Effect of the Initial Strategy for Active Endocarditis Complicated With Acute Heart Failure.

BACKGROUND: Early surgery for infective endocarditis (IE) with acute heart failure (AHF) is recommended, despite clinical results being unclear. We investigated the effect of initial treatment in such patients. Methods and Results: Outcomes for 470 patients with active IE who underwent valvular surgery during 2009-2016 were reviewed. Of them, 177 had symptomatic AHF when diagnosed with IE (excluding those with cardiogenic shock or intubated for AHF). They were divided into 2 groups based on initial treatment: Group S (underwent valvular surgery immediately; n=74) and Group M (received initial medical treatment for infection and HF; n=103). The median (interquartile range) waiting period from diagnosis to surgery in Groups S and M was 1 (1-3) and 15 (8-33) days, respectively (P<0.001). The 5-year survival rate was higher in Group S than Group M (80% vs. 64%; P=0.108). Group M was divided into Group P (initial medical treatment was effective and elective surgery was performed; n=62) and Group E (emergency surgery was necessary during medical treatment; n=41); overall 5-year survival was significantly worse in Group E than Group P (42% vs. 79%; P<0.012). In Group M, multivariate analysis indicated that Staphylococcus aureus infection (odds ratio 3.82; 95% confidence interval 1.19-13.3; P=0.024) was a significant risk factor for conversion to emergency surgery. CONCLUSIONS: Considering poor outcomes of emergency surgery for medically refractory HF, early surgery may be a reasonable option for IE patients, especially those with S. aureus infection.

To what extent can 3D model replicate dimensions of individual mitral valve prolapse?

Determining the complex geometry of mitral valve prolapse is often difficult. We constructed 3D models of six prolapsed mitral valves for surgical assessment, and evaluated how accurately the models could replicate individual valve dimensions. 3D polygon data were constructed based on an original segmentation method for computed tomography images. The model's replication performance was confirmed via dimensional comparison between the actual hearts during surgery and those models. The results revealed that the prolapsed segments matched in all cases; however, torn chordae were replicated in four cases. The mean height differences were 0.0 mm (SD 1.6, range - 2 to + 2 mm) for the anterolateral side, 0.0 mm (SD 1.7, range - 2 to + 2 mm) for the prolapsed leaflet center, and - 1.5 mm (SD 0.6, range - 1 to - 2 mm) for the posteromedial side. Regression analysis showed a strong and positive correlation, and Bland-Altman plots indicated quantitative similarity of the models to the actual hearts. We concluded that our 3D valve models could replicate the actual mitral valve prolapses within acceptable dimensional differences. Our concepts are useful for better 3D valve creation and better surgical planning with reliable 3D valve models.

[Splenic Artery Left Common Iliac Artery Bypass for Hepatocellular Carcinoma with Celiac Artery Compression Syndrome - A Case Report].

Celiac artery compression syndrome(CACS)is a rare disorder characterized by postprandial intestinal angina caused by insufficient blood supply to the gastrointestinal organs. In this syndrome, the root of the celiac artery is compressed and narrowed by the median arcuate ligament of the diaphragm during expiration, sometimes causing difficulties in trans-arterial intervention. We report here a case that trans-hepatic arterial intervention was able to performed by splenic bypass. A 74- year-old man with multiple hepatocellular carcinoma(HCC)was performed the angiography, and diagnosed as CACS due to celiac artery root obstruction. The median arcuate ligament was incised in order to introduce trans-arterial intervention, but sufficient resumption of blood flow in the root of celiac artery could not be obtained, so bypass surgery was added from left common iliac artery to splenic artery with grafted right saphenous vein. One month later, trans hepatic arterial intervention is performed via graft, and treatment of HCC is ongoing. Splenic artery left common iliac artery bypass surgery was also considered to be an option for cases in which the resurgence of the blood flow in the root of the celiac artery was not obtained even in the median arcuate ligament dissection for CACS.

Diagnosis of Type IV Endoleak After Endovascular Aneurysm Repair Using Visualization With Novel Software.

A Type IV endoleak is a very rare complication following endovascular aneurysm repair (EVAR) and differential diagnosis can be difficult. Reported here is a case that showed the development of a Type IV endoleak after an EVAR procedure, for which a novel software was useful to differentiate that from Type I based on visual confirmation. The 89-year-old man was diagnosed with a large abdominal aortic aneurysm, sized 70 mm, as shown by computed tomography (CT). EVAR was performed in a routine fashion using an Endurant II stent graft. Postoperative CT revealed a massive endoleak around the neck that was difficult to differentiate between Types I and IV. The use of the novel software Viewtify (SCIEMENT, Inc., Tokyo, Japan) to visualize the endoleak with surrounding tissues as real-time three-dimensional computer graphics (3DCG) resulted in confirmation that the endoleak was not from the proximal end but rather the stent graft body. CT findings obtained one week later showed that the endoleak had diminished and no additional procedures were needed. Following a diagnosis of endoleak after EVAR, images viewed with Viewtify helped to confirm the appropriate diagnosis. This novel software was found useful to clarify the position and mechanism of a Type IV endoleak.

Surgical Treatment for Giant Multiple Coronary Artery Aneurysms Caused by an IgG4-Related Disease.

Coronary artery aneurysms (CAAs) due to an immunoglobulin G4 (IgG4)-related disease (IgG4-RD) are relatively rare, and there is no consensus on the choice of treatment method. In the present study, we report the results of the surgical treatment for multiple giant CAAs caused by IgG4-RD. A 71-year-old man was diagnosed with severe aortic regurgitation and CAAs. A blood test showed high IgG4 levels, and computed tomography revealed four giant coronary artery aneurysms: two in the right coronary artery (RCA) (proximal RCA and posterior descending artery (PDA)), one in the left anterior descending (LAD), and one in the diagonal branch (Dx). We planned aortic valve replacement, coronary aneurysm resection, and coronary artery bypass grafting (CABG). After finishing aortic valve replacement, the CAAs in proximal RCA, LAD, and Dx were resected. The proximal and distal tracts of the aneurysm were closed with a pericardial bovine patch and ligation. However, since the distal PDA was too calcified to be anastomosed, and the PDA aneurysm was smaller than the others, it was decided to leave the PDA aneurysm. The anastomoses of SVG-RCA and Dx, as well as the left internal thoracic artery to LAD, were performed. Histopathological examination of the aneurysm wall showed a high IgG4-positive cell/IgG-positive cell ratio, and a diagnosis of IgG4-RD was made. In the treatment of CAAs due to IgG4-RD, it is essential to select a procedure that takes into account the size, location, and nature of the aneurysm, and comorbidities. To ensure resection of the aneurysm and blockade of blood flow, closure of the inflow and outflow tracts with a pericardial bovine patch and CABG are effective.

An operative case of pseudocoarctation with chronic dissection.

A 47-year-old man with a history of hypertension was found to have a prominent aortic knob on routine chest X-ray and was referred to our hospital. Enhanced computed tomography angiography showed severe flexion at the proximal descending aorta with chronic type B dissection localized to the flexion region. Graft replacement of the distal aortic arch was performed. Surgical management of chronic pseudocoarctation dissection is sparsely reported in the literature because of its rare occurrence. We present an operative case of a patient with chronic dissection of distal aortic arch pseudocoarctation.

[Stanford type a acute aortic dissection with pectus excavatum].

Pectus excavatum is generally an isolated abnormality of the chest wall. However, some patients have a concomitant pectus deformity and cardiac & aortic disease. Decisions must be made regarding the operative approach and whether the pectus excavatum should be corrected during the same session. We report 2 patients with acute Stanford type A aortic dissection and pectus excavatum who underwent emergency operation. In case 1, median sternotomy is an unsuitable approach for open heart surgery, since the heart and great vessels are displace into the left hemithorax. But combined sternotomy and left anterior thoracotomy provided excellent surgical exposure. In case 2, we proceeded with a leftsided costotomy of four ribs and place a normal chest retractor providing as excellent exposure as combined sternotomy and left anterior thoracotomy. A left-sided costotomy of four ribs can be performed safely, eliminating the risks of median sternotomy in acute stanford type A aortic dissection with pectus excavatum.

Towards a Clinical Implementation of Measuring the Elastic Modulus of the Aorta From Cardiac Computed Tomography Images.

OBJECTIVE: The elasticity of the aortic wall varies depending on age, vessel location, and the presence of aortic diseases. Noninvasive measurement will be a powerful tool to understand the mechanical state of the aorta in a living human body. This study aimed to determine the elastic modulus of the aorta using computed tomography images. METHODS: We constructed our original formulae based on mechanics of materials. Then, we performed computed tomography scans of a silicon rubber tube by applying four pressure conditions to the lumen. The segment elastic modulus was calculated from the scanned images using our formulae. The actual modulus was measured using a tensile loading test for comparison. RESULTS: The segment moduli of elasticity from the images were 0.525 [0.524, 0.527], 0.524 [0.520, 0.524], 0.520 [0.515, 0.523], and 0.522 [0.516, 0.532] (unit: MPa, median [25%, 75% quantiles]) for the four pressure conditions, respectively. The corresponding measurements in the tensile test were 0.548 [0.539, 0.566], 0.535 [0.528, 0.553], 0.526 [0.513, 0.543], and 0.523 [0.508, 0.530], respectively. These results indicated errors of 4.2%, 2.1%, 1.1%, and 0.2%, respectively. CONCLUSION: Our formulae provided good estimations of the segment elastic moduli of a silicon rubber tube under physiological pressure conditions using the computed tomography images. SIGNIFICANCE: In addition to the elasticity, the formulae provide the strain energy as well. These properties can be better predictors of aortic diseases. The formulae consist of clinical parameters commonly used in medical settings (pressure, diameter, and wall thickness).

Successful surgical case of refractory chronic expanding intrapericardial hematoma treated with preoperative coil embolization of the feeding vessels.

Complete surgical resection of chronic expanding intrapericardial hematoma was often difficult because of the severe adhesion. Preoperative coil embolization of the feeding vessels can prevent recurrent expanding of the residual hematoma and would achieve good results.

Stent grafting simulation using a three-dimensional printed model for extensive aortic arch repair combined with coarctation.

Stent grafting for complex aortic anatomy remains a challenge. In particular, stent graft collapse (i.e. infolding) is possible when an excessive oversized device is needed. We describe a case of preoperative stent grafting simulation using a three-dimensional (3D) printed model for extensive aortic arch repair in a 69-year-old woman with multiple aneurysms combined with coarctation. The patient was scheduled to undergo staged hybrid repair. A stent graft larger than 28 mm in diameter was needed to deploy into a coarctation of 15 mm in diameter during the 2nd stage of the operation. Preoperative, experimental stent grafting using a 3D printed model indicated that infolding would likely not occur. Therefore, we proceeded with surgery, which was successful. This technology could be a useful application for planning complicated stent grafting.

3D-printed aortic stenosis model with fragile and crushable calcifications for off-the-job training and surgical simulation.

Surgical simulation devices can be helpful and cost-effective adjuncts to on-the-job training. In this tutorial we present our method for creating an aortic stenosis model with realistically fragile and crushable calcifications, using modern 3D-printing techniques.  The model can be used for training and surgical simulation and is an effective aid to learning for young cardiovascular surgeons.

Complete removal of infected devices and simultaneous implantation of new devices for infective endocarditis after pacemaker implantation.

Two cases of infective endocarditis after pacemaker implantation were reported. Complete removal of infected devices was performed under cardiopulmonary bypass, and simultaneous implantation of new devices was performed using epicardial leads and generator on the abdominal wall. The postoperative course was uneventful and recurrence was not recognized. These procedures may be suitable for the patients who depend on the pacemaker or who have repeat bacteremia with other infectious disease or conditions.

Morphological analysis and preoperative simulation of a double-chambered right ventricle using 3-dimensional printing technology.

We present a case of a double-chambered right ventricle in adulthood, in which we tried a detailed morphological assessment and preoperative simulation using 3-dimensional (3D) heart models for improved surgical planning. Polygonal object data for the heart were constructed from computed tomography images of this patient, and transferred to a desktop 3D printer to print out models in actual size. Medical staff completed all of the work processes. Because the 3D heart models were examined by hand, observed from various viewpoints and measured by callipers with ease, we were able to create an image of the complete form of the heart. The anatomical structure of an anomalous bundle was clearly observed, and surgical approaches to the lesion were simulated accurately. During surgery, we used an incision on the pulmonary infundibulum and resected three muscular components of the stenosis. The similarity between the models and the actual heart was excellent. As a result, the operation for this rare defect was performed safely and successfully. We concluded that the custom-made model was useful for morphological analysis and preoperative simulation.

Changes in left anterior descending coronary artery flow profiles after coronary artery bypass grafting examined by means of transthoracic Doppler echocardiography.

OBJECTIVE: We sought to investigate the changes of velocity profiles in the left anterior descending coronary artery after coronary artery bypass grafting using transthoracic Doppler echocardiography. METHODS: Forty-five patients who received a bypass graft to the left anterior descending coronary artery were studied. Before coronary artery bypass grafting, Doppler velocity profiles of the distal left anterior descending coronary artery were recorded with transthoracic Doppler echocardiography. Peak systolic velocity, mean systolic velocity, peak diastolic velocity, mean diastolic velocity, total velocity time integral, systolic velocity time integral, and diastolic velocity time integral were measured. Three weeks after coronary artery bypass grafting, left anterior descending coronary artery antegrade flow in the distal portion of the anastomosis was obtained by using the same method. Coronary angiography was performed before and 3 weeks after coronary artery bypass grafting. RESULTS: The overall success rate of measuring the left anterior descending coronary artery flow was 60.0% preoperatively and 80.0% postoperatively. In 25 patients, in whom all parameters were obtained both before and after coronary artery bypass grafting, the following increased significantly after coronary artery bypass grafting: peak systolic velocity (14.86 +/- 7.50 vs 25.07 +/- 17.02 cm/s, P =.0045), mean systolic velocity (9.86 +/- 5.42 vs 18.03 +/- 12.94 cm/s, P =.0026), peak diastolic velocity (24.26 +/- 12.54 vs 48.28 +/- 31.66 cm/s, P =.0021), mean diastolic velocity (14.94 +/- 6.65 vs 30.36 +/- 20.71 cm/s, P =.0022), diastolic velocity time integral (7.22 +/- 2.88 vs 15.55 +/- 10.39 cm, P =.0009), total velocity time integral (10.50 +/- 4.48 vs 19.27 +/- 12.63 cm, P =.0034), and diastolic-to-systolic velocity time integral ratio (3.09 +/- 1.53 vs 4.97 +/- 2.75, P =.0044). Angiography showed graft patency and no significant change in left anterior descending coronary artery stenosis in all patients. CONCLUSIONS: Transthoracic Doppler echocardiography showed a significant increase in some parameters in left anterior descending coronary artery flow after coronary artery bypass grafting. Measurement of left anterior descending coronary artery flow by means of transthoracic Doppler echocardiography might be a noninvasive method to evaluate the effect of bypass grafting on the left anterior descending coronary artery.

Relationship between coagulation cascade, cytokine, adhesion molecule and aortic aneurysm.

OBJECTIVES: Patients with aortic aneurysm (AA) were in the chronic inflammatory condition and are often combined with disseminated intervascular coagulation. Recent studies demonstrated that atherosclerosis was inflammatory disease. AA and severe atherosclerosis with ulcer formation contain macrophages and T lymphocytes and accelerate the production of interleukin (IL)-2, which activates lymphocytes and lead to further adhesion of leukocytes. This study was designed to clarify the coagulation condition, cytokine, adhesion molecule, and collagen turnover in patients with AA and finally their relationship with the aneurysmal size. METHODS: Thrombin-antithrombin III complex (TAT), plasma D-dimer, serum type III procollagen peptide (PIIIP), serum soluble IL-2 receptor (sIL-2R), Free tissue factor pathway inhibitor (TFPI), and soluble intercellular adhesion molecule (ICAM-1) were measured preoperatively around the same period when computed tomography (CT) was taken in 17 patients with AA (mean age: 72.2 years). Age-matched (mean age:70 years) volunteers were served as control. Maximum aneurysmal size was measured by CT and aneurysmal volume was also calculated from CT. RESULTS: AA patients showed significantly higher level in preoperative TAT and D-dimer compared to control (TAT: control 2.5+/-1.2 ng/ml, pre 7.2+/-4.5,ng/ml; P=0.0001; D-dimer: control 107+/-46 U/ml, pre 420+/-256 U/ml; P=0.0001). Cytokine also showed higher level preoperatively (sIL-2R: control 398+/-132 U/ml, pre 735+/-260 U/ml; P=0.0001). TFPI showed higher value preoperatively (control 22.9+/-4.9 ng/ml, pre 30.4+/-6.9 ng/ml; P=0.003). PIIIP (collagen turnover) showed no difference between the groups (P=0.0057) and neither did ICAM-1(P=0.0087). TAT (r=0.799, P=0.0001), D-dimer (r=0.56, P=0.0193), sIL-2R (r=0.709, P=0.0021), PIIIP (r=0.561, P=0.00239), and sICAM-1 (r=0.505, P=0.046) level showed positive correlation with aortic aneurysmal size and also TAT D-dimer, and sIL-2R levels were positively correlated with aneurysmal volume (r=0.714 P=0.0013, r=0.556 P=0.00204, r=0.693 P=0.0029, respectively). CONCLUSIONS: AA patients were in the hypercoagulation and inflammatory condition. Aneurysmal size was well correlated with TAT, D-dimer, sIL-2R, PIIIP, and sICAM-1, suggesting that these markers could be good diagnostic and monitoring tool for the disease progression.

Aortic arch replacement with proximal first technique.

BACKGROUND: Deep hypothermic circulatory arrest (DHCA) without retrograde cerebral perfusion (RCP) has a strict time limit. We modified a surgical technique for anastomosis to shorten the period of DHCA and unilateral cerebral perfusion (UCP). METHODS: Between March 1993 and August 2001, retrospective analysis was done on 23 consecutive patients, who underwent aortic arch replacement with branches. The patients were divided into two groups: DHCA group and UCP group. The DHCA group, in which DHCA alone and without additional cerebral perfusion was performed, comprised of nine patients. Proximal aortic anastomosis was performed first during systemic cooling; then both the brachiocephalic artery and left carotid artery were reconstructed with the branches of the artificial graft during circulatory arrest; thereafter, cerebral and coronary perfusions were resumed. The UCP group, in which DHCA was not used but right hemisphere perfusion during deep hypothermia was performed when the origin of brachiocephalic artery was safely clamped, consisted of 14 patients. RESULTS: Mean time of DHCA was 18.8+/-4.2 minutes and that of right hemisphere perfusion time was 11.0+/-3.8 minutes, respectively. Twenty-one patients survived the surgery (91.3%), and two (8.7%) died during hospitalization. Transient cerebral complication occurred in four patients in the DHCA group and all recovered. Logistic regression analysis revealed that DHCA was the only parameter to significantly influence temporary neurological dysfunction. There was no other significant difference between the two groups. CONCLUSION: With our modified and simple surgical technique for aortic arch repair, we were able to successfully shorten the DHCA time and right hemisphere perfusion time. However, because DHCA was the only parameter to significantly influence temporary neurological dysfunction, some form of continuous cerebral perfusion at deep hypothermia may be a safer method to preserve cerebral function.

Combined aortic valve replacement and coronary artery bypass grafting with in situ arterial grafts for porcelain aorta.

Patients with porcelain aorta carry a high risk of cerebral as well as systemic embolism during cardiac surgery. Here we describe a case of severe aortic stenosis and coronary artery disease combined with the circumferentially calcified aorta. The patient was a 77-year-old man who successfully received four coronary artery bypass grafts with in situ arterial grafts without clamping the aorta and aortic valve replacement. Aortic valve replacement and two distal coronary artery anastomoses to the left circumflex artery and obtuse marginal branch were performed under cardiac arrest during hypothermic perfusion with endoaortic balloon occlusion, followed by partial endarterectomy and closure of the aorta buttressed with bovine pericardium under deep hypothermic circulatory arrest. While rewarming, the other two distal coronary anastomoses to the left anterior descending artery and diagonal branch were done on the beating heart in order to minimize cardiac arrest time. On-pump beating heart coronary artery bypass grafting (CABG) can be useful especially for combined complex cardiac surgery.

A simple way to treat mitral valve prolapse: chordal replacement using a new mitral leaflet retractor.

OBJECTIVES: The most difficult aspect of chordal replacement during mitral valve repair is to determine the correct length of the new chordae. A simple technique of chordal replacement was developed employing the new mitral leaflet retractor that enables easy adjustment of the length of artificial chordae. METHODS: For prolapse of the anterior mitral leaflet (AML), the level of the normal opposing posterior leaflet can be used to determine the length of new chordae. We developed a double-headed leaflet retractor with which both mitral leaflets can be retracted simultaneously at the same level. This retractor makes it easy to tie the slippery Gore-Tex sutures for artificial chordae adjusting the length of the new chordae on AML to the level of the opposing normal posterior leaflet. We employed this retractor for the creation of artificial chordae in 55 consecutive patients with degenerative AML prolapse between 2005 and 2013. A ring annuloplasty was concomitantly performed to stabilize the reconstruction. RESULTS: We had no hospital death. Follow-up was 100% complete with a mean follow-up duration of 1181 ± 839 (range 50-2892) days. Reoperation-free survival at 5 years was 98.2%. Freedom from moderate-to-severe mitral regurgitation was 88.0% at 5 years. At follow-up, all non-reoperated survivors were in New York Heart Association Class I or II. CONCLUSIONS: We have reported the chordal replacement using the new double-headed mitral leaflet retractor. Our leaflet retractor is a convenient tool representing an easy creation of artificial chordae in mitral valve repair.

Advanced left-atrial fibrosis is associated with unsuccessful maze operation for valvular atrial fibrillation.

OBJECTIVE: Atrial dilatation and fibrosis are considered to be important factors in the occurrence and maintenance of atrial fibrillation (AF). However, the relationship between those structural remodeling and postoperative sinus conversions after a maze operation has been rarely studied. The purpose of this study was to determine whether pathological evaluation of atrial tissues was useful for predicting an unsuccessful maze operation in patients with valvular AF. METHODS: Between March 2006 and June 2007, left-atrial tissues in the posterior wall and right-atrial appendage were obtained from 47 consecutive patients (24 patients with chronic AF, and 23 with sinus rhythm) undergoing mitral valve surgery (MVS). A concomitant maze operation was performed for all patients with chronic AF. Atrial cell diameters were measured using hematoxylin and eosin staining, and quantitative assessment of atrial fibrosis was performed with Masson trichrome staining using an image analyzer (Image Processor for Analytical Pathology, Sumika Technoservice Co., Hyogo, Japan). RESULTS: Successful MVS was performed for all patients and there were no complications associated with tissue sampling. Patients with chronic AF had more advanced histological features in both atria as compared with those with sinus rhythm. Sixteen of 24 patients, who underwent a maze operation, had successfully restored sinus rhythm (successful maze group), while that in the remaining eight was not restored (unsuccessful maze group). Patients in the unsuccessful maze group had a larger left-atrial dimension and cardiothoracic ratio as compared with those in the successful group, whereas the duration of AF was not significantly different. Patients in the unsuccessful maze group also had greater hypertrophy of cardiomyocytes and more extensive intercellular fibrosis in the left atrium, while there were no differences for right-atrial pathological features between the groups. Multivariate logistic analysis confirmed that a larger amount of left-atrial fibrosis (>15%) was significantly associated with an unsuccessful maze operation. CONCLUSIONS: The present results suggested that advanced fibrosis in the left atrium, but not in the right atrium, might be significantly associated with an unsuccessful maze operation in patients with valvular AF.