Predictive role of regional thigh tissue oxygen saturation monitoring during cardiopulmonary bypass in lung injury after cardiac surgery.

Acute respiratory distress syndrome (ARDS) is a serious complication following cardiac surgery mainly associated with the use of cardiopulmonary bypass (CPB), which could increase the risk of mortality and morbidity. This study investigated the association of regional oxygen saturation (rSO2) during CPB with postoperative outcomes, including respiratory function. Patients who underwent cardiac surgery with CPB from 2015 to 2019 were included. Near-infrared spectroscopy was used to monitor rSO2 at the forehead, abdomen, and thighs throughout the surgery. Postoperative markers associated with CPB were assessed for correlations with PaO2/FiO2 (P/F) ratios at intensive care unit (ICU) admission. Postoperative lung injury (LI) was defined as moderate or severe ARDS based on the Berlin criteria, and its incidence was 29.9% (20/67). On multiple regression analysis, the following were associated with P/F ratios at ICU admission: vasoactive-inotropic scores at CPB induction (P = 0.03), thigh rSO2 values during CPB (P = 0.04), and body surface area (P < 0.001). A thigh rSO2 of 71% during CPB was significantly predictive of postoperative LI with an area under the curve of 0.71 (P = 0.03), sensitivity of 0.70, and specificity of 0.68. Patients with postoperative LI had longer ventilation time and ICU stays. Thigh rSO2 values during CPB were a potential predictor of postoperative pulmonary outcomes.

Recurrent left ventricular thrombus due to essential thrombocythemia complicated by COVID-19.

Essential thrombocythemia is a risk factor for thrombosis and hemorrhage. During the perioperative period of cardiac surgery, the risk of thrombosis and hemorrhage increases. Coronavirus disease 2019 (COVID-19) is also associated with thrombosis. We present the case of a 69-year-old man with essential thrombocythemia complicated by COVID-19 who developed a left ventricular thrombus. We performed thrombectomy, but the patient developed recurrent left ventricular thrombus 8 days after surgery. Emergency redo thrombectomy was performed followed by aggressive blood-thinning therapy. The postoperative course was complicated by cardiac tamponade requiring surgical drainage 8 days after the second surgery. The patient was discharged home 25 days after the second operation without any complications. Learning objective: Left ventricular thrombus is a rare but fatal complication associated with essential thrombocythemia. COVID-19 has also been reported to cause coagulopathy. This case suggested that after surgery for left ventricular thrombus complicated by multiple risk factors including essential thrombocythemia and COVID-19, aggressive blood-thinning therapy with combination of anticoagulation, antiplatelet, and metabolic antagonist may help prevent recurrent thrombosis.

Initial thickness of the crescent may not be a reliable predictor of complications in type A intramural haematoma.

OBJECTIVES: This study aimed to investigate changes in haematoma thickness during the early period and their association with disease progression in patients who received initial medical treatment for type A intramural haematoma (IMH). METHODS: Medical records and serial computed tomography angiography (CTA) images of patients who did not undergo emergency aortic repair for type A IMH upon presentation were retrospectively reviewed. The haematoma remodelling rate was determined using the following equation: thickness of the haematoma on the first CTA (mm) - thickness of the haematoma on the second CTA (mm)time between the first and second CTAs (h). RESULTS: Among the 40 patients included in this study, 38 were indicated for initial watch-and-wait strategy, whereas 2 were indicated for emergency aortic repair but declined it. During hospitalization, 10 patients developed disease progression, with 2 in-hospital mortality cases. Analysis of the haematoma remodelling rate in 39 patients revealed that such a rate was significantly associated with the reciprocal of the time from onset. Analysis of all 70 CTA examinations performed within 24 h after the onset of IMH showed that haematoma thickness was significantly associated with the logarithm of the time from onset. Initial regression of the haematoma was not necessarily associated with avoidance of disease progression. CONCLUSIONS: In type A IMH, the thickness of the haematoma in the ascending aorta tended to decrease in the very early period; however, prompt regression of the haematoma was not necessarily associated with avoidance of disease progression.

Watch-and-wait strategy for selected patients with type A intramural hematoma.

OBJECTIVE: This single-center retrospective study evaluated early and midterm outcomes of 100 consecutive patients with type A intramural hematoma. METHODS: Initial watch-and-wait strategy was indicated if the maximum aortic diameter was < 50 mm, pain score was < 3/10 on the numerical rating scale, and no ulcer-like projection was observed in the ascending aorta. The primary endpoints of this study were all-cause and aorta-related deaths, and the secondary endpoint was aortic events. RESULTS: Initial watch-and-wait strategy was indicated in 52 patients. Emergency aortic repair was indicated in the remaining 48 patients; 2, 31, and 15 patients died before surgery, underwent emergency surgery, and declined emergency surgery, respectively. Among the watch-and-wait group, 11 (21%) patients underwent aortic repair during hospitalization. In-hospital mortality rates, 5-year survival rates, and 5-year freedom from aorta-related death were not significantly different between the initial watch-and-wait strategy and emergency surgery (2% vs. 6%, 92% vs. 82%, and 100% vs. 94%, respectively). In the initial watch-and-wait strategy group, 5-year freedom from aortic events and freedom from aortic events involving the ascending aorta were 60% and 66%, respectively. CONCLUSIONS: The early and midterm outcomes with the initial watch-and-wait strategy in patients with type A intramural hematoma with a maximum aortic diameter of ≤ 50 mm, pain score of ≤ 3/10, and no ulcer-like projection in the ascending aorta were favorable with no aorta-related death.

Coil-in-Plug Method for Left Subclavian Artery Embolization in Thoracic Endovascular Aortic Repair with Arch Vessel Debranching.

Objectives: Since 2018, we have routinely placed an Amplatzer vascular plug (AVP) in the proximal left subclavian artery (LSCA) to prevent embolic events during thoracic endovascular aortic repair with arch vessel debranching (d-TEVAR). Type II endoleaks of LSCA origin were observed in two patients (20%), and the coil-in-plug (CIP) method, i.e., microcatheter insertion through the plug and addition of coil embolization, which has been used since August 2019, was performed. This study aims to evaluate the effectiveness of the CIP method for LSCA embolization. Methods: A total of 26 patients who underwent d-TEVAR for an aortic arch aneurysm between 2018 and 2022 were retrospectively reviewed. Ten patients who underwent d-TEVAR with a simple AVP placement (the control group) and 16 patients who underwent d-TEVAR with the CIP method (the CIP group) were compared. Results: Two patients had type II endoleaks in the control group, whereas none had them in the CIP group. LSCA length was significantly shorter in patients with endoleaks than in those without endoleaks (24.5 vs. 50.3 mm; p<0.01). No perioperative deaths or cerebral infarctions occurred in either group. Conclusions: AVP placement in the LSCA during d-TEVAR effectively prevented perioperative cerebral infarction. d-TEVAR with CIP was especially useful in patients with a short LSCA.

[Mitral Valve Surgery for Active Infective Endocarditis:Techniques to Preserve Native Valve].

OBJECTIVE: In surgery for active infective endocarditis (aIE), it is often difficult to achieve balance between thorough debridement and preservation of native valve. This study aimed to evaluate the validity of our native valve preservation techniques including leaflet peeling and autologous pericardial reconstruction. METHODS: From January 2012 to December 2021, 41 consecutive patients underwent mitral valve surgery for aIE. Twenty-four patients who underwent mitral valve plasty (group P) and 17 patients who underwent mitral valve replacement (group R) were retrospectively compared regarding early and long-term outcomes. RESULTS: Patients in the group P were significantly younger and had fewer preoperative shock, congestive heart failure and cerebral embolism. There was 18% in-hospital mortality in the group R, but none in the group P. In the group P, one patient underwent valve replacement for recurrence of mitral regurgitation 3-years after surgery, and 5-year freedom from mitral reoperation was 93%. CONCLUSIONS: Techniques of leaflet peeling and autologous pericardial reconstruction improved the feasibility of mitral valve plasty for aIE, and the early and long-term outcomes were favorable.

Acute Kidney Injury after High-Flow Regional Cerebral Perfusion in Neonatal and Infant Aortic Arch Repair.

OBJECTIVES: We applied high-flow regional cerebral perfusion (HFRCP) for aortic arch reconstruction in neonates and infants by monitoring regional oxygen saturation of the thigh (rSO2T) using near-infrared spectroscopy to maintain peripheral perfusion. This study was designed to investigate the optimal perfusion flow of HFRCP for renal protection. METHODS: From 2009 to 2021, 28 consecutive neonates and infants who underwent aortic arch reconstruction with HFRCP were enrolled. The median age of the patients was 27 days; the median body weight was 3.0 kg. In HFRCP, perfusion flow was targeted at approximately 80-100 mL/kg/min and then lowered corresponding to brain rSO2 levels and blood gas data. Isosorbide dinitrate and chlorpromazine were administered to enhance peripheral perfusion flow. Regional oxygen saturation of the forehead and thighs were monitored. The stage of acute kidney injury (AKI) was classified based on the Kidney Disease Improving Global Outcomes criteria. RESULTS: No patients had neurological events and peritoneal dialysis after surgery. The incidence of AKI was 39.3% with only three patients having greater than stage 2 AKI. The maximum postoperative serum creatinine concentration was negatively associated with the lowest rSO2T during HFRCP. The rSO2T during HFRCP was a predictive factor for postoperative creatinine increase of ≧0.3 mg/dL. The area under receiver operating characteristic curve was 0.78 with the cutoff value of 48% for rSO2T. CONCLUSIONS: The rSO2T during HFRCP is a potential predictor of postoperative renal function. To prevent AKI, the rSO2T should be preserved more than 48% by increasing HFRCP flow.

Outcomes after Rivaroxaban Treatment of Extensive Deep Vein Thrombosis.

BACKGROUND: Regression of thrombus in response to treatment with direct oral anticoagulants (DOACs) in patients with extensive deep vein thrombosis (DVT) has not been fully evaluated. This study aimed to determine the therapeutic efficacy of rivaroxaban in the treatment of extensive DVT. METHODS: We retrospectively evaluated 76 patients treated with rivaroxaban among 728 new DVT patients, at our hospital from January 2018 to March 2021. Extensive DVT was defined as thrombus connecting to 2 or more segments of the inferior vena cava (IVC), iliac vein, femoral vein, or popliteal vein. Localized DVT was defined as a thrombus confined to 1 segment of the inferior vena cava (IVC), iliac vein, femoral vein, or popliteal vein. We compared the changes in thrombus between the extensive DVT group (36 patients) and the localized DVT group (40 patients). RESULTS: In the localized DVT group, 14 (37%) had total recanalization within 3 weeks after DOAC initiation, and 30 (79%) had total recanalization within 3 months. In the extensive DVT group, only 3 (9%) had total recanalization within 3 weeks after starting DOAC, and even after 3 months, only 5 (15%) had total recanalization. Symptoms (P = 0.01) and extensive DVT (P < 0.01) were significantly associated with the risk for failure of total recanalization. CONCLUSIONS: Rivaroxaban was highly effective for total recanalization of localized DVT but not for symptomatic or extensive DVT. In patients with symptomatic extensive DVT, catheter-based thrombolysis may be considered in selected cases.

Aortic valve replacement and coronary artery bypass grafting through a right thoracotomy for a patient with a left chest wall tumor.

A 68-year-old man was diagnosed with severe aortic stenosis and right coronary artery occlusion on preoperative examination for total extirpation of a giant left breast liposarcoma. Prior to the intervention for the liposarcoma, he underwent successful aortic valve replacement and coronary artery bypass grafting via a right anterolateral thoracotomy to avoid the tumor close to the sternum. On postoperative day 28, the patient underwent a successful wide excision of the left chest wall tumor.

A simple technique of artificial chordae implantation in robotic cardiac surgery using a novel tube device supporting expanded polytetrafluoroethylene chordae ligation.

Artificial chordae implantation is an important technique for treating leaflet lesions in mitral valve repair. Considering that the expanded polytetrafluoroethylene (ePTFE) suture is slippery on the surface, adequate ligation without laxity should be critically considered, especially in robotic surgery. To resolve this issue, we applied a novel device that controls the length of an ePTFE suture (Chordarizer) for artificial chordae implantation in robotic mitral valve repair. After assessing the mitral valve via the right side of the left atrium, we stitched a CV-4 ePTFE suture to the target papillary muscle. Using a calliper, we measured the length of the artificial chordae and passed the CV-4 through the appropriate Chordarizer. Then, we stitched the CV-4 to the tip of the leaflet from the left ventricle side and tied it using da Vinci arms. Finally, the Chordarizer was peeled away. Chordarizer ensured safe and reliable artificial chordae implantation procedures with robotic mitral surgery, by maintaining the desired CV4 length.

[Simultaneous Surgery of Gastrectomy and Rerouting of the Pre-existing Right Gastroepiploic Artery Bypass Graft for Gastric Cancer].

The patient was a 76-year-old man with advanced gastric cancer who had a history of coronary artery bypass grafting using the right gastroepiploic artery. Although coronary angiography confirmed the patency of all the coronary artery bypass grafts, his right gastroepiploic artery was required to be cut for curative gastrectomy. To prevent serious myocardial ischemia, rerouting of the right gastroepiploic artery graft was performed using a saphenous vein graft via right mini-thoracotomy. The proximal end of the saphenous vein graft was anastomosed to the ascending aorta. Then, gastrectomy via epigastric median re-laparotomy was performed. His postoperative course was uneventful.

[Staged operation of aortic valve stenosis with concomitant sigmoid colon cancer by minimally invasive cardiac surgery; report of a case].

Severe aortic stenosis was found by preoperative echocardiography in a 79-year-old female patient with sigmoid colon cancer. Staged operation was planned. First, bioprosthetic aortic valve replacement was performed by minimally invasive cardiac surgery. She underwent concomitant colostomy to avoid malnutrition which may have occurred in case of colon obstruction. On 25th day after cardiac surgery, curative sigmoidectomy was performed. One year after the operation, she is doing well without any major complications.

Acute subdural hematoma following thoracoabdominal aortic repair in a patient with Marfan syndrome: a rare complication of cerebrospinal fluid drainage.

Cerebrospinal fluid (CSF) drainage is a routinely used adjunct in operation of thoracoabdominal aortic aneurysm (TAAA), which may reduce the incidence of perioperative paraplegia by improving spinal cord perfusion. Neurological complications of CSF drainage have been reported, possibly due to excessive CSF drainage, and acute subdural hematoma (SDH) in particular may lead to catastrophic complications. We present a rare case of acute SDH due to CSF drainage that was not excessive, after TAAA repair in a patient with Marfan syndrome, who recovered without invasive treatment.

Long-term follow-up of acute type B aortic dissection: ulcer-like projections in thrombosed false lumen play a role in late aortic events.

OBJECTIVE: Patients with Stanford type B dissection treated medically during the acute phase have a risk of surgery and aortic rupture during the chronic phase. We investigated the predictors for late aortic events by focusing on the false lumen status with computed tomography. METHODS: A total of 160 patients were enrolled in the study, with a mean follow-up interval of 44.6 ± 25.4 months. Patients were divided into 3 groups according to the false lumen status at the time of onset: group T, thrombosed in 49 patients (30.6%); group U, thrombosed with ulcer-like projections in 52 patients (32.5%); and group P, patent in 59 patients (36.9%). RESULTS: The mean aortic enlargement rate of groups U and P was greater than that of group T (0.40 ± 0.91 mm/month in group U, 0.44 ± 0.49 mm/month in group P, and -0.016 ± 0.23 mm/month in group T). The event-free rate in groups U and P was lower than in group T: 5-year event-free rates of 67.4% ± 8.2% in group U and 57.7% ± 10.9% in group P versus 95.0% ± 4.9% in group T (group T vs group U: P = .0011, group U vs group P: P = .96, group P vs group T: P = .0004). Cox regression analysis revealed that the false lumen status (patent or ulcer-like projections) (P = .029), maximum aortic diameter at onset (P < .0001), and patient age (P = .0069) were predictors of the late aortic events. CONCLUSIONS: In type B aortic dissection, a thrombosed false lumen with ulcer-like projections and a patent false lumen had an influence on late aortic dilation and late aortic events.

Surgical strategy for subepicardial aneurysm: two case reports.

Subepicardial aneurysm is a rare complication of acute myocardial infarction (AMI) and is associated with the risk of spontaneous rupture. We present two patients with subepicardial aneurysms detected after 1 day and 6 weeks after AMI. Both lesions were successfully treated by patch repair.

Hypothermic circulatory arrest: renal protection by atrial natriuretic peptide.

Moderate hypothermic circulatory arrest with selective cerebral perfusion has been developed for cerebral protection during thoracic aortic surgery. However, visceral organs, particularly the kidneys, suffer greater tissue damage under moderate hypothermic circulatory arrest, and acute renal failure after hypothermic circulatory arrest is an independent risk factor for early and late mortality. This study investigated whether atrial natriuretic peptide could prevent the reduction in renal perfusion and protect renal function after moderate hypothermic circulatory arrest. Twelve pigs cooled to 30 degrees C during cardiopulmonary bypass were randomly assigned to a peptide-treated group of 6 and a control group of 6. Moderate hypothermic circulatory arrest was induced for 60 min. Systemic arterial mean pressure and renal artery flow did not differ between groups during the study. However, renal medullary blood flow increased significantly in the peptide-treated group after hypothermic circulatory arrest. Myeloperoxidase activity was significantly reduced in the medulla of the peptide-treated group. Renal medullary ischemia after hypothermic circulatory arrest was ameliorated by atrial natriuretic peptide which increased medullary blood flow and reduced sodium reabsorption in the medulla. Atrial natriuretic peptide also reduced the release of an inflammatory marker after ischemia in renal tissue.

Mitral valve repair for infective endocarditis.

OBJECTIVE: This study investigated the feasibility of mitral valve (MV) repair in patients with active or healed infective endocarditis (IE) with mitral regurgitation and evaluated effects on left ventricular (LV) function and structure. METHODS: Subjects comprised 19 patients who underwent MV operations for IE between December 2004 and September 2007. MV repair was performed for acute IE in 10 of 15 patients (67%) and for healed IE in 4 of 4 patients (100%). RESULTS: No early or late postoperative deaths were encountered. One patient underwent redo MV repair owing to severe mitral regurgitation 1 month postoperatively. Postoperative echocardiography after MV repair demonstrated less than trivial (acute IE in seven, healed IE in three) or mild (acute IE in three, healed IE in one) mitral regurgitation. In patients with MV replacement, the postoperative left atrial dimension (LAD) was decreased (51.5 +/- 39.2 vs. 39.2 +/- 1.9 mm, P = 0.007); however LV end-diastolic dimension (LVDD) and LV end-systolic dimension were unchanged. In patients with MV repair, LVDD (57.5 +/- 6.5 vs. 46.0 +/- 5.6 mm, P < 0.001), LV end-systolic dimension (36.1 +/- 5.2 vs. 32.4 +/- 6.2 mm, P = 0.04), LAD (43.1 +/- 8.1 vs. 33.6 +/- 7.7 mm, P = 0.003) were reduced. Postoperative ejection fraction (55.3 +/- 13.5% vs. 41.8% +/- 10.0%, P = 0.03) and fraction shortening (30.1% +/- 9.2% vs. 20.7% +/- 5.5%, P = 0.03) were better in patients with MV repair than those with MV replacement. CONCLUSIONS: MV repair is feasible in patients with both active and healed IE. MV repair preserves better LV function and structure postoperatively.