Left ventricular remodeling and long-term outcomes of aortic stenosis patients receiving 19 mm Mosaic.

Mosaic valve shows higher pressure gradient after aortic valve replacement compared to other same size labeled prostheses in postoperative echocardiogram. The purpose of this study was to evaluate the mid-term echocardiogram findings and long-term clinical outcomes of patients receiving a 19 mm Mosaic. Forty-six aortic stenosis patients receiving 19 mm Mosaic and 112 patients receiving either 19 mm Magna or Inspiris, who underwent mid-term follow-up echocardiogram were included in the study. Mid-term hemodynamic measurements evaluated by trans-thoracic echocardiogram and long-term outcomes were compared. Patients receiving Mosaic were significantly older (Mosaic: 76 ± 5.1 years vs. Magna/Inspiris: 74 ± 5.5 years, p = 0.046) and had smaller body surface area (Mosaic: 1.40 ± 0.114m2 vs. Magna/Inspiris: 1.48 ± 0.143m2, p < 0.001). There were no significant differences in comorbidities and medications. Post-operative echocardiogram performed at 1 week after the surgery showed higher maximum pressure gradient in patients receiving Mosaic (Mosaic: 38 ± 13.5 mmHg vs. Magna/Inspiris: 31 ± 10.7 mmHg, p = 0.002). Furthermore, mid-term echocardiogram follow-up performed at median duration of 53 ± 14.9 months after the surgery continuously showed higher maximum pressure gradient in patients receiving Mosaic (Mosaic: 45 ± 15.6 mmHg vs. Magna/Inspiris: 32 ± 13.0 mmHg, p < 0.001). However, there were no significant difference in changes in left ventricular mass from baseline in both groups. Kaplan-Meyer curve also showed no difference in long-term mortality and major adverse cardiac and cerebrovascular event between the two groups. Although the pressure gradient across the valve evaluated by echocardiogram was higher in 19 mm Mosaic compared to 19 mm Magna/Inspiris, there were no significant differences in left ventricular remodeling and long-term outcomes between the two groups.

The effect of balloon-expandable stent and self-expanding stent on changes in mitral annular motion after aortic valve replacement in patients with aortic stenosis.

OBJECTIVES: The purpose of this study was to evaluate the effect of decalcification and existence of stent at the aortic annulus on mitral annular motion after surgery. METHODS: Patients receiving Inspiris (Edwards, CA, USA, n = 117), Intuity (Edwards, n = 36), Perceval (Corcym, London, UK, n = 36), Evolut (Medtronics, MN, USA, n = 81) and Sapien 3 (Edwards, n = 250) were included in the study. Mitral annular motion was evaluated by E', using tissue doppler imaging. RESULTS: After surgery, a significant increase in E' was observed in patients receiving Inspiris (Before: 4.2 ± 1.21 cm/s vs. Discharge: 5.0 ± 1.23 cm/s, p < 0.001). Mid-term echocardiogram performed at 11.8 ± 2.2 months after the surgery, showed a significant increase in E' in patients receiving Inspiris (Before: 4.2 ± 1.21 cm/s vs. Mid-term: 5.2 ± 1.20 cm/s, p < 0.001) and Perceval (Before: 3.9 ± 1.34 cm/s vs. Mid-term: 4.5 ± 1.24 cm/s, p = 0.008). Univariable analysis showed a higher increase in E' in patients with decalcified annulus compared to those without decalcified annulus (Decalcification: 0.15 ± 1.321 cm/s vs. No Decalcification: 0.66 ± 1.420 cm/s, p < 0.001). Multivariable analysis showed that balloon-expandable stent (ß = - 0.6960, p < 0.001) and self-expanding stent (r = - 0.3592, p = 0.042) were independent limiting factors for an increase in E' at discharge. However, balloon-expandable stent (ß = - 0.8382, p < 0.001), and not self-expanding stent (ß = - 0.3682, p = 0.089), was a remaining independent factor associated with E' at mid-term follow-up. CONCLUSIONS: Decalcification was associated with improvement in E' after surgery. Balloon-expandable stent was an independent limiting factor for improvement in E' up to 1 year after the surgery, while self-expanding stent was not a significant factor after 1 year.

[Non-A Non-B Aortic Dissection Complicated with Right Aortic Arch Treated by Extended Thoracic Aortic Repair].

A 44-year old man with a history of Stanford type B acute aortic dissection was admitted for the treatment of acute aortic dissection. Computed tomography( CT) scan showed a descending entry-type non-A non-B aortic dissection with a maximum diameter of 65 mm occurring in a patient with Edwards typeⅢ right aortic arch whose left subclavian artery was obliterated. The patient was initially treated conservatively and underwent one-stage extended aortic repair from the ascending aorta to the descending thoracic aorta via median sternotomy 22 days after the symptom onset. Although the patient suffered from right empyema postoperatively, he was discharged from the hospital on postoperative day 64 after 4 weeks antibiotics therapy. The patient was also complicated by right recurrent nerve palsy, hoarseness improved over the 8 months after surgery.

Impact of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation.

Negative impact of prosthesis-patient mismatch on long-term survival after valve replacement has been reported. However, the effect of prosthesis-patient mismatch after bioprosthetic mitral valve replacement has not yet been well examined. The purpose of this study was to investigate the effect of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation. A total of 181 patients underwent bioprosthetic mitral valve replacement between April 2008 and December 2016. After excluding patients with mitral stenosis and those with incomplete data, 128 patients were included in the study. Postoperative transthoracic echocardiography was performed before discharge for all patients and the effective orifice area of bioprosthetic mitral valve was calculated using the formula: 220/pressure half-time, and the effective orifice area index was calculated by the formula: effective orifice area/body surface area. Prosthesis-patient mismatch was defined as a postoperative effective orifice area index ≤ 1.2 cm2/m2. The characteristics and outcomes were compared between the groups. There were 34 patients (26.6%) with prosthesis-patient mismatch and 94 patients (73.4%) without prosthesis-patient mismatch. There were no significant differences in the in-hospital mortality and morbidities. Multivariable analysis showed that prosthesis-patient mismatch was an independent predictor of late mortality (hazard ratio 3.38; 95% confidence interval 1.69-6.75; p = 0.001) and death from heart failure (hazard ratio 31.03, 95% confidence interval 4.49-214.40, p < 0.001). Prosthesis-patient mismatch at discharge after mitral valve replacement for mitral regurgitation was associated with long-term mortality and death from heart failure.

Evaluation of oversizing in association with conduction disorder after implantation of a rapid deployment valve.

Rapid deployment valve has expanded surgical indication for high-risk patients with aortic stenosis despite its accommodated risk for conduction disorder (CD). The purpose of this study was to evaluate the degree of oversizing in association with postoperative CD. During June 2019 to September 2021, 25 patients underwent aortic valve replacement with Edwards INTUITY. Device size selection was evaluated intraoperatively using provided sizers. Oversizing was evaluated retrospectively by measuring the difference of the dimension of the annulus and left ventricular outflow tract (LVOT) compared to the dimensions of the device used by preoperative-computed tomography. Although there was no incidence of pacemaker implantation, seven patients (28.0%) experienced CD after surgery. There was no difference in device area and annulus area (CD: - 37 ± 22.7 mm2 vs. no CD: - 56 ± 63.6 mm2, p = 0.47), and device circumference and annulus circumference (CD: - 4.4 ± 2.77 mm vs. no CD: - 6.9 ± 5.60 mm, p = 0.26) in patients with and without CD. However, there was a significant difference in area of the device skirt and sub-annular area at the LVOT (CD: 114 ± 28.4 mm2 vs. no CD: - 8 ± 80.0 mm2, p < 0.001), and circumference of device skirt and the LVOT (CD: 3.9 ± 2.08 mm vs. no CD: - 4.6 ± 5.24 mm, p < 0.001) between the two groups. Receiver operating characteristic curve analysis showed that an area difference of 77.7 mm2 and circumference difference of 0.91 mm at LVOT were associated with postoperative CD with specificities of 0.83, 0.78 and sensitivity of 1.0, 1.0, respectively. Preoperative measurement of the LVOT may be useful in evaluating the risk of postoperative CD in patients receiving rapid deployment valve.

The effect of stent and decalcification on mitral annular motion after aortic valve replacement.

OBJECTIVE: The purpose of this study was to evaluate the changes in mitral annular motion after surgery in patients with aortic stenosis. METHODS: Patients receiving Edwards (Edwards) valves were included in the study. Echocardiographic findings were compared among the three treatments postoperatively, at discharge, and at 1 year after the surgery. Mitral annular motion was evaluated by e prime, using tissue doppler imaging. RESULTS: There were 111 patients receiving Inspiris, 30 patients receiving Intuity and 241 patients receiving Sapien 3. The patients receiving Sapien 3 were significantly older, (Inspiris: 71 ± 6.7 years vs. Intuity: 75 ± 5.2 years vs. Sapien 3: 84 ± 5.1 years, p < .001), and prevalence of hemodialysis were significantly higher in patients receiving Intuity (Inspiris: 11.7% vs. Intuity: 46.7% vs. Sapien 3: 0.0%, p < .001). There was a significant improvement in mean pressure gradient in all groups (Inspiris: 55 ± 21.2-13 ± 5.2 mmHg, p < .001; Intuity: 48 ± 17.6-12 ± 4.9 mmHg, p < .001, Sapien 3: 55 ± 16.6-14 ± 5.2 mmHg, p < .001). Decalcification was associated with increase in e prime after surgery (no decalcification: 0.10 ± 1.280 cm/s vs. decalcification: 0.68 ± 1.405 cm/s, p < .001) Further, existence of stent was associated with less increase in e prime after surgery (no stent: 0.83 ± 1.210 cm/s vs. stent: 0.10 ± 1.356; p < .001). Multivariate analysis showed that existence of stent but not decalcification of the aortic valve was independently associated with changes in e prime after surgery (ß: -.4679, 95% confidence interval: -0.93389 to -0.00200, p = .049). CONCLUSIONS: Although improvement in pressure gradient was achieved in all treatments, existence of stent inhibited mitral annular motion after surgery.

Effect of nadir hematocrit during cardiopulmonary bypass on the early outcomes after surgical repair of acute type A aortic dissection.

OBJECTIVE: Although hemodilution during hypothermic cardiopulmonary bypass (CPB) had been thought to improve microcirculation and reduce blood viscosity, there has been no report investigating the effect of low nadir hematocrit (Hct) values caused by severe hemodilution on the surgical outcomes of patients with acute type A aortic dissection (ATAAD). METHODS: We retrospectively reviewed 112 consecutive patients who emergently underwent emergency surgical repair of ATAAD at our institution. The patients were classified into the high Hct (nadir Hct ≥ 21% during CPB; n = 51) and low Hct (nadir Hct < 21% during CPB; n = 61) groups. After propensity score matching of preoperative characteristics, surgical outcomes were compared between the groups. RESULTS: Although there was no difference in the surgical procedure, longer CPB time and more blood transfusion during surgery were needed in the low Hct group than in the high Hct group. After surgery, estimated glomerular filtration rate was significantly lower (p = .015), lactaic acid was higher (p = .045), and intubation time was longer (p = .018) in the low Hct group than in the high Hct group, although there was no difference in hospital mortality between the groups. The AUC of the nadir Hct during CPB as a prognostic indicator of prolonged postoperative ventilator support was 0.8, with the highest accuracy at 16.7% (sensitivity 88%, specificity 76.9%). In all cohorts, female sex was an independent risk factor for a lower nadir Hct value of <21% during CPB. CONCLUSION: A lower nadir Hct value of <21% during CPB may be associated with postoperative renal dysfunction and prolonged ventilator support in patients with ATAAD.

An increased prothrombin time-international normalized ratio in patients with acute type A aortic dissection: contributing factors and their influence on outcomes.

PURPOSE: We investigated factors contributing to coagulopathy in patients with acute type A aortic dissection (ATAAD) and coagulopathy's influence on patient outcomes. METHODS: We grouped 420 patients who underwent ATAAD repair-none under anticoagulation therapy or with liver disease-by the prothrombin time-international normalized ratio (PT-INR) at admission: < 1.2 (no coagulopathy, n = 371), 1.2-1.49 (mild coagulopathy, n = 33), or ≥ 1.5 (severe coagulopathy, n = 16). We then compared the clinical presentation, dissection morphology, and outcomes among the groups. We assessed the PT-INR in relation to the preoperative hemodynamics and searched for factors predictive of a PT-INR ≥ 1.2. RESULTS: The transfusion volume and operation time were increased among patients with coagulopathy (P < 0.05). The in-hospital mortality (15.2-37.5% vs. 5.1%, P < 0.001) and 5-year survival (61.1-74.4% vs. 87.6%) were relatively poor for these patients. The median PT-INR was 1.03 (0.97-1.1) for patients with stable hemodynamics (n = 318), 1.11 (1.02-1.21) for those in shock (blood pressure < 80 mmHg) not given cardiopulmonary resuscitation (CPR) (n = 81), and 1.1 (1.0-1.54) for those in shock given CPR (n = 21) (P < 0.001). A multivariable analysis identified shock (P < 0.001), a partially thrombosed false lumen (P = 0.006), and mesenteric malperfusion (P = 0.016) as predictive variables. CONCLUSIONS: Shock, a partially thrombosed false lumen, and mesenteric malperfusion appear to be predictive of dissection-related coagulopathy, which influences outcomes negatively.

Relationship between endothelial function and vascular stiffness on lower limit of cerebral autoregulation in patients undergoing cardiovascular surgery.

Hemodynamic management based on cerebral autoregulation range is a possible strategy for preserving major organ perfusion during cardiovascular surgery. The purpose of this study was to evaluate the relation of vascular properties with lower limit of cerebral autoregulation (LLA). LLA was monitored in 66 patients undergoing cardiovascular surgery using near-infrared spectroscopy. To determine the clinical importance of LLA monitoring, association of blood pressure excursions below LLA and acute kidney injury (AKI) was evaluated. Flow-mediated dilation (FMD) and pulse wave velocity (PWV) were measured for the evaluation of endothelial function and aortic stiffness. Variables associated with LLA were evaluated. Excluding patients on hemodialysis, there were 15 patients (25.9%) who developed AKI. Blood pressure excursions below LLA were higher in patients who developed AKI (4.55 mm Hg × hr vs. 1.23 mm Hg × hr, P = .017). In the univariate analysis, prevalence of ischemic heart disease (No IHD: 53 ± 13.0 mm Hg vs. IHD: 60.0 ± 13.6 mm Hg, P = .056) and FMD (r = -0.42, 95% CI -0.61 to -0.19, P < .001) were associated with LLA before cardiopulmonary bypass (CPB). During CPB, calcium channel blocker (No Ca blocker: 42 ± 10.6 mm Hg vs. Ca blocker: 49 ± 14.3 mm Hg, P = .033), diabetes (no DM: 44 ± 13.2 mm Hg vs. DM: 55 ± 10.0 mm Hg, P = .024), FMD (r = -0.32, 95% CI -0.55 to -0.05, P = .021), and PWV (r = 0.28, 95% CI 0.012 to 0.513, P = .041) were associated with LLA. Multivariate analysis showed that FMD was correlated with LLA before CPB (r = -2.19, 95% CI -3.621 to -0.755, P = .003), while PWV was correlated with LLA during CPB (r = 0.01, 95% CI 0.001-0.019, P = .023). Endothelial function and aortic stiffness may be important factors in determining LLA at different phases in cardiovascular surgery.

Early cardiac contractility outcome of reoperative coronary artery bypass grafting using right gastroepiploic artery.

BACKGROUND AND AIM OF THE STUDY: Reoperative coronary artery bypass grafting (redo CABG) still carries higher mortality and increased morbidity compared with primary CABG. In this study, we retrospectively reviewed our operative outcome of redo CABG to evaluate the impact of the left anterolateral thoracotomy approach using the right gastroepiploic artery (RGEA). METHODS: Between 1994 and 2020, 11 patients (mean age 60.3 ± 13.1 years; nine men, two women) underwent isolated redo CABG using the RGEA via the left anterolateral thoracotomy. RESULTS: The mean duration from the initial CABG was 128.3 ± 88.4 months. Redo CABG was performed because of graft occlusion in six patients (54.5%), graft stenosis in one patient (9.1%), and progressive disease of previously ungrafted vessels in four patients (36.4%). The total number of bypasses using RGEA (including Y-composite vein grafts) was 16 (four left anterior descending branches, two diagonal branches, five circumflex branches, five right coronary arteries). No residual graft injury, major comorbidity, or in-hospital death was observed. Changes in echocardiographic values before and after redo CABG were 210.9 ± 48.2 ml and 175.0 ± 41.4 ml in left ventricular end-diastolic volume, 130.2 ± 49.2 ml and 94.4 ± 33.0 ml in left ventricular end-systolic volume, and 45.6 ± 11.0% and 52.2 ± 10.7% in left ventricular ejection fraction, respectively. These parameters significantly improved after redo CABG. CONCLUSIONS: Redo CABG with RGEA grafting via the left anterolateral thoracotomy approach is a safe and effective surgical procedure especially in improving cardiac contractility in patients who required revascularization.

[Rapid Growing Thoracic Aortic Aneurysm in a Patient with Relapsing Polychondritis].

A 26-year-old man with relapsing polychondritis was admitted for the treatment of multiple thoracic aortic aneurysms in the ascending and descending aorta. Descending thoracic aortic aneurysm showed rapid expansion, therefore, the patient underwent an extended thoracic aortic repair from the ascending aorta to the descending aorta via anterolateral thoracotomy and partial sternotomy. Although postoperative course was uneventful, aortic root enlargement and severe aortic insufficiency progressed over the next two years. He and his family refused redo surgical intervention and the patient died of heart failure. Careful perioperative follow-up may be mandatory in a patient with relapsing polychondritis complicated by cardiovascular disease.

Long-Term Outcomes and Echocardiographic Data After Aortic Valve Replacement With a 17-mm Mechanical Valve.

BACKGROUND: We investigated the long-term clinical and hemodynamic outcomes after aortic valve replacement (AVR) with a 17-mm mechanical valve.Methods and Results:Between January 2005 and December 2011, 80 patients with aortic stenosis underwent AVR with the 17-mm St. Jude Medical Regent prosthetic valve. Echocardiography was performed preoperatively, at discharge, and at follow-up, which was performed at least 2 years postoperatively (median interval, 7.3 years). Prosthesis-patient mismatch (PPM) was defined as an indexed effective orifice area <0.85 cm2/m2at discharge and occurred in 25 patients (31%). The median follow-up period was 8.7 years (100% complete). Overall in-hospital mortality was 2.5% (2 patients) with 27 late deaths (34%). The 5- and 10-year survival rates were 78.7% and 63.0%, respectively. Peripheral arterial disease and concomitant mitral valve repair were independent predictors of late mortality. The 5- and 10-year freedom from major adverse valve-related events (MAVRE) rates were 91.6% and 83.5%, respectively. PPM at discharge did not affect long-term survival, freedom from MAVRE, or freedom from heart failure. Echocardiographic data at follow-up revealed a significant reduction in the mean left ventricular mass index (LVMI). LVMI reduction observed at follow-up was similar between patients with and without PPM. CONCLUSIONS: AVR with the 17-mm mechanical prosthesis had acceptable long-term clinical and hemodynamic outcomes. Significant reduction in LVMI was observed regardless of PPM.

Minimized perfusion circuit for acute type A aortic dissection surgery.

A minimized perfusion circuit (MPC) may reduce transfusion requirement and inflammatory response. Its use, however, has not been standardized for complicated cardiovascular surgery. We assessed outcomes of surgery for acute type A aortic dissection (ATAAD) performed with a MPC under circulatory arrest. The study involved 706 patients treated surgically for ATAAD (by hemiarch repair [n = 571] or total arch repair [n = 135]). Total arch repair was performed using selective antegrade cerebral perfusion. Our MPC, a semi-closed bypass system, incorporating a completely closed circuit and a level-sensing reservoir in the venous circuit, was used. Clinical variables, transfusion volume, and outcomes were investigated in patients who underwent hemiarch repair or total arch repair. The overall incidences of shock, organ ischemia, and coagulopathy (prothrombin time-international normalized ratio >1.5) were 26%, 35%, and 8%, respectively. Mean extracorporeal circulation (ECC) time was 149 minutes for the hemiarch repair group and 241 minutes for the total arch repair group, respectively. No patient required conversion to conventional ECC, and there were no complications related to the use of the MPC. The need for transfusion (98% vs. 91%, P = .017) and median transfusion volume (1970 vs. 1680 mL, P = .002) was increased in the total arch repair group. Neither in-hospital mortality (total arch; 12% vs. hemiarch; 7%, P = .11) nor 10-year survival (74.4% vs. 68.4%, P = .79) differed significantly. Outcomes of surgery for ATAAD performed with the MPC were acceptable. The possibility of transfusion and transfusion volume remains high during such surgery, despite the use of the MPC.

Early superior mesenteric artery revascularization for acute type A aortic dissection with cardiac tamponade and mesenteric malperfusion.

We report herein the successful treatment of a case of acute type A aortic dissection complicated by cardiac tamponade and mesenteric malperfusion. The patient was a 60-year-old man with back and abdominal pain and in shock, who was transported to our hospital 2 h after symptom onset. Computed tomography revealed DeBakey type I dissection with massive hemopericardium and obstruction of both the celiac artery and superior mesenteric artery. After emergency pericardiotomy and removal of the hematoma, superior mesenteric artery-external iliac artery bypass was constructed with a vein graft, and this restored mesenteric perfusion. Open distal hemiarch replacement was then performed. The postoperative course was uneventful. Superior mesenteric artery revascularization achieved immediately after release of the cardiac tamponade prevented further mesenteric ischemia and paved the way for the aortic repair.

Etiology and impact on outcomes of polycystic kidney disease in abdominal aortic aneurysm.

PURPOSE: We investigated the etiology and impact on outcomes of polycystic kidney disease in patients with abdominal aortic aneurysm. METHODS: Eight-hundred patients who underwent open (n = 603) or endovascular aortic repair (n = 197) were divided into three groups: no cyst (n = 204), non-polycystic kidney (n = 503), and polycystic kidney (≥ 5 cysts in the bilateral kidneys, n = 93). The characteristics and outcomes were compared among the groups. RESULTS: In the polycystic kidney group, the age was increased and the proportions of patients with male sex, hypertension, and estimated glomerular filtration rate < 30 mL/min/1.73 m2 were greater. The overall hospital mortality rates were similar. The incidence of acute kidney injury after elective open aortic repair was increased in the polycystic kidney group (12%, 17%, and 29%, P = 0.020). In the polycystic kidney group, 80 patients did not have renal enlargement or a family history of renal disease, while 13 (corresponding to 1.6% [13/800] of the overall patients), had renal enlargement, suggesting the possibility of hereditary polycystic kidney disease. CONCLUSIONS: In our cohort, 1.6% of the patients with abdominal aortic aneurysm who underwent surgery were at risk of hereditary polycystic kidney disease. Polycystic kidney disease was associated with acute kidney injury after open aortic repair.

[Bioprosthetic Mitral Valve Thrombosis in Patient with Antiphospholipid Antibody Syndrome;Report of a Case].

A 66-year-old woman with primary antiphospholipid antibody syndrome (APS) was admitted due to severe dyspnea. Eight months prior to admission, she underwent bioprosthetic mitral valve replacement for mitral valve stenosis and regurgitation. Transthoracic echocardiogram showed thickening bioprosthetic valve leaflets and severe valve stenosis. Emergency reoperation for artificial valve failure was performed. The explanted bioprosthetic valve showed massive thrombus formation. After the operation, she started strict anticoagulant and antiplatelet therapies and was discharged without recurrence of valve thrombosis.

Outcomes of Early-Onset Acute Type A Aortic Dissection　- Influence of Etiologic Factors.

BACKGROUND: Outcomes of early-onset acute type A aortic dissection (ATAAD) associated with Marfan syndrome (MFS) are known, but not with other etiologies. Methods and Results: ATAAD patients from 2 centers (n=1,001) were divided into 2 groups: age ≤45 years (n=93) and age >45 years (n=908). Although in-hospital death and 10-year survival were similar (12% vs. 7% and 62.6% vs. 67.3%), the 10-year aortic event-free survival differed (50.0% vs. 80.2%; P<0.01). ATAAD patients from 3 centers (n=132), all aged ≤45 years, were divided into 5 groups: lone hypertension (HTN, n=71), MFS (n=23), non-syndromic familial thoracic aortic aneurysm and dissection (NS-FTAAD, n=16), bicuspid aortic valve (BAV, n=11), and no known etiologic factor (n=11). The incidence of severe aortic insufficiency varied between groups (HTN: 11%, MFS: 39%, NS-FTAAD: 38%, BAV: 55%, no known factor: 46%; P<0.01), whereas in-hospital death did not (14%, 22%, 0%, 0%, and 9%; P=0.061). The 10-year survival was 52.2%, 64.7%, 83.6%, 100%, and 90.9%, respectively, and 10-year aortic event-free survival was 55.6%, 36.3%, 77.5%, 90.0%, and 30.0%. Median descending aorta growth (mm/year) was 1.1 (0.1-3.4), 2.3 (0.3-5.3), 1.9 (1.3-2.7), 0.9 (-0.1-2.0), and 1.0 (-0.2-2.9) (P=0.15), respectively. CONCLUSIONS: Late aortic events are common in young ATAAD patients. Known etiologic factors, though not BAV, negatively influence late outcomes in these patients.

Perioperative factors associated with aneurysm sac size changes after endovascular aneurysm repair.

PURPOSE: To identify the perioperative factors associated with aneurysm size changes after endovascular aortic aneurysm repair (EVAR). METHODS: Between August, 2008 and December, 2014, 187 patients underwent EVAR treatment in our institution. The subjects of this study were 135 of these patients without peripheral artery disease, who were followed up with computed tomography (CT) for 3 years. Significant aneurysm size change was defined as sac size change of more than 5 mm from the baseline. RESULTS: Sac enlargement was identified in 25 patients (18.5%) and sac shrinkage was identified in 59 (43.7%) patients. The factors associated with sac enlargement were postoperative pulse wave velocity (OR: odds ratio 3.80, p = 0.047), prevalence of a type 2 endoleak 1 week after surgery (OR 4.26, p = 0.022), inner diameter (OR 1.10, p = 0.005), and distance from the lower renal artery to the terminal aorta (OR 1.05, p = 0.017). The factors associated with sac shrinkage were prevalence of a type 2 endoleak (OR 0.09, p < 0.001) and preoperative pulse wave velocity (OR 0.32, p = 0.022). The factors independently associated with type 2 endoleak were the use of an Excluder device (OR 3.99, p = 0.002) and the length of the aneurysm (OR 1.02, p = 0.027). CONCLUSION: Inner diameter, treatment length, perioperative pulse wave velocity, and type 2 endoleak were associated with sac size changes after EVAR.

Successful Surgical Treatment of Giant Coronary Artery Aneurysm and Concomitant Coronary Artery Fistula to the Pulmonary Artery.

Giant coronary artery aneurysm (GCAA) combined with coronary artery fistula to the pulmonary artery (PA) is rare. A 79-year-old man was accidentally discovered with GCAA. He was operated on by use of aneurysmorrhaphy, and closure of the fistulae was performed. Because ischemic changes appeared, coronary artery bypass grafting was done. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. We report here a case of GCAA with a size of 66 × 52 mm in diameter associated with a fistula formation into the PA. It is one of the largest sizes of GCAA that has occurred after fistula formation.

Acute type a aortic dissection associated with a sporting activity.

PURPOSE: To investigate the clinical characteristics of acute type A aortic dissection (ATAAD) occurring during a sporting activity. METHODS: The subjects of this study were 615 patients who underwent surgery for ATAAD between 1990 and 2015. The patients were divided into two groups according to whether the ATAAD was associated with a sporting activity (sports group: n = 25, mean age 62.3 years; non-sports group: n = 590, mean age 63.7 years). Specific activity was assessed in the sports group, and the characteristics and outcomes were compared between the groups. RESULTS: The sports group accounted for 5% of the patients with daytime onset ATAAD (25/479). The most common sport was golf (n = 8), followed by swimming (n = 4), cycling (n = 4), and weight lifting (n = 3). The average diameter of the ascending aorta on preoperative computed tomography was 4.8 cm. The dissection characteristics of the sports group included DeBakey type I (n = 23, 92%) and malperfusion (n = 9, 36%), which were similar to those of the non-sports group. The 30-day mortality rates were 16% (4/25) for the sports group and 8% (49/590) for the non-sports group (P = 0.33). CONCLUSIONS: The most common sport associated with ATAAD was golf, followed by swimming cycling, and weight lifting. The findings of this study reinforce that sports-related aortic dissection is not a unique clinical condition of young syndromic patients, but can occur in all age groups.