Pulmonary Tumor Thrombotic Microangiopathy Suspected to be COVID-19 Vaccine-Related Myocarditis: A Case Report.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a very rare condition that can lead to acute severe pulmonary hypertension and circulatory failure. It is caused by tumor cell microvascular obstruction and is usually difficult to diagnose; in fact, it is often diagnosed after death. We report the case of a patient who experienced a sudden cardiac arrest and developed severe pulmonary hypertension two days after receiving the coronavirus disease (COVID-19) vaccine. The patient was initially diagnosed with vaccine-associated myocarditis, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) implantation with median sternotomy was performed. The patient survived for more than two weeks. PTTM was later diagnosed during a pathological autopsy.

Temporary Epicardial Pacing Wire Migration to the Pulmonary Artery in the Early Postoperative Stage.

Temporary epicardial pacing wires (TEPWs) are widely used during open heart surgery to treat postoperative bradycardia or arrhythmia. They are usually removed, but the wire is cut at the skin entrance site if there is resistance upon removal. Residual TEPWs have risks of complications such as infection, but they rarely migrate to distant organs. We report a case of TEPW migration from the right ventricle to the pulmonary artery during the early stage after acute type A aortic dissection surgery. Residual TEPW migration was detected incidentally during follow-up imaging for aortic dissection, and no other complications, such as residual wire infection or thrombus, were noted. The residual TEPW was safely treated using catheter therapy. This case report utilized existing patient information without intervention for research purposes, and the requirement for obtaining written patient consent was waived.

Early mortality of emergency surgery for acute type A aortic dissection in octogenarians and nonagenarians: A multi-center retrospective study.

OBJECTIVES: The clinical data on postoperative mortality and central nervous system (CNS) complications in older adults who underwent acute type A aortic dissection are limited. Thus, in this study we aimed to evaluate the association between age and early postoperative mortality and occurrence of CNS complications. METHODS: This multicentric retrospective cohort study included 5 tertiary hospitals in Japan. All patients who underwent emergency surgery for acute type A aortic dissection between October 1998 and December 2019 were enrolled. The multilevel Cox proportional hazards model, which considered years as level 1, institutions as level 2, and surgeons as level 3, was used to evaluate the association between age and early postoperative hospital mortality and occurrence of CNS complications. RESULTS: Of the 1037 patients, 227 (21.9%) were ≥80 years old and 810 (78.1%) were <80 years old. Overall, 134 patients (12.9%) died within 30 days postoperatively; among them, 42/227 (18.5%) and 92/810 (11.4%) were aged ≥80 and <80 years, respectively (hazard ratio [HR], 1.63; P = .0046). CNS complications within 30 days postoperatively occurred in 140/1037 (13.5%) patients; among them, 42/227 (18.5%) and 98/810 (12.1%) were aged ≥80 and <80 years, respectively (HR, 1.63; P = .011). In multivariate analysis, age ≥80 years was associated with mortality within 30 days postoperatively (adjusted HR, 2.37; 95% CI, 1.23-4.57; P = .01) but not with CNS complications (adjusted HR, 1.58; 95% CI, 0.93-2.69; P = .091). CONCLUSIONS: The early postoperative mortality in older patients was approximately 50% higher than in the younger population. A thorough discussion regarding the surgical indications should be done.

Experiences in Emergency Cardiac Surgery of COVID-19-Positive Patients: A Case Series.

The coronavirus disease-2019 (COVID-19) pandemic has placed many restrictions on medical care. The timing of surgical treatment has been particularly affected, with patients experiencing delayed operation dates. This report describes three patients with preoperative COVID-19-positive diagnoses, tested with reverse transcription-polymerase chain reaction, who were urgently treated surgically with excellent results. Case 1 involved an 89-year-old woman with a left ventricular rupture after a myocardial infarction. Case 2 involved a 52-year-old male patient with an acute type A aortic dissection. Case 3 involved a patient with an occlusion of an autologous dialysis shunt. All patient conditions were either life-threatening or overwhelmed hospital beds without surgical treatment. In Japan, we still experience cases where surgery is refused because of COVID-19 positivity, even if emergency surgery is necessary. This report describes three cases where standard precautions were taken, postoperative management was devised, and good results were achieved.

Utility of cardiac magnetic resonance imaging for pre-operatively evaluating the degree of caseous calcification of the mitral annulus infiltration within the left ventricular myocardium: a case report.

Background: Depending on the degree of infiltration of dry mitral annulus calcification (MAC) into the left ventricular myocardium, calcification removal may cause thinning of the left ventricular wall and increase the risk of post-operative left ventricular rupture. Therefore, the degree of pre-operative infiltration into the left ventricular myocardium should be assessed as accurately as possible. We report a case of caseous calcification of the mitral annulus (CCMA), a subtype of MAC, in an 84-year-old woman; cardiac magnetic resonance imaging (MRI) was useful in assessing the degree of left ventricular infiltration of calcification. Case summary: The patient was referred to our hospital for surgery due to respiratory distress and severe mitral insufficiency. Echocardiography revealed a mass under the posterior mitral annulus adjacent to the mitral valve ring, suspected to be a CCMA. Cardiac MRI was performed to assess the risk of left ventricular rupture. Pre-operatively, no valve ring or left ventricular myocardium infiltration was confirmed. Surgical caseous calcification removal and artificial valve implantation within the preserved valve annulus were then performed. The patient had an uneventful post-operative course and was discharged without complications on the 21st post-operative day. Discussion: In this CCMA case, a pre-operative cardiac MRI was useful for evaluating the degree of the valve annulus and left ventricular myocardial involvement and estimating the risk of left ventricular rupture.

Effect of waiting time for COVID-19 screening on postoperative outcomes of type A aortic dissection: An institutional study.

BACKGROUND: Since November 2020, all patients undergoing emergency surgery at our hospital have been subjected to preoperative reverse transcription polymerase chain reaction (RT-PCR) screening to prevent nosocomial COVID-19 infection, with admission to the operating room requiring a negative result. Herein, we compared the pre- and postoperative outcomes of acute type A aortic dissection surgery before and after implementing the RT-PCR screening for all patients. METHODS: We compared the postoperative results of 105 patients who underwent acute type A aortic dissection emergency surgery from January 2019 to October 2020 (Group I) and 109 patients who underwent the surgery following RT-PCR screening from November 2020 to March 2022 (Group II). RESULTS: The average waiting time from arrival at the hospital to admission to the operating room was 36 and 81 min in Groups I and II, respectively. Ruptured cardiac tamponade was observed preoperatively in 26.6% and 21.1% of Groups I and II patients, respectively. The preoperative waiting time due to RT-PCR screening did not contribute to the cardiac tamponade. Surgical complications such as bleeding (reopened chest), respiratory failure, cerebral neuropathy, or mediastinitis did not increase significantly. The number of deaths 30 days after surgery (Group I = 13 and Group II = 3) showed no significant difference between the groups. There were no cases of nosocomial COVID-19 infections. CONCLUSIONS: Preoperative COVID-19 screening is an important method to prevent nosocomial infections. The associated waiting time did not affect the number of preoperative ruptures or affect postoperative complications or mortality.

A rare case of asymptomatic right coronary artery ectasia associated with giant aneurysm.

A rare case of giant coronary artery ectasia associated with coronary artery aneurysm was recognized. A 69-year-old woman presented with an ischemic electrocardiogram changes during a medical check-up. Coronary computed tomography angiography showed right coronary artery (RCA) ectasia associated with a giant aneurysm originating from the distal RCA. She was asymptomatic and exhibited no risk factors, including Kawasaki disease, hypertension, diabetes mellitus or family history. The patient underwent surgery for giant coronary aneurysms to prevent rupture. The aneurysm was on the peripheral side of the right coronary artery; hence, coronary artery bypass was not performed. The patient's postoperative course was uneventful. Histopathological examination of the aneurysm revealed degeneration due to atherosclerosis. She was prescribed warfarin and aspirin for thrombus prevention.

[Four Times Aortic Valve Replacement for Recurrent Aortic Annulus Destruction Due to Behçet's Disease:Report of a Case].

Surgical results of aortic regurgitation with Behcet's aortitis is associated with high morbidity and mortality due to risk of annular dehiscence. Here we describe a case of severe aortic regurgitation with Behcet's disease in 51-year-old man who underwent aortic valve replacement and subannular patch reconstruction for suspected infectious endocarditis with severe aortic regurgitation and subannular abcess. Then we performed three times aortic valve replacement for recurrent prosthetic valve dehiscence. Before the fourth operation, the patient was diagnosed with Behcet's disease and given immunosuppressant. Postoperative course was uneventful and he was discharged on postoperative day 59th, and doing well.

Hybrid treatment of a giant coronary artery aneurysm in a patient with immunoglobulin G4-related disease.

A 62-year-old man was diagnosed with a giant coronary artery aneurysm associated with immunoglobulin G4 (IgG4)-related disease. He had previously undergone two thoracic operations with sternotomies and abdominal aortic aneurysm repair for IgG4-related aortopathy. We opted for hybrid open and endovascular repair to reduce risk and avoid complications of a resternotomy and extracorporeal circulation. This first successful case of hybrid repair of a giant coronary artery aneurysm shows that the procedure is safe and feasible in patients with IgG4-related vasculopathy. It is critical to carefully monitor these patients for the occurrence of new IgG4-related aneurysms and other manifestations of vasculopathy.

Post-myocardial infarction left ventricular septal dissecting aneurysm: a case report.

BACKGROUND: Post-infarction perforation of the ventricular septum is recognized as a major complication of post-myocardial infarction. However, post-infarction ventricle dissection is seldom reported, as the ventricular shunt often accompanying this condition is a significant cause of cardiogenic shock. We encountered a rare case of ventricular dissection unaccompanied by a shunt, which caused a state of shock. CASE PRESENTATION: A 67-year-old man was diagnosed with acute myocardial infarction with a left ventricular oozing rupture. The occlusion of the left anterior descending artery was aspirated, followed by drainage of the pericardial bleeding and hemostasis of the left ventricle. After 15 h, he presented with sudden cardiogenic shock requiring extra-corporeal membrane oxygenation. The transesophageal echocardiogram showed a left ventricular septal aneurysm. Five days later, he underwent an operation, in which a ventricular septal wall dissection with a tear-forming large pseudoaneurysm was found. The tear was closed with a patch. He was weaned off extra-corporeal membrane oxygenation the next day. Αfter 4 months, he was discharged in a stable condition. CONCLUSIONS: Recognizing and identifying the cause of cardiogenic shock after myocardial infarction is crucial to provide the best treatment and surgical approach. Ventricular septal dissection should be considered, in addition to the usual complications, such as possible papillary muscle rupture, cardiac rupture, and perforation of the interventricular septum.

[Successful Use of Percutaneous Left Ventricular Assist Device( Impella) and Veno Artery Extracorporeal Membrane Oxygenation( VA-ECMO) for Ischemic Cardiogenic Shock;Report of a Case].

A 73-year-old male was referred to our hospital for acute congestive heart failure. His cardiac and respiratory conditions were worsening with cardiogenic shock requiring intubation. Coronary angiography revealed severe triple vessel disease, and echocardiography showed severe left ventricular dysfunction. Therefore, he underwent veno artery extracorporeal membrane oxygenation (VA-ECMO) followed by percutaneous left ventricular assist device (Impella). His cardiac condition improved and VA-ECMO and Impella were removed on the 2nd day and the 4th day after surgery, respectively. He underwent off-pump coronary artery bypass grafting (OPCAB) without any complication on the 36th day. Postoperative course was uneventful and he was discharged on postoperative day 30. Concomitant use of Impella and VA-ECMO (Ecpella) remarkably improved ischemic cardiogenic shock by unloading the left ventricle and increasing the cardiac output.

Dimerized glycosaminoglycan chains increase FGF signaling during zebrafish development.

Proteoglycans (PGs) modulate numerous signaling pathways during development through binding of their glycosaminoglycan (GAG) side chains to various signaling molecules, including fibroblast growth factors (FGFs). A majority of PGs possess two or more GAG side chains, suggesting that GAG multivalency is imperative for biological functions in vivo. However, only a few studies have examined the biological significance of GAG multivalency. In this report, we utilized a library of bis- and tris-xylosides that produce two and three GAG chains on the same scaffold, respectively, thus mimicking PGs, to examine the importance of GAG valency and chain type in regulating FGF/FGFR interactions in vivo in zebrafish. A number of bis- and tris-xylosides, but not mono-xylosides, caused an elongation phenotype upon their injection into embryos. In situ hybridization showed that elongated embryos have elevated expression of the FGF target gene mkp3 but unchanged expression of reporters for other pathways, indicating that FGF/FGFR signaling was specifically hyperactivated. In support of this observation, elongation can be reversed by the tyrosine kinase inhibitor SU5402, mRNA for the FGFR antagonist sprouty4, or FGF8 morpholino. Endogenous GAGs seem to be unaffected after xyloside treatment, suggesting that this is a gain-of-function phenotype. Furthermore, expression of a multivalent but not a monovalent GAG containing syndecan-1 proteoglycan recapitulates the elongation phenotype observed with the bivalent xylosides. On the basis of these in vivo findings, we propose a new model for GAG/FGF/FGFR interactions in which dimerized GAG chains can activate FGF-mediated signal transduction pathways.

[Ruptured thoracic aortic aneurysm complicated by acute aortic dissection and aortic valve regurgitation; report of a case].

An 87-year-old man was found loss of consciousness after falling. He was found in a state of shock. Computed tomography showed rupture of aneurysm of the ascending aorta and aortic arch with acute aortic dissection. Echocardiography revealed aortic valve regurgitation and cardiac tamponade. As the result of emergency operation, a large hematoma in the mediastinum and pleural cavity as well as massive serous pericardial effusion were found. The dissection was seen in aneurysm of the ascending aorta and aortic arch with an intimal tear located in the aortic arch. After aortic valve replacement was performed, the ascending aorta and aortic arch were replaced, and reconstruction of 3 cervical vessel branches was performed under deep hypothermic circulatory arrest with selective cerebral perfusion. Despite the complex clinical state and serious condition in the elderly patient, emergency surgery saved the life of the patient without complications.

[Mobile mass in the descending aorta with multiple embolism].

A 46-year-old man was referred to our hospital for abdominal pain. Computed tomography (CT) revealed mobile mass in the descending aorta and multiple systemic embolism. Emergent operation was indicated. Under femoral vein to femoral artery bypass, removal of mobile mass was performed. We resected the mass with stem including aortic wall and closed the aortic defect with the pericardial patch. Postoperative course was uneventful. Histopathology of the mass was organized thrombus with inflammatory change.

Cardiogenic shock without cardiac tamponade caused by a subepicardial hematoma after percutaneous coronary intervention.

A 73-year-old man complaining of pain on effort was admitted to a hospital for a percutaneous coronary intervention (PCI) because of severe stenosis of the mid right coronary artery. During PCI, a coronary artery was ruptured, and the patient suddenly went into shock. Percutaneous pericardiocentesis was successfully performed, and cardiac tamponade was relieved. Despite the echocardiographic finding of no cardiac tamponade, the patient remained in the shock state. An emergency operation was performed. There was little pericardial effusion, but a large subepicardial and intramyocardial hematoma was present and was being compressed by the pericardium. Pericardial incision and off-pump coronary artery bypass grafting were performed. The patient was discharged on the 12th postoperative day. Decompression of the subepicardial hematoma by pericardiotomy ameliorated the condition of the patient, who was in cardiogenic shock. We thus report a rare case of subepicardial hematoma resulting in shock during PCI in which cardiac tamponade was not observed.

[Cylindrical patch repair for circumferential subvalvular abscess due to prosthetic valve endocarditis].

A 51-year-old male underwent aortic valve replacement and vascular prosthesis implantation due to an aneurysm of the ascending aorta combined with aortic regurgitation caused by the bicuspid aortic valve. Semi-emergency surgery was performed due to severe paravalvular leakage with prosthetic valve endocarditis 16 months after the 1st operation. The circumferential annular abscess cavities were closed with a cylindrical patch, and a mechanical valve was installed on the upper edge of the sutured cylindrical patch. A vascular prosthesis was reimplanted to the ascending aorta. Use of the cylindrical patch provides a good exposure of operative field to close circumferential annular abscess cavity.

Ventricular septal perforation caused by right-sided infective endocarditis associated with giant vegetation.

A 71-year-old man presented with general fatigue associated with syncope and fever, and was admitted to our hospital and treated with antibiotics for pneumonia. On day 10 after admission, cardiac echocardiography showed a ventricular septal perforation and giant vegetation floating in the right ventricle near the tricuspid valve, which had not been detected at the time of admission. An emergency operation (including vegetation excision, debridement, ventricular septal perforation patch closure, and tricuspid valve replacement) was performed. A permanent pacemaker was implanted on postoperative day 34, and the patient was discharged without any complications. A culture of the excised vegetation and blood culture revealed methicillin-susceptible Staphylococcus aureus. There has been no previous report of a presenting ventricular septal perforation caused by right-sided infective endocarditis.