowry syndrome was referred to our institution for valve disease surgery for worsening cardiac failure. Echocardiography showed severe mitral valve regurgitation associated with tricuspid valve regurgitation. Mitral valve implantation with a biological valve and tricuspid annular plication with a ring was performed. The ascending aorta was hypoplastic. Both the mitral papillary muscle originating near the mitral annulus and the chordae were shortened. The patient's postoperative course was uneventful and his cardiac failure improved.

Congenital pericardial defect with ruptured acute type A aortic dissection.

We report 2 cases of congenital pericardial defect with ruptured acute type A aortic dissection. Case 1: An 83-year old man presented with sudden chest and back pain, and computed tomography (CT) showed acute aortic dissection with left pleural massive effusion. Because of his unstable haemodynamic condition with low blood pressure, an emergency operation was performed. We observed small amounts of bloody pericardial effusion, massive left-sided bloody pleural effusion and a partial left-sided pericardial defect of the pulmonary artery. The ascending aorta was replaced. The postoperative course was uneventful. Case 2: A 79-year old man presented with fainting followed by cardiac arrest and was resuscitated. Chest CT showed acute aortic dissection and massive haemothorax. Emergency operation was attempted, but was given up. We observed partial left-sided pericardial defect of the pulmonary artery. Further, we reviewed 6 cases of congenital pericardial defect with ruptured acute aortic dissection, including our 2 cases. In all the cases, the patients did not develop cardiac tamponade but had massive haemothorax due to congenital pericardial defects leading to confusion in diagnoses and surgical strategies. Therefore, it may be necessary to consider congenital pericardial defects before performing an operation in case of acute type A aortic dissection with massive haemothorax.