Long-term valve performance of St Jude Medical Epic porcine bioprosthesis in aortic position.

The aim of this study was to review long-term clinical outcomes and valve performance after Epic Supra valve implantation in aortic position. From 2011 to 2022, 44 patients (mean age 75 ± 8 years) underwent surgical aortic valve replacement (SAVR) with an Epic Supra valve at our hospital. Survival, incidence of late complications, and echocardiographic date were retrospectively analyzed. During a mean follow-up period of 6.2 ± 3.5 years, the overall survival rate was 91 ± 4% at 2 and 88 ± 5% at 5 years, while rates of freedom from major adverse cardiovascular and cerebrovascular events (MACCE) were 86 ± 5% and 83 ± 6%, respectively. There was one case of reoperation for prosthetic valve endocarditis at 6 years after the initial surgery. Echocardiographic examinations showed 5-year rates of freedom from severe structural valve deterioration (SVD) and moderate SVD of 100 and 92%, respectively. There was no significant increase in mean pressure gradient or decrease in left ventricular ejection fraction from 1 week after surgery to the late follow-up period. Long-term clinical results and durability of the Epic Supra valve in aortic position were satisfactory.

[Risk Analysis of Acute Kidney Injury after Cardiac Surgery and Protective Effect by Less Invasive Surgery].

OBJECTIVE: We aimed to determine the incidence and risk of acute kidney injury (AKI) in patients after cardiac surgery, and to assess the effects of less invasive cardiac surgery on the prevention of postoperative AKI. METHODS: We retrospectively analyzed perioperative parameters in patients who underwent cardiac surgery. Risk factors for AKI were determined using univariate and multiple logistic regression models. The incidence of postoperative AKI was also compared between conventional and minimally invasive cardiac surgeries. RESULTS: Among 126 patients, 36 (28.6%) who developed postoperative AKI stayed significantly longer in the intensive care unit(ICU), required prolonged postoperative ventilation and had a higher frequency of renal replacement therapy. Multivariate analysis revealed cardio-pulmonary bypass (CPB) duration and red blood cell transfusion as independent risk factors for postoperative AKI. The incidence of postoperative AKI was significantly lower after off-pump coronary artery bypass grafting than conventional coronary artery bypass grafting (CABG)(0% versus 11%, p=0.025), and after minimally invasive cardiac surgery compared with conventional valve surgery( 4% versus 44%, p=0.01) Conclusion:The duration of CPB and red blood cell transfusion were considered independent factors for the development of postoperative AKI. Less invasive cardiac surgeries might protect against postoperative AKI.

[Quadricuspid Aortic Valve: Report of a Case].

A 69-year-old woman with general fatigue was admitted to our hospital for further examination of mediastinal lymph node swelling. Mediastinal lymph node sampling was planned. Preoperative transthoracic echocardiography revealed severe aortic regurgitation, and aortic valve replacement combined with mediastinal lymph node sampling was performed. Following lymph node sampling, the ascending aorta was opened, and the aortic valve was found to be quadricuspid. An accessory cusp was existed between the left coronary cusp and the non coronary cusp. Aortic valve replacement was successfully performed. A quadricuspid aortic valve is a very rare anomaly.

[Rapid Rise of Trans-oxygenerator Pressure Gradient Accompanied by Rapid Decrease of Platelet Counts During Open-heart Surgery].

A 77-year-old male patient with 2-vessel coronary artery disease and previous myocardial infarction underwent on-pump coronary artery bypass grafting (CABG). Following systemic heparinization, cardiopulmonary bypass using heparin coated circuit was started. Ten minutes after starting the cardiopulmonary bypass, the trans-oxygenerator pressure gradient rapidly increased accompanied by a rapid decrease of platelet counts. Emergency replacement of cardiopulmonary bypass circuit with a non-heparin coated one was performed because the development of heparin induced thrombocytepenia (HIT) was strongly suspected. On-pump CABG was accomplished as planned, and the postoperative course was uneventful. HIT might be ruled out as HIT specific antibodies were not detected in the intraoperative serum samples.

Redo cardiac surgery for active prosthetic valve endocarditis associated with hereditary hemorrhagic telangiectasia: report of a case.

Hereditary hemorrhagic telangiectasia (HHT) is caused by an autosomal dominant gene and characterized by multiple arteriovenous malformations in several organs, leading to bleeding or shunting. These patients often suffer severe infections and heart failure, which should be managed in the perioperative period, when open heart surgery is indicated. We report a case of successful aortic root replacement for active prosthetic valve endocarditis and ventricular septal perforation in a patient with HHT, who had severe heart failure.

Risk factor analysis for aortic dissection after aortic valve replacement in patients with tricuspid aortic valve.

OBJECTIVE: Aortic dilatation concurrent with aortic valve disease is a common condition. However, the incidence of aortic dissection after aortic valve replacement for tricuspid aortic valve has not been fully investigated. Therefore, we performed a risk factor analysis for the incidence of aortic dissection after aortic valve replacement in patients with tricuspid aortic valve. METHODS: We retrospectively reviewed 599 patients who underwent aortic valve replacement at our hospital between January 2000 and December 2020. We performed a risk factor analysis for the incidence of aortic dissection after aortic valve replacement in patients with tricuspid aortic valve. RESULTS: Seven patients developed late aortic dissections during the follow-up period. All patients with aortic dissection underwent aortic valve replacement for aortic regurgitation. Multivariable analysis revealed that aortic regurgitation was an independent predictor of aortic dissection (p < 0.0001). The mean ascending aortic diameter at aortic valve replacement for aortic regurgitation was significantly greater in patients with aortic dissection than in those without aortic dissection (46 [43.5-46] mm vs. 39 [36-42] mm, p < 0.001). The predictive cutoff value of ascending aortic diameter was indicated using receiver operating characteristic curve analysis; 46.0 mm (area under the curve: 0.8987). Freedom rates from aortic dissection in patients with aortic regurgitation and an ascending aortic diameter ≥ 46 mm were significantly lower than those in patients with an ascending aortic diameter < 46 mm (66.7% vs. 100% at 5 years, p < 0.0001). CONCLUSION: Aortic regurgitation combined with ascending aortic dilatation at aortic valve replacement could be a significant risk factor for late aortic dissection.

Successful surgical treatment of brachial aneurysm associated with arteriovenous fistula for hemodialysis.

A 58-year-old female who underwent renal transplantation and closure of arteriovenous fistula (AVF) for hemodialysis at age 24 was presented with left forearm pain and cyanosis. Computed tomography revealed an obstructed true brachial aneurysm at the anterior aspect of the elbow joint. Under a diagnosis of true brachial aneurysm associated with AVF, aneurysm resection and brachial to ulnar artery bypass grafting using a reversed great saphenous vein were performed. To prevent graft occlusion due to elbow flexion, it was routed through the ulnar side of the elbow joint. One year after surgery, the patient was asymptomatic with a patent graft.

Successful Surgical Treatment for Ruptured Aneurysm of Coronary-Pulmonary Artery Fistula Complicated With Cardiac Tamponade.

A 74-year-old woman with no past medical history showed cardiac tamponade caused by rupture of a coronary-pulmonary artery fistula-related aneurysm. Preoperative pericardial puncture and multidetector computed tomography imaging enabled patient condition optimization and accurate morphologic evaluation of fistula and aneurysm, leading to complete surgical resection of the aneurysm. (Level of Difficulty: Advanced.).

A rapid aneurysmal formation after late open conversion of endovascular abdominal aortic repair with complete endograft explant.

Late open conversion (LOC) after endovascular aneurysm repair (EVAR) is associated with high morbidity and mortality. Standard surgical technique of LOC has not been established. This report presents a rapid aneurysmal formation in the unreplaced infrarenal aorta after LOC with complete endograft explantation without suprarenal fixations. A 76-year-old man presented with a left common iliac artery aneurysm (CIAA), for which he underwent EVAR to embolize the left internal iliac artery. Although his aneurysmal sac size initially showed a reduction, computed tomography at the 3-year interval post-EVAR demonstrated an increased sac size. Thus, he underwent open aortic repair of the CIAA. Though the postoperative course was uneventful, the size of the unreplaced infrarenal aorta showed a significant increase one year after open conversion. Reoperation was performed, but vascular prosthesis infection occurred as a complication and the patient died on the 196th postoperative day.

Regional myocardial blood flow measured by stress multidetector computed tomography as a predictor of recovery of left ventricular function after coronary artery bypass grafting.

BACKGROUND: Multidetector-row computed tomography (MDCT) applications have expanded to evaluation of myocardial blood flow (MBF) and viability. We quantified regional MBF pre- and post-coronary artery bypass grafting (CABG) using adenosine stress and cardiac 64-MDCT, and investigated whether the results predict MBF and left ventricular (LV) function recovery after CABG. METHODS: We studied 321 regions in 19 CABG patients who underwent adenosine stress 64-row MDCT perfusion imaging and cine magnetic resonance imaging pre- and post-CABG. Myocardial blood flow was estimated from linear regression equation slopes using Patlak plot analyses and compared with LV function by measuring wall thickening (%WT) using cine magnetic resonance imaging. RESULTS: Overall mean MBFs were 1.39 +/- 0.49 and 1.95 +/- 0.49 mL/(g min) pre- and post-CABG (P < .0001). Myocardial blood flow in revascularized areas increased significantly (pre-CABG 1.18 +/- 0.45, post-CABG 1.99 +/- 0.66 mL/[g min], P < .001), whereas nonischemic areas showed no difference (1.79 +/- 0.70 and 1.97 +/- 0.46 mL/[g min], P = .14). Revascularized areas with preoperative MBF > or = 0.9 mL/(g min) showed significantly greater MBF improvement than those with preoperative MBF <0.9 mL/(g min) (P = .04). In patients with preoperative LV dysfunction (ejection fraction <40%), %WT in revascularized areas with pre-CABG MBF > or = 0.9 mL/(g min) improved significantly after CABG (pre-%WT 40.9 +/- 22.9, post-%WT 52.8 +/- 20.6, P = .03) versus those with pre-CABG MBF <0.9 mL/(g min) (pre-%WT 53.2 +/- 35.5, post-%WT 42.5 +/- 17.0, P = .40). CONCLUSIONS: Our results demonstrated more significantly increased MBF post-CABG than pre-CABG, particularly in revascularized areas. Regional MBF before CABG may predict MBF and LV function recovery, in the short term, after CABG.

Anomalous subaortic left brachiocephalic vein in surgical cases and literature review.

Anomalous subaortic left brachiocephalic vein (ASLBV) is a rare systemic venous anomaly. We review our experience with patients associated with ASLBV who underwent cardiac surgery at three institutions. From 1989 to 2009, the medical records of surgically treated patients with ASLBV were analyzed; the incidence of ASLBV, clinical characteristics, and associated anatomical findings were assessed. Fifteen patients had ASLBV. All ASLBVs coursed left lateral to the aortic arch, passed under the ascending aorta anterior to the central pulmonary artery, and joined the right brachiocephalic vein. Fourteen patients had congenital heart disease (CHD), and the remaining patient did not have cardiac anomalies. Its incidence was 0.57% (14 of 2,449) in patients with CHD and only 0.02% (1 of 4,805) in patients without CHD. In patients with CHD, 73.3% (11 of 15) of the patients had conotruncal cardiac anomalies such as tetralogy of Fallot, ventricular septal defect with pulmonary atresia, truncus arteriosus, and interruption of the aortic arch. Eight patients had aortic arch anomalies, including right aortic arch and cervical aortic arch. The deletion of chromosomal 22q11.2 was confirmed in two patients, and one patient was diagnosed with DiGeorge syndrome. ASLBV was clinically silent even without any surgical intervention. ASLBV is a very rare anomaly and is highly associated with conotruncal cardiac anomalies and aortic arch anomalies, including right aortic arch and cervical aortic arch. Preoperative diagnosis is important when any surgical interventions are intended, especially, in patients with conotruncal cardiac anomalies.

Is using an open-reservoir cardiopulmonary bypass circuit after 6 days on standby safe?

OBJECTIVES: To investigate the sterility and biocompatibility of a stored open-reservoir cardiopulmonary bypass circuit maintained on standby. METHODS: A total of four cardiopulmonary bypass circuits were assembled, primed and left to recirculate. One unit was placed in a positive-pressure operating room and the other three were placed in the intensive care unit. The primed solutions, which employed Ringer's acetate, hydroxyethylated starch and hydrate steroid, were sampled after 0, 24, 48, 72, 96, 120 and 144 h in all cardiopulmonary bypass circuits to measure the bacteria count, endotoxin count and chemical substances within the primed solution. Chemical substances were detected by assessing the following: the total organic carbon by the combustion oxidation infrared spectrometry, and molecular weight spread by gel permeation chromatography. The environments were left unattended and were uncovered during the storage period to mimic the clinical scenario. RESULTS: There were no bacteria in any of the primed solutions, and only very minute concentrations of endotoxins were detected, both in the operating room and in the intensive care unit. The total organic carbon concentration was slightly more concentrated in the 144-h samples when compared with that in the 0-h samples. However, the molecular weight spread of the 0-h sample was identical to that in the 144-h sample. DISCUSSION: With regard to the presence of bacteria and endotoxins, we noted that the hardshell reservoirs in the cardiopulmonary bypass circuit were effectively sealed and not invaded by bacteria. With regard to the presence of chemical substances, we noted that an increase in total organic carbon concentration was caused by bedewing, and that there was no release of chemical substances such as a polymer-coating agent, or other molecular materials in the primed solution. CONCLUSIONS: There was no contamination or release of chemical substances in 6-day old cardiopulmonary bypass circuits maintained on standby, confirming that they are safe to use in terms of sterility and biocompatibility.

Late Sac Behavior after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm.

BACKGROUND: Sac behavior after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) is considered as a surrogate for the risk of late rupture. The purpose of the study is to assess the sac behavior of AAAs after EVAR. METHODS AND RESULTS: Late sac enlargement (LSE) (≥5 mm) and late sac shrinkage (LSS) (≥5 mm) were analyzed in 589 consecutive patients who were registered at 14 national centers in Japan. The proportions of patients who had LSE at 1, 3 and 5 years were 2.6% ± 0.7%, 10.0% ± 1.6% and 19.0% ± 2.9%. The proportions of patients who had LSS at 1, 3 and 5 years were 50.1% ± 0.7%, 59.2% ± 2.3% and 61.7% ± 2.7%. Multiple logistic regression analysis identified two variables as a risk factor for LSE; persistent endoleak (Odds ratio 9.56 (4.84-19.49), P <0.001) and low platelet count (Odds ratio 0.92 (0.86-0.99), P = 0.0224). The leading cause of endoleak in patients with LSE was type II. CONCLUSIONS: The incidence of LSE is not negligible over 5 year period. Patients with persistent endoleak and/or low platelet count should carefully be observed for LSE. CLINICAL TRIAL REGISTRATION: UMIN-CTR (UMIN000008345).

BH4 peptide derivative from Bcl-xL attenuates ischemia/reperfusion injury thorough anti-apoptotic mechanism in rat hearts.

OBJECTIVE: To prevent apoptosis is thought to be promising for myocardial protection in cardiac surgery. Recently, we showed that BH4 domain of Bcl-xL is essential for the prevention of apoptosis, and that BH4 fused to HIV TAT protein (TAT-BH4) prevented apoptotic cell death. Then, we hypothesized TAT-BH4 may attenuate ischemia/reperfusion injury in rat hearts. METHODS: The isolated rat hearts in the TAT-BH4 preconditioning group (BH4 group, n=8) or control group (C group, n=8) were subjected to warm ischemia (37 degrees C) for 30 min followed by 60 min of reperfusion using Langendorff perfusion system. RESULTS: Left ventricular developed pressure and maximum dP/dt after reperfusion were significantly improved in the BH4 group than those in the C group (P<0.01). Recovery of mitochondrial respiration was significantly better in the BH4 group (P<0.05). Moreover, expression of caspase-3 and TUNEL-positive myocardium were decreased in the BH4 group than those in the C group. CONCLUSIONS: These results demonstrated that TAT-BH4 attenuates myocardial ischemia/reperfusion injury through preventing myocardial apoptosis. Thus, TAT-BH4 may be a novel therapeutic agent for myocardial protection in cardiac surgery.

Myocardial protective effect of human recombinant hepatocyte growth factor for prolonged heart graft preservation in rats.

BACKGROUND: In heart transplantation, myocardial apoptosis during hypothermic storage contributes to graft dysfunction. On the other hand, hepatocyte growth factor (HGF) has been reported to be an antiapoptotic factor in the heart. Therefore, we assessed whether the administration of recombinant human HGF (rh-HGF) prevents apoptosis in the prolonged preserved myocardium, resulting in an improvement in the cardiac function of the graft. METHODS: Isolated rat hearts were subjected to 4 hr (group A), 6 hr (group B), and 8 hr (group C: without rh-HGF vs. group D: with 100 microg of rh-HGF) of hypothermic storage followed by 60 min of normothermic reperfusion (n=5 in each group). RESULTS: Compared with non-HGF-treated hearts (group C), HGF-treated hearts (group D) showed a significantly higher recovery rate of left ventricular developed pressure (38+/-5% vs. 58+/-6%, P<0.01) and maximum dp/dt (53+/-7% vs. 74+/-4%, P<0.01) and a lower rate of TUNEL-positive cardiomyocytes (7.8+/-6.0% vs. 25.3+/-8.9%, P<0.05) after 60 min of reperfusion. Western blot analysis revealed that c-Met/HGF receptor expression was stronger in the HGF-treated myocardium than in the non-HGF-treated myocardium after 8 hr of storage and was associated with a weaker expression of caspase-3 and a stronger expression of Bcl-xL after 60 min of reperfusion. CONCLUSION: The administration of rh-HGF before storage improved cardiac function after prolonged myocardial preservation by preventing apoptosis through the c-Met/HGF receptor. Thus, the addition of rh-HGF in the storage solution may be a promising strategy for prolonged heart graft preservation.

Pharmacologic preconditioning of JTE-607, a novel cytokine inhibitor, attenuates ischemia-reperfusion injury in the myocardium.

BACKGROUND: Myocardial ischemia-reperfusion injury is a main cause of postoperative cardiac dysfunction, and a burst of proinflammatory cytokines, such as tumor necrosis factor alpha, interleukin 1 beta, interleukin 6, and interleukin 8, plays a pivotal role. Recently, JTE-607 has been reported as a potent inhibitor of the multiple inflammatory cytokines in the endotoxin shock mouse model. In this study we proved the hypothesis that JTE-607 might attenuate myocardial ischemia-reperfusion injury in a rat model. METHODS: The isolated rat hearts in the JTE-607 preconditioning group (J group, n = 8) or control group (C group, n = 8) were subjected to warm ischemia (37 degrees C) for 30 minutes, followed by 60 minutes of reperfusion with the Langendorff perfusion system. RESULTS: Left ventricular developed pressure and maximum dp/dt after reperfusion were significantly improved in the J group than in the C group (P <.01). Creatine phosphokinase leakage is significantly lower in the J group (P <.05). Moreover, the tissue cytokine levels, such as tumor necrosis factor alpha, interleukin 6, and interleukin 8, in the myocardium were significantly lower in the J group than in the C group (P <.05). CONCLUSION: These results suggested that the pharmacologic preconditioning of JTE-607 inhibits a burst of endogenous cytokines in the myocardium, resulting in the improvement of cardiac function after ischemia-reperfusion injury. Thus JTE-607 might be a novel therapeutic strategy for the protection of postoperative cardiac dysfunction in cardiac surgery.

The analysis of ascending aortic dilatation in patients with a bicuspid aortic valve using the ratio of the diameters of the ascending and descending aorta.

BACKGROUND: A bicuspid aortic valve (BAV) is associated with premature valve dysfunction and abnormalities of the ascending aorta. The aim of our study was to assess the degree of ascending aortic dilatation by measuring the ratio of the dimension of the AAo to that of the descending aorta (DAo) using preoperative computerized tomography (CT). METHODS: A review of our institutional clinical database identified 76 patients undergoing aortic valve replacement (AVR) and 73 control patients undergoing off-pump coronary artery bypass (OPCAB group) between September 2009 and April 2012. RESULTS: There were 17 patients diagnosed with BAV (BAV group), and the remaining 59 patients had a tricuspid aortic valve (TAV group). The ratios of the dimensions of the AAo to that of the DAo (AAo/DAo) for each group were: BAV, 1.58 ± 0.25; TAV, 1.32 ± 0.11; and OPCAB, 1.29 ± 0.12. Interestingly, the AAo/DAo of the BAV group was significantly larger than that of the other groups. CONCLUSIONS: Although progressive AAo dilatation for BAV is well documented, the diameter of the AAo is currently the only estimate of aortic dilatation. In this study, we report that the ratio of the AAo and DAo diameters in patients with BAV can be a new index for assessing the dilatation of the AAo and differentiating the patients with BAV from those with TAV.

Pathophysiology of lung injury induced by common bile duct ligation in mice.

BACKGROUND: Liver dysfunction and cirrhosis affect vasculature in several organ systems and cause impairment of organ functions, thereby increasing morbidity and mortality. Establishment of a mouse model of hepatopulmonary syndrome (HPS) would provide greater insights into the genetic basis of the disease. Our objectives were to establish a mouse model of lung injury after common bile duct ligation (CBDL) and to investigate pulmonary pathogenesis for application in future therapeutic approaches. METHODS: Eight-week-old Balb/c mice were subjected to CBDL. Immunohistochemical analyses and real-time quantitative reverse transcriptional polymerase chain reaction were performed on pulmonary tissues. The presence of HPS markers was detected by western blot and microarray analyses. RESULTS: We observed extensive proliferation of CD31-positive pulmonary vascular endothelial cells at 2 weeks after CBDL and identified 10 upregulated and 9 down-regulated proteins that were associated with angiogenesis. TNF-α and MMP-9 were highly expressed at 3 weeks after CBDL and were less expressed in the lungs of the control group. CONCLUSIONS: We constructed a mouse lung injury model by using CBDL. Contrary to our expectation, lung pathology in our mouse model exhibited differences from that of rat models, and the mechanisms responsible for these differences are unknown. This phenomenon may be explained by contrasting processes related to TNF induction of angiogenic signaling pathways in the inflammatory phase. Thus, we suggest that our mouse model can be applied to pulmonary pathological analyses in the inflammatory phase, i.e., to systemic inflammatory response syndrome, acute lung injury, and multiple organ dysfunction syndrome.