[L-shaped Partial Upper Sternotomy Approach for Aortic Valve Replacement].

Transcatheter aortic valve implantation is a recent innovation in the treatment of severe aortic stenosis. On the other hand, several reports suggested that minimally invasive aortic valve replacement (MICS-AVR) is likely to be associated with reduced postoperative discomfort and faster recovery. Of note, an upper partial sternotomy for isolated aortic valve replacement( L-shaped MICS-AVR) has been accepted as the most common approach to the MICS-AVR. Since October 2013, we have preformed L-shaped MICS-AVR at our hospital. In L-shaped MICS-AVR group(16 patients, 74.4±8.7 years),there was no operative mortality and any other complication including reexploration for postoperative bleeding, wound infection, peri-valvular leakage, pulmonary complication like re-intubation or minitracheostomy. To demonstrate the benefits of this approach, over-octogenarian subgroup( n=7)was analyzed and compared with the isolated AVR using a conventional sternotomy (C-AVR, n=10)in the same period. A trend was seen toward better postoperative course in the L-shaped MICS-AVR group than in the C-AVR group;however, this difference was not statistically significant. The mean duration of cardiopulmonary bypass(120±29 min vs 93±24 min, p=0.005)and cross clamp time(151±36 min vs 124±32 min, p=0.038)were significantly longer than C-AVR. We believe that more clinical experience is required to clarify the benefits of this approach and we must more consider the preoperative images for the attainment of the excellent exposure. Moreover, the concomitant use of this new device and L-shaped MICS-AVR may enable a big improvement in the future.

[Primary cardiac angiosarcoma in the right atrium with cardiac tamponade].

Primary cardiac angiosarcoma is very rare with an incidence of 0.0017∼0.19% in collected autopsy series, and its prognosis has been reported as being extremely poor( average survival of 6∼9 months). A 56-year-old man was referred to our hospital with cardiac tamponade caused by right atrial angiosarcoma, after initially being misdiagnosed as acute type A dissection. Echocardiography and chest computed tomography (CT) revealed a pedunculated tumor with a broad base which was originating from the right atrial wall and extended into atrio-ventricular (AV) groove. The tumor was completely resected, and a bovine pericardium patch was used for cardiac reconstruction. Histological examination showed angiosarcoma and a sign of radical excision. The patient, who made an uneventful recovery,was given postoperative radiotherapy and chemotherapy. He died of multiple systemic metastases 14 months postoperatively despite of multidisciplinary treatment. We discuss the therapeutic strategies available for this highly malignant cardiac tumor.

[Completion bentall procedure after aortic valve replacement].

A 51-year-old man, who had undergone aortic valve replacement with a mechanical valve 30 years ago, was referred to our hospital due to acute type A aortic dissection. Pre- and intra-operative echocardiographic evaluation showed no evidence of valve dysfunction or paravalvular leak. Intraoperative inspection revealed a thin pannus covering the leaflet housing of the mechanical valve, which we easily removed. We performed aortic root replacement while leaving the valve in situ, and total aortic arch replacement using elephant trunk technique under hypothermic circulatory arrest. He was discharged from the hospital 31 days after operation and retains normal valve function. For patients with aneurysms and acute type A aortic dissection having aortic valve prosthesis that does not require replacement, the completion Bentall procedure is a more secure and safer repair than complete aortic root reconstruction.

[Aortic root replacement with the freestyle stentless bioprosthesis for infective endocarditis associated with aortic annular destruction].

Treatment of infective endocarditis (IE) associated with aortic annular destruction remains a formidable surgical challenge. Discussions about the optimum modality for reconstruction are still continuing. In such severe endocarditis, we have performed aortic root replacement using the Freestyle stentless bioprosthesis with the full root technique. From 2005 through 2012, 11 patients who had aortic valve endocarditis with annular destruction underwent aortic root replacement at our institute. All of them were treated with the Freestyle stentless bioprosthesis. Their mean age was 69.9 years, and 8 patients were men. Two patients had native valve endocarditis and 9 patients had prosthetic valve endocarditis. Despite appropriate antibiotic therapy, 3 patients required emergency surgery because of hemodynamic deterioration. In-hospital death occurred in 1 patient due to progressive hemodynamic failure. The 10 hospital survivors were followed up for a mean of 27.7±23.1 months (range 5 to 82). Although late death occurred in 2 patients, recurrent IE was not observed in any patients during the follow-up. The results of our study suggest that the Freestyle stentless bioprosthesis could be an excellent alternative to a homograft in the treatment of infective endocarditis associated with aortic annular destruction.

Management of cardiopulmonary bypass in patients with ischemic and hemorrhagic strokes in surgery for active infective endocarditis.

Stroke and intracranial hemorrhage (ICH) are serious complications that are difficult to manage during surgery for active infectious endocarditis (AIE). Relevant society guidelines still recommend delaying the cardiac surgery for AIE with ICH for 4 weeks. Some early studies indicated that the mortality rate decreases when cardiac surgery for ICH is delayed. In contrast, some reported that surgical intervention should not be delayed if an early operation is demanded, even in patients with ICH. The current literature on early vs. late surgery for infectious endocarditis (IE) with ICH is conflicting. Changing the cardiopulmonary bypass (CPB) strategy might be necessary to improve the surgical outcomes of IE with ICH. Some studies reported that cardiac surgery using nafamostat mesylate (NM) as an alternative anticoagulant during CPB was performed successfully. The combination of NM and low-dose heparin was beneficial for early surgery in patients with AIE complicated by cerebral infarction and ICH, without worsening cerebral lesions. In this report, we review and discuss the management of CPB in patients with ischemic and hemorrhagic stroke during surgery for AIE.

Aggressive early surgical strategy in patients with intracranial hemorrhage: a new cardiopulmonary bypass option.

OBJECTIVE: We present a novel strategy in cardiac surgery with a cardiopulmonary bypass with low-dose heparin and Nafamostat mesylate as an anticoagulant (NM-CPB), which reduces postoperative neurological complications. METHOD AND RESULTS: 19 patients with a mean age of 63.6 ± 20.2 years (range 24-91) and an indication of early cardiac surgery with intracranial complication (ICC) underwent surgery with NM-CPB. The preoperative diagnoses included seven cases of infective endocarditis and six of left atrial appendage thrombosis. ICC were noticed in seven cases with hemorrhages (hemorrhagic infarction: n = 4, subarachnoid hemorrhage: n = 3) and 12 without hemorrhage (large infarction: n = 10, small-multiple infarction at the risk for hemorrhagic transformation: n = 2). The mean interval between a diagnosis and cardiac surgery was 1.1 ± 1.5 days in the ICH cases and 1.4 ± 1.4 days otherwise. In-hospital mortality was 5.3%. The mean CPB time was 146.7 ± 66.03 min, the mean dose of NM, heparin were 2.23 ± 1.59 mg/kg/hr and 56.8 ± 20.3 IU/kg, respectively. The mean activated clotting time (ACT) was 426.8 ± 112.4 s. No further intracranial bleeding and no new hemorrhages were observed after surgery. CONCLUSIONS: In early cardiac surgery with ICC, especially with hemorrhage, NM-CPB reduced postoperative neurological complications. We plan to use NM-CPB to expand the indications and to establish an early aggressive treatment.

Two Cases of Protruding Thrombus in the Ascending Aorta.

In the first case, a 60-year-old man was referred to our hospital for a sudden stomachache. A computed tomography scan revealed a thrombus at ascending aorta with acute mesenteric ischemia. In the second case, a 62-year old man developed a hypoglycemic attack with unbalanced diet. A computed tomography showed a thrombus at ascending aorta without thromboembolism. Laboratory data of both cases showed elevated platelet and a loss of antithrombin III. We administered a resection of thrombus to prevent a systemic embolism. We suggested that the risk of ascending aorta thrombus was elevated platelet and a loss of antithrombin III.

Surgical strategy for the treatment of aortoesophageal fistula.

OBJECTIVE: To present a surgical strategy for aortoesophageal fistula (AEF). METHODS: From October 1999 to May 2017, 27 patients with AEF were treated at Kobe University Hospital. After 9 patients with malignancies or fish bone penetration were excluded, 18 patients who had AEF secondary to aortic lesions were investigated. The mean age was 67.2 ± 10.4 years, and the male/female ratio was 16:2. Twelve patients had a nondissection thoracic aneurysm, and 6 patients had a chronic aortic dissection. Six patients were in shock. Seven patients had a previous thoracic endovascular aortic repair (TEVAR) in the descending aorta, 2 patients had descending aorta replacement, 1 had hemiarch replacement, and 2 had total arch replacement. As the first treatment for AEF, 3 patients underwent TEVAR as destination therapy, 3 patients had a bridge TEVAR to open surgery, 1 patient had an extra-anatomical bypass from the ascending aorta to the abdominal aorta, and 11 patients had an in situ reconstruction of the descending aorta. The esophagus was resected in 16 patients, and an omental flap was installed in 16 patients. Additional procedures were extra-anatomical bypass in 2 patients and in situ reconstruction of the aorta in 3 patients. RESULTS: Hospital mortality was noted in 4 patients (22.2% persistent sepsis, n = 3: pneumonia, n = 1). However, since 2007, only 1 of 13 patients has died (pneumonia). Late death occurred in 5 patients, due to pneumonia, cerebral bleeding, diarrhea, sudden death, and persistent infection. Actuarial survival was 42.4 ± 12.8% at 5 years and freedom from aorta-related death was 59.4 ± 13.5% at 5 years. Nine patients achieved completed reconstruction of the esophagus 172 ± 57 days after initial surgery. CONCLUSIONS: Although a comparative study was not performed, 1-stage surgery consisting of resection of an aneurysm and esophagus, in situ reconstruction of the descending aorta, and omental flap installation provided a better outcome in the treatment for AEF. Bridging TEVAR to the open surgery is a useful adjunct in patients with AEF with hemorrhagic shock. Later reconstruction of the esophagus can be performed in the survivors.

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

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

Impact of positional relationship of commissures on cusp function after valve-sparing root replacement for regurgitant bicuspid aortic valve.

OBJECTIVES: The aim of this study is to investigate the longitudinal valve function after valve-sparing root replacement in patients with bicuspid aortic valves (BAVs), in terms of both transvalvular pressure gradient (TVPG) and freedom from aortic regurgitation. METHODS: In this non-randomized retrospective study, two different approaches were chosen for correcting the circumferential orientation of commissures during aortic root reimplantation for Sievers type I BAV: (i) 180° orientation, in which both cusps occupy equal surface areas and (ii) preserving native commissural orientation. From 2005 to 2015, 41 consecutive patients with Sievers type I BAV undergoing valve-sparing root replacement were divided into two groups according to the techniques: native orientation group and 180° group. RESULTS: The native orientation group included 22 patients (age, 45.1 ± 13.6 years) and the 180° group included 19 patients (age, 36.6 ± 13.7 years; P = 0.053). There was no significant difference in preoperative variables between the two groups. Postoperative and follow-up echocardiography revealed the following: the average TVPG at the time of discharge in the native orientation and the 180° groups was 17.3 ± 6.6 and 21.7 ± 11.1 mmHg (P = 0.16), respectively, at peak and 10.0 ± 3.7 and 11.7 ± 6.0 mmHg (P = 0.33), respectively, at mean; at follow-up, the corresponding values were 19.1 ± 6.6 and 22.9 ± 10.6 mmHg (P = 0.24) at peak and 9.9 ± 3.8 and 13.2 ± 7.2 mmHg (P = 0.12) at mean. Thus, there was a trend towards higher TVPG in the 180° group. The difference between the preoperative and postoperative commissural angles was correlated with higher postoperative peak and mean TVPG (r = 0.53, P = 0.041, 95% confidence interval, 0.029-0.82 at peak and r = 0.58, P = 0.024, 95% confidence interval, 0.092-0.84 at mean). CONCLUSIONS: In terms of freedom from aortic regurgitation and valve function, similar outcomes were achieved in both despite different repair techniques used for fixation of commissures during valve-sparing aortic root replacement in BAV. However, attention should be paid to patients with 180° commissural reposition because of a trend towards higher TVPG.