Effective application of a direct-acting oral anticoagulants reversal agent in acute type A aortic dissection repair: A case report.

There are insufficient reports on the use of andexanet alfa in cardiac surgery. A 67-year-old man was diagnosed with type A aortic dissection and performed emergent surgery. His medical history included atrial fibrillation treated with Edoxaban. We performed total arch replacement. Despite administration of enough protamine, fresh frozen plasma, and platelet administration, controlling bleeding was difficult. Thus, Andexanet Alfa was initiated after CPB withdrawal. Surgical bleeding was dramatically controlled after its administration. There were no findings suggestive of an embolic event. In conclusion, administration of Andexanet Alfa is safe after cardiopulmonary bypass withdrawal.

Impact of persistent malperfusion syndrome following central repair of acute type A aortic dissection on early outcomes.

We investigated impact of persistent malperfusion syndrome (MPS) following central repair of acute type A aortic dissection (ATAAD) on outcomes. Thirty patients who underwent central repair for ATAAD with MPS were included. Patients were divided into two groups:23 patients without MPS following central repair (No-MPS group) and 7 with MPS (Persistent-MPS group). The mean age was 66.8±9.6 and 59.4±13.4 years in the No-MPS and Persistent-MPS groups, respectively (P=0.176). Preoperative MPS included the left coronary artery (n=3), brain (n=3), abdomen (n=7), and extremities (n=11) in the No-MPS group. In the Persistent-MPS group, the right coronary (n=1), brain (n=2), abdomen (n=3), and extremities (n=5) were observed. In the No-MPS group, one patient died of extensive cerebral infarction (4.3%). In the Persistent-MPS group, 2 patients died of sepsis and multi-organ failure, respectively (28.6%) (P=0.061). The Persistent-MPS group had more patients requiring hemodialysis than the No-MPS group (P=0.009). Three patients underwent intestinal resection due to persistent MPS (P<0.001). Persistent MPS following central repair for ATAAD significantly contributed to outcomes. J. Med. Invest. 71 : 158-161, February, 2024.

Fixation devices made of poly-L-lactide composite for rib reconstruction after thoracotomy.

GRAND FIX mesh-type plates and pins (Gunze, Kyoto, Japan) are thin, bioabsorbable fixation devices made of poly-L-lactide (PLLA) composite. These devices are new, and how best to use them in clinical practice remains to be determined. Thus, we describe our approach to rib fixation after thoracotomy in an aortic surgery using GRAND FIX mesh-type plates and pins. The advantage of our approach is that it is easy to perform, but careful attention should be paid to fix the ribs appropriately.

Outcomes of ascending aorta and partial arch replacement with entry resection for DeBakey type I acute aortic dissection.

OBJECTIVES: This study investigated early and late outcomes between ascending aorta/partial arch replacement and total arch replacement with entry resection in DeBakey type I acute aortic dissection (DIAAD) repair. METHODS AND RESULTS: This study included 98 patients who underwent DIAAD repair from January 2005 to December 2020. Seventy-four patients underwent ascending aorta and partial arch replacement with entry resection (Non-TAR group), and 24 underwent total arch replacement with entry resection (TAR group). The mean follow-up period was 4.8 ± 3.2 years. The follow-up rate was 92.3%. The mean age in the Non-TAR and TAR groups was 68.8 ± 10.4 years and 61.6 ± 13.7 years, respectively (P = 0.046). No difference in preoperative shock and malperfusion syndrome was observed between the groups. Hospital death was observed in 5.4% and 12.5% of the Non-TAR and TAR groups, respectively (P = 0.241). Postoperative permanent neurologic deficits and temporary hemodialysis were more frequently seen in the TAR compared to the Non-TAR group (P = 0.03 and 0.003, respectively). The 5-year survival rates were 95.1% ± 3.4% and 89.2% ± 7.2% in the Non-TAR and TAR groups, respectively (Log-rank P = 0.603). Freedom from downstream aorta-related reinterventions at 5 years was 87.8% ± 4.5% and 64.1% ± 11.0% in the Non-TAR and TAR groups, respectively (Log-rank P = 0.007). Three patients in each group underwent thoracic endovascular aortic repair for residual aortic dissection. CONCLUSIONS: Early and late outcomes in the Non-TAR group were satisfactory compared to those in the TAR group. Entry resection with graft replacement remains a standard approach in DIAAD repair.

[Surgical Removal of a Transvenous Pacemaker Lead with the Right Atrial Perforation:Report of a Case].

Cardiac perforation by a transvenous pacemaker lead is an uncommon, but serious complication. Management strategies in pacemaker lead cardiac perforation depend on the symptoms, the presence of pericardial effusion, hemodynamic status, and injured neighboring organs. A 70-year-old man was admitted due to suspicious right atrial perforation with pneumothorax secondary to a transvenous pacemaker lead. Right atrial perforation was confirmed on computed tomography (CT). A large laryngopharyngeal hemangioma compressing the trachea was also observed. Although he was hemodynamically stable, we chose a surgical removal of a transvenous pacemaker lead considering his large laryngopharyngeal hemangioma. A tracheotomy followed by lower hemisternotomy were performed. A perforated pacemaker lead was observed on the right atrium. The lead was pulled out, and a hole in the right atrium was fixed. His postoperative course was uneventful.

[Stanford Type A Acute Aortic Dissection Accompanying Aberrant Right Subclavian Artery:Report of a Case].

A 64-year-old man was transferred to our hospital due to a diagnosis of Stanford type A acute aortic dissection complicated by cardiac tamponade. He was in shock status as well. Careful inspection of contrast- enhanced computed tomography revealed Kommerell's diverticulum with the aberrant right subclavian artery running behind the esophagus. The artery connected to the right axillary artery. The left vertebral artery was separately branched from the aortic arch. Primary entry was not detected on the preoperative computed tomography( CT). Left ventricular function was preserved by transthoracic echocardiography. At emergency surgery, total aortic arch replacement with reconstruction of the right axillary artery, both carotid arteries, and the left subclavian artery along with the left vertebral artery was successfully performed. The aberrant right subclavian artery was ligated at the origin. Kommerell' s diverticulum was completely excluded. Postoperative contrast-enhanced CT showed the patency of all reconstructed arteries. Although he suffered from acute cholecystitis and persistent bilateral pleural effusion, he was discharged in a good condition.

Mid-term outcomes and hemodynamic performance of the St Jude Medical Epic aortic bioprosthesis for severe aortic stenosis.

The St. Jude Medical Epic Supra valve is a porcine bioprosthesis designed for complete supraannular implantation. No report has shown the hemodynamic performance and clinical outcomes of aortic valve replacement with the Epic Supra valve for severe aortic stenosis in a Japanese cohort. We retrospectively evaluated 65 patients who underwent aortic valve replacement using the Epic Supra valve for aortic stenosis at our department between May, 2011 and October, 2016. The mean follow-up period was 68.7 ± 32.7 months, and the follow-up rate was 89.2%. The mean age was 76.8 ± 5.3 years. The 1-, 5-, and 8-year survival rates were 96.9%, 79.4%, and 60.3%, respectively. The rates of freedom from valve-related events were 96.6% and 81.9% at 5 and 8 years, respectively. Four patients were diagnosed with structural valve deterioration (SVD), and reintervention was performed in two patients. The rates of freedom from SVD were 98.2% and 83.3% at 5 and 8 years, respectively, and the mean time to diagnosis of SVD was 72.5 ± 25.3 months. The mean pressure gradient (MPG) was 16.8 ± 6.0 mmHg postoperatively, 17.5 ± 9.4 mmHg at 5 years, and 21.2 ± 12.4 mmHg at 8 years (p = 0.08). The effective orifice area index (EOAI) was 0.95 ± 0.2 cm2/m2 immediately after surgery, 0.96 ± 0.27 cm2/m2 at 5 years, and 0.84 ± 0.2 cm2/m2 at 8 years (p = 0.10). An increase in MPG and decrease in EOAI were also observed, which may be associated with SVD. Follow-up after 5 years is important to determine if there is an increase.

[Stanford Type A Acute Aortic Dissection Associated with Polycystic Kidney Disease].

Whereas cerebral aneurysm is a well-known consequence of autosomal dominant polycystic kidney disease (ADPKD), acute aortic dissection has been rarely reported. A patient was a 44-year-old male with a diagnosis of ADPKD, who had previously undergone transcatheter arterial embolization for a renal cyst hemorrhage. He presented with sudden onset of back pain, which got worse at emergency service. Contrast-enhanced computed tomography (CT) revealed Stanford type A acute aortic dissection. The patient subsequently underwent partial aortic arch replacement with a vascular graft under circulatory arrest. His postoperative course was complicated by pneumonia and required ventilation support for a week. Peak creatinine level was 3.28 mg/dl, but hemodialysis was not required. Patients with ADPKD should be considered a high-risk cohort of aortic dissection.

[Idiopathic Ascending Aortic Thrombosis with Multiple Embolism:Report of a Case].

Ascending aorta thrombosis unaccompanied by an aneurysm or a primary hypercoagulable state is rare. We report a surgical case of ascending aorta thrombosis with multiple emboli. A 44-year-old woman visited the hospital for evaluation of dysarthria and was diagnosed with multiple cerebral infarcts. Contrast-enhanced computed tomography (CT) revealed a mass in the ascending aorta and the brachiocephalic artery. We performed emergency removal of the masses and endarterectomy with cardiopulmonary bypass under hypothermic circulatory arrest. Histopathological examination of the resected specimen showed thrombi. The patient had an uneventful recovery and was discharged 12 days postoperatively. No recurrent thrombus or hypercoagulable state was observed for 3 years postoperatively.

Surgical repair of a right coronary artery fistula to the left ventricle.

A 17-year-old male complained of exertional dyspnea and was referred to our hospital after he was diagnosed with a right coronary artery fistula into the left ventricle. Surgical repair was considered to improve the symptoms. We identified the distal end of the right coronary artery entering the left ventricle under cardiopulmonary bypass with cardiac arrest. The fistula was transected at the distal end of the right coronary artery and closed at both ends without incision of the left ventricle. Coronary angiography revealed the patency of the right coronary artery and the peripheral branches four months after surgery. The coronary computed tomography four years and four months after operation showed no pseudoaneurysm formation, no thrombosis, and subsequent regression of the dilated right coronary artery. Learning objective: The coronary artery fistula is a rare congenital anomaly, and the treatment strategies of the coronary fistula are controversial. We performed ligation of the coronary fistula under cardiac arrest on cardiopulmonary bypass without incision of the left ventricle. This strategy may contribute to the accurate identification and ligation of the fistula without pseudoaneurysm formation.

Early and mid-term outcomes after aortic valve intervention in patients with previous stentless or stented bioprostheses.

BACKGROUND: Limited data are available concerning comparative outcomes of redo aortic valve interventions, including surgery after aortic valve replacement (AVR) with either stented or stentless bioprostheses. We investigated the comparative outcomes of redo aortic valve interventions, including surgery after AVR with either stented or stentless bioprostheses. METHODS: The cohort consisted of 112 patients who underwent aortic valve intervention for infective endocarditis or structural valve deterioration between 2001 and 2020. One hundred patients received a stented valve (stented group) and 12 patients received a stentless valve (stentless group) during the initial surgery. Early and late outcomes were evaluated. RESULTS: The mean [IQR] ages during the current interventions were 66 [54, 77] years in the stented group and 74 [67, 79] years in the stentless group (P = 0.13). In the stented group, aortic valve interventions included redo AVRs with stented valves (n = 54), mechanical valves (n = 26), stentless valves (n = 16), and transcatheter aortic valve implantations (n = 4). In the stentless group, redo AVRs were performed with stented valves (n = 4), mechanical valves (n = 2), stentless valves (n = 1), and transcatheter valve implantations (n = 5). Hospital mortality was observed in 2 (2%) patients in the stented group and 1 (8%) patients in the stentless group (P = 0.29). The 5-year survival was 80.8% [66.8, 88.5] in the stented group and 91.7% [53.9, 98.8] in stentless group. Statistically significant differences in thromboembolisms were observed between the groups. CONCLUSIONS: No significant differences in early and mid-term outcomes (except thromboembolism) after aortic valve interventions were detected between patients with stented and stentless AVRs.

[Surgical Outcomes of Mycotic Aneurysm of the Aortic Arch].

Mycotic aneurysm of the aortic arch is a rare, but critical entity. We reviewed our surgical experience of mycotic aneurysm of the aortic arch. Between January 2007 and December 2015, we operated on six patients who had mycotic aneurysm of the aortic arch. The mean age was 72 years old, and four males were included. Preoperative white blood cell count was 18,266/µl and C-reactive peptide was 18.5 µg/dl, respectively. The initial presentations included fever( n=2), hoarseness( n=2), weakness of a leg( n=1), dyspnea (n=1) and hemoptysis (n=1). Preoperative blood cultures were positive in three patients. All patients underwent a total aortic arch repair with a four-branched vascular tube, and five received pedicled omental grafting. One patient who did not receive pedicled omental grafting died of recurrence of infection on postoperative day 21, and the other died of multi-organ failure on postoperative day 77. We experienced tracheostomy( n=1), minor stroke( n=1), and atrial fibrillation( n=1). During the follow-up period, no recurrence of infection was observed in four survivors. Our surgical strategy is satisfactory to achieve good clinical outcomes.

Pneumatosis intestinalis and hepatic portal venous gas caused by enteral feeding after a heart valve surgery.

An 81-year-old female with a history of type I diabetes mellitus underwent mitral valve repair and tricuspid annuloplasty for severe mitral and tricuspid regurgitation. A nasogastric tube was inserted on postoperative day 2, and enteral feeding was initiated. She complained about severe abdominal pain on postoperative day 7. Contrast-enhanced computed tomography revealed a massive hepatic portal venous gas and pneumatosis intestinalis of the small intestine. Emergency laparotomy showed no evidence of transmural necrosis. Bowel resection was not performed. On the next day, computed tomography showed an almost complete resolution of the portal venous gas and pneumatosis intestinalis. She was discharged home. Learning objective: Cardiac surgeons should still be aware that enteral feeding is a potential risk factor for pneumatosis intestinalis and hepatic portal venous gas as a sign of non-occlusive mesenteric ischemia due to impaired blood supply, intestinal distension, and toxic mucosal injury.

Midterm Outcomes After Surgical Management for Mitral Valve Regurgitation in Infancy.

BACKGROUND: Mitral valve repair is preferred for pediatric mitral valve disease. However, it is technically difficult because of complex lesions, poor surgical exposure, and tissue fragility, especially in infants. We investigated the midterm outcomes of mitral valve surgery for mitral regurgitation in infancy. METHODS: We retrospectively reviewed 18 patients (aged <12 months old) undergoing mitral valve surgery for mitral regurgitation at our institution between October 2005 and March 2019. The patients had 10 acquired and 8 congenital valve lesions as follows: torn chordae (n = 6), leaflet prolapse (n = 4), posterior leaflet hypoplasia (n = 3), anterior leaflet cleft (n = 2), infective endocarditis (n = 1), papillary muscle rupture (n = 1), and hammock valve (n = 1). RESULTS: All patients initially underwent mitral valve repair. There was no operative mortality, and 1 case of late death. The median follow-up period was 7 years and 9 months. Reoperation was performed in 3 patients, re-repair (twice) in 1 patient with a hammock valve, and mitral valve replacement in 2 patients. Fifteen patients had at most mild mitral regurgitation at the last follow-up. A transmitral mean pressure gradient of over 5 mm Hg was observed in 3 cases, including the patient with a hammock valve. Postoperative mitral annular diameter increased within the normal range in all patients. Survival and reoperation-free rates at 5 and 10 years were 94.4% and 83.0%, respectively. CONCLUSIONS: Mitral valve repair for mitral regurgitation in infancy is safe and feasible with satisfactory midterm outcomes, even under serious preoperative conditions.

Ghrelin May Inhibit Inflammatory Response and Apoptosis During Ischemia-Reperfusion Injury.

BACKGROUND: Ghrelin, a novel growth hormone-releasing peptide, has both anti-inflammatory and anti-apoptotic effects on human endothelial cells. We evaluated the protective effects of ghrelin against ischemia-reperfusion injury (IRI) in a murine heterotopic cervical heart transplantation model. METHODS: Donor hearts from C57BL/6J wild-type mice, which were kept in cold saline for 60 minutes, were heterotopically transplanted into C57BL/6J wild-type recipients. A day prior to heterotopic cervical heart transplantation, donor animals received either ghrelin (300 nmol/kg) or saline (0.3 mL) intraperitoneally. Upon reperfusion and postoperative day 1, ghrelin or saline was administered to the recipients. Donor hearts were procured on day 2. RESULTS: Ghrelin injection did not result in any adverse effects in donors or recipients. Terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling-positive cells were significantly decreased in the ghrelin group (0.38% ± 0.21% vs 5.74% ± 3.68%; P < .001). Both cleaved caspase-3 activity and Bcl-2/Bax ratio from the ghrelin group were significantly reduced compared to those in the control. Furthermore, the phosphorylated Akt/Akt ratio was higher in the ghrelin group (0.44 ± 0.21 vs 0.14 ± 0.03; P = .043). Nuclear factor-kappa B p65 nuclear translocation was reduced in the ghrelin hearts compared to the controls (3.17% ± 1.84% vs 19.28% ± 13.14%; P = .009). Vascular cell adhesion molecule-1, intracellular adhesion molecule-1, nuclear factor-kappa B, and tumor necrosis factor alpha levels were also significantly reduced in the ghrelin-treated group. No significant difference was observed in 8-isoprostane production between groups. CONCLUSION: Ghrelin inhibits the inflammatory response and apoptosis during transplant-related IRI. This study demonstrates the protective effects of ghrelin against IRI.

[Primary Volvulus of the Small Intestine Mimicking Nonocclusive Mesenteric Ischemia Following Open-heart Surgery].

A 73-year-old female who underwent aortic valve replacement with a biological valve, coronary artery bypass, and left atrial appendage closure had sudden onset of nausea and abdominal pain 43 days after surgery. She had a history of nonocclusive mesenteric ischemia on 4th postoperative day, for which conservative management was successfully carried out. A contrast-enhanced computed tomography(CT) was performed because a recurrence of nonocclusive mesenteric ischemia was suspected. It revealed a whirl sign in the small intestine, suggestive of small intestine volvulus. At the subsequent emergency laparotomy, volvulus caused severe congestion in the small intestine, aproximately 40 cm from the cecum. However, there was no evidence of transmural necrosis, and reduction of torsion notably improved blood supply to the small intestine. Her regular diet was resumed on 4th postoperative day, and her postoperative course was uneventful. Volvulus should be considered as a differential diagnosis in the setting of acute abdominal pain after open-heart surgery.

Surgical strategy for treating mycotic aneurysms of thoracic and abdominal aorta and iliac artery: Analysis of long-term follow-up data.

Mycotic aneurysms of the aorta and iliac arteries are rare, but life-threatening conditions. We reviewed our experience to determine the best surgical strategy. Between 2007 and 2015, we operated 14 patients with mycotic aneurysms of the aortic arch (n = 6), descending aorta (n = 1), thoracoabdominal aorta (n = 2), abdominal aorta (n = 4), and iliac artery (n = 1). The mean age was 70.4 ± 8.8 years, and 10 males were included. Blood culture, tissue culture, or both were positive in 11 patients. Four of five patients with mycotic aneurysms of the abdominal aorta and iliac artery underwent extra-anatomical bypass. Ten underwent in-situ graft replacement for managing mycotic aneurysms of the thoracic aorta. One patient with a mycotic thoracoabdominal aortic aneurysm underwent visceral bypass of the descending aorta and extra-anatomical bypass. Omental pedicle grafting was performed in 10 patients. The mean follow-up period was 8.6 ± 3.1 years. Three patients (21.4%) died. Recurrent infection was observed in one patient with a mycotic aneurysm of iliac artery three months after the initial surgery. The patient underwent extra-anatomical bypass with omental pedicle grafting as a redo. Nine patients were discharged, and no recurrence of infection was observed. Two patients died of cancer and heart failure. The five- and seven-year survival rates were 100% ± 0.0% and 85.7% ± 13.2%, respectively. A combination of radical debridement of the infectious source and omental pedicle grafting with either in-situ graft replacement or extra-anatomical bypass is an effective strategy.