[Left Ventricular Outflow Tract Obstruction After Transcatheter Aortic Valve Replacement due to Pannus Formation].

We experienced a case of surgical aortic valve re-replacement due to structural valve deterioration caused by pannus formation 4 years after transcatheter aortic valve replacement( TAVR). The patient underwent surgery because the mean transvalvular pressure gradient increased to 48 mmHg on echocardiography. Contrast-enhanced computed tomography (CT) was useful for predicting the site of adhesion to surrounding tissue preoperatively and exploring the presence of the pannus. Intraoperative findings showed the TAVR valve was covered with neointima except around the origins of the left and right coronary arteries and was firmly adhered to the surrounding tissues. As residual pannus was present in the subvalvular tissues, it was carefully removed. The explanted TAVR valve functioned well with good opening and closure. The postoperative course was uneventful. Pannus formation can result from mechanical stress. TAVR valves put significantly greater stress on the left ventricular outflow tract than surgical valves and may be more likely to cause pannus formation.

[Valve Replacement for Isolated Pulmonary Valve Infective Endocarditis without Congenital Heart Defects:Report of a Case].

We report a rare case of isolated pulmonary valve endocarditis in a 60-year-old man without congenital heart defects. He had a persistent fever and back neck pain after pulling out his teeth. Echo cardiography revealed a mobile vegetation (measuring 53 mm in size) adhering to the pulmonary valve and blood cultures showed the presence of Staphylococcus aureus( S. aureus). Because of mobile vegetation, pulmonic embolism and presence of S. aureus, surgical treatment was selected. During surgical procedure, we found that the vegetation had destroyed markedly pulmonary valve leaflets. After excising pulmonary valve leaflets, we implanted a bioprosthetic valve and enlarged the pulmonary artery with autologous pericardium. A year after surgery, the patient is stable with no sign of infection.

[Concomitant Tricuspid Annuloplasty with Resection of a Giant Right Atrial Myxoma:Report of a Case].

Myxomas account for the vast majority of heart tumors in adults. About 70% originate in the left atrium, while about 10% of these are reported to originate in the right atrium. A 70-year-old man with dyspnea, was found to have a giant right atrial mass by echocardiography, and tumor resection was performed under cardiopulmonary bypass( CPB) through a median sternotomy. At weaning from CPB the patient was hemodynamically unstable. Intraoperative echocardiography showed severe tricuspid regurgitation( TR), and tricuspid annuloplasty was performed. The postoperative course was uneventful and histopathological examination confirmed that the tumor was a myxoma. It is important to keep in mind that regurgitation of the atrio-ventricular valve might occur after resection of atrial myxoma.

[Gradual Enlargement of Saphenous Vein Graft Aneurysm Causing Chest Symptom after Coronary Artery Bypass Grafting;Report of a Case].

A 70-year-old man was admitted to our hospital because of shortness of breath. He had undergone coronary artery bypass grafting at another hospital 18 years before. We had detected his saphenous vein graft to the right coronary artery being aneurysmal 3 years before. The aneurysm had grown from 23 mm to 42 mm during the follow-up. Because of an angina-like symptom and the possibility of rupture, we performed resection of the aneurysm and redo coronary artery bypass grafting to the right coronary artery using another saphenous vein. His symptom has disappeared since then. Saphenous vein graft aneurysm needs close follow-up even when conservative therapy is selected.

[Surgical Treatment of Abdominal Aortic Aneurysm with Ectopic Kidney with Stanford Type A Acute Aortic Dissection;Report of a Case].

We experienced a surgical case of Stanford type A acute aortic dissection with abdominal aortic aneurysm (AAA) associated with ectopic kidney. Computerized tomography did not detect any ulcer-like projections, but 3 days later, it appeared, and emergency surgery was performed. Second-stage surgery was selected and done later to repair AAA. The right kidney was an ectopic pelvic kidney. The renal arteries had branched off from the left common iliac artery, and the renal artery lumen narrowed. With a 4 Fr catheter, cold Ringer's solution was given to protect the kidneys during surgery. The patient showed no deterioration of kidney function and made good progress. After rehabilitation, the patient had no complications and was discharged from the hospital.

[Treatment Strategy for Stanford Type A Acute Aortic Dissection].

The fundamental treatment of Stanford type A acute aortic dissection is a lifesaving emergency surgery in our hospital. We perform hemiarch replacement with a focus on entry tear, but an extended surgery is also performed only when resection of the entry tear is difficult. The outcomes of current therapeutic policy, along with the short-term and the long-term outcomes of different sites of entry tear, were examined retrospectively. Three hundred and twenty surgery of Stanford type A acute aortic dissection were performed between 1991 and 2015 at our hospital. Their short-term and long-term outcomes were examined after dividing them into 7 groups according to their entry sites. We also investigated surgical methods and effects of presence/absence of residual entry tear. As a result, overall hospital mortality was 13.1%. There was no significant difference in either shortterm or long-term outcome among the groups. Likewise, no significant difference was observed in the surgical methods or the presence/absence of residual entry tear. Recently, minimally invasive procedures, such as stent-grafting, have been applied to manage the residual entry tear. Therefore, an aggressive extended surgery is no longer inevitable and our current therapeutic policy is considered reasonable.

[Retrograde Stanford type A aortic dissection treated by thoracic endo-vascular aortic repair (TEVAR) after ascending aortic replacement].

A 77-year-old woman was admitted to a hospital with complaints of back pain, nausea and vomiting for 4 days. She underwent enhanced aortic computed tomography (CT) and was diagnosed with Stanford type A acute aortic dissection. Then she was transferred to our hospital. CT showed aortic dissection spreading from the ascending aorta up to the abdominal aorta and an intimal tear located at the descending thoracic aorta. Although the false lumen of the ascending aorta was thrombosed, emergency ascending aorta replacement and aortic valve replacement were performed, because pericardial effusion and severe aortic regurgitation were found by echocardiography. Postoperative enhanced CT showed an intimal tear and residual flow in the false lumen from the distal arch to the descending aorta. So an additional thoracic endo-vascular aortic repair (TEVAR) procedure was performed to close the entry tear 20 days after the 1st operation. She uneventfully left our hospital on the 15th postoperative day.

[Intraoperative aortic dissection].

Intraoperative aortic dissection is a rare complication of open heart operations. Once dissection has occurred, great caution is required because of high mortality rate. We reported 4 cases of intraoperative aortic dissection. The incident rate was 0.08%, and the most common site of aortic injury was the aortic cannulation site( 3/4 patients). Intraoperative epiaortic echography is effective in diagnosis. All cases underwent graft replacement of the ascending aorta. The postoperative course was uneventful. Both prompt recognition and appropriate surgical management are mondatory to improve operative outcome.

[Vascular Behçet disease presenting large right coronary artery pseudoaneurysm after percutaneous coronary intervention( PCI): report of a case].

A 37-year-old man was diagnosed with angina pectoris and underwent percutaneous coronary intervention(PCI) procedure for right coronary artery in other hospital. Five months after PCI procedure, he was admitted to the hospital because of fever, chest pain and respiratory discomfort. He was diagnosed as having a large right coronary artery pseudoaneurysm which was about 40 mm in diameter. He was transfered to our hospital. We did coronary artery bypass grafting(CABG)[ saphenous vein graft (SVG)-#3] and pseudoaneurysm closure, and he left our hospital on 37 post-operative day. After discharge from our hospital, he developed iliocecal ulcer, oral aphtha, folliculitis and arthralgia and was diagnosed with Behçet disease. Seven months after the 1st surgery, proximal anastomosis site of SVG was ruptured and presented huge ascending aorta pseudoaneurysm. We performed autologous pericardial patch plasty on ascending aorta, and covered there with omentum flap. He uneventfully left our hospital on 19 post-operative day.

[Thoracic and cardiovascular surgery in Jehovah's Witness].

A Jehovah's Witness who requires thoracic and cardiovascular surgery represents a challenge to both the surgeon and the patient because of the patient's refusal to accept blood transfusion. We reported 15 cases of Jehovah's Witness patients from 43 to 80 years of age who underwent cardiac operations or thoracic vascular operations. There was 1 emergency operation case and 2 re-do operation cases. Erythropoietin and serum albumin injections were allowed to be used in some cases. The mean pre-operative haemoglobin level in these patients was 12.3 g/dl. The mean postoperative lowest haemoglobin level was 9.2 g/dl. The mean haemoglobin level at the point of leaving hospital was 11.4 g/dl. There were no postoperative complications and no operative deaths. We successfully performed the thoracic and cardiovascular operations on Jehovah's Witnesses, including emergency cases, safely without blood transfusion. The most important thing is a careful and safe operative technique which reduces perioperative bleeding as much as possible.

Statin for prevention of atrial fibrillation after off-pump coronary artery bypass grafting in Japanese patients.

BACKGROUND: The purpose of the present study was to assess the preventive effect of preoperative statin treatment on atrial fibrillation (AF) after elective isolated off-pump coronary artery bypass grafting (off-pump CABG) in propensity score-matched Japanese patients. METHODS AND RESULTS: Among 770 consecutive patients undergoing isolated CABG by the same surgeon (99.2% with off-pump technique without conversion to cardiopulmonary bypass) between 2002 and 2009, after excluding emergency (n=150), chronic AF (n=30), and use of cardiopulmonary bypass (n=6), 584 patients were retrospectively reviewed. Of this cohort, 364 patients received statin at least 5 days before operation and 220 patients received no statin. We identified 195 propensity score-matched pairs. Propensity scores were created based on 8 preoperative factors (C statistics, 0.69). There was no significant difference between the 2 groups in baseline characteristics, perioperative medications, or operative procedures. AF occurred in 14.4% in the statin group and in 24.6% in the no statin group (P=0.01). Multivariate logistic regression including potential univariate predictors identified statin (odds ratio [OR] =0.49; 95% confidence interval [95%CI] =0.22-0.81; P=0.01), age (OR =1.33 per 10-year increase; 95%CI =1.04-1.69; P=0.02), and transfusion (OR =2.21; 95%CI =1.38-3.55; P=0.01) as independent predictors of postoperative AF. CONCLUSIONS: Preoperative statin significantly reduces the incidence of AF after elective isolated off-pump CABG in Japanese patients.

Does off-pump bilateral internal thoracic artery grafting increase operative risk in dialysis patients?

BACKGROUND: We compared short-term outcomes of patients with chronic dialysis receiving bilateral internal thoracic artery (BITA) grafting with single internal thoracic artery (SITA) grafting using propensity score analysis. METHODS: Between 2002 and 2008, 656 consecutive patients underwent isolated coronary artery bypass grafting (99.1% off-pump). Of these, 56 patients with chronic dialysis and multivessel disease were retrospectively compared according to surgical technique, BITA (n = 32) or SITA (n = 23) grafting. In an attempt to minimize the selection bias, propensity scores were created based on 13 preoperative factors (C statistics, 0.914). RESULTS: There was no significant difference in age, left ventricular ejection fraction, prevalence of diabetes mellitus, and logistic euroSCORE between the 2 groups. All patients underwent revascularization using the off-pump technique without conversion to cardiopulmonary bypass. All arterial conduits were harvested using skeletonization technique. Except for 1 patient, all ITAs were used as in situ graft. Complete revascularization was achieved in all patients. There was no significant difference in occurrence of mediastinitis, impaired wound healing, and stroke between the 2 groups. The 30-day mortality was 6.3% in the BITA group and 13.0% in the SITA group (P = .64). After adjusting for propensity score, BITA grafting was not associated with impaired wound healing (odds ratio, 0.63; 95% confidence interval, 0.04 to 8.79; P = .73) and 30-day mortality (odds ratio, 0.60; 95% confidence interval, 0.05 to 6.82; P = .68). CONCLUSION: In situ skeletonized BITA grafting is safe and feasible in dialysis patients with multivessel disease.

Bilateral versus single internal thoracic artery grafting in dialysis patients with multivessel disease.

BACKGROUND: The purpose of our study was to compare mortality in dialysis patients undergoing bilateral internal thoracic artery (BITA) or single internal thoracic artery (SITA) grafting and to quantify the magnitude of the BITA grafting benefit for survival. METHODS: Between January 2002 and December 2008, 656 consecutive patients underwent isolated coronary artery bypass grafting (99.1% by an off-pump technique). Fifty-six of these patients with chronic dialysis and multivessel disease were retrospectively compared with respect to surgical technique: BITA (n = 32) or SITA (n = 23) grafting. End points were all-cause and cardiovascular mortality (mean follow-up duration, 2.5 years). In an attempt to minimize the selection bias, we created propensity scores based on 13 preoperative factors that would affect the surgeon's decision about operative strategy; these factors were used for regression adjustment (C statistic, 0.914). RESULTS: There were no significant differences between the 2 groups with respect to age, sex, left ventricular ejection fraction, prevalence of diabetes mellitus and peripheral arterial disease, and logistic EuroSCORE. All patients under-went revascularization with the off-pump technique, with no conversion to cardiopulmonary bypass. All arterial conduits were harvested with a skeletonization technique in all cases. Except for 1 patient who received a SITA, internal thoracic arteries were used as in situ grafts in both groups. Complete revascularization was achieved in all patients. The 1-, 3-, and 5-year survival rates free from all-cause mortality for BITA grafting versus SITA grafting were 94% versus 73%, 72% versus 42%, and 52% versus 28%, respectively (P = .01, logrank test). For survival free from cardiovascular mortality, the respective rates were 100% versus 90%, 80% versus 77%, and 80% versus 58% (P = .06). After propensity score adjustment, BITA grafting was significantly associated with lower risks for all-cause mortality (hazard ratio, 0.27; 95% confidence interval, 0.09-0.81; P = .02) and cardiovascular mortality (hazard ratio, 0.20; 95% confidence interval, 0.04-0.93; P = .04). CONCLUSION: In situ skeletonized BITA grafting provides better long-term survival in dialysis patients with multivessel disease.

[Acute type A aortic dissection, developed shortly after aortic valve replacement and coronary artery bypass grafting].

We experienced a case of acute type A aortic dissection shortly after a cardiac operation. A 73-year-old man underwent aortic valve replacement and coronary artery bypass grafting for aortic regurgitation and angina pectoris. Aortic valve was tricuspid and the ascending aorta was mildly dilated in preoperative studies. The postoperative computed tomography (CT) revealed aortic dissection, from the ascending aorta to the arch of aorta, although the patient was asymptomatic. Reoperation for the aortic dissection was performed on the 22nd post operative day. Re-do sternotomy was safely carried out prior to heparinization. Under hypothermic circulatory arrest with femoral arterial and venous cannulations, the ascending aorta was replaced and re-implantation of the saphenous vein graft was carried out. The postoperative recovery was uneventful and he was discharged on the 17th postoperative day.

Efficacy of bilateral internal thoracic artery grafting in patients with chronic kidney disease.

BACKGROUND: This study compared short-term and long-term outcomes in propensity score-matched patients with chronic kidney disease receiving bilateral internal thoracic artery (ITA) or single ITA grafting and assessed any benefit of bilateral ITA grafting for survival. METHODS: Among 656 consecutive patients undergoing isolated coronary artery bypass grafting (99.1% by off-pump technique) between 2002 and 2008, 361 had chronic kidney disease with no history of dialysis. After excluding 10 patients who would not be potential candidates for bilateral ITA grafting because they were aged older than 85 years and 15 who had only one target vessel at the left coronary area, we identified 157 propensity score-matched pairs. Propensity scores were created based on 13 preoperative factors (C statistics, 0.787). RESULTS: During a mean observation of 2.9 years, the rates of overall death and cardiac death (myocardial infarction, heart failure, and sudden death) in the bilateral ITA group were significantly lower than those in the single ITA group (5.1% vs 15.9%, p=0.01; 1.3% vs 8.3%, p=0.01). In multivariate Cox models including bilateral ITA grafting and all other potential predictors, bilateral ITA grafting was significantly associated with a lower risk for overall death (hazard ratio, 0.29; 95% confidence interval, 0.10 to 0.89; p=0.03) and cardiac death (hazard ratio, 0.14; 95% confidence interval, 0.03 to 0.63; p=0.02). CONCLUSIONS: Among patients with chronic kidney disease, bilateral ITA grafting provides better long-term survival than single ITA grafting.

Left main coronary artery disease does not affect the outcome of off-pump coronary artery bypass grafting.

BACKGROUND: Left main coronary artery (LMCA) stenosis (≥50%) has historically been recognized as a risk factor among patients undergoing coronary artery bypass grafting. METHODS: From January 2002 to December 2008, a total of 665 patients, 268 of whom had significant LMCA disease, underwent isolated off-pump coronary artery bypass surgery at Shiga Medical University Hospital. We compared the clinical results in the 237 patients with LMCA stenosis (LMCA group) with those in the propensity score-matched 237 patients without LMCA stenosis (non-LMCA group). We performed off-pump surgery in all coronary artery bypass grafting cases with no exclusion criteria. RESULTS: All procedures were performed by off-pump technique without conversion to on-pump. Two patients in the LMCA group (2 of 237; 0.8%) and four in the non-LMCA group (4 of 237; 1.7%) died within 30 days after surgery. Follow-up was completed in 96.2% of the patients. The rates of six-year freedom from all cause death were 87.3% and 60.7% in the LMCA group and non-LMCA group, respectively (p = 0.17), and the corresponding rates for the combined endpoint of cardiac death, myocardial infarction, angina pectoris, repeat coronary intervention, and heart failure were 80.4% and 70.4% (p = 0.98). Multivariate Cox regression analysis revealed chronic renal failure as a statistically significant predictor for late cardiac event. CONCLUSIONS: Off-pump coronary artery bypass grafting is feasible and safe in patients with critical LMCA stenosis and LMCA disease is not recognized as a risk factor after off-pump coronary artery bypass grafting in either the short or the long term.

Safety and efficacy of central cannulation through ascending aorta for type A aortic dissection.

The femoral and axillary arteries are common arterial cannulation sites for repair of type A dissection. However, these peripheral approaches involve certain problems. From January 2002 to August 2009, a total of 77 patients underwent emergency surgery for acute type A dissection. Central cannulation was applied in 26 patients and peripheral cannulation in 51. The arterial cannulation site was decided according to preoperative computed tomography findings, the patient's condition, and intraoperative epiaortic ultrasonography findings. Central cannulation was avoided in cases of cardiac tamponade with shock. A cannula was inserted under ultrasound guidance using the Seldinger technique. Preoperative patient comorbidities and dissection-related complications were equally distributed between the two groups. Central cannulation was successfully performed in all 26 cases without incident. Operation time, cardiopulmonary bypass time, mean intubation time and mean intensive care unit stay duration were significant shorter in the central group. One patient (4%) died in the central group compared with four patients (8%) in the peripheral group (P=0.45). Direct central cannulation was successful for repair of type A dissection in selected patients and produced equal or superior surgical data to peripheral cannulation, thus providing one option in the approach to this condition.

Impact of Previous PCI on Hospital Mortality After Off-Pump Coronary Artery Bypass Grafting in Diabetic Patients With Multivessel Disease.

OBJECTIVE: : Because percutaneous coronary intervention (PCI) has been performed excessively, many patients initially managed with PCI are being referred for coronary artery bypass grafting (CABG). The purpose of this study was to assess the impact of previous PCI on surgical mortality after off-pump CABG in diabetic patients with multivessel disease. METHODS: : Between January 2002 and April 2008, 595 consecutive patients (99.8% off-pump) had isolated CABG by one single surgeon. Of these, 274 patients with diabetes mellitus and multivessel disease were retrospectively analyzed. Patients with previous PCI (n = 79) were compared with patients with no previous PCI (n = 196), and risk-adjusted impact of previous PCI on surgical mortality after CABG was determined using multivariate and propensity score analyses. RESULTS: : All patients underwent off-pump CABG without conversion to cardiopulmonary bypass during operation. Patients with previous PCI had a significantly higher prevalence of history of myocardial infarction, renal dysfunction, and hemodialysis. Rates of surgical mortality were higher in patients with previous PCI (7.6% versus 1.0%, P = 0.008). After multivariate logistic regression analysis including all potential univariate predictors, previous PCI remained a strong predictor of surgical mortality [odds ratio (OR), 6.9; 95% confidence interval (CI), 1.2 to 42.1; P = 0.035]. After matching and regression adjustment by propensity score, the impact of previous PCI on surgical mortality was similar in direction (matching OR, 6.5; 95% CI, 0.8 to 55.0; P = 0.088; regression adjustment OR, 6.3; 95% CI, 1.2 to 33.6; P = 0.031). CONCLUSIONS: : Previous PCI increases the risk of surgical mortality after off-pump CABG in diabetic patients with multivessel disease.