Transcatheter aortic valve implantation with pre-existing mitral valve prosthesis using cardiopulmonary bypass: A case report.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is rarely performed in patients with a pre-existing mitral valve prosthesis, which was excluded from the Placement of Aortic Transcatheter Valve trial. Cardiopulmonary bypass (CPB) can provide sufficient hemodynamic stability to facilitate safe implantation; specifically, we prefer using normothermic femoro-femoral CPB. Careful attention should be paid to determine the positional relationship between the two valves in such patients. PRESENTATION OF CASE: We present a case of transfemoral TAVI using femoro-femoral CPB in a 90-year-old female patient with a pre-existing bioprosthetic mitral valve. Baseline echocardiography revealed severe aortic valve stenosis; hence, emergency balloon valvuloplasty was performed. Three months later, elective TAVI was performed; subsequently, left ventricular ejection fraction reached 63 % without mitral valve regurgitation or stenosis. DISCUSSION: Despite the safety of TAVI using CPB in older patients, cannula insertion into peripheral vessels carries a high risk. CONCLUSION: As CPB can increase tissue invasion for a short duration, the safety of this procedure needs further validation.

[Re-operative Cardiac Surgery in Patients with Patent In Situ Coronary Artery Bypass Grafts].

BACKGROUND: Re-operative cardiac surgery after prior coronary artery bypass grafting( CABG), using in situ graft is a challenge. Technical difficulties regarding this procedure include risks of graft injury and myocardial protection. The conventional strategy involves re-sternotomy, dissection, and temporary occlusion of the in situ graft to prevent cardioplegia washout. However, the problem with this procedure is that injury to the in situ graft can result in catastrophic complications. METHODS: We reviewed 25 redo cases of patients who had prior CABG with patent in situ grafts. The in situ grafts were dissected and clamped in 18 (group C) patients, whereas in 7 (group U) patients, the in situ grafts were not dissected or clamped. All patients underwent re-sternotomy, aortic cross clamping and cardiac arrest with cardioplegia. Besides, myocardial protection was obtained using moderate hypothermia and systemic potassium injection in group U. RESULTS: There were no injuries to the in situ grafts in either group. The peak creatine kinase-MB values were not significantly different between the two groups. Postoperative ejection fraction was preserved in both groups. CONCLUSIONS: The simplified approach of no-clamping technique yielded safety and effectiveness for myocardial protection in redo cases for patients with prior CABG in the presence of patent in situ grafts.

Comparison of Outcomes and Complications Among Patients with Different Indications of Acute/Subacute Complicated Stanford Type B Aortic Dissection Treated by TEVAR: Data from the JaPanese REtrospective multicenter stuDy of ThoracIc Endovascular Aortic Repair for Complicated Type B Aortic Dissection (J-Predictive Study).

PURPOSE: To investigate the relationships between indications for thoracic endovascular aortic repair for acute/subacute complicated Stanford type B aortic dissection and clinical outcomes, and complications specific to thoracic endovascular aortic repair. MATERIAL AND METHODS: The J-predictive study retrospectively collected data of patients treated with thoracic endovascular aortic repair for complicated Stanford type B aortic dissection at 20 institutions from January 2012 to March 2017. From the database, those treated for acute/subacute complicated Stanford type B aortic dissection were extracted (n = 118; 96 men; average age, 66.1 years; standard deviation, ± 13) and classified into groups 1, 2, and 3 according to thoracic endovascular aortic repair indications (rupture, superior mesenteric artery malperfusion, and renal or lower extremity malperfusion, respectively). Primary and secondary measures were mortality (overall and aortic-related) and complications related to thoracic endovascular aortic repair, respectively. For each outcome, the risks of being in groups 1 and 2 were statistically compared with that of being in group 3 as a control using Fisher's exact test. RESULTS: Mortality rate (odds ratio, 5.22; 95% confidence interval [CI], 1.33-20.53) and prevalence of paraparesis/paraplegia (odds ratio, 30.46; confidence interval, 1.71-541.77) were higher in group 1 than in group 3. Compared to group 3, group 2 showed no statistically significant differences in mortality or complications related to thoracic endovascular aortic repair. CONCLUSIONS: Rupture as an indication for thoracic endovascular aortic repair for type B aortic dissection was more likely to result in worse mortality and high prevalence of spinal cord ischemia. LEVEL OF EVIDENCE: Level 4, Case series.

[Concomitant Transapical Transcatheter Aortic Valve Implantation and Coronary Artery Bypass Grafting via the Left Thoracotomy].

A 79-year-old man presented with progressive congestive heart failure symptom as a result of severe aortic stenosis. A rescue balloon aortic valvuloplasty was performed. After a transient improvement, computed tomographic scan revealed a porcelain aorta, and it showed a high risk for a surgical aortic valve replacement. Routine preoperative coronary angiography revealed tight stenosis of a proximal left anterior descending coronary artery. Percutaneous coronary intervention was performed unsuccessfully due to the severe calcification of the coronary artery. Therefore, a concomitant transapical transcatheter aortic valve implantation and coronary artery bypass grafting via the left thoracotomy was indicated. Under a veno-arterial extracorporeal circulatory support, we performed the transcatheter aortic valve implantation (TAVI) and coronary artery bypass grafting (CABG) successfully via a left thoracotomy. Even though the approach for TAVI is from fifth and CABG is from forth intercostal space respectively, it could be manipulated using the same skin incision. Concomitant TAVI and CABG via the left thoracotomy might be a reasonable and feasible option for the patients presented with severe aortic stenosis and coronary artery disease who are not eligible for conventional surgical solutions.

[Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis with Preexisting Mitral Prosthesis;Report of a Case].

An 81-year-old woman presented with progressive congestive heart failure. Seventeen years before, she had undergone mitral valve replacement with a mechanical prosthesis. Echocardiography revealed severe aortic stenosis with a depressed left ventricular ejection fraction of 32%.At first, rescue balloon aortic valvuloplasty (BAV) was performed. After transient improvement of symptoms, she was readmitted 2 months later with recurrence of severe congestive heart failure. Transcatheter aortic valve implantation (TAVI) with an Edwards Sapien valve was performed. During the procedure, BAV was performed to confirm that the balloon did not interfere the movement of the mechanical valve. Moreover, supported by a veno-arterial extracorporeal membrane oxygenation, we could prevent myocardial ischemia during rapid pacing and slowly deploy the valve in a precise position. TAVI can be safely and successfully performed in patients with a preexisting mechanical mitral prosthesis.

Bronchogenic cyst of the interatrial septum.

Although bronchogenic cysts are the most common primary mediastinal cysts, intracardiac bronchogenic cysts are extremely rare. We report a case of a bronchogenic cyst of the interatrial septum in a 42-year-old woman who presented with recent onset of dyspnea on exertion. Cardiac investigations including transthoracic echocardiography and computed tomography revealed a cystic homogeneous mass in the interatrial septum. The patient underwent surgical resection, and the resultant atrial septal defect was repaired using an autologous pericardial patch. Histopathological examination of the resected specimen revealed findings consistent with a benign bronchogenic cyst. Although bronchogenic cysts are extremely rare, they should be considered in the differential diagnoses of intracardiac tumors. Complete resection of bronchogenic cysts is recommended primarily for diagnostic and potentially therapeutic purposes.

Management of Renal Arteries in Conjunction with Thoracic Endovascular Aortic Repair for Complicated Stanford Type B Aortic Dissection: The Japanese Multicenter Study (J-Predictive Study).

Background Management of abdominal branches associated with Stanford type B aortic dissection is controversial without definite criteria for therapy after thoracic endovascular aortic repair (TEVAR). This is in part due to lack of data on natural history related to branch vessels and their relationship with the dissection flap, true lumen, and false lumen. Purpose To investigate the natural history of abdominal branches after TEVAR for type B aortic dissection and the relationship between renal artery anatomy and renal volume as a surrogate measure of perfusion. Materials and Methods This study included patients who underwent TEVAR for complicated type B dissection from January 2012 to March 2017 at 20 centers. Abdominal aortic branches were classified with following features: patency, branch vessel origin, and presence of extension of the aortic dissection into a branch (pattern 1, supplied by the true lumen without branch dissection; pattern 2, supplied by the true lumen with branch dissection, etc). The branch artery patterns before TEVAR were compared with those of the last follow-up CT (mean interval, 19.7 months) for spontaneous healing. Patients with one kidney supplied by pattern 1 and the other kidney by a different pattern were identified, and kidney volumes over the course were compared by using a simple linear regression model. Results Two hundred nine patients (mean age ± standard deviation, 66 years ± 13; 165 men and 44 women; median follow-up, 18 months) were included. Four hundred fifty-nine abdominal branches at the last follow-up were evaluable. Spontaneous healing of the dissected branch occurred in 63% (64 of 102) of pattern 2 branches. Regarding the other patterns, 6.5% (six of 93) of branches achieved spontaneous healing. In 79 patients, renal volumes decreased in kidneys with pattern 2 branches with more than 50% stenosis and branches supplied by the aortic false lumen (patterns 3 and 4) compared with contralateral kidneys supplied by pattern 1 (pattern 2 vs pattern 1: -16% ± 16 vs 0.10% ± 11, P = .002; patterns 3 and 4 vs pattern 1: -13% ± 14 vs 8.5% ± 14, P = .004). Conclusion Spontaneous healing occurs more frequently in dissected branches arising from the true lumen than in other branch patterns. Renal artery branches supplied by the aortic false lumen or a persistently dissected artery with greater than 50% stenosis are associated with significantly greater kidney volume loss. © RSNA, 2019 Online supplemental material is available for this article.

[Total Arch Replacement with Concomitant Thoracic Endovascular Aortic Repair Via the Ascending Aorta for Extended Thoracic Aneurysm;Report of a Case].

The patient was a 66 year-old male. Computed tomography (CT) angiography showed a huge aneurysm(120 mm) in the aortic arch and chronic type B aortic dissection(45 mm) in the descending aorta. Echocardiography showed patent ductus arteriosus( PDA). Because of pulmonary hypertension due to PDA, it was considered unacceptable to put him under general anesthesia twice. We performed thoracic endovascular aortic repair (TEVAR) via the ascending aorta and total arch replacement (TAR) simultaneously to prevent paraplegia. After establishment of cardiopulmonary bypass( CPB), a stent graft was inserted via the ascending aorta to cover the dissection site of descending aorta, the aorta was opened under circulatory arrest, and PDA was suture closed. Another stent graft whose two proximal rows of Z-stent was removed, was inserted to descending aorta via the ascending aorta landing on the previous stent graft. The proximal end of this stent graft was anastomosed to the distal end of the prosthetic arch graft and arch branches were reconstructed as usual. The postoperative course was uneventful.

Surgically cured paraneoplastic hypoglycemia associated with solitary fibrous tumor of the pleura: report of two cases.

Hypoglycemia is seldom seen in association with insulinomas, rare autoimmune diseases, and paraneoplastic situations. Paraneoplastic hypoglycemia is known as nonislet cell tumor-induced hypoglycemia (NICTH). It is also known that a solitary fibrous tumor of the pleura can cause NICTH and that surgical resection is crucial to the success of NICTH treatment.

Obturator foramen bypass for infective groin caused by closure device.

A 69-year-old man underwent carotid artery stenting through the right femoral artery with a percutaneous vascular closure device for hemostasis. Eleven days later, an infective femoral artery pseudoaneurysm was diagnosed by computed tomography. At surgery, a defect in the femoral artery was observed, corresponding to the remnants of the closure device. Removal of the foreign material, debridement, wound irrigation, and arterial patch plasty were performed, but the infection and leg ischemia did not improve. After several failed attempts to revascularize and control the infection, obturator foramen bypass was performed. The postoperative course was uneventful, indicating the usefulness of this procedure.

Endovascular Total Arch Repair Using In Situ Fenestration for Arch Aneurysm and Chronic Type A Dissection.

BACKGROUND: Total arch replacement and ascending aorta and arch replacement are the gold standard treatments for aortic arch aneurysm and are possible treatment strategies for chronic type A dissection, with good reported outcomes. However, because total arch replacement is extremely invasive, it can be difficult to perform in some patients. We designed an endovascular total arch repair procedure with the use of in situ fenestration and commercially available devices, and we present our initial experience. METHODS: Seven patients (chronic type A aortic dissection, n = 3; thoracic arch aneurysm, n = 4) who underwent endovascular total arch repair with the use of in situ fenestration thoracic endovascular aortic repair from a zone 0 landing were retrospectively analyzed. All the procedures were performed under general anesthesia and cardiopulmonary bypass. The triple branches were manually punctured in a retrograde manner with the use of an 18-gauge/30-cm needle or a 21-gauge aspiration needle, and all the branches were reconstructed with the use of stent grafts; balloon touch-up was performed if appropriate. RESULTS: The procedure was successful in 6 of the 7 patients; the remaining 1 patient additionally underwent an axillary-axillary artery bypass during the operation because the left subclavian artery was difficult to puncture. All the patients had an acceptable postoperative course, with no 30-day and in-hospital deaths. None of the patients had endoleaks, and all the patients exhibited a reduction in aneurysm diameter or thrombosed false lumen during a mean follow-up period of 17.6 months. CONCLUSIONS: Endovascular total arch repair with the use of in situ fenestration can be performed with commercially available devices with acceptable interim results.

[Surgical Treatment of Prosthetic Valve Endocarditis; Tips of Complete Resection of Infective Tissue and Valve Replacement].

Fifteen consecutive prosthetic valve endocarditis (PVE) patients were operated from March 2009 to September 2014. The average age of patients was 68 years ( range 49 to 82) and 7 patients were male. The interval between initial surgery and reoperation was 62.4 months(range 2.6 to 340.9). Seven of these cases(47%) developed PVE within the 1st year after surgery were defined as early PVE. All microorganisms isolated from blood cultures in early PVE were Staphylococcus species. Generally, the infective prosthetic valve was removed 1st, then all infective tissues were excised from the periannular cavity. A new prosthetic valve was replaced in supra-annular fashion. One patient who had a severe discontinuity between the most part of left ventricle and aorta necessitated a root replacement. One patient in aortic PVE, needed an additional patch-plasty of anterior mitral leaflet. The mean cardiopulmonary bypass and aortic clamping times were 250 minutes( range 132 to 426) and 165 minutes( range 117 to 309), respectively. Four patients needed permanent pacemaker implanted for complete A-V block. Five patients had transient acute renal failure, and 1 required dialysis could be weaned at 40 post operative day. Average postoperative hospital stay was 39 days (range 21 to 108), and the operative mortality was 0%. The postoperative follow up was 3.1 years( range 0.6 to 6.0), all patients were doing well without re-infection and heart failure except 1 patient died by non-cardiac disease.

Type IA endoleak embolization after TEVAR via direct transthoracic puncture.

We report the case of a 74-year-old man who developed type IA endoleak after endovascular thoracic aortic repair. The patient was admitted with expansion of the aneurysm after TEVAR, for additional therapy. Fluoroscopy and cone-beam computed tomography-guided direct transthoracic sac puncture and complete embolization of the endoleak channels with metal coils and glue were performed, and resulted in complete exclusion of the endoleak. One month after the coil embolization, the type IA endoleak was completely excluded, and the thoracic aneurysm had decreased in size.

[Effectiveness of Mitral Natural Folding Plasty for Minimally Invasive Cardiac Surgery Mitral Valve Plasty (MICS MVP)].

We performed 45 cases of Natural folding plasty without leaflet resection for degenerative mitral regurgitation (MR) between September 2005 and July 2014. Twenty cases of 45 were operated by right small intercostal approach (MICS). There was no operative mortality. No patient had greater than mild MR intraoperative transesophageal echocardiography. The median follow-up was 847 (19~1,747) days. One case needed a second pump run performed without complication. One patient had a reoperation performed for recurrent MR 20 months later. Natural folding plasty for degenerative MR with favorable long term out come in our results. This technique is simple and reproducible for most surgeons. Furthermore, with its simplicity and reversibility, we considered it to be suitable for MICS approach.

[Thoracic Endovascular Aortic Repair (TEVAR) Combined with Embolization Technique for Saccular Aortic Arch Aneurysm].

Many of saccular aortic arch aneurysms exist near left subclabian artery(LSA). The thoracic endovascular aneurysm repair( TEVAR) landing on zone 2 is a less invasive and suitable procedure for this type of aneurysm. However, there are several cases with the aneurysm located close to LSA necessitate landing TEVAR on zone 1 or zone 0, otherwise the aneurysm could not be sealed completely. And this procedure seems to increase the invasiveness. In order to complete the sealing of the aneurysm and also keep the less invasiveness, we performed TEVAR using an axillo-axillary bypass or simple occlusion of LSA followed by an embolization using metal coil and NBCA through the catheter which detained in the saccular aneurysm beforehand. We report our experience of seven cases have been successfully treated by this procedure with good results.

[Diffuse descending necrotizing mediastinitis with cardiac tamponade;report of a case].

Descending necrotizing mediastinitis( DNM) is often a lethal condition resulting from odontogenic or cervical infection, with a previously reported mortality rate of 25 to 40%, which is known to accompany occasional pericardial effusion. Here, we report a case of diffuse DNM with cardiac tamponade.

[Prevention of cerebral infarction in thoracic endovascular aneurysm repair(TEVAR) of distal aortic arch aneurysms; left subclavian artery balloon technique].

Thoracic endovascular aneurysm repair(TEVAR) has been applied more and more frequently to an atherosclerotic distal aortic arch aneurysm. Even if the procedure is successful, extensive cerebral infarction might occur, especially in the left vertebral artery area. We therefore devised a new method to prevent embolic events using a thrombectomy catheter with an end hole, which was placed at the origin of the letf subclavian artery via the radial artery. This simple left subclavian artery balloon technique not only prevents cerebral embolism in the left vertebral artery system, but also provides a position marker under X-ray, and enables tight compaction of the embolization coils.

Pulmonary artery sarcoma successfully treated by right pneumonectomy after definitive diagnosis.

Pulmonary artery sarcoma (PAS) is a rare and lethal neoplasm that is usually diagnosed during surgery or autopsy. Early diagnosis and radical surgical resection offer the only chance for survival. However, making a preoperative histopathological diagnosis is quite difficult. We encountered a 57-year-old woman presenting a PAS that mimicked a pulmonary thromboembolism. After confirming a definitive diagnosis using a catheter suction biopsy, we successfully performed a right pneumonectomy via a median sternotomy without cardiopulmonary bypass. Eighteen months after surgery, no recurrence was observed.