Surgical outcomes of acute type A aortic dissection in septuagenarians and octogenarians.

BACKGROUND: We studied surgical outcomes of acute type A aortic dissection and compared early and late outcomes between septuagenarians and octogenarians. METHODS: From 2010 to 2019, we evaluated 254 consecutive patients with acute type A aortic dissection. We performed emergent operations within 48 h of symptom onset for 188 patients, including 59 septuagenarians and 32 octogenarians. RESULTS: The overall 30-day mortality rate was 8.5% in septuagenarians and 9.4% in octogenarians (p = 1.0). The hospital mortality rate was 10.2% in septuagenarians and 12.5% in octogenarians (p = 0.74). Multivariate analysis identified prolonged ventilation (≥ 72 h) as a significant risk factor for hospital mortality. Being an octogenarian was not significantly associated with hospital mortality. The actuarial survival rate at 5 years was 80.1% in septuagenarians and 58.5% in octogenarians (log-rank p = 0.09). The freedom from aortic event rate at 5 years was 91.0% in septuagenarians and 100% in octogenarians (log-rank p = 0.23). CONCLUSION: The two groups showed no significant differences in hospital mortality or morbidity. Our tear-oriented strategies might be appropriate for both septuagenarians and octogenarians. Prolonged ventilation (≥ 72 h) was a significant risk predictor for hospital mortality.

Use of stent-grafts for the ductus arteriosus and its related lesions.

Five cases of ductal lesions with various anatomies have been successfully treated by thoracic endovascular aortic replacement in recent years; 4 using mainly fenestrated stent-grafts, and one using a non-fenestrated stent-graft. Considering the invasive nature of open surgery and the anatomical limitations of the catheter technique for occluding a patent ductus in many adult cases, thoracic endovascular aortic replacement should be the first option because of its broad applicability for ductal lesions.

Plural large floating thrombi in the ascending aorta.

Floating thrombi in the ascending aorta are a very rare finding in non-aneurysmal, mildly atherosclerotic or normal aortas. We report a case of floating thrombi in a 66-year-old man who was admitted to the hospital with acute chest pain and dyspnea. Enhanced computed tomography showed two large floating thrombi in the ascending aorta, type B aortic dissection, deep venous thrombosis, and pulmonary embolism. A temporary inferior vena cava filter was inserted and the subject underwent an emergency surgical intervention to remove both masses. His postoperative course was uneventful; the etiology of the thrombi is unknown. Lifelong anticoagulation therapy was started and the subject has been stable without recurrence for the last 2 years.

Isolated right ventricular metastasis of uterine cervical carcinoma.

Isolated direct metastasis of uterine cervical carcinoma to the right ventricular endocardium is very rare. A 68-year-old woman was initially diagnosed as having stage IIIb squamous cell carcinoma of the uterine cervix, and was treated with radiation therapy. After 2 years, she developed heart failure and presented with a mass in the right ventricle. The results of further examinations were consistent with a tumor or a thrombus in the right ventricle. She underwent excision of the mass under cardiopulmonary bypass, and histopathologic examination of the resected tissue revealed metastatic squamous cell carcinoma of the uterine cervix. She was discharged 3 weeks after the operation, and underwent chemotherapy. However, she was readmitted with drug-induced interstitial pneumonia and died 5 months after the surgery. Patients with an intracardiac mass and a history of uterine cervical cancer should be suspected of having a myocardial metastasis until it is proven otherwise.

Type II endoleak repair after endovascular abdominal aortic repair using a computed tomography-guided percutaneous transabdominal approach.

The current treatment of type II endoleaks includes either transarterial or sac puncture techniques. Sac puncture can be further divided into translumbar, transabdominal, and transcaval approaches.1 However, transabdominal techniques for the treatment of type II leak are not well established. Herein, we report a case of a type II endoleak repaired in a 76-year-old woman using a computed tomography-guided percutaneous transabdominal approach. This type of transabdominal repair is easy and safe because punctures to the aneurysm sac are visualized in real time by computed tomography. It is possible to selectively embolize persistent blood flow in arteries in either the sac or main artery.

Percutaneous transluminal balloon aortic valvuloplasty with a small balloon as a bridge to surgery for severe aortic stenosis in an 83-year-old patient.

An 83-y-old man was admitted to our hospital with pneumonia and critical cardiac failure. He had severe calcific stenosis of a bicuspid aortic valve, with a pressure gradient of about 100 mmHg, poor left ventricular function and an ascending aortic aneurysm. His family requested the surgery, but there was an unacceptably high surgical risk because of the presence of serious infection. We tried percutaneous transluminal balloon aortic valvuloplasty (PTAV) with a small sized (12 mm) peripheral percutaneous transluminal angioplasty balloon as a bridge to surgery. We managed to control his critical hemodynamics and infection after the procedure. Thereafter, he underwent successful aortic valve replacement and ascending aorta replacement. PTAV may be a useful palliative therapy, but there are various procedure-related complications. To avoid such complications, we used a small sized balloon. Actually we could not completely normalize the pressure gradient, but it was enough to control his critical cardiac failure until he could undergo surgery.

Left atrial papillary fibroelastoma accidentally diagnosed with gastric cancer.

Papillary fibroelastoma is a rare but benign cardiac tumor and usually originates from the cardiac valve. We describe a 78-year-old woman who was initially diagnosed with gastric cancer, and was incidentally found to have a mass in the free wall of her left atrium between the left atrial appendage and the left superior pulmonary vein. An excision was performed through the left atrial appendage under cardiopulmonary bypass. The histopathologic examination of the resected tissue revealed a papillary fibroelastoma. The unusual localization of this papillary fibroelastoma was discussed.

Mesenteric artery fenestration for type B dissection with visceral ischemia.

We describe a successful case of direct superior mesenteric artery fenestration for an acute type B dissection complicated by bowel necrosis in a 68-year-old man. At 11 days after the onset, computed tomography showed superior mesenteric artery obstruction. We fenestrated and connected the true lumen to the false lumen of the superior mesenteric artery, and performed thrombectomy in both lumens. A bowel resection was carried out immediately. The patient was discharged uneventfully after recovery.

Acute cardiac tamponade caused by the extension of multiple hepatic actinomycotic abscesses.

A 60-year-old man was diagnosed as multiple hepatic abscesses. Failure in the first empiric therapy led to extension into the pericardium, causing acute cardiac tamponade. Actinomyces species were not cultured from the pericardial effusion. The definitive diagnosis was acquired by ultrasound guided needle biopsy.

Purulent pericarditis caused by the Streptococcus milleri group: a case report and review of the literature.

A 69-year-old woman with a history of diabetes mellitus presented at our emergency room with chest pain and dyspnea. A chest computed tomography revealed a pericardial effusion. Pericardiocentesis was performed; strains of the Streptococcus milleri group were detected on culture of the fluid thus obtained. Therefore, purulent pericarditis was diagnosed. Despite treatment with panipenem/betamipron, the pericarditis worsened leading to the development of cardiac tamponade. Emergency pericardial drainage was performed, after which the condition resolved without any complications. We report an extremely rare case of purulent pericarditis caused by a strain of the Streptococcus milleri group. In addition, we review 5 previously reported cases of purulent pericarditis caused by strains.