Surgical Strategy for Chronic Type B Dissecting Aortic Aneurysm to Prevent Aorta-Related Events.

BACKGROUND: This study was aimed to evaluate the outcomes of performing open repair or thoracic endovascular aortic repair for chronic type B dissecting aortic aneurysm. METHODS: From July 2004 to February 2019, 52 patients underwent surgery as open repair (n = 32) or endovascular repair (n = 20) for chronic type B dissecting aortic aneurysm. Replacement of the aorta was limited to the aneurysmal portion with or without reconstructing the visceral arteries or the segmental arteries. Stent grafts were deployed in the true lumen above the celiac artery to cover the primary entry for even DeBakey IIIb dissection. RESULTS: Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. In the endovascular repair group, 3 patients died due to rupture of residual false lumen in the early, and late postoperative follow-up. The 5-year rate of freedom from all-cause death, aorta-related death, and aorta-related event were 84% ± 6%, 94% ± 3% and 84% ± 6%. The endovascular repair was independently associated with all-cause death (hazard ratio [HR], 5.7; confidence interval [CI], 1.02-31.6; P = 0.04) and aorta-related event (HR, 30.9; CI 4.9-195.0; P < 0.001). In the open group, postoperative residual aortic diameter was an independent predictor of aorta-related events, and the threshold was 41 mm. CONCLUSIONS: Open repair remains a better option than simple endovascular repair alone in DeBakey IIIb dissection, but the distal un-resected aortic portion over 41 mm was associated with late aortic events.

Hypo-attenuated leaflet thickening and reduced leaflet motion after the implantation of the Perceval S sutureless bioprosthesis.

Hypo-attenuated leaflet thickening (HALT) is gaining attention as a relatively common issue after surgical or transcatheter aortic valve replacement (AVR). However, only a few reports have described HALT in sutureless bioprosthesis, which has emerged as a promising tool with excellent hemodynamics and enhanced implantability. We herein report a 75-year-old woman who underwent quintuple coronary artery bypass grafting and sutureless AVR with a Perceval S bioprosthesis (LivaNova PLC, London, UK). Despite an uneventful perioperative course, her recovery was slow with persistent pleural effusion. Echocardiography revealed an increased transvalvular pressure gradient, and HALT was confirmed by computed tomography. The patient received aggressive anticoagulation therapy with resolution of the HALT and made an uneventful recovery. Current guidelines provide no specific recommendations for peri-procedural antithrombotic therapy for sutureless AVR. However, HALT is not rare after sutureless AVR and can lead to significant clinical consequences. In this case, aggressive anticoagulation therapy with systemic heparinization was effective as HALT treatment following early post-sutureless AVR. Further investigation is required to determine the optimal antithrombotic strategy for sutureless AVR.

Sutureless aortic valve replacement with concomitant aortic arch reconstruction.

Sutureless aortic valve replacement (AVR) offers an alternative approach to the standard AVR in aortic valve disease. We herein report a case of an 82-year-old woman with severe aortic insufficiency and a persistent type 1 endoleak following a thoracic endovascular aortic repair, who underwent successful combined aortic arch reconstruction and sutureless AVR. The bioprosthesis, Perceval (LivaNova PLC, London, UK), a self-anchoring, self-expanding, sutureless valve, which can be implanted in selected patients with aortic insufficiency was used. Although the patient was frail and at a high risk of open-heart surgery, she had an uneventful postoperative course. Hence, Perceval may be a useful option for combined aortic arch reconstruction and aortic valve surgery in high-risk elderly patients.

A Novel Approach to Prevent Perioperative Stroke in Patients Undergoing Debranching Thoracic Endovascular Aortic Repair with a Mini-Cardiopulmonary Bypass Support.

BACKGROUND: Perioperative stroke is a major complication after debranching thoracic endovascular aortic repair (TEVAR), with a reported incidence of 7.0-26.9%. Subsequent functional recovery is difficult in most cases. This study was performed to evaluate the efficacy of mini-cardiopulmonary bypass (mini-CPB) support in debranching TEVAR to prevent perioperative stroke. METHODS: From December 2010 to July 2017, 32 patients with a shaggy aorta or intimal irregularity in the aortic arch identified on preoperative computed tomography underwent debranching TEVAR. Nineteen patients underwent debranching TEVAR without mini-CPB, and 13 patients underwent debranching TEVAR with a mini-CPB support. Mini-CPB support had been used in November 2014 to treat perioperative stroke, which had occurred in 8 (42%) patients at that time. The form of the debranching arch vessels was not changed; bypass from the right axillary artery to the left axillary artery was performed for one debranching, and bypass from the right axillary artery to the left common carotid artery and left axillary artery was performed for two debranchings. After establishment of mini-CPB support through this debranching graft and right femoral vein cannulation, all endovascular manipulations were initiated. The left subclavian artery was occluded with a plug at the end of the procedure. RESULTS: The proximal landing zones of the endoprosthesis were as follows: zone 0 in 9 patients, zone 1 in 5 patients, and zone 2 in 5 patients in the no-CPB era and zone 1 in 3 patients and zone 2 in 10 patients in the CPB era. The mean mini-CPB support period was 51 minutes. Postoperative respiratory support and hospitalization were not prolonged with mini-CPB support. The incidence of perioperative stroke was 42% in the no-CPB era and 8% in the CPB era. No operative mortality was observed in the CPB era, although 5 (26%) patients died in the no-CPB era. The cause of operative mortality in the no-CPB era was perioperative stroke in 4 patients and acute myocardial infarction in 1 patient. No significant difference in the cumulative survival rate was found between patients with and without mini-CPB support. CONCLUSIONS: Our mini-CPB system may have the potential to prevent perioperative stroke during debranching TEVAR for treatment of aortic arch pathologies.

Endovascular Aortic Arch Repair with Mini-Cardiopulmonary Bypass to Prevent Stroke.

Debranching thoracic endovascular aortic repair for aortic arch pathology is an important alternative to total arch replacement. However, the problem of intraoperative stroke due to atherosclerotic changes in the aorta remains. We apply our minimally invasive mini-cardiopulmonary bypass system to prevent intraoperative stroke during the endovascular procedure. Once debranching from the right axillary artery to the left common carotid and the left axillary artery is constructed; only the brachiocephalic artery is a pathway to the brain. After mini-cardiopulmonary bypass using the debranching graft is established, all cerebral perfusions are not only maintained, but retrograde blood flow from the brachiocephalic artery to the aortic arch is secured. All endovascular procedures can be performed under this situation. Our technique could be effective for preventing intraoperative stroke for endovascular repair with the debranching method for aortic arch pathology.

Aortic valve prosthesis selection in dialysis patients based on the patient's condition.

Previous studies have examined outcomes in dialysis patients undergoing cardiac surgery. However, only a few studies have solely focused on outcomes after aortic valve replacement (AVR). This study aimed to clarify independent predictors of the long-term survival of dialysis patients with AVR and to determine whether a mechanical valve or bioprosthesis is suitable based on the patient's condition. A total of 38 consecutive dialysis patients who underwent AVR at our institute were reviewed (mean age 69.1 ± 9.4 years). There were 23 bioprostheses and 15 mechanical valve replacements. The operative mortality and the long-term survival were not different between the bioprosthesis and the mechanical valve group (13.0 vs. 13.3%). The significant multivariate predictors for long-term survival were concomitant coronary artery bypass grafting (CABG) and prosthesis size. Valve types and age at operation did not affect long-term survival. Five-year survival of patients with small prosthetic valves and concomitant CABG was 0%. When the patient's quality of life is taken into account, it may be appropriate to use a bioprosthesis in a dialysis patient with a small annulus and concomitant CABG even if the patient is young.

Temporary axillo-femoral bypass during open repair for abdominal aortic aneurysm: report of a case.

Open repair is the "gold standard" treatment for abdominal aortic aneurysm (AAA) and although considered safe, this operation is very invasive for high-risk patients with severe aortic valve stenosis (AS) because the left ventricular after-load changes sharply with the clamping and unclamping of the aorta. We prevented the change in left ventricular after-load by establishing a temporary axillo-bilateral femoral arterial shunt, which enabled us to perform open repair of an AAA safely in a patient with severe AS.

Papillary Muscle Reorientation for Systolic Anterior Motion After Mitral Valve Repair.

Systolic anterior motion (SAM) of the mitral valve is a well-known complication in mitral valve repair. Because excessive leaflet tissue is an important mechanism, surgical correction is sometimes required to reduce leaflet height or mobility. However, a different approach may be necessary in cases of normal leaflet height. Herein, we describe papillary muscle reorientation for treating SAM after isolated anterior leaflet repair. The papillary muscle heads were approximated and fixed to the posterior ventricular wall, relocating them away from the ventricular septum. This technique is useful for treating postrepair SAM, without addressing the leaflet, in patients with degenerative mitral disease.

Repair of pacemaker lead-induced right ventricular perforation via a left mini-thoracotomy.

Cardiac perforation is a rare but serious and life-threatening complication of permanent pacemaker implantation, with an incidence of 0.1-6%. Surgery is usually performed through a median sternotomy; however, sternotomy-related morbidity remains a concern. Herein, we report a case of surgical repair performed via a left mini-thoracotomy for a right ventricular perforation caused by implantation of a permanent pacemaker lead in a 56-year-old woman. Through the left fifth intercostal space, the pacemaker lead was observed to have penetrated the left ventricular myocardium, reaching the pericardium. The lead had passed through the right ventricle and the inferior ventricular septum and protruded from the left ventricular myocardium. After pacemaker lead removal, a dark blow-out type hemorrhage occurred; hence, repair was performed using a pair of pledgeted Mattress sutures. In conclusion, left mini-thoracotomy provides an adequate surgical field and has less impact on hemodynamics when operating at the cardiac apex. .

Perceval sutureless aortic valve replacement after ascending aortic replacement.

In patients with a narrow sinotubular junction, small sinus of Valsalva, or extensibility loss in the aortic root, aortic valve replacement (AVR) with a standard valve is challenging due to limited surgical field. Detailed preoperative measurements of the aortic root render performing AVR using the Perceval valve easy.

Inactive large cerebral hemorrhage is not exacerbated by the adjustment of anticoagulation post open-heart surgery.

Optimal timing of open-heart surgery for the treatment of patients with cerebral hemorrhage remains controversial because systemic heparinization may lead to catastrophic bleeding. Several recent reports have shown that patients who undergo open-heart surgery .within a few weeks of cerebral hemorrhage have a much lower risk of exacerbated bleeding than previously considered. Herein, we report a case of left atrial myxoma and large hemorrhagic embolic stroke, which was successfully operated on with no exacerbation of cerebral hemorrhage. Careful assessment of time-course changes in cerebral hemorrhage by neurological imaging and adjustment of anticoagulation can help prevent the exacerbation of postoperative cerebral hemorrhage and neurological deterioration. .

Titanium plate to fix crossed rib can cause cardiac tamponade: A cautionary note.

A 78-year-old woman diagnosed with an infected descending aortic aneurysm underwent graft replacement through a left rib-cross thoracotomy. She developed shock suddenly on the postoperative day 3 owing to cardiac tamponade. We performed emergent surgery and identified a small myocardial laceration in the left ventricular obtuse marginal area and a small perforation on the pericardium. One of the claws used to fix the titanium plate in the cross-rib repair caused this complication. This is a cautionary note regarding this type of titanium plate, which is used in many procedures.

Off-Pump Resection of an Epicardial Cyst by Using a Minimally Invasive Approach.

A 25-year-old man presented with palpitations and subsequently received a diagnosis of a large epicardial cyst (6.8 × 3.8 cm) originating from the left ventricle. The cyst compressed the left atrium and ventricle and led to left ventricular diastolic dysfunction. Contrast-enhanced chest computed tomography revealed that the circumflex artery passed over or through the cyst. We successfully resected the cyst without using cardiopulmonary bypass through a left mini-thoracotomy with thoracoscopic assistance. The diastolic dysfunction improved after the procedure. Most epicardial cysts may be treated in this fashion if the cyst is located in the left side of the heart.

Graft Traction Resolved Left Ventricular Outflow Tract Obstruction.

We admitted a 76-year-old woman for treatment of an ascending aortic aneurysm with left ventricular outflow tract (LVOT) obstruction and systolic anterior motion (SAM) of the mitral valve. Echocardiography showed an elevated velocity of the LVOT flow with a sigmoid septum. Mild mitral regurgitation was also detected due to SAM. We performed a graft replacement of the ascending aorta, after which the LVOT obstruction and SAM were resolved. We report a case in which the traction of a graft likely released the compression on the aortic root and ventricular septum.

Late reoperations after repair of acute type A aortic dissection.

BACKGROUND: Regarding surgical interventions for type A acute aortic dissection (AAD), it is currently unclear if an initial, less invasive approach followed by later reoperations is safer than an extended approach aimed at preventing future reinterventions. We retrospectively reviewed our surgical cases to clarify the safety of late reoperation after repair of acute AAD. METHODS: Since 2004, 17 patients (eight female; mean age: 64.1 +/- 9.3 years) of all 115 AAD cases in our institute underwent reoperations after initial repair of acute AAD, and operative factors were evaluated. RESULTS: Anastomotic pseudoaneurysms were the main reason for reoperation; one distal, seven proximal, and two both. Seven patients required surgical reintervention because of aneurysmal dilatation of the remaining aorta. The duration between the initial and late operations was 6.4 +/- 5.1 years in the anastomotic pseudoaneurysm group and 4.6 +/- 4.5 years in the recurrence group. In the anastomotic pseudoaneurysm group, there were three root replacements, four resuspensions of the aortic valve, and two aortic valve replacements. Six patients required replacement of the aortic arch. Total arch replacement was the most frequent operation in the recurrence group. Three patients who required sternum reentries underwent concomitant right thoracotomies to dissect adhesions between the sternum and the aneurysm. There were no mortalities. CONCLUSIONS: Although most cases required extended procedures for late reoperation after repair of acute AAD, reoperations can be performed safely by careful choice of appropriate operative methods and strategies. Our data suggest that ascending aortic replacement is an effective initial procedure for patients with acute AAD.

Usefulness of Glycemic Control Using an Artificial Pancreas Apparatus for Cardiovascular Surgery.

Blood glucose management is important for cardiovascular surgery using cardiopulmonary bypass. The usefulness of an artificial pancreas apparatus (STG-55) to control blood glucose in patients undergoing cardiopulmonary bypass was investigated. Subjects comprised 44 patients using the artificial pancreas during cardiopulmonary bypass between June 2016 and March 2017; 55 were initially enrolled, but 11 were excluded because of blood removal failure. Patients were divided into a monitoring group in which blood glucose levels were only monitored using the artificial pancreas (11 patients: six people with diabetes and 5 people without diabetes) and a management group with glycemic control by automatic insulin administration using the artificial pancreas (33 patients: people with diabetes and 21 people without diabetes). Mean maximum blood glucose levels and variation ranges significantly differed between the monitoring and management groups (p = 0.02). The variation range significantly differed between people with and without diabetes in the monitoring group (p = 0.008), but not in the management group. The artificial pancreas apparatus continuously and accurately reflected glycemic variations, facilitating strict and favorable control.

Usefulness of Abdominal Duplex Ultrasound for Detecting Endoleaks after Endovascular Aneurysm Repair.

Objective: The usefulness of abdominal duplex ultrasound (DUS) for the detection of endoleaks after endovascular aneurysm repair (EVAR) was evaluated. Materials and Methods: Among 286 patients who underwent EVAR between September 2007 and July 2017, 241 patients were followed up using abdominal DUS. Endoleaks were detected in 74 patients (31%), who were divided into enlarged and nonenlarged sac groups. Endoleak velocities and widths were measured using abdominal DUS every 6 months after EVAR and were compared between the 2 groups. Results: The aneurysm diameter in the nonenlarged sac group was 54.4±8.7 mm in the final follow-up. None of the patients in the nonenlarged sac group were subjected to reintervention, whereas all patients in the enlarged sac group were subjected to reintervention. The aneurysm diameter in the enlarged sac group was 62.8±8.8 mm at the time of reintervention, and the maximum endoleak flow velocities and endoleak widths were significantly higher in the enlarged sac group than in the nonenlarged sac group (p<0.05). The cutoff values on receiver operating characteristics curves for endoleak velocity and width were 83.4 cm/s and 4.0 mm, respectively. Conclusion: Follow-ups using abdominal DUS are useful after EVAR. Endoleak velocity and width measurements are important, and reintervention may be needed when these measurements exceed their cutoff values.

Long-term outcomes after entry closure and aneurysmal wall plication for type B aortic dissection.

OBJECTIVE: To examine the long-term outcomes after entry closure and aneurysmal wall plication for type B chronic dissecting aortic aneurysm. This procedure uses no artificial graft and preserves all intercostal arteries. METHODS: We reviewed the records of 40 consecutive patients who underwent this procedure between September 1983 and December 2002. The mean age at operation was 60+/-12 years (range, 38-79 years). The mean follow-up period was 9.8+/-5.1 years (range, 4-23 years). Follow-up was completed in 38 patients (95%). The latest computed tomography scans (n=22) were obtained 9.5+/-5.1 years (range, 3-18 years) after surgery. RESULTS: There were no operative deaths and 14 late deaths, none of which were related to the aneurysm. No paraplegia or paraparesis occurred. The survival rate was 92+/-4% at 5 years and 64+/-9% at 10 years; 24 patients are still alive. Follow-up computed tomography revealed that the mean diameter of the plicated descending aorta was 31+/-5mm (range, 22-39 mm) except in four patients. One of the four patients required reoperation for recurrent aneurysm of the plicated aorta 3 years postoperatively. In the remaining three patients, the plicated aorta has become enlarged; however, these patients have not yet undergone reoperation. Reoperation for residual dissecting aneurysm was performed in another three patients whose plicated aorta was normal. Freedom from reoperation for residual dissecting aneurysm was 78+/-5% at 10 years. CONCLUSIONS: This procedure produces excellent short-term outcomes and low long-term morbidity. It could be the procedure of choice in selected patients to prevent paraplegia, although graft replacement is currently the standard treatment for chronic aortic dissecting aneurysm.

Pretreatment with the Free Radical Scavenger Edaravone Mitigates Kidney Glycogen Depletion and Neutrophil Infiltration after Leg Ischemia in a Rat Model: A Pilot Study.

Objective: We have previously shown that pretreatment with the free radical scavenger edaravone (Radicut®, Mitsubishi Tanabe Pharma Co., Japan) mitigated skeletal muscle damage due to ischemia reperfusion. In this study, we sought to validate its use in an experimental model of myonephropathic-metabolic syndrome (MNMS). Methods: Either edaravone (3.0 mg/kg; edaravone group; n=4) or saline (saline group; n=6) was intraperitoneally injected into male Lewis rats (508±31 g). Normal kidneys were harvested as control (n=3). MNMS was induced by bilaterally clamping the common femoral arteries for 5 h and declamping 5 h later. Kidney damage was evaluated by quantifying Periodic Acid Schiff (PAS)-positive area (glycogen storage) and esterase-positive cells (neutrophil infiltration). Results: The PAS-positive area in the saline group was significantly lower than that in the normal group (36.9±2.6 vs. 66.9±1.2%, P<0.01); the PAS-positive area in the edaravone group remained comparable to that in the normal group (52.9±0.9%, P<0.01). Esterase-positive cells in the saline group were significantly higher than in normal kidneys (62.4±5.6 vs. 17.5±2.4 cells/mm2, P<0.01), while they were significantly reduced in the edaravone group (32.8±5.7 cells/mm2, P<0.01). Conclusion: Edaravone pretreatment mitigates MNMS-induced kidney damage by reducing both glycogen depletion and neutrophil infiltration.