Postoperative anticoagulation management using subcutaneous unfractionated heparin for a patient with nonbacterial thrombotic endocarditis: a case report.

Nonbacterial thrombotic endocarditis (NBTE) presents nonbacterial vegetation on cardiac valves. NBTE requires appropriate anticoagulant therapy to prevent recurrence after surgery. However, there has not yet been established evidence for anticoagulant therapy in NBTE, and low molecular weight heparin is not approved in Japan. We present a case of NBTE that was successfully managed with anticoagulant therapy using subcutaneous unfractionated heparin. A 59-year-old woman was diagnosed with NBTE on the mitral and tricuspid valve associated with breast cancer, underwent valve replacement. Warfarin and continuous intravenous unfractionated heparin were started. However, disseminated intravascular coagulation occurred after heparin was discontinued. Continuous intravenous unfractionated heparin injection was resumed immediately, and subcutaneous unfractionated heparin was administered before discharge. Postoperative echocardiography revealed no vegetation on the prosthetic valves thereafter. Subcutaneous unfractionated heparin therapy is useful to prevent the recurrence of NBTE as the anticoagulation in outpatients.

Early thrombus formation including hypo-attenuated leaflet thrombosis after surgical bioprosthetic aortic valve replacement.

OBJECTIVE: To assess the occurrence, predictors, and outcomes of hypo-attenuated leaflet thickening (HALT) and thrombus outside the prosthetic valve following surgical aortic valve replacement. METHODS: A total of 118 patients underwent surgical aortic valve replacement with bioprosthetic valves between July 2020 and June 2022. Sixty-two (52.5%) patients, which is a fairly high number of patients, underwent cardiac computed tomography and transthoracic echocardiography one week after surgery. Patients were divided into two groups, those with HALT (n = 14) and those without HALT (n = 48). RESULTS: Of the 62 patients who underwent cardiac computed tomography, HALT was observed in 14 (22.5%) patients during the very early postoperative phase. Reduced leaflet motion was observed in two of the 14 patients. The low-attenuation areas were located outside the prosthetic valve in 10 cases (71.4%) in the HALT group and in 14 cases (29.2%) in the non-HALT group. More than 50% of patients (57.1%) with HALT and 79.2% without HALT were administered warfarin. Neither in-hospital deaths nor postoperative thromboembolic events were observed during hospitalization. No patient had a mean pressure gradient > 20 mmHg in either group. CONCLUSION: HALT was observed in one-fifth of the cases after surgical aortic valve replacement during the very early postoperative phase in an institution wherein administration of continuous heparin infusion after surgery is a standard practice. HALT did not affect the early prognosis or incidence of cerebral infarction.

Mitral valve repair using a semi-rigid posterior band: a 10-year Japanese single-center experience of 244 patients.

Background: Mitral valve repair (MVr) is an established procedure for patients who require surgery for primary mitral regurgitation (PMR). The Colvin-Galloway Future Band (CGFB) is a semi-rigid posterior band expected to improve the clinical outcomes of MVr. However, information on the hemodynamic and functional performance and long-term outcomes of CGFB is limited. We evaluated the quality, durability, and clinical performance after MVr using CGFB for PMR as the cohort study. Methods: A total of 244 patients who underwent MVr with CGFB were enrolled. Clinical and echocardiographic assessments were performed (mean follow-up period, 4.0±2.4 years). Results: Posterior mitral leaflet resection was the most common MVr procedure. CGFBs measuring 28 mm (35.2%) and 30 mm (36.5%) were used. The incidence of systolic anterior motion (SAM) was 1.6%. A total of 93.4% of the patients had no or trace MR at discharge. Over 90% of patients had no or mild MR at the last follow-up. The mean pressure gradient and mitral valve orifice area one year after MVr ranged between 2.6 and 3.6 mmHg and 2.3 and 3.4 cm2, respectively. At follow-up, 85.4% of the patients were New York Heart Association class I. Three patients underwent repeat mitral valve surgery. Conclusions: The CGFB demonstrates satisfactory quality and durability in MVr for PMR. Other advantages include a low occurrence of SAM and acceptable hemodynamic outcomes, particularly in patients requiring a smaller annuloplasty device.

Preoperative management using Impella support for acute aortic dissection with left coronary malperfusion: a case report.

BACKGROUND: Acute aortic dissection (AAD) with impaired perfusion of the left coronary artery has a poor prognosis, even after urgent radical aortic surgery, due to extensive myocardial damage. Although Impella, a microaxial-flow catheter pump, is useful in managing acute myocardial infarction, it is generally contraindicated in patients with AAD because it is an intra-aortic device and the aortic structure is compromised in these cases. Here, we introduce a novel intervention that allowed a planned aortic repair after managing circulation using Impella and venoarterial extracorporeal membrane oxygenation in a case of AAD with left main trunk malperfusion. CASE PRESENTATION: A 40-year-old man presented with cardiogenic shock. Percutaneous coronary intervention was performed to address left main trunk obstruction using an intra-aortic balloon pump; however, circulatory instability persisted. The patient was transferred to our hospital after venoarterial extracorporeal membrane oxygenation. Impella CP™ was used to improve his circulatory status. However, a subsequent CT scan confirmed an AAD diagnosis. After 5 days of stable circulatory support, the patient underwent aortic root replacement and coronary artery bypass grafting. CONCLUSIONS: In patients with AAD and coronary malperfusion, adjunctive circulatory management with Impella may be a valuable therapeutic option.

[Result of Surgical Treatment for Active Infective Endocarditis at the Aortic Position].

Herein, we retrospectively review our experience with surgical treatment of active aortic valve infective endocarditis, particularly aortic annular abscess, and central nervous system complications. From 2012 to 2021, 46 consecutive patients underwent surgery during the active phase of infective endocarditis, 25 of which were performed at the aortic position. One patient died early (<30 days) due to low output syndrome and another 2 patients who were never discharged died because of general prostration. The actuarial survival rate was 84% at 1 year, and 80% at 3 and 5 years. Eleven patients [6 native valve endocarditis (NVE), 5 prosthetic valve endocarditis (PVE)] had valve annular abscess requiring removal of the infected tissue and reconstruction of a definite anatomic continuity, and aortic valve replacement was subsequently performed in 7 patients and aortic root replacement in 4 patients. Direct closure was performed in 4 patients with partial annulus defects, and reconstruction with an autologous nor bovine pericardium patch was performed in 6 patients with large annulus defects. Preoperative imaging revealed acute cerebral embolism in 10 patients. In eight cases, surgery was performed within 7 days after diagnosis of cerebral embolism. No patient had abnormal postoperative neurological findings. There were no reoperations and no recurrence of infective endocarditis.

A Case of Andexanet Alfa Induced Heparin Resistance in Emergent Aortic Surgery: Successful Anticoagulation Management Using Antithrombin Administration.

Andexanet alfa (AnAl) is utilized for the urgent reversal of direct oral anticoagulants (DOACs) in cases of severe bleeding. While the guidelines from the Society of Thoracic Surgeons recommend AnAl for urgent cardiac surgery in patients treated with DOACs, concerns persist regarding the potential of AnAl to induce heparin resistance. This report details the case of an 85-year-old woman diagnosed with acute type A aortic dissection, who received AnAl due to prior edoxaban use. During the emergent aortic surgery, she exhibited heparin resistance following the administration of unfractionated heparin (UFH). The administration of antithrombin III (ATIII) significantly influenced activated clotting times, facilitating successful surgery while maintaining adequate anticoagulation. This case underscores the importance of cautious management of AnAl-induced heparin resistance during critical surgeries, emphasizing the role of ATIII supplementation for effective anticoagulation.

Hemodynamic and clinical performance of the 25-mm Medtronic Mosaic porcine bioprosthesis in the mitral position.

The 25-mm Medtronic Mosaic porcine bioprosthesis (MB25) is the smallest bioprosthesis that has been approved for use in the mitral position in Japan. Various studies have reported satisfactory hemodynamic performance and good long-term outcomes of the Medtronic Mosaic porcine bioprosthesis. However, the hemodynamic and clinical performances of the MB25 in the mitral position remain unknown. This study aimed to evaluate the hemodynamic and clinical performance of the MB25 in mitral valve replacement (MVR). Twenty patients who underwent MVR using the MB25 between February 2013 and April 2018 were studied. We evaluated the hemodynamic performance of the MB25, cardiac chamber size, cardiac function, and systolic pulmonary artery pressure (PAP) using echocardiography during follow-up. The study outcomes were major adverse cardiac events (MACEs) and all-cause mortality. Sixteen patients (80%) had a patient prosthesis mismatch defined as an index effective orifice area of ≤ 1.2 cm2/m2. The left atrial dimension was significantly reduced after surgery (p = 0.0282). The mean pressure gradients (MPG) in the mitral position were 5.5 ± 1.7 mmHg at discharge and 4.2 ± 1.3 mmHg at 1 year postoperatively. The MPG in the mitral position significantly decreased during the follow-up period (p = 0.0489). Systolic PAP significantly improved postoperatively. The 1-, 3-, and 5-year survival rates were 87, 79, and 70%, respectively. No cardiac death occurred. There were no MACEs or reports of structural valve degeneration during the follow-up period. The hemodynamic and clinical performances of the MB25 in the mitral position were satisfactory as the smallest biological mitral valve. The MB25 is a reasonable option for MVR to reduce the surgical difficulty in high-risk patients with an advanced age, a small body size or MAC and when recurrent MVR or complex procedures are performed.

Prosthetic cardiac valves: history and review of cardiac prostheses clinically available in Japan.

Recently developed prosthetic valves are reliable and essential for the treatment of valvular heart disease. The mechanical valve evolved remarkably following the introduction of pyrolite carbon material, which enabled the creation of a bileaflet form incorporated with a pivot mechanism. The improved durability of the biological valve is attributed mainly to the development of a tissue fixation process and anti-calcification treatments. However, optimal antithrombogenicity and durability have not yet been achieved for either prosthetic valve type. To select the most suitable prosthetic valve for each individual patient from among the many clinically available prosthetic valves, it is necessary to have a thorough understanding of the characteristics of each valve.

Successful Repair of a Forme Fruste Bicuspid Aortic Valve by the Raphe Suspension Technique.

A 52-year-old man underwent surgery due to shortness of breath caused by severe aortic regurgitation with right coronary cusp prolapse. Operative findings revealed 3 symmetric cusps with small raphe between the right and noncoronary cusps situated lower than the others, indicating a forme fruste bicuspid aortic valve (BAV). The BAV was successfully repaired by tricuspidization, including raphe suspension, right coronary cusp plication, and double annuloplasty. The postoperative course was uneventful, and echocardiography at 3 months showed mild aortic regurgitation with adequate left ventricular reverse remodeling. Here we present the technical details of the raphe suspension procedure for forme fruste BAV.

Short-segment coronary artery bypass grafting using radial artery to repair bilateral coronary ostial aneurysms after aortic root replacement in a patient with Marfan syndrome.

Coronary ostial aneurysm is a complication of aortic root replacement, particularly in Marfan syndrome. Reconstructing the coronary artery is an important problem during reoperation. Herein, we report a case of coronary artery bypass grafting using radial artery to repair bilateral coronary ostial aneurysms after aortic root replacement in a patient with Marfan syndrome.

Evaluation of hemodynamics after mitral valve replacement with the St Jude Medical Epic bioprosthesis: a Japanese single-center experience.

To assess the early hemodynamics after mitral valve replacement (MVR) using the St Jude Medical (SJM) Epic bioprosthesis. MVR was performed using the SJM Epic bioprosthesis in 35 patients from June 2018 to April 2020; three patients were excluded because the postoperative transthoracic echocardiography (TTE) data were unavailable. Data from postoperative TTE at 1 week and 3 months after the procedure were reviewed. The mean mitral pressure gradient (mMPG) was calculated using a continuous wave Doppler method. Left ventricular outflow tract (LVOT) was calculated using a pulse wave Doppler method. The effective orifice area (EOA) was measured from pressure half time. There were 12 men (37.5%) and 20 women (62.5%) with a mean age of 75.9 years (61-88 years). The mean body surface area was 1.51 ± 0.22 cm2. The 25 mm and 27 mm valves were used in more than 50% of cases. The mMPG was 4.9 ± 1.7 mmHg and 5.4 ± 1.6 mmHg at 1 week and 3 months after surgery, respectively. EOA was 2.18 ± 0.50 cm2 and 2.31 ± 0.59 cm2 at 1 week and 3 months after surgery, respectively. The peak velocity of the LVOT (n = 22) was 103.3 ± 21.3 cm/s and 106.8 ± 27.4 cm/s at 1 week and 3 months after surgery, respectively. No findings suggested paravalvular regurgitation and LVOT obstruction. Using the SJM Epic bioprosthesis in MVR resulted in satisfactory hemodynamics in the early postoperative period, even with small valve sizes. Further accumulation of cases and evidence, including mid- to long-term results, is required in the future.

Isolated right ventricular metastasis of hepatocellular carcinoma induced by epithelial-mesenchymal transition: a case report.

BACKGROUND: Hepatocellular carcinoma (HCC) that metastasizes to the right ventricle has rarely been reported. An important link between epithelial-mesenchymal transition (EMT) and the invasion and metastasis of cancer cells has recently been demonstrated. However, there are few reports on the relationship between HCC metastasized to the heart and EMT. CASE SUMMARY: We here report the case of a 74-year-old woman who had type C HCC referred to our hospital with general fatigue due to a right ventricular tumour diagnosed at a general hospital. Anticoagulation therapy was done, but the mass had rapidly grown. We performed surgical resection of the mass. Histopathological examination revealed that the tumour was diagnosed as a poorly differentiated HCC metastasis induced by EMT. DISCUSSION: Isolated metastasis of HCC to the right ventricle is extremely rare. The HCC with EMT has a potentially high risk of metastasizing to the heart and other organs, and the prognosis is poor.

Clinical outcome of cardiac surgery in patients with remitted or active hepatocellular carcinoma.

PURPOSE: Hepatocellular carcinoma (HCC) is one of the most common primary cancers worldwide. HCC has unique characteristics such as co-existing chronic liver damage and a high recurrence rate. A negative impact on the surgical outcome due to these backgrounds could be expected. We aimed to evaluate the clinical outcomes of cardiac surgery in these patients. METHODS: Between January 2000 and December 2019, 16 patients with remitted cancer and 5 patients with active HCC who underwent open heart surgery were studied. The clinical data were retrospectively evaluated from hospital records. Follow-up information was collected via telephone interviews. RESULTS: The major cause of HCC was viral hepatitis. Eighteen patients (86%) were classified as having Child-Pugh class A cirrhosis. The mean model of end-stage liver disease (MELD) score was 7.2 ± 5.2. There was no 30-day mortality. During follow-up, 11 patients died due to HCC. The 1-, 3-, and 5-year survival rates were 80.0, 42.5, and 22.3%, respectively. A univariate analysis identified a higher preoperative MELD score and lower serum cholinesterase levels as prognostic factors for long-term survival. CONCLUSION: We could safely perform cardiac surgery in selected patients with remitted and active HCC. The postoperative life expectancy of these patients was limited but acceptable.

Prevention of postoperative intrapericardial adhesion by dextrin hydrogel.

OBJECTIVE: Postoperative intrapericardial adhesion increases the risk of complications in patients undergoing reoperation. We investigated the effect of a bioabsorbable dextrin hydrogel (DHG) on the formation of intrapericardial adhesions. METHODS: Intrapericardial adhesion was surgically induced in Japanese white rabbits with DHG treatment (Adh + DHG) or without DHG treatment (Adh). The sham group was not treated with DHG and intrapericardial adhesion was not induced. The extent of intrapericardial adhesion was assessed by adhesion scoring and crystal violet staining of the pericardial cavity. Bromodeoxyuridine (BrdU) uptake assay was performed to assess the proliferative response to the injury in the tissue beneath the intrapericardial adhesion. RESULTS: The Adh + DHG group showed looser intrapericardial adhesions compared to the Adh group. The adhesion area of the Adh + DHG group was 4.6 ± 2.2%, whereas that of the Adh group was 32.6 ± 6.4% at the end of the 28-day observation period (p < 0.01). The induction of intrapericardial adhesion resulted in a proliferative response mainly in the cardiac tissue just beneath the adhesion. There were 48.6 ± 10.7 cells/0.1 mm2 BrdU-positive cells in the Adh + DHG group and 135.7 ± 23.8 cells/0.1 mm2 BrdU-positive cells in the Adh group on day 28 (p < 0.05). CONCLUSION: These findings indicate that DHG effectively prevented intrapericardial adhesion in this model.

Pathological Role of Receptor for Advanced Glycation End Products in Calcified Aortic Valve Stenosis.

Background Aortic stenosis (AS) is highly prevalent in patients with atherosclerotic cardiovascular disease. Advanced glycation end products (AGEs) and the receptor for AGEs (RAGE) play a pivotal role for vascular calcification in atherosclerosis. We hypothesize that the AGEs-RAGE axis could also be involved in the pathophysiological mechanism of calcified AS. Methods and Results A total of 54 patients with calcified AS who underwent aortic valve replacement were prospectively enrolled from 2014 to 2016 (mean age 75.3±7.7 years). Aortic valve specimens were obtained from 47 patients and 16 deceased control subjects without aortic valve disease (mean age 63.2±14.5 years). The valvular expression of RAGE was evaluated by immunohistochemistry. Serum levels of AGEs and soluble RAGE were measured in 50 patients with calcified AS and 70 age-matched and sex-matched control subjects without heart disease. The valvular RAGE expression in patients with calcified AS was higher than controls (P=0.004) and was significantly associated with a decreased ankle-brachial pressure index (P=0.007) and an increased intima-media thickness (P=0.026). RAGE and α-smooth muscle actin were coexpressed and were partially costained with osteocalcin and alkaline phosphatase. The serum levels of AGEs and soluble RAGE were significantly higher in the patients with calcified AS than in the controls (P=0.013 and P<0.001, respectively). Soluble RAGE (inversely) and use of aspirin were independently correlated with changes in left ventricular systolic function after aortic valve replacement (P=0.012 and P=0.002, respectively). Conclusions Our present study suggests that RAGE may play a role in the pathogenesis of calcified AS, which is a prognostic marker in patients with AS after aortic valve replacement.

Aortic valve replacement with or without concomitant coronary artery bypass grafting in very elderly patients aged 85 years and older.

Degenerative aortic stenosis is the most common structural heart valve disease affecting the aging population. Catheter-based heart valve interventions are less invasive and very useful for very elderly patients. However, we often consider open heart surgery for these patients because of anatomical reasons and co-existing cardiac diseases, i.e., severe coronary artery disease. We aimed to analyze the outcomes of very elderly patients aged ≥ 85 years undergoing aortic valve replacement (AVR) with or without coronary artery bypass grafting (CABG). Twenty-nine very elderly patients aged ≥ 85 years who underwent AVR with CABG (n = 11, Group AC) or isolated AVR (n = 18, Group A) were examined. The overall mean age of the patients was 87.2 ± 2.6 (range 85-94) years. The estimated operative mortality rate, calculated using the Japan score, EuroSCORE II, and STS risk score, was 5.72%-10.88% in Group AC and 5.63%-8.30% in Group A. Aortic cross-clamp time (126.5 ± 29.0 vs. 96.9 ± 29.2 min, p = 0.016) was significantly longer in Group AC than in Group A. Although the major morbidity rate was higher in Group AC than in Group A (36% vs. 6%, p = 0.0336), the length of intensive care unit stay and hospital stay was comparable between both groups. There was no 30-day and hospital mortality in both groups. Eleven patients died during follow-up (senility, 5; cerebrovascular events, 2; renal failure, 1; unknown, 3). There were no significant differences in survival rates during follow-up (log-rank p value = 0.1051). The 1-, 2-, 3-, 4- and 5-year survival rates were 91%, 80%, 69%, 69% and 69%, respectively, in Group AC and 94%, 94%, 94%, 94% and 88%, respectively, in Group A. In conclusion, AVR with or without CABG could be safely performed in carefully selected very elderly patients with acceptable early- and long-term results. AVR with CABG in very elderly patients aged ≥ 85 offers similar results to isolated AVR in terms of 30-day mortality, hospital mortality, and long-term survival.