[Aortic Dissection with Fistula between the Sinus of Valsalva and the Right Atrium:Report of a Case].

We report a case of a 72-year-old male with Stanford type A aortic dissection with a fistula between the sinus of Valsalva and the right atrium. Six years before, the patient had undergone coronary artery bypass grafting (CABG) using the left internal thoracic artery and two saphenous vein grafts. This time he was admitted to our hospital due to dyspnea. Computed tomography revealed Stanford type A aortic dissection. Conservative treatment was first adopted, because severe adhesion was expected after CABG and the false lumen of the aorta was partially thrombosed. However, heart failure could not be managed. Repeated transthoracic echocardiography revealed aorto-right atrial shunt. Retrospective reexamination of the echocardiography, the shunt had existed since admission. We performed replacement of the ascending aorta and reimplantation of the saphenous vein grafts. The patient recovered uneventfully.

[Descending Necrotizing Mediastinitis after Graft Replacement of the Thoracic Aorta:Report of a Case].

We report a case of a 64-year-old man with descending necrotizing mediastinitis. He had undergone ascending aortic replacement for Stanford type A acute dissection five years before, and thoracic endovascular aortic repair from the distal arch to the descending aorta for dilation of residual dissection three years before. The patient was admitted to our hospital complaining persistent fever, rubescent neck and chest. Computed tomography( CT) revealed a deep-seated mass extending between the neck and the right upper mediastinum and another mass around the ascending aorta graft. Computed tomography-guided drainage revealed infection of both masses. Surgical debridement, graft replacement, and omental flap transposition were performed. He recovered uneventfully, and no relapse of infection was observed.

Hypofibrinogenemia can be estimated by the predictive formula in aortic surgery.

OBJECTIVE: Aortic surgery often causes massive bleeding due to hypofibrinogenemia. Predicting hypofibrinogenemia is useful for developing a hemostasis strategy, including preparing for blood transfusion. We made a formula for predicting the serum fibrinogen level (SFL) at the termination of cardiopulmonary bypass (CPB) in aortic surgery and examined its validity. METHODS: We performed a retrospective observational study that consisted of 267 patients (group A) who underwent aortic surgery from July 2013 to December 2016 and made a formula for predicting the SFL at the termination of CPB in group A by a multiple linear regression analysis. The validity of this formula was then examined in another 60 patients (group B) who underwent aortic surgery from January 2017 to December 2017. RESULTS: We developed the following predictive formula: SFL at the termination of CPB (mg/dL) = 14.7 + 0.44 × preoperative SFL (mg/dL) + (- 0.14) × CPB time (min) + 0.64 × preoperative body weight (kg) + (- 17.3) × lateral thoracotomy (Yes/No, Yes: 1, No: 0). In group B, the predictive formula proved to be statistically valid in group B (R2 = 0.531, p < 0.001). CONCLUSION: The SFL at the termination of CPB in aortic surgery can be predicted by the preoperative SFL, body weight, CPB time and surgical approach. The predictive formula is useful for developing a hemostasis strategy, including preparing for blood transfusion.

Worsening renal function after transcatheter aortic valve replacement and surgical aortic valve replacement.

Several prior reports have investigated worsening renal function around transcatheter aortic valve replacement (TAVR) procedures. However, in clinical practice, it seems more important to evaluate changes associated with TAVR-related procedures, including preoperative enhanced computed tomography (CT), as well as the TAVR procedure itself, as CT assessment is considered essential for safe TAVR. This study evaluated worsening renal function during the TAVR perioperative period, from the preoperative enhanced CT to 1 month after TAVR, and then compared the incidence with that in patients undergoing surgical aortic valve replacement (SAVR). This retrospective single-center study investigated 123 TAVR patients and 130 SAVR patients. We evaluated baseline renal function before enhanced CT in TAVR patients and before operation in SAVR patients, and again at 1 month post-operatively. We defined worsening renal function at 1 month according to three definitions: (1) an increase in serum creatinine ≥ 0.3 mg/dL or ≥ 1.5-fold from baseline or initiation of dialysis, (2) a decline in eGFR at 1 month ≥ 20% from baseline or initiation of dialysis, (3) a decline in eGFR at 1 month ≥ 30% from baseline or initiation of dialysis. TAVR patients were significantly older and had higher surgical risk scores than SAVR patients. In TAVR patients, serum creatinine levels were 1.00 ± 0.32 mg/dL at baseline and 1.01 ± 0.40 mg/dL at 1 month post-operatively (p = 0.58), while in SAVR patients, these levels were 0.99 ± 0.51 mg/dL and 0.98 ± 0.49 mg/dL, respectively (p = 0.59). In TAVR patients, 7 (5.7%), 14 (11.4%), and 3 (2.4%) patients experienced worsening renal function according to the three definitions, respectively, but there were no significant differences from those in SAVR patients, for any definition. Worsening renal function after TAVR was uncommon, and the incidence rate was comparable to that in SAVR patients, even though TAVR patients had worse baseline characteristics.

Spinal cord injury following aortic arch replacement.

PURPOSE: Postoperative spinal cord injury is a devastating complication after aortic arch replacement. The purpose of this study was to determine the predictors of this complication. METHODS: A group of 254 consecutive patients undergoing aortic arch replacement via median sternotomy, with (n = 78) or without (n = 176) extended replacement of the upper descending aorta, were included in a risk analysis. The frozen elephant trunk technique was used in 46 patients. The patients' atherothrombotic lesions (extensive intimal thickening of > 4 mm) were identified from computed tomography images. RESULTS: Complete paraplegia (n = 7) and incomplete paraparesis (n = 4) occurred immediately after the operation (permanent spinal cord injury rate, 1.97%; transient spinal cord injury rate, 2.36%). A multivariable logistic regression analysis identified the use of the frozen elephant trunk technique (odds ratio 36.3), previous repair of thoracoabdominal aorta or descending aorta (odds ratio 29.4), proximal atherothrombotic aorta (odds ratio 9.6), chronic obstructive lung disease (odds ratio 7.1) and old age (odds ratio 1.1) as predictors of spinal cord injury (p < 0.0001, area under curve 0.93). CONCLUSIONS: Spinal cord injury occurs with a non-negligible incidence following aortic arch replacement. The full objective assessment of the morphology of the whole aorta and the recognition of the risk factors are mandatory.

The incidence and risk factors of hypofibrinogenemia in cardiovascular surgery.

OBJECTIVE: Cardiovascular surgery often causes massive bleeding due to coagulopathy, with hypofibrinogenemia being a major causative factor. We assessed the intraoperative incidence of hypofibrinogenemia and explored predictors of hypofibrinogenemia. METHODS: The intraoperative serum fibrinogen level (SFL) was routinely measured in 872 consecutive patients [mean age: 66.9 ± 13.3 years; 598 men (68.6%)] undergoing cardiovascular surgery from July 2013 to November 2016 at Nagoya University Hospital. There were 275 aortic surgeries, 200 cases of coronary artery bypass grafting (CABG), 334 valvular surgeries and 63 other surgeries. We estimated hypofibrinogenemia incidence (intraoperative lowest SFL ≤ 150 mg/dL) and identified its predictors by a logistic regression analysis. RESULTS: The average intraoperative lowest SFL of all cases, aortic surgery, CABG and valvular surgery was 185 ± 71, 156 ± 65, 198 ± 69 and 198 ± 68 mg/dL, respectively. Aortic surgery had a significantly lower intraoperative lowest SFL than CABG (p < 0.001) and valvular surgery (p < 0.001). The incidence of hypofibrinogenemia was 32.8%, 50.2%, 26.5% and 22.8% in all cases, aortic surgery, CABG and valvular surgery, respectively. The predictors of hypofibrinogenemia were the preoperative SFL, re-do surgery and perfusion time. A receiver operating characteristics curve analysis showed that the best preoperative SFL cutoff value for predicting hypofibrinogenemia was 308.5 mg/dL. Assuming preoperative SFL 300 mg/dL as the cutoff, the odds ratio for hypofibrinogenemia was 7.22 (95% confidence interval 5.26-9.92, p < 0.001). CONCLUSIONS: The incidence of hypofibrinogenemia in aortic surgery was high. The preoperative SFL, re-do surgery and perfusion time were identified as predictors for hypofibrinogenemia. Intraoperative measurement of SFL is important for detecting hypofibrinogenemia and applying appropriate and prompt transfusion treatment.

Intrapericardial lipoma compressing the right atrium.

We report a case of intrapericardial lipoma compressing the right atrium. Cardiac lipomas are very rare benign tumors that may cause life-threatening complications by rapid growth. A 67-year-old woman presented with dyspnea and palpitations on effort due to compression of the right atrium. The tumor was surgically resected. There was no local recurrence after surgery.

[Right Atrial Rupture due to Blunt Trauma;Report of a Case].

The survival rate of cardiac rupture due to blunt trauma is generally low. We report a case of surgical treatment of blunt cardiac trauma. A 55-year-old man was admitted to our hospital for blunt trauma due to a car accident. His hemodynamics was compromised due to cardiac tamponade. The patient underwent pericardial drainage by small subxiphoid incision. Although about 400 ml of blood was evacuated, hemorrhage was still continuing. After full sternotomy, we found a 3 mm tear in the right atrial appendage and sutured it easily without cardiopulmonary bypass. The patient recovered uneventfully and was discharged on the 10th postoperative day. He is now leading a normal life.

Analysis of myocardial temperature changes in conventional isolated coronary artery bypass grafting.

BACKGROUNDS: To determine whether cold blood cardioplegia (CBCP) can get over coronary artery lesions, we analyzed the relationship between myocardial temperature changes and lesion severity of major coronary arteries. METHODS AND RESULTS: From April 1991 to October 2003, we measured myocardial temperature before and after antegrade and retrograde delivery of CBCP in 492 patients undergoing conventional coronary artery bypass grafting. Stenotic severity of three major coronary arteries was classified into four grades according to preoperative coronary arteriography; grade 0 for 50 % or less, 1 for 75 %, 2 for 90 %, 3 for 99 % or 100 %. We analyzed relationships between myocardial temperature changes [ΔT-A (antegrade) & ΔT-R (retrograde)] and the coronary artery lesion's severity. Average ΔT-A of the right coronary artery had no relationship with stenotic grades. Mean ΔT-A of the left anterior descending (LAD) became less and less in proportion to its stenotic grade [9.7 °C for grade 0, 8.2 °C for grade 1, 7.1 °C for grade 2, and 6.0 °C for grade 3, respectively, (p = 0.0042)]. ΔT-A of the circumflex artery showed similar but weaker tendency than those of LAD. Significant inverse correlations were found between ΔT-A and ΔT-R1 in each territory (p < 0.001). CONCLUSIONS: Antegrade delivery was less effective in situations with tight proximal lesion, especially in the LAD territory. Retrograde delivery supplemented antegrade delivery. Myocardial temperature monitoring enables us to deal with inadequate cardioplegic delivery, and is a good indicator of myocardial protection.