The impact of increased pulmonary arterial pressure on outcomes after transcatheter aortic valve replacement.

OBJECTIVE: To evaluate the impact of increased pulmonary artery systolic pressure (PASP) on outcomes after transcatheter aortic valve replacement (TAVR). METHODS: A total of 242 patients who underwent TAVR were retrospectively reviewed. Transthoracic echocardiography estimated PASP. The cohorts were divided into three groups according to the numerical change of PASP; Increased (post-TAVR PASP at 1 month minus pre-TAVR PASP, ≥ + 5 mmHg; n = 52), No change (-5 to +5 mmHg; n = 86) and Decreased (≤ -5 mmHg; n = 104). Patient demographics and clinical outcomes until 1 year were evaluated. Logistic regression model was used for multivariate risk analysis. RESULTS: At 1 year, the Increased group showed higher mortality (21 ± 6%) than the No change group (5 ± 2%) (hazard ratio [HR]: 4.8, 95% confidence interval [CI]: 1.7-13.5; p < .01) and the Decreased group (8 ± 3%) (HR: 2.8, 95% CI: 1.1-6.7; p = .02). Rehospitalization rate for valve-related or heart failure was also higher in the Increased group (21 ± 6%) than the No change group (10 ± 3%) (HR: 2.4, 95% CI: 1.1-6.0; p = .04). Predictors of PASP deterioration were hypertension (odds ratio [OR]: 3.9, 95% CI: 1.1-13.8; p = .04) and left ventricular end-diastolic diameter >50 mm (OR: 2.2, 95% CI: 1.1-4.6; p = .04), and the increased PASP remained an independent predictor of 1-year all-cause mortality (HR; 2.7, 95% CI: 1.0-6.8; p = .04). CONCLUSIONS: Regardless of the baseline PASP, patients with increased PASP at 1 month after successful TAVR were at higher risk of mortality and rehospitalization within 1 year. Strict medical management should be considered for patients who showed dilated left ventricle preoperatively.

Transcatheter aortic valve replacement in patients with anomalous left circumflex coronary artery.

The anomalous left circumflex artery can be a risk for coronary stenosis or obstruction during transcatheter aortic valve replacement; however, the best procedural management has not been clarified. We describe three patients with severe aortic valve stenosis as well as anomalous left circumflex artery. In the first patient, a coronary guidewire with balloon was placed before deploying a SAPIEN 3 transcatheter heart valve, as protection from the coronary occlusion or stenosis. For the second and third patients, no coronary protection was used. All procedures were completed safely and no complications were detected at one-year follow-up.

Postoperative initial 2-day blood pressure management facilitates the shrinkage of abdominal aortic aneurysm after endovascular aneurysm repair by reducing the incidence of type II endoleak.

OBJECTIVE: The aim of this study was to evaluate the effect of initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the incidence of subsequent type II endoleak (T2E) and shrinkage of abdominal aortic aneurysm (AAA) sac diameter. METHODS: We reviewed 136 patients who underwent EVAR for atherosclerotic AAA between July 2008 and July 2014 with one of three stent grafts (Excluder [W. L. Gore & Associates, Flagstaff, Ariz], Powerlink [Endologix Inc, Irvine, Calif], and Endurant [Medtronic Vascular, Santa Rosa, Calif]). Starting from 2013, the mean blood pressure of 76 participating patients (treatment group) was maintained at 75 to 90 mm Hg for the initial 48 hours after EVAR. The incidence of T2E at 7 days and AAA sac diameter 12 months after EVAR were evaluated using computed tomography scanning. The results so obtained were then compared with those of the control group composed of 60 consecutive patients who underwent EVAR before 2013. RESULTS: The incidence of T2E at 7 days was significantly lower in patients who received treatment (treatment group, 19.7%; control group, 40.0%; P = .013), and AAA sac diameter at 12 months in the treatment group had a mean decrease of 5.1 mm compared with the mean 2.2 mm in the control group (P = .004). In multivariate regression analysis, BPM was significantly related to the reduction of incidence of T2E at 7 days (odds ratio, 0.31; P = .007) and a decrease in AAA sac diameter at 12 months (P = .005). In addition, although the use of Endurant had less effect, the use of Excluder under controlled blood pressure conditions improved the incidence of T2E from 80% to 23% compared with those under normal postoperative management (P = .001). CONCLUSIONS: The initial 2-day postoperative BPM might have positive effects, such as lower incidence of T2E and facilitation of AAA sac shrinkage.

[Total debranching through mini-sternotomy].

Aneurysms of the aortic arch are technically challenging to repair with thoracic endovascular aneurysm repair (TEVAR). Various optional techniques such as debranching or hybrid TEVAR enable landing zones to extend, however, there is still room for improvement. We have performed total debranching to facilitate TEVAR with adequate central neck length more than 2.5 cm. In summary our procedure has 3 features:mini-thoracotomy to minimize its surgical stress which might cause post-operative respiratory failure, side-to-side anastomosis of trifurcated graft with ascending aorta to avoid its kinking after chest closure, and the usage of Pruitt-Inahara shunt tube during anastomoses of the carotid artery.

Emergency Endovascular Aneurysm Repair Coupled with Staged Omentopexy for Primary Aorto-Duodenal Fistula.

A primary aorto-duodenal fistula (ADF), a rare, spontaneous development of a communication between the aorta and duodenum, is a disastrous complication of an abdominal aortic aneurysm. A 73-year-old patient with primary ADF underwent emergent endovascular aneurysm repair (EVAR), followed by staged omentopexy, without removing a stent graft (SG). The patient received long-term treatment with antibiotics, and there has been no evidence of infection during a follow-up period of three years. Emergency EVAR coupled with omentopexy, may be a treatment option for primary ADF, even when it means leaving the SG in a potentially infectious site.

Impaired mitochondrial oxidative phosphorylation capacity in epicardial adipose tissue is associated with decreased concentration of adiponectin and severity of coronary atherosclerosis.

Epicardial adipose tissue (EAT), a source of adipokines, is metabolically active, but the role of EAT mitochondria in coronary artery disease (CAD) has not been established. We investigated the association between EAT mitochondrial respiratory capacity, adiponectin concentration in the EAT, and coronary atherosclerosis. EAT samples were obtained from 25 patients who underwent elective cardiac surgery. Based on the coronary angiographycal findings, the patients were divided into two groups; coronary artery disease (CAD; n = 14) and non-CAD (n = 11) groups. The mitochondrial respiratory capacities including oxidative phosphorylation (OXPHOS) capacity with non-fatty acid (complex I and complex I + II-linked) substrates and fatty acids in the EAT were significantly lowered in CAD patients. The EAT mitochondrial OXPHOS capacities had a close and inverse correlation with the severity of coronary artery stenosis evaluated by the Gensini score. Intriguingly, the protein level of adiponectin, an anti-atherogenic adipokine, in the EAT was significantly reduced in CAD patients, and it was positively correlated with the mitochondrial OXPHOS capacities in the EAT and inversely correlated with the Gensini score. Our study showed that impaired mitochondrial OXPHOS capacity in the EAT was closely linked to decreased concentration of adiponectin in the EAT and severity of coronary atherosclerosis.

Novel Dry-Lab Training Method for Totally Endoscopic Coronary Anastomosis: A Pilot Study.

OBJECTIVE: We describe our original dry-lab training system for nonrobotic and beating heart endoscopic coronary artery anastomosis. METHODS: All the materials used for this training were commercially available. We selected a boxed machine, which can produce pulsatile movements of artificial vessels, and on its roof, we installed a two-dimensional home video camera and a monitor. A multiple-holed plate was placed in front of the machine, and through these holes, a trainee inserted endoscopic surgical instruments and anastomosed the artificial vessels by running fashion while watching the monitor. This training program has four stages. During the first stage, a trainee has to demonstrate mastery in conducting a conventional off-pump coronary artery anastomosis without assistance. The second stage is the "nonbeating" version, and the third stage is the "beating" version with the model mentioned previously. After a trainee gets accustomed to the third stage, the original artificial vessel is replaced with an extremely fragile one, and this is the fourth stage. Our trainee conducted one hundred fourth-stage anastomoses and each procedure was recorded with the video camera. We analyzed several factors from the videos and evaluated the efficacy of the training method. We compared the outcomes of the first 50 consecutive anastomoses with the following 50 ones and described the learning curves. RESULTS: The comparison showed a significant decrease in anastomotic time and vessel injury. We considered the quality of anastomosis acceptable after 47 anastomoses, and anastomotic time fell below 15 minutes at the 81st training at the fourth stage. CONCLUSIONS: Our dry-lab system might be an effective training method for endoscopic coronary anastomosis.

Outcomes of surgical aortic valve replacement using Carpentier-Edwards PERIMOUNT bioprosthesis series in elderly patients with severe aortic valve stenosis: a retrospective cohort study.

OBJECTIVE: We sought to compare the outcomes of Carpentier-Edwards PERIMOUNT (CEP), Magna and Magna Ease valves in Japanese elderly patients with severe aortic valve stenosis (AS). METHODS: We retrospectively identified 136 patients (mean age 76.61 ± 5.5 years old) who had undergone isolated surgical aortic valve replacement (SAVR) using CEP, Magna, and Magna Ease valves at a single institution, from January 2001 to December 2013. We compared the valves according to their survival rates, freedom from major adverse cardiovascular and cerebrovascular events (MACCE), and durability and hemodynamic performance by echocardiographic data. RESULTS: The thirty-day mortality after isolated SAVR in all the valve groups was "zero". The differences among the three groups in terms of survival rates, freedom from MACCE at 2 years, durability and hemodynamic performance of the valves by echocardiographic data was not statistically significant. CONCLUSION: All CEP, Magna and Magna Ease valves seemed to be similarly useful in Japanese elderly patients with severe AS. Our data did not clearly support the superiority of one valve over another. A longer follow-up period might be necessary to compare the durability and hemodynamic performance of these valves with more certainty.

Bladder and rectal incontinence without paraplegia or paraparesis after endovascular aneurysm repair.

Spinal cord ischemia is a well-known potential complication of endovascular aneurysm repair (EVAR), and it is usually manifested by paraplegia or paraparesis. We describe a case in which spinal cord ischemia after EVAR presented by isolated bladder and rectal incontinence without other neurological deficits. A 63-year-old woman presented with intermittent claudication secondary to an infrarenal abdominal aortic aneurysm (AAA), and a left common iliac artery obstruction, for which she underwent EVAR using an aorto-uniiliac (AUI) device and ilio-femoral artery bypass. On postoperative day 3, she developed urinary and fecal incontinence without signs of paraplegia or paraparesis. Magnetic resonance imaging (MRI) showed a hyper-intense signal in the spinal cord. She received hyperbaric oxygen (HBO) therapy and was discharged after 18 days when her urinary and fecal incontinence were almost resolved. This report suggests that spinal cord ischemia after EVAR for aortoiliac occlusive disease might present as bladder and rectal incontinence without other neurological manifestations.

A case report of primary cardiac myxofibrosarcoma presenting with severe congestive heart failure.

BACKGROUND: Primary cardiac sarcomas are extremely rare. Furthermore, the myxofibrosarcomas are one of the rarest forms of cardiac sarcomas, and its prognosis is known to be quite poor. CASE PRESENTATION: This is a case of a 23-year-old man who presented with acute severe congestive heart failure caused by almost complete obstruction of the mitral valve due to a large left atrial tumor. The patient required endotracheal intubation before his arrival to the hospital, and underwent an emergent surgical excision of the tumor. The tumor had a complex shape and originated from the orifice of the right upper pulmonary vein. Because the tumor seemed to extend over most of the surface of the left atrium, it seemed impossible to reconstruct the left atrium had we done a complete transmural resection. Instead, we carefully peeled the tumor leaving the outer layer of the left atrial wall. We applied cryoablation to the attached site, in order to prevent a recurrence of the tumor. The pathology report revealed that the tumor was a myxofibrosarcoma, and it seemed to originate from the heart. The patient received radiation therapy after the surgery and continues to be alive and well after 1-year, without apparent recurrence. CONCLUSIONS: Cardiac myxofibrosarcoma can cause acute, severe left-sided heart failure. Non-transmural atrial wall resection with cryoablation might be effective for patients with cardiac myxofibrosarcomas with extensive atrial attachment.

Alternative Treatment for Residual Aortobronchial Fistula After Thoracic Endovascular Aortic Repair.

A patient with an aortobronchial fistula secondary to a thoracic endovascular aortic repair was successfully treated with a re-thoracic endovascular aortic repair with debranching technique. Five months postoperatively, the aneurysm had shrunk; however, computed tomography revealed air in the thrombo-excluded aortic aneurysmal sac without signs of infection. Because of worsening air finding at the eighth month, we performed a resection of the residual fistula and wrapped the stent graft in a pedicled muscle flap.