[Disruption of Matsui-Kitamura Stent-graft Six Years after Treatment for Rupture of Thoracic Aortic Aneurysm].

Matsui-Kitamura stent-graft (MKSG) is a home-made device for thoracic endovascular aortic repair (TEVAR) developed in Japan. A 76-year-old man who had been treated by TEVAR (zone 3) with a MKSG for ruptured thoracic aortic aneurysm was diagnosed as having type Ia endoleak caused by suture disruption and aneurysmal sac expansion 6 years later. He underwent TEVAR (zone 1) with debranching and type Ia endoleak disappeared. MKSG had been the effective device especially for acute aortic emergencies in the descending thoracic aorta until the stent-grafts became commercially available, but careful observation and appropriate re-intervention is mandatory for the continued life-saving contribution.

Efficacy of nafamostat mesilate as anticoagulation during cardiopulmonary bypass for early surgery in patients with active infective endocarditis complicated by stroke.

BACKGROUND AND AIM OF THE STUDY: Recent brain complications (e.g., bleeding or infarction) in patients with active infective endocarditis (AIE) are recognized as a contraindication for early surgery. Nafamostat mesilate (NM) is a synthetic protease-inhibiting agent that has not only potent inhibitory activity against coagulation factors (Xlla, Xa) but also an anti-inflammatory action. Herein is reported the authors' successful surgical experience using NM with low-dose heparinization in patients with AIE complicated by recent cerebral complications. METHODS: Twenty-eight patients (mean age 54.9 +/- 18.7 years) who had undergone surgery for AIE of the native valve (n = 21) or prosthetic valve (n = 7) were reviewed retrospectively. AIE was present in the aortic (n = 8), mitral (n = 16), aortic/mitral (n = 4) and tricuspid (n = 1) valves. Twenty-two of 28 patients had preoperative stroke, and six had active brain bleeding. Surgery was performed at a mean of 2.4 +/- 2.1 days after the onset of stroke. NM (209 +/- 152 mg) with low-dose heparin (3796 +/- 1218 IU; 67.4 +/- 20.3 IU/kg) was used for anticoagulation during cardiopulmonary bypass (CPB). The activated clotting time (ACT) was maintained at 350-450 s by the precise administration of NM into a cardiotomy reservoir (0.5 mg/kg/h) and a venous reservoir (sliding controlled dose at 1.5 mg/kg/h). RESULTS: The CPB time was 181.3 +/- 92.6 min. Five patients (17.8%) died during hospitalization due to persistent sepsis (n = 3), brain death caused by massive brain embolism before CPB establishment (n = 1), and pneumonia (n = 1). There was no further aggravation of intracranial bleeding, and no new hemorrhagic stroke. CONCLUSION: Nafamostat mesilate, administered in conjunction with low-dose heparinization, served as an effective anticoagulant for early surgery in patients with AIE complicated by stroke, and caused no further deterioration of the cerebral lesions.

Association of computed tomography-derived muscle mass and quality with delayed acquisition independent walking after cardiovascular surgery.

BACKGROUND: In the context of cardiovascular surgery, the foremost concern lies in delayed functional recovery, as typified by the acquisition of independent walking after surgery, among older patients with decline in skeletal muscle mass and quality. Computed tomography (CT), which is typically employed for the preoperative assessment of pathological conditions in patients undergoing cardiovascular surgery, is also suitable for screening for potential decline in skeletal muscle mass and quality. The aim of this study was to examine the predictive capabilities of CT-derived parameters such as muscle mass and muscle quality for the delayed acquisition of independent walking in the postoperative period. METHODS: This retrospective study enrolled consecutive Japanese patients who underwent elective cardiovascular surgery between May 2020 and January 2023. In total, 139 patients were included in the analyses. Based on the preoperative CT image, the psoas muscle volume index (PMVI) and psoas muscle attenuation (PMA) were calculated. Information on patient characteristics, including preoperative physical fitness such as handgrip strength/body mass index (GS/BMI), short physical performance battery (SPPB), and 6-min walking distance (6MWD), were obtained from the medical records. We defined delayed acquisition of independent walking after surgery as the inability to walk 100 m within 4 days after surgery. RESULTS: The median age of the patients was 72 (interquartile: 64-78) years, and 74.8% (104/139) were men; 47.5% corresponded to the delayed group. The areas under the curves of SPPB, GS/BMI, 6MWD, PMVI, and PMA against delayed acquisition of independent walking after surgery were 0.68 [95% confidence interval (CI): 0.59 to 0.77], 0.72 (95% CI: 0.63 to 0.80), 0.73 (95% CI: 0.65 to 0.82), 0.69 (95% CI: 0.60 to 0.78), and 0.78 (95% CI: 0.70 to 0.85), respectively. In the multivariate logistic regression analysis, low PMA was significantly associated with delayed acquisition of independent walking even after adjustment for patient characteristics including physical fitness [model 1: SPPB (OR, 1.14; 95% CI: 1.03-1.25), model 2: GS/BMI (OR, 1.13; 95% CI: 1.03-1.25), and model 3: 6MWD (OR, 1.14; 95% CI: 1.03-1.25)], but PMVI was not. CONCLUSIONS: Our study revealed a strong association between PMA, a marker of CT-derived muscle quality, and the postoperative delay in achieving independent walking in patients who underwent cardiovascular surgery. The technique to obtain information on muscle quality during the time period before surgery may be an option for timely therapeutic intervention in patients who may have delayed acquisition of independent walking after surgery.

[Total aortic arch replacement;our current surgical management and outcomes].

OBJECTIVE: We report our current surgical management and early and late outcomes of total arch replacement. METHOD: From October 1999 to December 2012, 372 consecutive patients (mean age 71.8±12.0) underwent total arch replacement through a median sternotomy at our institute. Mean Japan score (predicted 30 day mortality) was 8.0±9.2( median 4.4). Our current surgical approach included the following:(1) meticulous selection of arterial cannulation site and type of arterial cannula;(2) circulatory arrest at tympanic temperature (below 23 °C) and rectal temperature (below 30 °C);(3) antegrade selective cerebral perfusion and cerebral monitoring of regional cerebral saturation;(4) early rewarming just after distal anastomosis;(5)maintaining fluid balance below 1,000 ml during cardiopulmonary bypass. RESULTS: Overall 30 day and in-hospital mortality was 1.6%( 6/372) and 3.8%( 14/372), and was 1.0%(3/308)and 2.6% (8/308) in elective cases. Permanent neurologic deficit occurred in 2.2%(8/372) of patients. The mean follow up period were46±39months(range2~165 months). Survival at 5 and 10 years after surgery was 75.8±2.8% and 66.0±3.8%, respectively. During follow up period, there was only one total arch replacement related problem (proximal anastomosis aneurysm). Freedom from additional aortic surgery and aortic related event at 5 and 10 years was 90.8 ±2.2% and 86.1±3.4%,respectively. CONCLUSION: Our current approach for total aortic arch replacement was associated with low hospital mortality and morbidities and with favorable long-term outcome.

Acute lower limb malperfusion triggered by a large vegetation located on the proximal entry tear of chronic type B aortic dissection.

A 74-year-old man who had been receiving antibiotic treatment for meningitis was transferred to our hospital because of a sudden decrease in lower limb blood pressure. Computed tomography revealed a type B aortic dissection with obstruction of the abdominal aorta. Furthermore, transesophageal echocardiography revealed a large vegetation on the proximal entry tear of the descending aorta. We performed successful emergency descending and abdominal aorta replacement, which prevented complications from intraoperative organ malperfusion. In the present report, we have described an effective treatment for lower limb malperfusion complicated by a combination of chronic aortic dissection and bacteremia.

Off-pump coronary artery bypass grafting in an octogenarian with situs inversus and dextrocardia: report of a case.

Dextrocardia associated with situs inversus totalis is a rare condition. A small number of patients with the condition have been reported after undergoing myocardial revascularization. We experienced a case of this rare disorder in an 83-year-old man. He was successfully treated by off-pump coronary artery bypass grafting with bilateral internal thoracic arteries and a saphenous vein. Except for the mirror-image anatomy, the surgical technique was similar to that used for a patient with situs solitus.

Efficacy of left atrial plication for atrial functional mitral regurgitation.

OBJECTIVE: Atrial functional mitral regurgitation (AFMR) is caused by atrial fibrillation and left atrial enlargement. Our study aimed to evaluate the efficacy of left atrial plication (LAP) for AFMR. METHODS: Of 1164 mitral valve surgery patients at our hospital from January 2000 to May 2019, 22 patients underwent surgery for AFMR. Our retrospective analysis divided the patients with AFMR into two groups according to whether LAP was performed (LAP + group, n = 9; LAP - group, n = 13). Mitral valve angle (MV angle) (horizontal inclination of mitral valve) was measured by pre- and post-operative computed tomography scan. Individuals with type II mitral regurgitation, left ventricular ejection fraction of < 55%, males with left ventricular endo-diastolic dimension of > 60 mm and females with > 55 mm, aortic valve disease, mitral valve calcification, hypertrophic obstructive cardiomyopathy, and both "redo" and emergency cases were excluded. RESULT: Mitral valve replacement was performed in 6 patients and mitral ring annuloplasty in 16 cases. No recurrence of mitral regurgitation or structural valve deterioration occurred during the follow-up period. There were no hospital deaths; 3 deaths occurred during the follow-up period. Compared to the LAP - group, the LAP + group demonstrated a significantly greater decrease of MV angle (16.6 ± 8.1° vs. 1.2 ± 6.9°, p < 0.01) and left atrial dimension (18.4 ± 7.0 mm vs. 6.9 ± 14.6 mm, p = 0.02). CONCLUSIONS: Surgical results of AFMR were satisfactory. LAP may be appropriate for correcting the angle of a mitral valve tilted horizontally. More cases need to be considered in the future.

Controlled low-flow reperfusion after warm brain ischemia reduces reperfusion injury in canine model.

BACKGROUND: Acute occlusion of the carotid artery caused by acute type A aortic dissection (AAD) induces on-going warm brain ischemia. The purpose of this study was to elucidate the hypothesis that low-flow reperfusion could mitigate reperfusion injury after warm ischemic damage to the brain. METHODS: Experiments were performed using a canine global brain ischemia model, with 15 minutes of ischemia followed by 3 hours reperfusion, which was established by a simple brain reperfusion circuit with a roller pump. The right common carotid artery (RCCA) flow ratio was determined as the mean RCCA flow during reperfusion divided by the mean RCCA flow during pre-ischemia. Animals were divided into two groups according to the RCCA flow ratio; low RCCA flow ratio of 0.3 to 0.6 (Group L, n=5) and control RCCA flow ratio of 1.0 to 1.4 (Group C, n=5). At the 3-hour reperfusion time point, physiological and histopathological assessments were performed in both groups. RESULTS: Electroencephalographic activity recovered in four of five animals (80%) animals in Group L, whereas no recovery (0%) in activity was observed in Group C. Brain water content in Group L animals was significantly less than that in Group C. Apoptosis, number of perivascular edematous regions and NFkappaB expression were apparently suppressed in Group L compared with Group C. There were significant positive correlations of RCCA flow with brain water content, apoptosis and number of perivascular edematous regions. CONCLUSIONS: Controlled low-flow reperfusion mitigated reperfusion-induced brain edema and apoptosis, leading to rescue of brain function in the canine model.

Bail-out thoracic endovascular aortic repair for incorrect deployment of frozen elephant trunk into the false lumen.

We report a rare case of bail-out thoracic endovascular aortic repair after incorrect deployment of a frozen elephant trunk into the false lumen. A 54-year-old man presented to our department complaining of chest pain. Enhanced computed tomography revealed Stanford type A acute aortic dissection, which had a large entry site at the mid-descending aorta. Emergency total aortic arch replacement with a frozen elephant trunk was performed. Progressive intraoperative acidosis was observed. Immediate postoperative enhanced computed tomography showed that the distal end of the frozen elephant trunk was deployed into the false lumen through the initial tear at the proximal descending aorta. We performed emergency thoracic endovascular aortic repair through a fenestration made into the intimal flap using an Outback LTD re-entry device. The patient was discharged home on postoperative day 67 after a complete recovery.

Hybrid Repair of Kommerell's Diverticulum with Embolization of Aberrant Left Subclavian Artery.

An asymptomatic 70-year-old man presented with Kommerell's diverticulum (KD) and an aberrant left subclavian artery. Computed tomography revealed a KD diameter of 53 mm, severe aortic arch angulation, and no landing zone for thoracic endovascular aortic repair from the arch vessels to the diverticulum. We performed single-stage hybrid repair of KD of the right aortic arch, left carotid-left subclavian artery bypass, and embolization of the subclavian artery, followed by replacement of the descending aorta through deep hypothermic circulatory arrest via right thoracotomy. He was discharged home without any symptoms and remained uneventful at 1 year after the operation.

Bioprosthetic pulmonary and tricuspid valve replacement in carcinoid heart disease from ovarian primary cancer.

Carcinoid tumors usually originate in the gastrointestinal tract, but in rare instances they may arise in other organs. A patient with severe tricuspid and pulmonary regurgitation because of carcinoid syndrome successfully underwent double valve replacement using bioprostheses. The patient was finally diagnosed with carcinoid heart disease from an isolated ovarian carcinoid cancer. The diagnosis of carcinoid syndrome should be recognized as an etiology in patients with organic tricuspid and pulmonary regurgitation without left valvular disease.

[Does aortic cusp repair influence the outcome of valve sparing aortic root replacement?].

BACKGROUND: Outcome of the patients who underwent aortic root replacement with valve sparing procedure concomitant with cusp repair was evaluated. METHODS: Between October 1999 and April 2009, valve sparing aortic root replacement were performed in 62 patients. Isolated valve sparing procedure was performed in 38 patients (control) and concomitant cusp repair was performed in 24 patients (aortic valve plasty: AVP). Cusp prolapse was corrected by plication of Arantius body (n = 13), cusp perforations were closed by pericardial patch (n = 6) or reinforcement of free margin (n = 6). RESULTS: No patient died during the hospital stay and no thromboembolic events occurred in the follow up. Pre-operative grade of aortic insufficiency was 3.0 +/- 0.9 in AVP group vs. 2.5 +/- 1.3 in control (NS). There was no significant difference between both groups regarding age, cardiac function and preoperative aortic root diameter. However, eccentric jet by preoperative transesophageal echocardiography (TEE) was more often in group AVP than in control (p<0.01). Five patients underwent reoperation because of recurrent aortic regurgitation (AR) or hemolysis. Postoperative AR grade were similar in both groups (0.9 +/- 0.5 vs 0.5 +/- 0.6). During follow up, the 5 year freedom from re-operation (aortic valve replacement: AVR) was 85.1+/- 8.2% in AVP and 94.0 +/- 4.1% in control (NS). 5-year-survival was 100% and 95.0 +/- 4.9% (NS), respectively. CONCLUSIONS: Valve sparing aortic root replacement with concomitant cusp repair provided satisfactory midterm result.

A case of type A acute aortic dissection with a common carotid trunk.

We present a rare case of common carotid artery with acute type A aortic dissection. A 72-year-old woman underwent emergent aortic arch repair using Antegrade selective cerebral protection. Bottom-tapped cannulae were inserted into three orifices of arch vessels, however, regional cerebral oxygen saturation decreased after rewarming. We found that arch branches were in order from front to back, right subclavian artery, common carotid trunk, and left subcravian artery. The patient complicated stroke in the right middle cerebral artery.

Successful hybrid treatment of a rare case of blunt traumatic rupture of the left atrial basal appendage and aortic arch.

Despite advances in emergency care and the emergent transportation system, cardiac and aortic ruptures after blunt trauma are associated with high mortality and morbidity. We present a rare case of a 70-year-old man with a ruptured left atrial basal appendage and distal aortic arch after sustaining blunt trauma to the chest during a motor vehicle accident. The patient was transported to our hospital in a state of shock and taken directly to the operating room. Hybrid treatment was performed, including surgical repair of the left atrium under cardiopulmonary bypass and thoracic endovascular aortic repair, was performed. The patient fully recovered without any complications.

Fatal Complications of New-Onset Complicated Type B Aortic Dissection After Endovascular Abdominal Aortic Aneurysm Repair: Report of 2 Cases and Literature Review.

New-onset antegrade Stanford type B aortic dissection (TBAD) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is rare. The extension of aortic dissection leads to various symptoms and affects the stent graft. Moreover, various symptoms may arise owing to a stent graft being present. We describe 2 cases of complicated acute TBAD occurring after EVAR, which were ultimately fatal. The case in which rupture occurred could not be treated and the patient died. In another case with bilateral lower extremity malperfusion caused by collapse and occlusion of the endograft, extra-anatomical bypass was performed. Although the collapsed endograft gradually re-expanded, the patient ultimately died because of multiorgan failure. We have reviewed the literature and analyzed the treatment of complicated TBAD after EVAR.

Outcomes of Late Open Conversion after Endovascular Abdominal Aneurysm Repair.

Objective: To review our experience with a late open conversion as a final option for an endograft infection and aneurysm expansion after endovascular aneurysm repair (EVAR), especially in endoleaks for which radiological intervention is impossible. Materials and Methods: In this retrospective study, 13 late open conversions out of 513 consecutive patients treated by EVAR were analyzed. Indications for an open conversion were aneurysm enlargement, including all endoleaks, endograft migration, and endograft infection. The patients' data on demographics, operative details, and outcomes were reviewed. Results: Indications for a late open conversion included endoleaks, infection, and migration in 61.5%, 30.8%, and 7.7% of patients, respectively. The median interval from the initial EVAR was 32.4 months. Complete endograft explantation was performed in four patients with an endograft infection. In endoleak cases, the endograft was partially preserved and a neo-neck was used. Sacotomy and branch ligation were performed in one case. One major operative complication was an aortic injury during infrarenal aortic cross-clamping in an endograft migration case. There was no operative mortality. Conclusion: A late open conversion after EVAR is valuable as a final option. The aortic cross-clamp site, especially in endograft migration cases, should be carefully considered. To avoid aneurysm-related events, graft replacement is recommended, if possible.

Preventing brain embolism by using a modified isolation technique in transcatheter aortic valve implantation for a patient with shaggy and porcelain aorta.

Transcatheter aortic valve implantation (TAVI) has become a useful and effective treatment for surgical high-risk patients with severe aortic valve stenosis (AS). Stroke is one of the most frequent complications associated with TAVI. Shaggy and porcelain aortas are a risk factor for procedure-related strokes. Preventing brain embolism is one of the most important goals in patients with diseased aortas. We present a case where we performed TAVI in an 89-year-old man with severe AS, a shaggy aorta, a porcelain aorta, and congestive heart failure. TAVI via a transfemoral approach was performed using a modified isolation technique with cannulation from bilateral axillary arteries and cardiopulmonary bypass to prevent brain embolism. The catheter-delivered embolic protection device is necessary to pass the diseased aorta, but the modified isolation technique can be used without any contact with the shaggy aorta. Embolism did not occur, and his heart failure improved immediately. .

Feasibility of intraoperative water testing in aortic valve repair: Direct visualization from left ventricle with a videoscope.

OBJECTIVE: We describe a simple method to assess the aortic valve using a videoscope inserted in the left ventricle (LV-VS) during valve-sparing root replacement. The aim of this study was to evaluate the feasibility of this technique by comparing it with the findings of postoperative transesophageal echocardiography (TEE). METHODS: Thirty-six patients (29 male, mean age 45.4 ± 20.1 years) undergoing aortic root reimplantation were assessed intraoperatively with LV-VS. The LV-VS was inserted from the right upper pulmonary vein into the left ventricle and set toward the aortic valve. After completion of graft implantation, inspection was performed with LV-VS by pressurizing the neo-sinus before attachment of coronary arteries. Valve competency evaluated by LV-VS was compared with postoperative TEE findings, according to the group of cusp morphologies. Group 1 included 26 patients with tricuspid aortic valve, and group 2 included 9 patients with bicuspid aortic valve and 1 quadricuspid aortic valve. RESULTS: The grade of aortic regurgitation (AR) improved from 2.9 ± 1.6 preoperatively to 0.33 ± 0.6 postoperatively (P < .001 vs preoperatively). In 4 patients, LV-VS was used only before repair. In group 1, intraoperative LV-VS showed a competent valve in 20 and an incompetent valve in 3 patients, and postoperative TEE showed non/trivial AR in 15, mild AR in 5, and mild-to-moderate AR in 3 patients. In group 2, 9 patients achieved a competent valve on intraoperative LV-VS and non/trivial AR on postoperative TEE. CONCLUSIONS: Intraoperative direct inspection with LV-VS is a feasible method for confirming the completion of cusp repair.

Impact of sarcopenia on the outcomes of elective total arch replacement in the elderly†.

OBJECTIVES: The purpose of this study was to identify the cut-off value of sarcopenia based on the psoas muscle area index and evaluate early and late outcomes following elective total arch replacement in the elderly. METHODS: Sarcopenia was assessed by the psoas muscle area index [defined as the psoas muscle area at the L3 level on computed tomography (cm 2 )/body surface area (m 2 )]. The cut-off value for sarcopenia was defined as > 2 standard deviations below the mean psoas muscle area index value obtained from 464 normal control patients. Between October 1999 and July 2015, 266 patients who were ≥ 65 years and had undergone psoas muscle area index measurement underwent elective total arch replacement. These patients were classified into the sarcopenia (Group S, n = 81) and non-sarcopenia (Group N, n = 185) groups. RESULTS: The mean age was 76.2 ± 5.6 years in Group S and 75.7 ± 5.7 years in Group N ( P = 0.553). Hospital mortality was 3.7% (3/81) in Group S and 2.2% (4/185) in Group N ( P = 0.483). Mean follow-up was 48.3 ± 38.7 months. Five-year survival was significantly worse in Group S (S: 63.2 ± 6.6% vs N: 88.7 ± 2.6%, P < 0.001). A multivariable Cox proportional hazard analysis showed that sarcopenia significantly predicted poor survival (hazard ratio 2.59; 95% confidence interval 1.27-5.29; P = 0.011). CONCLUSIONS: Sarcopenia did not predict hospital death following total arch replacement, but it was negatively associated with overall survival. Sarcopenia can be an additional risk factor to estimate the outcomes of thoracic aortic surgery.

Multiple penetrating atherosclerotic ulcers of the aorta: report of a case.

A 69-year-old hypertensive man who had 7 pseudoaneurysms caused by penetrating atherosclerotic ulcers underwent 2-staged endovascular grafting in the thoracic and thoracoabdominal aorta and a conventional graft replacement of the abdominal aorta. He had an uneventful postoperative course; follow-up computed tomography demonstrated that all aneurysmal lesions treated by endovascular grafting completely disappeared. He has been free from any aortic events 20 months after the last surgery.