[The Role of Corrugated Bioresorbable Sheet for Bone Fixation after Median Sternoto].

OBJECTIVES: Performing sternal reconstruction after a median sternotomy using a corrugated bioresorbable sheet composed of poly-L-lactide acid and hydroxyapatite can improve the safety and efficacy of the treatment outcome and promote bone healing. METHODS: We compared treatment outcomes of 53 patients who underwent sternal closure using a corrugated sheet (group P) from October 2018 with retrospectively evaluated outcomes of 57 patients who underwent sternal closure using a sternal pin-type device( group C). RESULTS: Sternal wound infection was not observed in either group. Significant sternal dehiscence was not observed in group P, but it was seen in three cases in group C( p=0.0449). Incomplete approximation by wire cutting was observed in 3% of patients in group P and 15% of patients in group C( p=0.0645). Displacement in the antero-posterior direction was 1.35 mm in group P and 1.67 mm in group C (p=0.0707). The drain discharge volume during 12 hours after operation was 175 ml for group P and 220 ml for group C (p=0.1958), while the total drain discharge volume was 380 ml for group P and 622 ml for group C( p=0.0068). The mean hospital stay was 23.9 days for group P and 26.3 days for group C( p=0.3637). CONCLUSIONS: The total volume of drain discharge significantly decreased when a bioresorbable corrugated sheet was used for sternal closure. We also consider that the bioresorbable corrugated sheet may improve repair of the split sternum and could result in decreased sternal dehiscence.

[Effects of Olmesartan Medoxomil on Patients with Thoracic and Thoracoabdominal Aortic Aneurysm;Evaluation of Anti-hypertensive Effect and Possible Suppression of Aneurysmal Dilation( OLM 40 Study)].

We evaluated the blood pressure( BP) lowering effect and possible suppression of aortic enlargement by olmesartan (OLM) in patients with thoracic and thoracoabdominal aortic aneurysm. In this single center prospective, forced titration study, 50 patients were registered between 2008 and 2011. After all patients received any of OLM 10, 20, and 40 mg/day as an initial dose, the dosage of OLM was titrated up to 40 mg as needed during follow-up period. Home BP (HBPs), aortic aneurysm size assessed by computed tomography (CT) scan, indices of renal function were recorded at 3- and 6-months follow-up. Depending on whether 40 mg/day of prescription was continued for more than 4 months or not, the patients were divided into 2 groups:less than 40 mg (<40 mg) and 40 mg groups. Morning HBPs tended to decrease in both groups, and the percent changes in BPs were essentially the same regardless of dosage. The absolute value of aortic diameter tended to slightly enlarge only in <40 mg group. Also in the <40 mg group, the absolute differences in aortic diameter between those at the time of study registration and each follow-up were 0.5±1.8 mm at 3-month and 1.2±2.3 mm at 6-month (p=0.047),whereas the percent changes were 0.9±3.3% and 2.2±4.5% at 3 and 6 months, respectively( p=0.058). As for 40 mg group, the absolute differences and percent changes did not reach statistically significant increase during the follow-up period. No severe renal dysfunction related to OLM 40 mg prescription was observed. Our results imply that OLM 40 mg may suppress aortic aneurysmal dilation independently of blood pressure lowering effect. Further study with larger number of sample size is warranted to assure this observation.

Predictors of the need for pacemaker implantation after the Cox maze IV procedure for atrial fibrillation.

PURPOSE: The Cox maze IV (CMIV) procedure is being used increasingly frequently for surgical ablation of atrial fibrillation (AF). This study aimed to identify the risk factors of the need for postoperative pacemaker implantation (PMI) after CMIV. METHODS: Preoperative, intraoperative, and postoperative data were retrospectively collected from 67 consecutive patients who underwent CMIV at our institution; 7 (10.4%) required PMI (as a treatment of brady AF or sick sinus syndrome). RESULTS: Patients who needed PMI tended to have lower preoperative heart rates than those who did not on a 12-lead electrocardiogram (ECG; 68.7 ± 11.6 vs. 79.1 ± 18.5 bpm, p = 0.07) and a 24-h ECG (94,772 ± 9800 vs. 109,854 ± 19,078 beats/day, p = 0.03). A multivariate analysis identified a low amplitude of the fibrillatory wave on preoperative ECG as a risk factor of PMI necessity after CMIV [odds ratio = 14.7; 95% confidence interval (CI) 1.9-324.7; p = 0.007] and internal use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) as a negative risk factor (odds ratio = 0.16; 95% CI 0.02-0.99; p = 0.049). CONCLUSIONS: A low amplitude of the fibrillatory wave was identified as a risk factor of PMI necessity, whereas the internal use of ACEIs/ARBs diminished the need for PMI. These factors should be considered before CMIV is performed.

Conversion from long-term AB-5000 to EVAHEART using a combined left thoracotomy and sternotomy approach.

Because of the extreme donor shortage in Japan, waiting times for heart transplantation exceed 2 years. Since 1980s in Japan, device availability has also been an issue, with only a few paracorporeal ventricular assist devices (VADs) available as a bridge to transplantation or recovery. However, two implantable VADs became commercially available in 2011. Given these constraints in our healthcare system, we report a relatively rare case of bridge-to-bridge use of an implanted EVAHEART after having used a paracorporeal AB-5000 support for an extended period of time. We successfully employed a combined left thoracotomy and median sternotomy approach as a conversion technique.

[Successful treatment using recombinant thrombomodulin for disseminated intravascular coagulation associated with recurrent prosthetic valve endocarditis].

Prosthetic valve endocarditis(PVE)occasionally evokes sepsis and disseminated intravascular coagulation(DIC). A 46-year-old man developed relapsing active PVE with an annular abscess and suffered from exacerbating sepsis and DIC. Despite the administration of antibiotics, his DIC score increased. Anti-DIC treatment with recombinant thrombomodulin (rTM) was initiated, and his DIC was remarkably resolved. Accordingly, the abscess cavity was closed by using a homograft anterior mitral leaflet, and the aortic root was replaced with the homograft. He is doing well without an evidence of recurrent endocarditis 18 months after the operation. rTM is a new and promising drug for the treatment of DIC with infective endocarditis.

Post-traumatic giant thrombosis of inferior vena cava induced right-sided blunt traumatic diaphragmatic injury: a case report.

BACKGROUND: Inferior vena cava thrombosis is a severe disease as it carries a higher risk of developing pulmonary embolism associated with a high mortality rate. The incidence of inferior vena cava thrombosis is extremely low and is commonly associated with outflow obstruction of the inferior vena cava. The frequency of traumatic diaphragmatic injuries is less than 1% of all traumatic injuries. In addition, it was not a typical cause of inferior vena cava obstruction. We report the case of the patient who presented with giant thrombosis of the inferior vena cava, which required surgical treatment-induced right-sided blunt traumatic diaphragmatic injury. CASE PRESENTATION: A 60-year-old male presented to the emergency department with pelvic and lower leg pain. He was working on a dump truck with the bed raised position. Suddenly, the bed came down, and his body was crushed and injured. Primary CT showed a right lung contusion and elevation of the right diaphragm but no apparent liver injury. The right pleural effusion gradually worsened after admission, as the traumatic diaphragmatic injury was highly suspected. Repeat CT showed aggravation of elevation of the right-sided diaphragm, narrowing of the inferior hepatic vena cava due to left cephalic deviation of the liver, and formation of a giant thrombus in the inferior vena cava. No adverse hemodynamic effects were observed due to thrombus formation, and we performed thrombolytic therapy. The day after starting thrombolytic therapy, the patient developed pulmonary embolism due to a dropped in SpO2 needed oxygen, and dyspnea triggered by coughing. Thrombolytic therapy was continued after the diagnosis of pulmonary embolism. However, thrombolytic therapy was ineffective, so we decided on surgical thrombectomy and inferior vena cava filter placement. The postoperative course was not eventful, and an anticoagulant was started. The patient was transferred to the hospital on the 62nd day for rehabilitation. CONCLUSIONS: When a diaphragmatic hernia is suspected of causing hepatic hernia and narrowing of the inferior vena cava, it may be necessary to consider emergency surgical treatment to prevent secondary inferior vena cava thrombosis and fatal pulmonary embolism.

[Successful repair of sealed-ruptured pararenal abdominal aortic aneurysm with left-sided inferior vena cava employing the technique for thoracoabdominal aortic aneurysm repair].

We describe a case with pararenal abdominal aortic aneurysm associated with anomalous inferior vena cava. We applied the technique similar to that employed in the thoracoabdominal aneurysm repair consisting of mild hypothermic cardiopulmonary bypass and selective visceral perfusion. Replacement of the abdominal aorta and reconstruction of the left renal artery were completed without an injury to the anomalous vein.

[Successful preoperative respiratory rehabilitation in patients with aortic valve stenosis associated with severe respiratory dysfunction].

We describe 2 cases of aortic valve stenosis with severe pulmonary dysfunction. Preoperative respiratory rehabilitation programmed by the rehabilitation doctors was cautiously undertaken to improve their exercise tolerance and respiratory reserve. These 2 patients underwent aortic valve replacement eventually. Postoperative course in each patient was uneventful without respiratory complication. Preoperative respiratory rehabilitation can be performed in the high risk patient with severe pulmonary dysfunction as long as careful risk management is guaranteed.

[Distal aortic repair after aortic arch replacement].

BACKGROUND: It is crucial to expose the proximal aorta in distal aortic repair, i.e., replacement of the descending thoracic aorta (DTA) or the thoracoabdominal aorta (TAA), after aortic arch replacement. With the elephant trunk (ET), it is usually easy to expose and clamp it. On the other hand, without the ET, it may be difficult or impossible to expose the proximal aorta and deep hypothermic circulatory arrest (DHCA) will be required. METHODS: Between April 1989 and March 2007, 17 patients underwent distal aortic repair after aortic arch replacement. Five patients underwent replacement of DTA and 12 of TAA. Five patients without the ET needed DHCA and open proximal anastomosis [OP (+) group], while in 12 patients, the ET or proximal aorta was successfully clamped [OP (-) group]. RESULTS: The mean extracorporeal circulation time in OP (+) group was significantly longer than that in OP (-) group (415 +/- 131 min v.s. 267 +/- 109 min, p < 0.05). There was no hospital death, cerebral infarction, fatal arrhythmia or low output syndrome in either group, and paraplegia in 2 patients and renal failure requiring hemodialysis in one were found only in OP (+) group. CONCLUSION: The ET procedure enables to avoid DHCA and may contribute to improving operative results in distal aortic repair after aortic arch replacement.

Marchiafava-Bignami disease with haemophagocytic lymphohistiocytosis as a postoperative complication of cardiac surgery.

Marchiafava-Bignami disease (MBD) is a rare complication of chronic alcoholism; however, MBD in a non-alcoholic diabetic patient has rarely been reported. The aetiology or pathophysiology of MBD is still unknown. A 50-year-old man with a history of untreated diabetes mellitus underwent on-pump beating coronary artery bypass graft surgery (CABG) surgery for three-vessel and left main coronary disease. 3 days after the surgery, he developed a fever over 40°C and entered a coma state. MRI revealed multiple lesions, including in the corpus callosum, globus pallidus, brain stem and upper cervical spinal cord, which suggested MBD. The patient did not respond to thiamine therapy, but partly responded to steroid therapy. He ultimately died of respiratory failure. The autopsy revealed MBD and haemophagocytic lymphohistiocytosis. It is rare, but systemic inflammatory response syndrome induced by on-pump beating CABG could develop these complication.

Differential selective hypothermic intercostal artery perfusion: a new method to probe spinal cord perfusion during thoracoabdominal aortic aneurysm repair.

OBJECTIVE: To prevent paraplegia in patients undergoing thoracoabdominal aortic aneurysm repair, the importance of preoperative identification of the Adamkiewicz artery and reconstruction of critical intercostal artery have been advocated. Conversely, significance of collateral network for spinal cord perfusion has been recognized. We invented a new system consisting of a direct monitoring of cerebrospinal fluid temperature (CSFT) and differential selective hypothermic intercostal artery perfusion (D-HIAP). METHODS: After exposing a critical intercostal artery, a 10-mm prosthetic graft was anastomosed in an end to side fashion. A balloon-tipped catheter was inserted into the graft to perfuse with 15 °C blood. Neighboring intercostal arteries were also perfused in the same fashion. Serial monitoring of CSFT was performed. Between January 2011 and January 2015, D-HIAP was employed in 50 patients with Adamkiewicz artery that located within a reconstructed area. RESULTS: Significant CSFT drop was recorded after initiation of D-HIAP in 42 (84%) patients. Of those, 34 (68%) patients showed significantly lowered CSFT with D-HIAP into a single critical intercostal artery. Perfusion into plural intercostal arteries was necessary for CSFT drop in 2 cases (4%), and plural intercostal artery perfusion further enhanced CSFT drop that had been modestly achieved by single intercostal artery perfusion in 6 cases (12%). Eight (16%) patients did not exhibit a significant drop in CSFT even when D-HIAP was employed for the critical and neighboring intercostal arteries. CONCLUSIONS: The detection of a disparity in temperature between the intrathecal space and blood generated by D-HIAP revealed individual variability in CSFT changes, which may imply a complexity in spinal cord perfusion. Intraoperative D-HIAP may help to identify a major blood supply for spinal cord perfusion and underlying collateral network.

Suppressive effect of pitavastatin on aortic arch dilatation in acute stanford type B aortic dissection: analysis of STANP trial.

OBJECTIVES: Medical therapy for patients with uncomplicated acute type B aortic dissection (ABAD) is essentially accepted for its excellent early outcome; however, long-term outcomes have not been satisfactory due to aorta-related complications. This trial was performed to investigate the efficacy of a statin as an additive that may enhance the effectiveness of conventional medical treatment in patients with ABAD. METHODS: This was a multi-center, prospective, and randomized comparative investigation of patients with uncomplicated ABAD. Fifty patients with ABAD compatible with inclusion criteria were randomly assigned to two groups and then received administration of pitavastatin (group P) or not (group C). We followed up the patients for 1 year from study onset. RESULTS: Two patients demised during the follow-up period (both were in group C). In addition, aorta-related interventions were performed in two patients (entry closure for aortic dissection by endovascular repair in one patient in each group). Aortic arch diameters at 1 year in group P tended to be smaller than in group C (P = 0.17), and the rate of change of the aortic arch diameters from onset to 1 year was significantly lower in group P (P = 0.046). Multivariate analysis identified patency of the false lumen was detected as a risk factor for aortic arch dilatation (P = 0.02), and pitavastatin intake was a negative risk factor (P = 0.03). CONCLUSIONS: Pitavastatin treatment, in addition to the standard antihypertensive therapy, may have a suppressive effect on aortic arch dilatation in patients with ABAD.

Predictors of Heparin Resistance Before Cardiovascular Operations in Adults.

BACKGROUND: Heparin resistance (HR) is often encountered during cardiovascular operations that require cardiopulmonary bypass. Clinical risk factors and the mechanism underlying heparin resistance are yet to be determined. The aim of this study was to elucidate the clinically valid preoperative predictors related to HR. METHODS: The study evaluated 489 patients undergoing cardiovascular operations. Of these, 25 patients presented with HR and received antithrombin III for the initiation of cardiopulmonary bypass with an effective activated coagulation time. The remaining 464 patients, who did not receive antithrombin III, served as controls (NHR). Preoperative patient demographic and laboratory data were analyzed to identify risk factors for HR. RESULTS: The preoperative laboratory data showed platelet count, fibrinogen, D-dimer, creatinine, and C-reactive protein were significantly higher in the HR group than in the NHR group. As expected, the antithrombin III level was significantly lower overall in the HR group (86.0% vs 95.5%, p = 0.009); however, 80% of the patients in the HR group showed normal antithrombin III levels preoperatively. Multivariable logistic regression analysis identified chronic aortic dissection, chronic obstructive pulmonary disease, smoking, and elevated fibrinogen levels as independent predictors for HR. CONCLUSIONS: HR was shown to be associated with preoperative high fibrinogen levels, a smoking habit, and a preoperative diagnosis of chronic, but not acute, aortic dissection, with chronic obstructive pulmonary disease as comorbidity. Administration of antithrombin III resolved HR in all of the affected patients, even when their preoperative antithrombin III level was within the normal limit.

Surgical removal of calcified amorphous tumor localized to mitral valve leaflet without mitral annular calcification.

A cardiac calcified amorphous tumor (CAT) localized to the mitral valve leaflet without mitral annular calcification (MAC) is a rare entity. We report a case of a 69-year-old woman with such a condition, who underwent successful excision of the tumor and mitral valvuloplasty using a glutaraldehyde-treated autologous pericardium. During 38 months of follow-up, no recurrence of a cardiac mass has been recognized. This report addresses questions on the surgical indication for CAT, particularly in cases without MAC, and reviews CATs of the mitral valve.

Outcomes of a staged surgical treatment strategy for aortoesophageal fistula.

BACKGROUND: Evolution of thoracic endovascular aortic repair (TEVAR) appears to have influenced the pathogenesis and treatment strategy for aortoesophageal fistula (AEF). The purposes of this study are to evaluate our current surgical strategy for AEF and to provide insight to further improve the prognosis of such a devastating condition. METHODS AND RESULTS: Between 2005 and 2013, we retrospectively reviewed the clinical charts of 10 patients requiring surgical treatment for AEF in Tohoku University Hospital. Four cases were primary and 6 were secondary. Initially, bridging TEVAR to control bleeding with concomitant subtotal esophagectomy and complete debridement of infected mediastinal tissue was performed. After a short interval, the patients underwent in situ aortic replacement with cryopreserved homografts or rifampicin-bonded Dacron grafts with omentopexy. Esophageal reconstruction was planned following general physical status improvement after 3-6 months. In-hospital mortality in the acute phase was 30%. Although the completion of the staged strategy achieving successful esophageal reconstruction was possible in 5 patients, no local relapses of infection were observed in these patients. Overall survival at 1 and 5 year were 68.6 and 42.9%, respectively. CONCLUSIONS: The staged surgical treatment strategy for AEF consisted of prompt TEVAR to control bleeding with concomitant subtotal esophagectomy and subsequent in situ reconstruction of the aorta with an aortic homograft. This procedure enabled us to control local mediastinal infection with acceptable mortality. Avoiding delay in the diagnosis and initial treatment and resolving complications at each treatment step should further improve AEF treatment.

Contemporary outcome of the surgical management of prosthetic graft infection after a thoracic aortic replacement: is there a room to consider vacuum-assisted wound closure as an alternative?

OBJECTIVE: Once a replaced prosthetic graft is infected, it is usually necessary to re-replace the thoracic aorta to achieve complete resolution of the infection. It is, however, an exceedingly invasive approach to perform such a repeat surgery on patients in a poor condition. We have managed both re-replacement of an infected prosthetic graft and conservative therapy with vacuum-assisted wound closure (VAC) without re-replacement. These two treatment modalities were retrospectively assessed. METHODS: Retrospective clinical chart review was undertaken on 21 patients with prosthetic graft infection after thoracic aortic replacement between December 1999 and December 2012. Surgical outcomes were evaluated between the two groups: re-replacement group (group R, n = 14) and no-replacement group (group NR, n = 7). RESULTS: In-hospital survival rates were 64.3% in group R and 85.7% in group NR. Mortality in group R included five patients, sepsis in two patients, and intraoperative aortic rupture, heart failure, and cerebral infarction in one. Mortality in group NR included one patient (sepsis). In terms of long-term outcome, one patient in group R and one patient in group NR died of rupture of a residual aortic aneurysm, and one patient in group NR died of renal disease during follow-up (52.8 ± 41.5 months for R and 43.2 ± 28.5 months for NR; mean ± standard deviation). CONCLUSIONS: Re-replacement of an infected prosthetic graft after a thoracic aortic operation still carries a significant risk for mortality. VAC therapy may provide an acceptable option for such a subgroup of patients with this serious condition.

Clinical features and long-term outcome of type A and type B intramural hematoma of the aorta.

OBJECTIVE: Most previous reports on intramural hematoma of the aorta have focused on the initial episode. The purpose of this study was to clarify the long-term outcome of intramural hematoma of the aorta. METHODS: Ninety-four cases of intramural hematoma of the aorta (41 type A and 53 type B) were reviewed. There were 69 male and 25 female patients, and their mean age was 66.7 +/- 8.7 years (range, 46-88 years). RESULTS: Eleven (27%) of the patients with type A hematoma and 1 (2%) of the patients with type B hematoma underwent early surgical intervention. Others were treated medically, and the overall hospital mortality was 7% for patients with type versus 2% for patients with type B intramural hematomas of the aorta (P =.315). Twenty-three patients, 9 (22%) with type A and 14 (26%) with type B intramural hematomas of the aorta, underwent late surgical intervention during the follow-up period, and there were no hospital deaths. A total of 23 patients died during the follow-up period, including 6 of intramural hematoma of the aorta-related deaths (3 in the type A group and 3 in the type B group). The estimated freedom from intramural hematoma of the aorta-related events at 1 and 5 years was 70% +/- 8% and 54% +/- 11% for the type A group versus 73% +/- 6% and 58% +/- 8% for the type B group, respectively (P =.972). After excluding the nonintramural hematoma of the aorta-related deaths, the survival rates at 5 and 10 years were 80% +/- 9% and 80% +/- 9% for the type A group and 91% +/- 8% and 81% +/- 11% for the type B group (P =.211). CONCLUSIONS: Intramural hematoma of the aorta-related events occur equally in both types of intramural hematoma of the aorta. We recommend close follow-up for at least 5 years because most intramural hematoma of the aorta-related events occur during this period.

Management of patients with intramural hematoma involving the ascending aorta.

OBJECTIVE: Although intramural hematoma of the aorta is considered a unique pathologic entity, the management of intramural hematoma involving the ascending aorta (type A) has not been well established. The purpose of this study was to establish the optimal mode of management of type A intramural hematoma. METHODS: We treated patients with type A intramural hematoma as follows. Early operation was carried out only for patients with cardiac tamponade, impending rupture, or rupture. Other patients were treated medically, but patients with progression of intramural hematoma during medical follow-up had their treatment converted to surgery. From February 1992 to March 2001, a total of 33 patients with type A intramural hematoma were treated as described here. Patients were divided according to initial treatment into an early surgery group (n = 9) and a medical treatment group (n = 24). Clinical profiles and in-hospital and long-term survival rates were compared between the groups. RESULTS: Compared with the early surgery group, the medical treatment group was younger (64.2 +/- 7.0 years vs 71.7 +/- 8.5 years, P =.0319) and had a greater number of involved segments (3.6 +/- 0.6 vs 3.0 +/- 0.9, P =.0395). Eight patients in the medical treatment group were switched to surgery during follow-up because of progression of intramural hematoma. In-hospital mortality rates in the early surgery and medical groups were 11% and 5% (P =.477), respectively. Cumulative 1- and 2-year survivals were 89% and 89%, respectively, in the early surgery group, and 92% and 81%, respectively, in the medical group (P =.49). CONCLUSION: We concluded that about 70% of type A intramural hematomas could be managed expectantly, and more than 50% could be treated medically alone.

Ascending aortic replacement through right thoracotomy.

A 62-year-old woman with a history of esophageal resection and colon interposition with anterosternal subcutaneous tunnel required replacement of the ascending aorta due to dissecting aortic aneurysm. Preoperative three-dimensional computed tomography enabled us to reveal that right thoracotomy could offer an ascending aortic operation. The patient underwent successful operation under hypothermic circulatory arrest and the right anterolateral thoracotomy provided safe exposure of the diseased ascending aorta even when the suprasternal tunnel precluded conventional median sternotomy.