Fifth-time redo mitral valve replacement via right thoracotomy under systemic hyperkalemia cardiopulmonary bypass without aortic cross-clamp.

The surgical management of prosthetic valvular endocarditis (PVE) can be challenging. We report a case of a 46-year-old female patient who had a history of four cardiac operations. We chose a mitral valve replacement via right thoracotomy to enable optimal exposure of the mitral valve (MV). Because of multi-reoperations, we employed systemic hyperkalemia for cardiac arrest to protect the heart during cardiopulmonary bypass (CPB) without aortic cross-clamping. Here, we present a complex operation that performed management of CPB under hyperkalemia and the patient had a good postoperative recovery.

Predictive Factors for Limb Salvage and Foot Ulcer Recurrence in Patients with Chronic Limb-Threatening Ischemia After Multidisciplinary Team Treatment: A 6-Year Japanese Single-Center Study.

Chronic limb-threatening ischemia (CLTI) is associated with a short-term risk of limb loss. Multidisciplinary teams are often involved in CLTI treatment; however, in Asian countries, multidisciplinary teams that include podiatrists specializing in foot wounds and vascular surgeons who can perform distal bypass surgery are lacking. We investigated predictive factors for limb salvage and foot ulcer recurrence in patients with CLTI treated by a Japanese single-center intensive multidisciplinary team over 6 years. We retrospectively investigated 84 patients with CLTI and foot ulcers who had undergone revascularization and wound treatment between October 2013 and December 2019. Following postrevascularization treatment, including undertaking minor amputations, the healing rate was 77.8%, and the average wound healing time was 75 ± 68 days. To achieve adequate blood supply, 17.7% of patients were treated using a combination of endovascular revascularization and bypass surgeries. Thirty-three (44%) patients had wound recurrence and there was wound recurrence within 6 months in 58.9% of these patients. Multivariate logistic regression analysis showed that postrevascularization skin perfusion pressure was significantly associated with wound healing (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.033-1.243, P = .0078). Diabetes mellitus (OR 9.72, 95% CI 1.855-50.937, P = .0071), and heart disease (OR 3.51, 95% CI 1.052-11.693, P = .0411) were significantly associated with wound recurrence (P < .05). Treatment within a single-center intensive multidisciplinary team resulted in good patient outcomes. Our study indicates that the revascularization endpoint of CLTI treatment should be marked by attainment of adequate blood supply and wound healing. The timing of revascularization and debridement is of utmost importance for the successful treatment of CLTI wounds.

Successful Open Thoracoabdominal Aortic Repair in a Patient with Severe Aorto-Iliac Occlusive Disease: A Rare Case Report.

Open repair of thoracoabdominal aortic aneurysm (TAAA) in a patient with severe aorto-iliac occlusive disease is considered to cause an extremely high risk for spinal cord injury. A 71-year-old man who had previously undergone axillo-bifemoral bypass for aorto-iliac occlusive disease presented with persistent dilation of a TAAA. Using distal perfusion via partial extracorporeal circulation at mild hypothermia, we performed segmental sequential repair of Crawford type II TAAA. Various efforts were made to avoid spinal cord injury and ischemic visceral organ damage. Consequently, the patient completely recovered without any serious complications.

Aortic Rupture due to Co-localization of Aortic Intimal Myofibroblastic Sarcoma and Urothelial Carcinoma: A Unique Case Report.

We herein report a unique case of aortic rupture due to co-localization of aortic intimal myofibroblastic sarcoma (IMFS) and urothelial carcinoma (UC). A 76-year-old man who was being followed up after surgery for UC 5 years earlier developed aortic rupture and underwent emergency surgery. Intraoperatively, a tumorous mass on the luminal side of the aortic arch was found near the rupture. A histopathological analysis of the mass revealed aortic IMFS. Furthermore, co-localization of IMFS and UC cells was found near the rupture. The fragility of the aortic wall due to co-localization of IMFS and UC was believed to contribute to the aortic rupture.

[Thymoma from the Thymus Covering Bypass Grafts in Previous Coronary Surgery].

To prevent graft injury at the thoracic surgery after coronary artery bypass grafting (CABG), thymus is often used to cover the grafts. We report a thymoma that developed 12 years after CABG in a 65-year-old woman. The patient had undergone percutaneous coronary intervention (PCI) with stenting of the left anterior descending( LAD) artery, 13 years ago, and a 4-vessel CABG, 12 years ago. Three-dimensional(3D) coronary computed tomography (CT) and angiography before surgery showed that all grafts were intact, but LAD artery occlusion was presented just distal to the stent. Since the thymoma was located in front of the ascending aorta and trunk of the pulmonary artery, abutting the left and right internal thoracic artery and radial artery graft, we performed PCI for LAD recanalization preoperatively, and complete resection of the thymoma with redo sternotomy was performed safely using an ultrasonic stethoscope without damage to the graft.

Midterm outcomes of thoracic endovascular repair for uncomplicated type B aortic dissection with double-barrel type.

OBJECTIVE: The midterm outcomes and aortic remodeling after thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (TBAD) were evaluated. METHODS: Forty-seven patients (mean age 66 ± 12 years) who underwent TEVAR for uncomplicated TBAD with double-barrel type from January 2012 to December 2017 were retrospectively analyzed. The indication for TEVAR for entry closure was a maximum aortic diameter > 40 mm with a patent false lumen. Twenty-six patients (55.3%) had TEVAR in chronic phase, over 6 months after the onset of aortic dissection. RESULTS: There was no hospital death or serious complication. During follow-up (mean 35 ± 16 months), overall 3-year survival was 95.6 ± 3.1%. A significant trend was observed with a higher rate of shrinkage of overall aortic diameter, expansion of the true lumen, and shrinkage of the false lumen more proximally from the stent graft-covered site. Rate of aortic shrinkage in chronic with aortic diameter more than 50 mm was lower compared with the other (proximal: 33.3% vs. 80-100%, distal 0-16.7% vs. 50-52.9%). Rate of aortic dilation distally to the stent graft-covered site was 28% in chronic compared with 5% in non-chronic. Adverse events were mainly due to distal aortic dilation, and 3-year freedom from all adverse events was 79.8 ± 6.5%. CONCLUSIONS: Favorable aortic remodeling of the proximal stent graft-covered site could be expected even in the chronic phase if preoperative aortic dilation over 50 mm is unaccompanied. Careful follow-up focusing on dilation of the distal aortic segment is mandatory especially in patients who underwent TEVAR in chronic phase.

Acute regeneration and chronic acellular transformation of rabbit cryopreserved aortic allografts.

An analysis of rabbit cryopreserved aortic allografts excised on postoperative days (POD) 2, 5, 11, 60, 210, 360, and 720, as well as controls that were untransplanted native aortas and cryopreserved aortas, was performed. On POD2, the number of medial smooth muscle cells in the allografts was reduced to approximately 50%. Ki-67 analysis revealed that medial smooth muscle cells in the allografts proliferated from the 2nd day. By the 11th day, their proliferation ceased and the number of medial smooth muscle cells was restored to almost at the same level as in the controls. Polymorphic microsatellite DNA marker analysis disclosed that the restored medial smooth muscle cells were of donor origin. From 7 months through 2 years, the media of cryopreserved aortic allografts were transformed into acellular structures, in which the elastic fibers were preserved. On the other hand, newly accumulated smooth muscle cells were observed in the adventitia just outside of acellular media after 7 months. In some cases, scattered lamellar calcium deposition was observed in the same regions. This study presents a comprehensive documentation of regeneration and acellular transformation in cryopreserved aortic allografts based on short and long-term analysis.

Aortic regurgitation caused by rupture of the abnormal fibrous band between the aortic valve and aortic wall.

This report documents the sudden onset of aortic regurgitation (AR) by an exceptional cause. A 68-year-old woman suddenly experienced general fatigue, and AR was diagnosed. One year later, we performed aortic valve replacement. At surgery, three aortic cusps with a larger noncoronary cusp had prolapsed along with a free-floating fibrous band that had previously anchored the cusp to the aortic wall. Its rupture had induced the sudden onset of AR. There was no sign of infectious endocarditis. We performed successful aortic valve replacement.

Aortic valve replacement and graft replacement of the ascending aorta using deep hypothermic circulatory arrest in a patient with myelodysplastic syndrome.

A 73-year-old woman with a 10-year history of myelodysplastic syndrome (MDS) had severe aortic regurgitation (AR) and an ascending thoracic aortic aneurysm (TAA) with a maximum diameter of 55 mm. By retrograde cerebral perfusion (RCP) in the patient under deep hypothermic circulatory arrest (DHCA), we replaced the ascending aorta graft and aortic valve. After surgery, we periodically administered granulocyte colony-stimulating factor (GCSF) with platelet aggregation. On postoperative day 20, the patient had a duodenal ulcer. On postoperative day 22, she had a subarachnoid hemorrhage, which was treated, nonoperatively, with a hemostatic agent. On postoperative day 126, she was discharged without sequelae, and 1.5 years after the surgery, she has had neither heart failure nor deterioration of MDS.

Successful operation for mitral regurgitation in a patient with Gilbert's syndrome.

A 72-year-old woman complaining of dyspnea on effort was diagnosed as having mitral regurgitation (MR). Asymptomatic jaundice had initially been noticed during primary school, and an examination had shown hyperbilirubinemia. After the diagnosis of constitutional jaundice, she had remained well without further examination or medical treatment. Laboratory data showed a total serum bilirubin (TB) level of 12.2 mg/dl and a direct bilirubin level of 0.6 mg/dl. Transesophageal echocardiography showed severe MR, and we replaced the mitral valve. Postoperatively, genetic analyses identified constitutional jaundice as Gilbert's syndrome with Y486D mutation. The TB level gradually decreased. Four years after operation she is doing well with moderate hyperbilirubinemia and a TB level of 5 mg/dl. She is free from heart failure.

Surgical removal of an intravascular ultrasonography catheter captured in a stent after percutaneous coronary intervention.

A-79-year-old woman underwent percutaneous coronary intervention (PCI) to the right coronary artery (RCA) for effort angina, followed by intravascular ultrasonography (IVUS) to ascertain stent expansion. The IVUS catheter became entangled in the stent and could not be withdrawn from the outside. The patient was transferred to our hospital for its surgical removal. For the emergent surgery, we opened the stent region in the RCA and directly removed the IVUS catheter with the twisted stent. Additional coronary artery bypass grafting (CABG) involving three vessels was performed. She was discharged 42 days after surgery.

Spontaneous dissection of the splanchnic arteries.

Three patients had severe abdominal pain of sudden onset. Computed tomography showed localized dissection in the superior mesenteric artery in two patients and in the celiac artery in one. With conservative therapy abdominal symptoms were self-remitted. All patients were successfully treated with medication and have been doing well during follow-up.

Brown-Sequard syndrome after thoracic endovascular aortic repair.

A 76-year-old female had suffered from distal arch aortic aneurysm and chronic DeBakey IIIB type dissecting aneurysm. The patient underwent thoracic endovascular aortic repair (TEVAR). After TEVAR the patient had a motor and proprioceptive loss on the left side and a pain and body temperature loss on the right side below the level of T7. At diagnosis of Brown-Sequard syndrome, corticosteroid and free radical scavenger were administered soon afterwards. Her neurological deficits gradually improved and the patient was discharged with the aid of a walking stick three months after TEVAR.

Surgical repair of coronary artery to pulmonary artery fistula with aneurysms.

A 58-year-old female was referred to our hospital with an abnormal shadow on her chest X-ray. Further examination revealed the left anterior descending coronary artery to pulmonary artery fistula with aneurysms. The patient was successfully repaired with operation and had no residual fistulas and aneurysms.