Renal Biomarkers in the Early Detection of Acute Kidney Injury After Off-Pump Coronary Artery Bypass Grafting.

BACKGROUND: Cardiac surgery-associated (CSA) acute kidney injury (AKI) is a severe postoperative complication in patients undergoing off-pump coronary artery bypass grafting (OPCAB). Early detection of postoperative CSA-AKI may be key to improving patient outcomes. This study explored the use of renal biomarkers measured immediately after surgery for the early detection of CSA-AKI in patients undergoing OPCAB.Methods and Results: In all, 111 patients who underwent OPCAB at Kumamoto University Hospital between June 2020 and October 2022 were included in this study. Urinary neutrophil gelatinase-associated lipocalin, liver-type fatty acid-binding protein, and N-acetyl-ß-D-glucosaminidase (NAG) were measured upon arrival in the intensive care unit (ICU) after surgery. AKI was diagnosed using KDIGO criteria. Of the 111 patients, 32 (28.8%) developed postoperative AKI. Regarding AKI staging, 19 (59.4%), 11 (34.4%), and 2 (6.3%) patients had Stage 1, 2, and 3 AKI, respectively. There were significant differences in chronic kidney disease, preoperative estimated glomerular filtration rate (eGFR), and NAG between the AKI and non-AKI groups. Multivariate analysis showed that preoperative eGFR (odds ratio [OR] for 5-mL/min/1.73 m2increase in eGFR 0.75; 95% confidence interval [CI] 0.63-0.89) and increasing urinary NAG concentrations at ICU admission (OR 2.44; 95% CI 1.30-4.60) were significant risk factors for CSA-AKI in OPCAB patients. CONCLUSIONS: NAG and eGFR may be valuable biomarkers for the early detection of CSA-AKI in patients undergoing OPCAB.

Free Jejunal Graft Interposition with Vascular Reconstruction in Patients Undergoing Pharyngo Laryngo Esophagectomy.

BACKGROUND: Pharyngo-esophageal reconstruction using free jejunal grafts has been widely used for the treatment of locally advanced carcinomas of the hypopharynx and cervical esophagus. However, the procedure is technically demanding and requires complex recontractions. The aim of this study was to evaluate our institutional outcomes of reconstruction using a free jejunal graft with vascular reconstruction in patients undergoing pharyngo laryngo esophagectomy with a multidisciplinary surgical team. METHODS: There were 90 consecutive patients between October 2006 and February 2021. The mean age was 64.6 ± 10.3 years, and there were 76 male patients. Of 90 patients, 49 underwent preoperative chemotherapy and/or radiotherapy. Jejunal vessels were commonly anastomosed to the common carotid artery and the internal jugular vein (77.8% and 92.2%, respectively). Continuous intravenous infusion of heparin was used postoperatively. RESULTS: Necrosis of the graft was observed in 5 patients. An isolated revision of vein was necessary in 1 patient. In all cases of graft failure, heparin was not used postoperatively. On the other hand, among the patients without graft failure, heparin was used for about two-thirds of the patients and was significantly different (0% vs. 66%, P = 0.01). CONCLUSIONS: Free jejunal graft with vessel reconstruction is a safe and effective method for patients undergoing pharyngo laryngo esophagectomy. The position for the prevention of kinking as well anastomosis maneuver of vein is especially important. Moreover, early postoperative anticoagulation is essential.

[A Combination Therapy with Antibiotic and Surgical Treatment in a Patient with Patent Ductus Arteriosus with Pulmonary Vegetation:Report of a Case].

We present a case of a 24-year-old female who presented with a history of fever and back pain. She had no particular medical history and was not taking any medication. Transthoracic echocardiology and computed tomography showed a patent ductus arteriosus with vegetation in the pulmonary artery. She was treated with penicillin G;however, the vegetation embolized into the left pulmonary artery. After the antibiotics was changed to clindamycin and ceftriaxone, the resolution of the lung abscess was shown by computed tomography( CT). Two months later, a surgical repair of the patent ductus arteriosus was successfully performed. Patent ductus arteriosus-associated infectious endocarditis is relatively rare in adulthood.

[Coronary Artery Bypass Grafting via Partial Sternotomy Late after Partial Chest Wall Resection:Report of a Case].

A 74-year-old man was referred to our department to receive coronary artery bypass grafting (CABG) because of severe triple vessel disease. He had undergone a chest wall resection including the right clavicle and the first and second ribs for the fibrosarcoma 40 years ago. The right internal thoracic artery was resected at the operation. Twenty-nine years after the operation, the plate used for the reconstruction of the chest wall was removed because of its infection. Off-pump CABG using left internal thoracic artery and vein grafts with lower partial sternotomy was successfully performed for the complete revascularization. This patient had a high possibility of sternum dehiscence and postoperative mediastinitis due to poor blood flow in the right upper sternum.

[Concurrent Surgical Venous Repair during Laser-assisted Pacemaker Lead Extraction].

Pacemakers are widely used to treat arrhythmia, however, one of problems after implantation of pacemaker is device infection. Total removal of leads and generator is recommended for radical cure. Recently, transvenous laser-assisted extraction of pacemaker leads has been developed and has achieved good results. However, catastrophic complications during pacemaker and implantable cardioverter-defibrillator leads extraction have been reported, and cases requiring surgical reconstruction have been also reported. Most of the repair technique include a direct suturing or a partial repair with patch. We herein report two cases of superior vena cava and innominate vein reconstruction with bovine pericardium during transvenous laser-assisted extraction. A hybrid approach using transvenous laser-assisted extraction and surgical repair through median sternotomy should be considered to perform complete lead extraction in complex cases with pacemaker lead infection.

[Reoperative Coronary Artery Bypass Grafting in Patients with Previous Heart Valve Surgery].

Recent progressive application of percutaneous coronary intervention has decreased the number of reoperative coronary artery bypass grafting( CABG), as well as that of primary CABG. Since CABG in patients with previous heart valve surgery is relatively uncommon, it is unfamiliar to many cardiac surgeons. Therefore, in-depth strategy for redo surgery is mandatory to perform the operation safely. This article summarizes the perioperative management and surgical techniques of reoperative CABG in patients with previous heart valve surgery.

[Asymptomatic Congenital Left Ventricular Aneurysm Treated with Endocardial Linear Infarct Exclusion Technique( ELIET):Report of a Case].

Surgical repair of asymptomatic congenital left ventricular aneurysm is poorly reported. A 30-yearold man presented with an asymptomatic abnormal electrocardiogram. Computed tomography (CT) and angiography revealed a congenital left ventricular aneurysm, and surgical repair was conducted with endocardial linear infarct exclusion technique (ELIET). His postoperative course was uneventful. Postoperative CT showed an elliptical cardiac shape with no recurrence of aneurysm. ELIET would serve as a surgical procedure for congenital left ventricular aneurysm.

Preserved Vasoconstriction and Relaxation of Saphenous Vein Grafts Obtained by a No-Touch Technique for Coronary Artery Bypass Grafting.

BACKGROUND: To obtain a saphenous vein graft (SVG) for coronary artery bypass grafting (CABG), the benefit of using a no-touch (NT) technique in vascular function has not been fully investigated. Methods and Results: The pathological and physiological functions of human SVGs with a NT technique to preserve the perivascular adipose tissue (PVAT) and ones obtained by using a conventional (CON) technique removing PVAT, were examined. Immunohistochemistry of the section of SVGs showed that the phosphorylation of endothelial nitric oxide synthase in the endothelium of the NT group was more responsive to vascular endothelial growth factor. A myograph of SVGs showed greater contraction with phenylephrine in the NT group. However, the strong contraction was eliminated in SVGs taken by electrocautery. In the 10 patients whose SVGs were taken without electrocautery, endothelial-dependent relaxation with bradykinin was apparently increased in the CON group more than in the NT group. Smooth muscle relaxation with nitroprusside was higher in the CON group at the lower concentrations; however, the relaxation became greater in the NT group at the high concentrations. Therefore, the effect of neutralizing PVAT-released factors in the both groups was further examined. After medium of NT and CON were exchanged in half, relaxation of SVGs was immediately restored in the NT group. CONCLUSIONS: The results suggest that the NT technique preserves the functions of vasoconstriction and relaxation. Also, the presence of PVAT-released vasoconstrictive factors was suspected.

[Off-pump Coronary Artery Bypass Grafting with Concomitant Coronary Endarterectomy for the Diffusely Diseased Coronary Artery].

Recent progress in percutaneous coronary intervention has driven more patients with complex or diffuse coronary artery disease to be referred for surgical revascularization. Coronary endarterectomy (CE) is a treatment option for diffusely diseased coronary arteries. On the other hand, off-pump coronary artery bypass grafting (off-pump CABG) has currently been the standard procedure for surgical revascularization in patients with coronary artery disease. We performed off-pump CABG with concomitant CE for the diffusely diseased left anterior descending artery( LAD) for 194 patients from September 2004 to August 2015. Mean age was 66.5±8.9 years and 168 were male. Mean preoperative ejection fraction was 54.9±12.4%. Mean length of arteriotomy in the LAD was 6.1±1.9 cm and endarterectomized LAD was reconstructed using the internal thoracic artery (ITA) with an onlay-patch fashion in all patients. On-pump conversion was required in 13( 6.7%) patients. 17( 8.8%) patients suffered from perioperative myocardial infarction. The 30-day mortality was 1.0 %.Patency rate of the reconstructed LAD at early postoperative angiography was 93.3%( 181/194). In summary, CE with onlay-patch grafting using the ITA for the diffusely diseased LAD with an off-pump technique can be performed safely with satisfactory outcomes.

Coexisting transthyretin and atrial natriuretic peptide amyloid on left atrium in transthyretin amyloid cardiomyopathy.

Atrial amyloidosis is primarily caused by atrial natriuretic peptide (ANP) amyloid deposition. The main precursor protein causing cardiac amyloidosis is transthyretin (TTR), also known as TTR amyloid cardiomyopathy (ATTR-CM). A 73-year-old man, who presented with external dyspnea, was diagnosed with decompensated heart failure due to atrial fibrillation and severe mitral regurgitation. Left ventricular hypertrophy and elevated levels of high-sensitivity cardiac troponin T indicated cardiac amyloidosis. 99mtechnetium pyrophosphate scintigraphy findings and cardiac magnetic resonance imaging in the absence of monoclonal proteins were consistent with those of ATTR-CM. The patient underwent mitral valve repair, a maze procedure, and left atrial appendage (LAA) excision. While the histological analysis of the sampled left ventricular tissue led to diagnosis of ATTR-CM, the histological analysis revealed the coexistence of ANP and TTR amyloid deposition in the resected LAA. We report a case of ATTR-CM in which TTR and ANP amyloid deposition coexisted in the surgically resected LAA, indicating that both TTR and ANP amyloid correlate with atrial amyloidosis development in ATTR-CM. Learning objectives: Atrial natriuretic peptide (ANP) and transthyretin (TTR) amyloids can coexist in the same atrium. Not only TTR amyloids but also ANP amyloids can be correlated with the development of atrial amyloidosis in TTR amyloid cardiomyopathy with subsequent increased risk of atrial fibrillation.

Acute heart failure due to coronary subclavian steal syndrome after coronary artery bypass grafting.

Key clinical message: An axillo-axillary bypass grafting is useful for coronary subclavian steal syndrome when occlusion of the proximal left subclavian artery. Abstract: An 81-year-old female who had undergone coronary artery bypass grafting 15 years previously was admitted and diagnosed with coronary subclavian steal syndrome. Preoperative angiography showed backflow from the left anterior descending coronary artery to the left internal thoracic artery and occlusion of the proximal left subclavian artery. Axillo-axillary bypass grafting was successfully performed.

Surgical aortic valve replacement provides better left ventricular mass regression than transcatheter aortic valve replacement in patients with small aortic annulus.

OBJECTIVES: This study aimed to evaluate the incidence of patient-prosthesis mismatch (PPM) and degree of left ventricular (LV) mass regression after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) in patients with small aortic annulus (defined as annular diameter of ≤ 21 mm). METHODS: We retrospectively analyzed echocardiographic findings in total of 277 patients with aortic stenosis and small aortic annulus (63 underwent SAVR and 214 underwent TAVR) between October 2013 and March 2019. PPM was defined as an effective orifice area index (EOAI) ≤ 0.85 cm2/m2. LV mass regression was evaluated as percentage change in LV mass index (LVMI) from baseline to the 1-year follow-up. RESULTS: The median EOAI before discharge was slightly larger in the TAVR group than in the SAVR group (1.09 vs. 1.07 cm2/m2; P = 0.030). However, the incidence of PPM before discharge (9.4 vs. 12.7%; P = 0.438) and at the 1-year follow-up (11.7 vs. 11.1%; P = 0.901) was similar between groups. Mild or greater paravalvular leakage (PVL) after the procedure was more frequent in the TAVR group (11.7 vs. 0%; P = 0.002). Reduction in LVMI was significantly higher in the SAVR group (19.3 vs. 6.4%; P < 0.001). Multivariate analysis demonstrated that reduction in LVMI was positively associated with higher baseline transaortic pressure gradient (P < 0.001) and higher baseline LVMI (P < 0.001) and negatively associated with older age (P < 0.001) and mild or greater PVL (P < 0.001). CONCLUSIONS: SAVR provides better LV mass regression than TAVR with a comparable rate of PPM in patients with small aortic annulus.

Outcomes of mitral valve replacement with complete annular decalcification.

BACKGROUND: This study aimed to examine the clinical outcomes of mitral valve replacement (MVR) in patients with severe mitral annular calcification (MAC) who required extensive decalcification and mitral annular reconstruction. METHODS: We reviewed 15 patients with severe MAC who underwent MVR between January 2016 and May 2022. In all cases, the calcified mitral annulus was resected completely using a Cavitron Ultrasound Surgical Aspirator, and a new annulus was created using bovine pericardium. In the acute postoperative phase, strict afterload reduction therapy using an intra-aortic balloon pump (IABP) was administered. RESULTS: The mean age of patients was 73 ± 8 years, and 13 (86.7%) were women. Concomitant aortic valve replacement was performed in 11 (73.3%) patients, tricuspid annuloplasty in 9 (60.0%), coronary artery bypass grafting in 1 (6.7%), and arrhythmia surgery in 7 (46.7%). The mean aortic cross-clamp and cardiopulmonary bypass times were 143 ± 32 min and 175 ± 34 min, respectively. In 13 patients, an IABP was used for 2 or 3 days postoperatively. There were no in-hospital deaths, left ventricular ruptures, or other MAC-related complications. Postoperative echocardiography revealed no paravalvular leakages. CONCLUSION: Our strategy for managing severe MAC is safe and reproducible even in relatively high-risk patients. Afterload reduction using an IABP in the acute postoperative phase may reduce the risk of fatal complications after extensive decalcification and mitral annular reconstruction.

Mitral valve replacement with annuloplasty in a patient with infected mitral annular calcification.

Key Clinical Message: Extensive resection of the infected calcified annulus and the reconstruction with a pericardial patch for the debrided annulus is an effective surgical option for the treatment of infectious endocarditis in patients with mitral annular calcification. Abstract: A 78-year-old woman was referred to our hospital because of left-sided hemiparesis. During the treatment for cerebral infarction, the patient became feverish and lost consciousness. Transthoracic echocardiography revealed mitral annular calcification and a tumor-like mass on the posterior leaflet despite no findings of mitral regurgitation. She underwent successful mitral valve replacement with debridement of the infected mitral annulus and reconstruction of the posterior annulus (annuloplasty) with bovine pericardium after removal of the mitral annular calcification.

Do chronic total occlusive lesions affect patency of coronary bypass grafts to the right coronary artery?

OBJECTIVES: To evaluate the impact of chronic total occlusion (CTO) lesions on the patency of bypass grafts to the right coronary artery territory. METHODS: Two hundred patients undergoing primary isolated coronary artery bypass grafting with revascularization to the right coronary artery territory between April 2015 and July 2022 were retrospectively analyzed. Study patients were divided into two groups according to their right coronary artery lesion: patients with CTO lesions (n = 76) and those without CTO lesions (n = 124). Graft flow of the right coronary artery territory was evaluated by intraoperative transit time flow measurement and patency of the bypass graft was evaluated by multidetector row computed tomography. RESULTS: A total of 200 patients (76 patients with CTO and 124 patients without CTO) were included in this study. Intraoperative transit time flow measurement demonstrated that there was no significant difference in the median mean graft flow (30 ml/min vs. 25 ml/min; p = 0.114), pulsatility index (2.1 vs. 2.4; p = 0.079), and diastolic filling rate (65% vs. 64%; p = 0.844) between patients with CTO and those without CTO. Postoperative multidetector row computed tomography demonstrated that the patency of bypass grafts to the right coronary artery territory was similar between the groups (94.7% in patients with CTO vs. 96.0% in those without CTO; p = 0.733). In patients with CTO, the patency of bypass graft tended to be worse in subgroup with rich collateral blood flow (Rentrop grade 3). CONCLUSIONS: Chronic total occlusion lesions do not affect the patency of bypass grafts to the right coronary artery territory.

Factors Affecting Recovery of 6-Minute Walk Distance After Coronary Artery Bypass Grafting.

Background: This single-center retrospective analysis investigated the number of days required for postoperative 6-minute walk distance (6MWD) to recover to preoperative values after coronary artery bypass grafting (CABG) and the factors influencing this recovery. Methods and Results: The 6MWD was measured in 101 patients (median age 69 years; 18 women) before and every day after CABG. Univariate and multivariate analyses were performed to identify factors affecting 6MWD recovery to preoperative values after CABG. The median number of days required for recovery of 6MWD after CABG was 9 (interquartile range 7-11 days). Patients were divided into 2 groups based on the median number of days required for recovery of 6MWD; there were 60 patients in the early recovery group (<9 days) and 41 in the "non-early" recovery group (38 who recovered after the median 9 days, and 3 who did not recover during hospitalization). Using univariate logistic regression analysis, diabetes (P=0.01), stroke (P=0.26), left ventricular ejection fraction (P=0.27), and grip strength (P=0.13) were selected for multivariate analysis. Multivariate logistic regression analysis revealed that diabetes (odds ratio 2.955; 95% confidence interval 1.208-7.229; P=0.02) was the only independent predictor of 6MWD recovery. Conclusions: Diabetes was the single factor influencing the recovery of postoperative 6MWD in patients undergoing CABG.

Left atrial intramural hematoma after percutaneous coronary intervention.

Left atrial intramural hematoma is a rare complication of percutaneous coronary intervention. The combination treatment with surgery and interventional therapy is one of therapeutic options.

Total arch replacement with open stent-grafting for aneurysm of ductus arteriosus after surgery for patent ductus arteriosus.

A 73-year-old woman who had undergone ligation of patent ductus arteriosus (PDA) via a left thoracotomy 19 years earlier was admitted to our hospital under the diagnosis of thoracic aortic aneurysm. An enhanced computed tomography of the chest revealed a saccular aneurysm measuring a maximum diameter of 28 mm in the lesser curvature of the distal aortic arch; she was diagnosed with an aneurysm of ductus arteriosus after surgery for PDA. We performed total aortic arch replacement with open stent-grafting through median sternotomy. This approach enabled us to avoid the risk of dissecting adhesions around the aneurysm and clamping the aorta distal to the aneurysm.

Preoperative renal malperfusion is an independent predictor for acute kidney injury and operative death but not associated with late mortality after surgery for acute type A aortic dissection.

OBJECTIVES: This study was aimed to investigate the impact of preoperative renal malperfusion on early and late outcomes after surgery for acute type A aortic dissection (AAAD). METHODS: Of 915 patients who underwent surgery for AAAD between September 2004 and September 2017, we enrolled 534 patients whose preoperative enhanced computed tomography images were retrospectively available in this study. Exclusion criteria were single kidney (n = 3) and dialysis-dependent preoperatively (n = 12). We compared early and late outcomes between patients who had preoperative renal malperfusion (n = 64) and those who did not have renal malperfusion (n = 470). RESULTS: The incidence of postoperative acute kidney injury, defined using the Kidney Disease: Improving Global Outcomes criteria, was higher in the renal malperfusion group than in the no renal malperfusion group (76.6% vs 39.4%; P < 0.001). Similarly, operative death was more frequently seen in the renal malperfusion group (12.5% vs 3.8%; P = 0.003). Multivariate analyses showed that renal malperfusion was the independent predictor for postoperative acute kidney injury [odds ratio 4.32, 95% confidence interval (CI) 2.25-8.67; P < 0.001] and operative death (odds ratio 3.08, 95% CI 1.02-8.86; P = 0.046). The median follow-up period in the hospital survivors was 3.3 years (interquartile range 2.1-6.7 years). The cumulative survival rate at 8 years was similar between the groups (74.6% in the renal malperfusion group and 76.0% in the no renal malperfusion group; P = 0.349). CONCLUSIONS: Preoperative renal malperfusion is an independent predictor for postoperative acute kidney injury and operative death but not associated with late mortality after surgery for acute type A aortic dissection.