Suturing Fenestration of the Left Subclavian Artery Orifice in Frozen Elephant Trunk Procedure.

The frozen elephant trunk (FET) procedure enables easier replacement of the entire aortic arch because it does not require reaching the distal part of the left subclavian artery (LSCA). However, it requires additional management for reconstruction of the LSCA, which is associated with bleeding events. However, the fenestrated FET technique confers a risk of endoleakage from the fenestration site. We report our unique novel technique in which the proximal side of the hybrid stent graft is cut into V-shape around the subclavian artery and sutured continuously around the orifice of the subclavian artery during aortic stump fixation.

Less Invasive Quick Open Stenting using a J Graft Open Stent for Distal Arch Aneurysms.

A new device of aortic stent graft made in Japan has been available since July 2014. Here, we describe a novel, unique surgical technique named "less invasive quick open stenting" at a rectal temperature of 28°C without any cerebral perfusion for treating distal arch aneurysms. All 12 patients were discharged from the intensive care unit within 24 hours after surgery without any complications. This technique aids in the exclusion of atherosclerotic plaques on the aortic wall and shortens the duration of circulatory arrest; moreover, it represents a very attractive option to prevent recurrent nerve injury.

Incidence of drug interaction when using proton pump inhibitor and warfarin according to cytochrome P450 2C19 (CYP2C19) genotype in Japanese.

OBJECTIVES: The US Food and Drug Administration has suggested that proton pump inhibitors (PPIs) increase the international normalized ratio (INR) when used concomitantly with warfarin (WF) because of being metabolized by cytochrome P450 2C19 (CYP2C19). We assessed whether CYP2C19 genotypes and type of PPI accentuated the drug interaction. METHODS AND RESULTS: The study group was 82 patients who needed WF after surgery and had their CYP2C19 genotypes analyzed in advance. We randomly divided them into two groups: group I (n = 41) included patients who had lansoprazole 15 mg/day and group II (n = 41) included patients who had rabeprazole 10 mg/day. The dose of WF was controlled by the doctor in charge as a target INR of 1.6 to 2.6 during the 2 months after surgery. The maximum INR was significantly higher in group I (3.36 ± 0.98) than in group II (2.29 ± 0.55, p < 0.0001). The incidence of over-INR (> 3.5) was significantly higher in group I (15 cases) than in group II (2 cases, p = 0.0001). Several bleeding events complicated 10 patients in group I, but none in group II (p = 0.015). Logistic regression analysis revealed that over-INR (odds ratio [OR] 3.58, 95% confidence interval [CI]: 3.48-368.25, p < 0.0001), and pair of lansoprazole and CYP2C19 intermediate metabolizer (OR 2.39, 95% CI: 1.108-29.491, p = 0.0009) were independent predictors of bleeding events. CONCLUSION: If a patient has had the intermediate metabolizer CYP2C19 genotype and concomitant use of WF and a PPI after open heart surgery, lansoprazole intensifies the effects of WF and is associated with bleeding events.

Screening and management for ischemic heart disease in patients undergoing emergency surgery for a type A acute aortic dissection.

PURPOSE: We assessed the incidence of coronary artery disease (CAD) during hospitalization after emergency surgery for a type A acute aortic dissection. METHODS: A total of 123 patients underwent multi-slice computed tomography (MSCT) scans during an early stage after surgery. The patients were divided into two groups: group I consisted of 14 patients (11.4%) who had coronary artery stenosis of more than 75% on MSCT, and group II consisted of 109 patients (88.6%) who had no coronary lesions. RESULTS: The prevalence of diabetes, dyslipidemia and a smoking history was significantly higher in group I. Although the serum low-density lipoprotein cholesterol levels were similar, the high-density lipoprotein cholesterol (HDL) level was significantly lower in group I (36.4 ± 7.9 mg/dl) than in group II (49.6 ± 13.5 mg/dl, P = 0.0005). The maximum carotid intima-media thickness (IMT) was significantly thicker in group I (1.17 ± 0.37 mm) compared to group II (0.96 ± 0.33 mm, P = 0.0297). The logistic regression analysis detected that a carotid IMT over 1.1 mm (odds ratio 4.35, P = 0.0371) and HDL less than 40 mg/dl (odds ratio 3.90, P = 0.0482) were predictors for CAD. CONCLUSIONS: CAD screening should be recommended for patients with aortic dissection who have several atherosclerosis risk factors, even after emergency surgery.

Comparison of febuxostat and allopurinol for hyperuricemia in cardiac surgery patients (NU-FLASH Trial).

BACKGROUND: Febuxostat has been reported to have a stronger effect on hyperuricemia than allopurinol. METHODS AND RESULTS: Cardiac surgery patients with hyperuricemia (n=141) were randomized to a febuxostat group or an allopurinol group. The study was single-blind, so the treatment was not known by the investigators. The primary endpoint was serum uric acid (UA) level. Secondary endpoints included serum creatinine, urinary albumin, cystatin-C, oxidized low-density lipoprotein (LDL), eicosapentaenoic acid/arachidonic acid ratio, total cholesterol, triglycerides, LDL, high-density lipoprotein, high-sensitivity C-reactive protein, blood pressure, heart rate, pulse wave velocity (PWV), ejection fraction, left ventricular mass index (LVMI), and adverse reactions. UA level was significantly lower in the febuxostat group than the allopurinol group from 1 month of treatment onward. Serum creatinine, urinary albumin, cystatin-C and oxidized LDL were also significantly lower in the febuxostat group. There were no significant changes in systolic blood pressure, PWV, and LVMI in the allopurinol group, but these parameters all had a significant decrease in the febuxostat group. CONCLUSIONS: Febuxostat was effective for high-risk cardiac surgery patients with hyperuricemia because it reduced UA more markedly than allopurinol. Febuxostat also had a renoprotective effect, inhibited oxidative stress, showed anti-atherogenic activity, reduced blood pressure, and decreased PWV and LVMI.

Long-term outcomes of patients undergoing extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock.

PURPOSE: Postcardiotomy cardiogenic shock is still associated with a poor prognosis. We reviewed patients undergoing extracorporeal membrane oxygenation (ECMO) support for postcardiotomy cardiogenic shock and assessed their long-term outcomes. METHODS: The subjects were 47 patients who received ECMO support for cardiogenic shock after open heart surgery. We analyzed the long-term survival and risk factors for early or late death. RESULTS: Twenty-nine patients were weaned off ECMO support, but 15 of these patients died during their hospital stay. An independent predictor of mortality during ECMO support was incomplete sternum closure (OR 4.089, 95 % CL 1.003-16.67, p = 0.049) and a predictor of mortality after weaning off ECMO was more than 48 h of support (OR 8.975, 95 % CL 1.281-62.896, p = 0.027). Fourteen patients were discharged from hospital, but seven of these patients died during the follow-up period owing to cardiac events (n = 2) or non-cardiac causes (n = 5). The actuarial survival rates were 34.0 % at 30 days, 29.8 % at 1 year, and 17.6 % at 10 years. CONCLUSION: Although postcardiotomy cardiogenic shock requiring ECMO support is associated with high morbidity and mortality, the long-term survival rate is acceptable.

Rapid aortic enlargement requiring surgery in patients with chronic type B aortic dissection.

We report the relationship between rapid aortic enlargement of chronic type B aortic dissection and sleep disorder due to anxiety after Tohoku disaster. Five patients underwent surgical procedures due to rapid aortic enlargement after the earthquake disaster. They reported that their morning blood pressure increased to approximately 190 mm Hg after the disaster. They were troubled with severe insomnia due to anxiety about the continuing aftershocks. In primary care for patients with mental stress after a big disaster, it is important to keep a careful monitoring of blood pressure besides assessment of anxiety and sleep.

The effect of combined treatment with Impella(®) and landiolol in a swine model of acute myocardial infarction.

Cardiogenic shock is associated with a high mortality rate in patients with acute myocardial infarction (AMI). We developed a new treatment approach named heart rest therapy (HRT) for complete revascularization in the early stage of AMI using an ultra-short-acting ß-blocker (landiolol) and an Impella(®) left ventricular assist device and verified the effect of this therapy in a swine model. In 18 male pigs, AMI was induced by left anterior descending coronary artery occlusion at the level of the second diagonal branch for 120 min, followed by 240 min of reperfusion. The animals were divided into three groups: group A had no support, group B was supported with the Impella(®), and group C was treated with HRT from 90 min after ischemia to 240 min after reperfusion. Infarct ratio (percentage of the infarct area relative to the area at infarct risk) was significantly reduced in group C (group A 65.38 ± 6.07, group B 39.66 ± 11.16, group C 21.78 ± 7.29), with a significant difference between groups A and B (P < 0.001), A and C (P < 0.001), and B and C (P = 0.006). Heart rates were significantly lower in group C at 30 min (P = 0.01), 60 min (P = 0.022), and 240 min (P = 0.032) after reperfusion compared with group B, without development of hypotension. HRT at the early stage in AMI stabilized the hemodynamic conditions and reduced infarct size and complications in a swine model. These results suggest that HRT can improve the prognosis of patients with AMI.

Concomitant aortic valve and ascending aorta replacement with moderate hypothermic circulatory arrest to treat an aortic bicuspid valve with post-stenotic dilatation.

We recommend concomitant surgery for aortic valve replacement (AVR) and ascending aortic replacement using moderate hypothermic circulatory arrest (CA) for post-stenotic dilatation complicated by an aortic bicuspid valve. Cardiopulmonary bypass (CPB) was established from the right atrium to the dilated ascending aorta. As soon as the rectal temperature decreased to 28 °C, CA was commenced and the open distal anastomosis of a polyester prosthesis, without any cerebral perfusion, was completed. AVR was then carried out during rapid re-warming with CPB using a side arm of the prosthesis. This procedure exhibited safe and satisfactory results. There are many benefits of carrying out the procedure in this way; it avoids the requirement for cannulation to a calcified aortic arch, provides a good operative field, for an easier distal anastomosis and suturing at the valve site, and reduces the risk of further dilatation or dissection of the residual ascending aorta in the later phase.

Sleep disorders and aortic dissection in a working population.

The aim of the present study was to assess the relationship between acute aortic dissection (AAD) and sleep disorders in a working population. Seventy (50.4%) of 139 younger subjects with AAD suffered from sleep disorders. Insomnia was reported by 35 patients (50%), sleep deprivation by 31 patients (44.3%), and sleep apnea syndrome was present in 43 patients (61.4%). The average apnea-hypopnea index was 22.0 ± 7.5 points, requiring appropriate treatment. Most of these patients had irregular daily schedules due to job pressure. Sixty-six (94.3%) complained of severe mental and physical stress in daily life. Sleep disorders are considered one of the risk factors for the occurrence of AAD at younger active ages. In primary care for patients with mental or physical stress due to their daily life, it is important to assess these individuals for the presence of sleep disorders.

Long-term patency rate for radial artery vs. saphenous vein grafts using same-patient materials.

BACKGROUND: The aim of the present study was to assess the long-term graft patency rate of the radial artery (RA), in comparison to the saphenous vein (SV) in patients harvested for both vessels. METHODS AND RESULTS: RA and SV were concomitantly used for coronary artery bypass grafting in 318 patients in an 8-year period from January 2002 to March 2010. During follow-up, graft patency was assessed on angiography or multi-slice computed tomography in 192 of these patients. Cumulative graft patency rates were compared between RA and SV. Independent predictors for graft failure were examined for both vessels. Cumulative graft patency rates at 8 years were 74.3% in RA and 64.7% in SV, respectively. There was no significant difference between these types of grafts. Independent predictors of late RA graft failure were native coronary stenosis <75% and peripheral vascular disease (PVD). Independent predictors of late SV graft failure were use of only one anti-platelet agent and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio >2.5. Cardiovascular event-free and actuarial survival rates at 8 years in this series were 81.2% and 89.7%, respectively. CONCLUSIONS: Cumulative graft patency rates between RA and SV were similar at 8 years. RA performed more poorly in patients with target vessel stenosis <75% and in those complicated by PVD. Aggressive anti-platelet therapy and strict lipid control may be important in maintaining long-term patency of SV.

Myocardial protective effect of human atrial natriuretic Peptide in cardiac surgery. -hANP Shot" in clinical safety trial-.

BACKGROUND: We studied low-dose human atrial natriuretic peptide (hANP) infusion therapy during cardiac surgery and reported the cardiac and renal protective effects. The efficacy of a bolus injection of hANP (the "hANP shot") simultaneously with induction of cardioplegia has been proven in animal experiments. In the present study the clinical effects of this "hANP shot" were examined. METHODS AND RESULTS: The subjects were 67 patients undergoing Coronary artery bypass grafting. At the time of inducing cardioplegia, 1 group received a simultaneous bolus injection of 100 µg of hANP (hANP group) and the other group received an injection of physiological saline (placebo group). The primary endpoints were (1) operative mortality and complications, and (2) the creatine kinase isoenzyme MB (CPK-MB), troponin-I, and human heart fatty acid binding protein (H-FABP) levels. The secondary endpoints were (1) the incidence of arrhythmia, and levels of (2) atrial and B-type natriuretic peptides, and cyclic guanosine monophosphate (cGMP), and (3) renin, angiotensin II, and aldosterone. Postoperative CPK-MB, troponin-I, and H-FABP levels were significantly lower in the hANP group than in the placebo group. Postoperative arrhythmia was significantly less frequent in the hANP group than in the placebo group. CONCLUSIONS: It is possible to achieve cardioprotective effects based on the safety of the "hANP shot", as well as from biomarkers of ischemia and results related to arrhythmia. The "hANP shot" should also be evaluated as a safer and new cardioprotective method for cardiac surgery.

Total arch replacement and open stent graft implantation using a newly developed stent graft: report of a case.

We experienced a case in which a total arch replacement and an open stent implantation were performed for a distal aortic arch aneurysm using a newly developed stent graft (Ube CL-0201; Ube Medical, Tokyo, Japan). This novel stent graft is composed of a woven polyester graft and a nickel-titanium alloy stent, and has been under evaluation in clinical trials at four institutions in Japan, including our hospital, since 2008. The patient was weaned from the respirator on the day after surgery, and 9 months have passed since the surgery with no complications. A follow-up computed tomography scan showed that the stent part was sufficiently open, and no complications, such as an endoleak, have been observed.

Efficacy of prophylactic treatment with selective serotonin reuptake inhibitors for depression after open-heart surgery.

PURPOSE: The aim of the present study was to evaluate the efficacy of prophylactic treatment with selective serotonin reuptake inhibitors (SSRIs) in female patients at high risk of suffering depression after cardiac surgery. METHODS: Female patients (n = 58; group I) who were over 70 years of age or who had undergone emergency surgery were administered prophylactic treatment with paroxetine immediately after surgery. The hospital mortality and morbidity data of these patients were compared with those of 59 patients (group II) without prophylactic medication. RESULTS: The Center for Epidemiological Studies Depression Scale (CES-D) score at 10 days after surgery was significantly lower in group I (15.2 ± 7.8) than in group II (21.8 ± 7.5, P = 0.0018). The incidence of depression (I: 12.1% vs II: 64.4%, P < 0.0001) and pneumonia (I: 0% vs II: 10.2%, P = 0.0127) were significantly lower in group I than in group II. In addition, the duration of postoperative hospital stay was significantly shorter for group I than for group II (I: 15.9 ± 56.5 vs II: 23.4 ± 20.5 days, P = 0.0102). The hospital mortality rates were similar. CONCLUSION: The quality of life of patients with depression after open-heart surgery is poor. The early administration of prophylactic medication is therefore necessary for those patients at risk for developing depression.

First clinical application of the DuraHeart centrifugal ventricular assist device for a Japanese patient.

The DuraHeart ventricular assist device (VAD) is a third-generation implantable centrifugal pump with a magnetically levitated impeller. Since February 2007, the device has been clinically applied with excellent results as a bridge to heart transplantation in Europe. As of this writing, however, the device has yet to be approved by the Ministry of Health, Labour and Welfare for clinical use in Japan. We herein report the first clinical application of this device for a Japanese patient. A 31-year-old man with dilated cardiomyopathy was transferred to the Heart and Diabetes Center NRW (HDZ-NRW) in Bad Oeynhausen, Germany, where he was to await heart transplantation. The transfer was safely completed under management with low-dose dopamine. His condition gradually deteriorated at HDZ-NRW, and the DuraHeart left ventricular assist device was implanted for the left ventricle at 7 weeks after admission. Shortly thereafter, however, on POD 7, a Thoratec VAD had to be inserted on the right side due to refractory right heart failure. The right ventricular assist device could be explanted after a 3-month assist, and the patient is now waiting for heart transplantation at home in Germany.

Correction to: Thoracic and cardiovascular surgery in Japan in 2016 : Annual report by The Japanese Association for Thoracic Surgery.

In the original publication of the article, the values of the row "Norwood procedure", under "(3) Main procedure" in Table 3 were published incorrectly. The corrected part of the table is given in this Correction.

Efficacy of modified less invasive quick replacement using mild hypothermic arrest and partial retrograde cerebral perfusion for type A acute aortic dissection.

OBJECTIVE: We previously reported a unique technique called "less invasive quick replacement (LIQR)" for treating type A acute aortic dissection with moderate hypothermic arrest (28 °C). This study examines the modified LIQR using mild hypothermic arrest (30 °C) with partial retrograde cerebral perfusion (RCP). METHODS: 187 patients were divided into 2 groups: group L consisted of 130 patients underwent LIQR without any cerebral perfusion; group M consisted of 57 patients who were treated with modified LIQR. In modified LIQR, circulatory arrest was commenced under the 30 °C for open distal aortic stamp fixation. RCP was used during final half anastomosis of the prosthesis and then rapid re-warming was initiated. RESULTS: The incidence of additional valve or coronary surgeries was significantly higher in group M (28.1%) than in group L (9.2%). The average rectal temperature was significantly higher in group M (29.5 °C) than in group L (27.4 °C). The durations of brain ischemia (M 7.7 min; L 18.6 min), cardiopulmonary bypass (M 82.0 min; L 93.3 min), and overall operation (M 145.2 min; L 154.2 min) were significantly shorter in group M. The incidence of postoperative brain damage was 6 patients (4.6%) in group L, but none in group M. The hospital mortality rate was 3 patients in group L (2.3%). All group M patients were discharged from the hospital without any complications. CONCLUSION: Modified LIQR is safe and effective. It makes the surgery much quicker and is a less invasive procedure. The surgical outcome was also favorable.

A surgical case of left ventricular pseudoaneurysm complicating myocardial infarction in a diabetic patient on dialysis.

A 57-year-old man was hospitalized with dyspnea and heart failure. We performed an electrocardiogram, coronary angiogram, echocardiogram, and magnetic resonance imaging. He was diagnosed with a left ventricular pseudoaneurysm (i.e., heart tumor) at the posterolateral wall. Minimal contrast medium was utilized when making the diagnosis as the patient was on dialysis. We subsequently repaired the ventricular unruptured pseudoaneurysm and performed a coronary artery bypass grafting. This case presented difficulty in ascertaining the difference between a cardiac tumor and a ventricular pseudoaneurysm.

Prophylactic reoperation after mitral valve replacement with the Starr-Edwards ball valve: a report of four cases.

PURPOSE: The Starr-Edwards ball valve was first applied clinically in 1960. In our hospital, this valve has been used since 1963, and some patients have been followed up for 30 years or more. Based on our experience, therapeutic strategies included revalve replacement as a preventive procedure in the absence of valve-related complications. In this study, we investigated whether prophylactic reoperation after valve replacement with the Starr-Edwards ball valve is appropriate. PATIENTS AND METHODS: Of 58 patients in our institute who underwent mitral valve replacement with the Starr-Edwards ball valve, 12 underwent revalve replacement. Of these 12, the subjects of the present study were 4 patients who underwent prophylactic revalve replacement. RESULTS: The mean postoperative follow-up of the 4 patients was 31.0+/-3.7 years. There were no operative deaths or postoperative complications. On examination of the extirpated Starr-Edwards valves, cloth wear was observed in all 4 patients. Although there was no influence on the range of ball motion, they showed the entity of "thrombus/pannus." CONCLUSION: In this study, all of the patients showed cloth wear in the absence of complications. Therefore we consider that prophylactic reoperation after valve replacement with the Starr-Edwards valve should be performed to prevent complications.

Child with fulminant myocarditis survived by ECMO Support--report of a child case.

A 6-year-old girl had cold-like symptoms. Administration of antibiotics did not improve the symptoms, and the patient had chronic chest pain. Electrocardiogram (ECG) demonstrated ventricular tachycardia (VT) and cardiac enzyme levels were increased. Mexiletine and olprinone were continuously administered, but slow VT and III degrees A-V block repeatedly occurred. Pulse therapy using methyl prednisolone was performed, but hemodynamics did not improve. Ejection fraction (EF) decreased to 20%, and metabolic acidosis occurred. Extra corporeal membrane oxygenation (ECMO) was applied 24 hours after admission to the intensive care unit (ICU). To apply ECMO, a median sternotomy was performed. An in-flow cannula (15 Fr) was inserted into the ascending aorta and an out-flow cannula (19 Fr) was inserted into the right atrium. After returning to the ICU, blood pressure (BP) were stable, and urine volume was maintained at about 100 ml/h. Methyl prednisolone and gamma-globulin were administered during circulatory assisted period. About 24 hours later, sinus rhythm was obtained, and weaning was started after improvement of the EF. BP was maintained at 100 mmHg with low dose catecholamine, which was weaned off 42 hours after commencement. Hemodynamics after this remained stable. EF improved to 54.2%. An ECG demonstrated right bundle branch block (RBBB) at the sinus rhythm. Severe inflammatory changes were pathologically observed, and we diagnosed myocarditis. The patient was discharged from the hospital on 43 days post admission, and currently attends school.