Recurrent left ventricular thrombus due to essential thrombocythemia complicated by COVID-19.

Essential thrombocythemia is a risk factor for thrombosis and hemorrhage. During the perioperative period of cardiac surgery, the risk of thrombosis and hemorrhage increases. Coronavirus disease 2019 (COVID-19) is also associated with thrombosis. We present the case of a 69-year-old man with essential thrombocythemia complicated by COVID-19 who developed a left ventricular thrombus. We performed thrombectomy, but the patient developed recurrent left ventricular thrombus 8 days after surgery. Emergency redo thrombectomy was performed followed by aggressive blood-thinning therapy. The postoperative course was complicated by cardiac tamponade requiring surgical drainage 8 days after the second surgery. The patient was discharged home 25 days after the second operation without any complications. Learning objective: Left ventricular thrombus is a rare but fatal complication associated with essential thrombocythemia. COVID-19 has also been reported to cause coagulopathy. This case suggested that after surgery for left ventricular thrombus complicated by multiple risk factors including essential thrombocythemia and COVID-19, aggressive blood-thinning therapy with combination of anticoagulation, antiplatelet, and metabolic antagonist may help prevent recurrent thrombosis.

Watch-and-wait strategy for selected patients with type A intramural hematoma.

OBJECTIVE: This single-center retrospective study evaluated early and midterm outcomes of 100 consecutive patients with type A intramural hematoma. METHODS: Initial watch-and-wait strategy was indicated if the maximum aortic diameter was < 50 mm, pain score was < 3/10 on the numerical rating scale, and no ulcer-like projection was observed in the ascending aorta. The primary endpoints of this study were all-cause and aorta-related deaths, and the secondary endpoint was aortic events. RESULTS: Initial watch-and-wait strategy was indicated in 52 patients. Emergency aortic repair was indicated in the remaining 48 patients; 2, 31, and 15 patients died before surgery, underwent emergency surgery, and declined emergency surgery, respectively. Among the watch-and-wait group, 11 (21%) patients underwent aortic repair during hospitalization. In-hospital mortality rates, 5-year survival rates, and 5-year freedom from aorta-related death were not significantly different between the initial watch-and-wait strategy and emergency surgery (2% vs. 6%, 92% vs. 82%, and 100% vs. 94%, respectively). In the initial watch-and-wait strategy group, 5-year freedom from aortic events and freedom from aortic events involving the ascending aorta were 60% and 66%, respectively. CONCLUSIONS: The early and midterm outcomes with the initial watch-and-wait strategy in patients with type A intramural hematoma with a maximum aortic diameter of ≤ 50 mm, pain score of ≤ 3/10, and no ulcer-like projection in the ascending aorta were favorable with no aorta-related death.

Gluteal Blood Flow Monitoring in Endovascular Aneurysm Repair With Internal Iliac Artery Embolization.

BACKGROUND: When an internal iliac artery (IIA) has to be embolized during endovascular aneurysm repair (EVAR), buttock claudication sometimes poses problems. However, there is no established method to evaluate intraoperative blood flow to the gluteal muscles.Methods and Results:Gluteal regional oxygen saturation (rSO2) was monitored using near-infrared spectroscopy (NIRS) during surgery, and changes in rSO2were compared with treatment results. Twenty-seven patients who underwent EVAR and IIA embolization at our institution between April 2019 and May 2020 were included in this study. The association between intraoperative changes in rSO2and postoperative incidence of buttock claudication was analyzed. Furthermore, the presence or absence of communication between the superior and inferior gluteal arteries and the intraoperative changes in rSO2were compared to ascertain whether rSO2reflects blood flow change. Postoperative buttock claudication occurred in 4 of 19 patients (21%) with unilateral occlusion of IIA and in 4 of 8 patients (50%) with bilateral occlusion of IIAs. rSO2was found to decrease significantly further in patients with buttock claudication than in patients without buttock claudication (-15±12% vs. -4±16%, P<0.05). In addition, rSO2was predominantly lower in patients without the communication between the superior and inferior gluteal arteries than in those with the communication. CONCLUSIONS: Gluteal rSO2is useful as an indicator of intraoperative gluteal blood flow.

The modified Ross Reversal operation: a new approach for preserving the autograft wall.

The Ross Reversal operation is a breakthrough strategy first reported by Flynn et al. in 2007. In a reoperation for pulmonary autograft dysfunction after the Ross operation, an excised autograft can be preserved by reusing it in a native pulmonary position. We report a case wherein we used a new approach to excise the autograft valve with less invasion. The patient underwent a modified Ross Reversal operation concomitant with aortic root replacement and recovered without any complications. Our new approach enables a safer operation with improved valve function.

Ketoacidosis related to sodium glucose cotransporter 2 inhibitors after emergency coronary surgery.

Sodium glucose cotransporter 2 inhibitors are currently widely used antihyperglycaemic medications that are considered to be associated with euglycaemic diabetic ketoacidosis. We report 2 cases of patients who received sodium glucose cotransporter 2 inhibitors until emergency coronary artery bypass grafting (CABG) and developed euglycaemic ketoacidosis after surgery; they were treated with sugar replenishment and insulin infusion. In one case, coronary angiography revealed a spastic change of the bypass graft possibly due to severe acidosis. A rapid diagnosis and proper intervention are crucial to achieve better outcomes with CABG.

Enhanced outcomes for coronary artery disease obtained by a multidisciplinary heart team approach.

BACKGROUND: We implemented our multidisciplinary heart team (MHT) approach since 2012 for patients with coronary artery disease (CAD) and assessed the effectiveness of it by comparing outcomes in patients treated before and after the introduction of the MHT approach. METHODS: Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for CAD were performed in 802 and 57 patients from 2009 to 2011 in Group NH, and were performed in 867 and 160 patients from 2012 to 2014 in Group H, respectively. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of all-cause death, myocardial infarction, stroke, cardiac-related readmission and target vessel repeat revascularisation (TVR) for PCI or revascularisation on grafted vessels for CABG. RESULTS: MACCE occurred significantly more often in Group NH than in Group H at 3 years postoperatively (28.1% vs 21.1%) (log rank P = 0.001). Cox regression analysis showed that the MHT approach [hazard ratio (HR), 0.737; 95% confidence interval (CI), 0.60-0.91; P = 0.004] and ejection fraction (HR 0.976; 95% CI, 0.97-0.98; P < 0.0001) were associated with significantly lower rates of MACCE events, while SYNTAX score (HR 1.023; 95% CI 1.00-1.03, P < 0.0001) and EuroSCORE II (HR 1.014, 95% CI 0.60-0.91, P = 0.004) were associated with a higher rate of MACCE events. CONCLUSION: Our MHT approach was able to reduce the MACCE events of treatment for CAD. The dedicated MHT approach might be beneficial for patients with CAD.

[Omental Flap for the Device Infection of the HeartMate II].

Case 1:An 18-year-old male underwent emergent left extracorporeal ventricular assist device(eVAD) implantation for a cardiogenic shock because of dilated cardiomyopathy (DCM). After listing for heart transplant, he underwent a HeartMate II implantation as bridge-to-bridge(BTB) therapy. The omental flap was simultaneously used to prevent device infection that could have been induced by the infected malgranulation around the cannulas of the eVAD. Eventually, he was discharged and waiting for transplantation. Case 2:A 30-year-old male with DCM underwent emergent eVAD implantation for left ventricular support, centrifugal veno-pulmonary artery extracorporeal membrane oxygenation (ECMO) for right ventricular and respiratory support, and mitral valve replacement. After weaning of ECMO, he was listed for a heart transplant and underwent a HeartMate II implantation as BTB therapy. However, liver dysfunction and malnutrition prolonged wound healing. Despite applying vacuum assist closure device to promote wound healing, part of the driveline and pump housing were exposed. Therefore, radical debridement and omentopexy were performed for infection control. He was discharged after complete wound healing.

Repeat surgical intervention after aortic repair for acute Stanford type A dissection.

OBJECTIVE: This study aimed to evaluate the outcomes of repeat interventions on the aorta and aortic valve after surgery for acute Stanford type A aortic dissection. METHODS: The hospital records of patients who underwent repeat surgical intervention between April 2011 and March 2017 for late complications after acute type A aortic dissection repair were retrospectively reviewed. RESULTS: We identified 17 patients with mean age of 62 ± 8 years; 13 were men. The mean interval from the initial emergency aortic repair to the repeat intervention was 5.8 ± 5.4 years (range 133 days-16.6 years). Ten patients had dilatation or rupture of the residual type B aortic dissection; six of them had retrograde type A aortic dissection at the onset and did not undergo resection of the primary entry. Five patients had a pseudoaneurysm at the anastomosis; four of them were receiving anticoagulation medication. Three patients had aortic regurgitation; two of them were associated with the gelatin-resorcinol-formaldehyde glue that was used during the initial surgery. There was no early mortality after repeat intervention and no late death after a mean follow-up period of 3.3 ± 2.0 years. CONCLUSIONS: Repeat surgical intervention on the aorta and aortic valve after repair of acute type A aortic dissection had favorable early and mid-term outcomes and was not associated with early or late death. Long-term follow-up with imaging and echocardiography was considered to be essential for early detection of residual type B dilatation, anastomotic pseudoaneurysm, and aortic regurgitation after initial aortic repair.

Correction to: Cerebral oximetry for cardiac surgery: a preoperative comparison of device characteristics and pitfalls in interpretation.

In the original publication, the length unit of the SCD in Table 1 and Fig. 2 has been incorrectly published as cm. The correct length unit is mm.

Cerebral oximetry for cardiac surgery: a preoperative comparison of device characteristics and pitfalls in interpretation.

Regional cerebral oximetry using near-infrared spectroscopy devices is commonly used for detecting cerebral ischemia during cardiopulmonary bypass, and aim to avoid poor cerebral perfusion which may result in perioperative neurological impairment. Today, several devices that can detect cerebral ischemia are commercially available. Although these devices operate on the same measurement principles, their algorithms for detecting and calculating cerebral ischemia are different and no criteria for directly comparing values measured by such different devices exist. From January 2017 to August 2017, 80 adult cardiovascular surgery patients were enrolled in the prospective study. In each patient, preoperative regional cerebral oxygen saturation values were measured by two different devices and their correlations with various preoperative factors were evaluated. Regional cerebral oxygen saturation levels were significantly higher for values of FORE-SIGHT ELITE (CAS Medical Systems, Branford, CT, USA) (F value) than those of the INVOS 5100C (Medtronic, Minneapolis, MN, USA) (I value). Scalp-cortex distance, hemoglobin concentration, and the presence or absence of hemodialysis showed significant correlations with ratios of measured values specific to each device (F/I). An appropriate device should be selected according to preoperative patient characteristics, and factors influencing regional cerebral oxygen saturation values should be considered to ensure the correct interpretation of measured values. This research was conducted with the approval of the ethics committee of our university (approval number: B16-96).

Samurai cannulation (direct true-lumen cannulation) for acute Stanford Type A aortic dissection.

OBJECTIVES: In this study, we investigated early outcomes of patients who underwent surgical aortic repair for acute Stanford Type A aortic dissection at the Kitasato University Hospital and compared the results of Samurai cannulation (direct true-lumen cannulation) with other cannulation options. METHODS: Inpatient and outpatient records were retrospectively reviewed. RESULTS: Among the 100 patients who were operated on for acute Type A aortic dissection between April 2011 and April 2017, sole Samurai cannulation was used in 61 patients (Group S) and other cannulation options were used in the remaining 39 patients (Group O). No significant difference was observed in preoperative demographics between the groups. True-lumen cannulation was successful in all Group S patients, whereas 3 cannulation-related complications were observed in Group O patients. In Group S, the 30-day and in-hospital mortality occurred in 3 (5%) and 4 (7%) patients, respectively, and in Group O, these occurred in 3 (8%), and 6 (15%) patients, respectively. Four patients in each group (7% and 10%) experienced disabling or fatal strokes. Early mortality or stroke rate between the groups were not significantly different. During follow-up, there was no statistically significant difference between the groups in terms of survival, freedom from aorta-related death or freedom from aortic events. CONCLUSIONS: Early outcomes of the initial series of surgery for Stanford Type A aortic dissection with Samurai cannulation was favourable with acceptable mortality and stroke rates without cannulation-related complications. Samurai cannulation represents an easy, safe and reasonable option for cardiopulmonary bypass in surgery for acute Stanford Type A aortic dissection.