[The Long-term Results of Valve Sparing Aortic Root Replacement and Aortic Cusp Repair for Aortic Regurgitation].

We reported our long-term results of valve sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation( AR) were satisfactory. Three hundred twenty-seven patients had VSRR, and 164 patients of them had aortic cusp repair for prolapse. At 10 years after the operation, the overall survival was 91.5%, the freedom from more than mild recurrent AR was 71.2%, and the freedom from aortic valve reoperation was 82.0%. As for the aortic cusp repair technique, there was no significant difference in the mid-term results of the recurrent AR and reoperation for the aortic valve between the central plication technique and the resuspension technique (two layers of continuous mattress sutures placed the entire length of the free margin of the aortic cusp). The resuspension technique might be useful for repairing the aortic cusp with prolapse. Furthermore, among the patients with acute aortic dissection, connective tissue disease, or aortitis, the long-term results of VSRR and aortic cusp repair were also satisfactory.

[Repair of Traumatic Brachiocephalic Artery Pseudoaneurysm by Open Surgery:Report of a Case].

The patient is a 56-year-old man. He fell while playing golf and sustained a contusion on his right chest. He fell into hemorrhagic shock during surgery for a right clavicle fracture at a nearby hospital and required cardiac resuscitation. Computed tomography( CT) scan revealed left pneumothorax and right hemothorax, and a contrast-enhanced CT scan revealed a pseudoaneurysm at the brachiocephalic artery origin. He underwent surgery three weeks later. Surgery was performed through a median sternotomy and partial arch replacement (zone 2) with antegrade cerebral perfusion under moderate hypothermia. He was discharged on postoperative day 10 without significant complications.

Long-term Results of Valve-Sparing Aortic Root Replacement and Aortic Cusp Repair.

BACKGROUND: Long-term results of valve-sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation are unclear. METHODS: VSRR by reimplantation was performed in 363 patients. Tricuspid aortic valve (TAV) and bicuspid aortic valve were found in 285 and 71 patients, respectively. RESULTS: Aortic cusp repair was performed in 268 patients. Of patients with TAV 129 had central plication of the Arantius node, 36 had free margin resuspension, and 71 had reinforcement. Mean follow-up was 71.4 months. Among TAV patients freedom from aortic valve reoperation at 10 and 15 years was 85.1% and 78.3%, respectively. Freedom from aortic valve reoperation at 10 years was lower in patients with cusp prolapse than without (77.4% vs 93.2%, P = .007). The overall freedom from more than mild aortic regurgitation at 10 and 15 years was 72.4% and 64.0%, respectively. It was also significantly greater in patients without cusp prolapse (78.4% vs 67.7%, P = .02). As for the cusp repair technique the freedom from aortic valve reoperation at 10 years was significantly better in patients who underwent only resuspension or reinforcement techniques compared with patients who underwent only central plication technique (100% vs 72.8%, P = .008). CONCLUSIONS: Long-term results of VSRR with aortic cusp repair were satisfactory. The resuspension technique appears to be useful for repairing aortic cusp prolapse in patients with TAV.

Right heart failure caused by direct pressure of distal arch aneurysm.

We report a rare case of right heart failure caused by distal aortic aneurysm. Although aortopulmonary fistula is a common complication of giant aortic arch aneurysm, right heart failure caused by mechanical pressure by aneurysm is very rare. A 79-year-old female patient presented dyspnea. Contrast computed tomography (CT) of the thorax delineated a 78 mm aortic arch aneurysm pressing the main to left pulmonary artery and a 40 mm pericardial effusion at maximum depth at posterior side. Echocardiography showed the acceleration flow from main to left pulmonary artery and moderate pulmonary hypertension. Left ventricular function, however, was preserved. We diagnosed right heart failure caused by giant aortic arch aneurysm and performed emergency aortic arch aneurysm replacement. After the operation, pulmonary artery pressure decreased and right heart failure improved.

Long-Term Results of Crossover Bypass for Iliac Atherosclerotic Lesions in the Era of Endovascular Treatment: The Re-ACTION Study (Retrospective Assessment of Crossover Bypass as a Treatment for Iliac LesiONs).

Objective: The aim of this study was to elucidate the long-term results of crossover bypass (CB) for iliac atherosclerotic lesions in the era of endovascular treatment (EVT). Methods: A retrospective multicenter cohort study was performed. CB was performed in 242 patients between 2003 and 2014 by vascular surgeons at multiple medical centers in Japan. Results: Perioperative mortality was 1.7%. Primary patency rates were 86% at 5 years and 82% at 8 years. Univariate analysis showed that critical limb ischemia (Rutherford class 4-6), vein graft, and superficial femoral artery occlusion were significantly associated with low primary patency. In multivariate analysis, only critical limb ischemia influenced primary patency. The secondary patency rate was 87% at both 5 and 8 years. The limb salvage rate was 98% at both 5 and 8 years. The overall survival rates were 71% at 5 years and 49% at 8 years. Conclusion: The long-term results of CB were good in our study, compared with previous reports. Our results suggest that CB remains an option for the arterial reconstruction in unilateral iliac occlusive disease after EVT failed.

Feasibility of intraoperative water testing in aortic valve repair: Direct visualization from left ventricle with a videoscope.

OBJECTIVE: We describe a simple method to assess the aortic valve using a videoscope inserted in the left ventricle (LV-VS) during valve-sparing root replacement. The aim of this study was to evaluate the feasibility of this technique by comparing it with the findings of postoperative transesophageal echocardiography (TEE). METHODS: Thirty-six patients (29 male, mean age 45.4 ± 20.1 years) undergoing aortic root reimplantation were assessed intraoperatively with LV-VS. The LV-VS was inserted from the right upper pulmonary vein into the left ventricle and set toward the aortic valve. After completion of graft implantation, inspection was performed with LV-VS by pressurizing the neo-sinus before attachment of coronary arteries. Valve competency evaluated by LV-VS was compared with postoperative TEE findings, according to the group of cusp morphologies. Group 1 included 26 patients with tricuspid aortic valve, and group 2 included 9 patients with bicuspid aortic valve and 1 quadricuspid aortic valve. RESULTS: The grade of aortic regurgitation (AR) improved from 2.9 ± 1.6 preoperatively to 0.33 ± 0.6 postoperatively (P < .001 vs preoperatively). In 4 patients, LV-VS was used only before repair. In group 1, intraoperative LV-VS showed a competent valve in 20 and an incompetent valve in 3 patients, and postoperative TEE showed non/trivial AR in 15, mild AR in 5, and mild-to-moderate AR in 3 patients. In group 2, 9 patients achieved a competent valve on intraoperative LV-VS and non/trivial AR on postoperative TEE. CONCLUSIONS: Intraoperative direct inspection with LV-VS is a feasible method for confirming the completion of cusp repair.

[Thoracic Endovascular Aortic Repair Via Internal Iliac Artery Conduit].

A 77-year-old man with a history of stent implantation in the right common iliac artery(CIA) and the left external iliac artery(EIA) was admitted to our hospital for a rapid growth of an aneurysm( max 53 mm) at Th11 level of the descending aorta. Although thoracic endovascular aortic repair (TEVAR) was required, there were many problems about access rout. The infrarenal abdominal aorta and the left EIA were severely calcified, and the lumens of the right CIA stent(5.3 mm) and the left EIA stent( 4.3 mm) were small in size. Besides, the left CIA was short(13 mm). Therefore, TEVAR was performed by retrograde approach from the left internal iliac artery( IIA) with a tube graft conduit in the hybrid operation room. IIA is a useful option for an access rout in endovascular aortic repair.

[Two-staged Hybrid Repair for Extensive Aortic Aneurysm;Report of a Case].

A 74-year-old woman progressed to extensive aortic aneurysm after 2 years and 6 months from onset of type B dissection. A computed tomography scan revealed aortic aneurysm from ascending aorta to Th12 level of descending aorta. Her appearance was very frailty. Therefore, we performed 2-staged hybrid repair for this case. First, surgical total arch replacement with elephant trunk via median sternotomy was performed. On the 47th days after the 1st operation, thoracic endovascular aortic repair was performed. The spinal drainage was done for spinal cord protection. Postoperative course was uneventful without any complications. Considering a surgical stress, 2-staged hybrid repair using a stent graft was less-invasive than 1 staged graft replacement.

[Cor Triatriatum Diagnosed in Adulthood;Report of a Case].

A 64-years-old man had cor triatriatum (Lucas-Schmidt type I A) with severe mitral regurgitation and atrial fibrillation. We perfomed resection of the anomalous septum between the accessory chamber and left atrium, and conducted mitral annuloplasty and maze procedure. Arrhythmia were not encountered after surgery. The maze procedure and resection of the anomalous septum with mitral surgery proved to be effective for atrial fibrillation with cor triatriatum.

DSE-FRET: A new anticancer drug screening assay for DNA binding proteins.

Nuclear factor-κB (NF-κB) is a key regulator of cancer progression and the inflammatory effects of disease. To identify inhibitors of DNA binding to NF-κB, we developed a new homogeneous method for detection of sequence-specific DNA-binding proteins. This method, which we refer to as DSE-FRET, is based on two phenomena: protein-dependent blocking of spontaneous DNA strand exchange (DSE) between partially double-stranded DNA probes, and fluorescence resonance energy transfer (FRET). If a probe labeled with a fluorophore and quencher is mixed with a non-labeled probe in the absence of a target protein, strand exchange occurs between the probes and results in fluorescence elevation. In contrast, blocking of strand exchange by a target protein results in lower fluorescence intensity. Recombinant human NF-κB (p50) suppressed the fluorescence elevation of a specific probe in a concentration-dependent manner, but had no effect on a non-specific probe. Competitors bearing a NF-κB binding site restored fluorescence, and the degree of restoration was inversely correlated with the number of nucleotide substitutions within the NF-κB binding site of the competitor. Evaluation of two NF-κB inhibitors, Evans Blue and dehydroxymethylepoxyquinomicin ([-]-DHMEQ), was carried out using p50 and p52 (another form of NF-κB), and IC50 values were obtained. The DSE-FRET technique also detected the differential effect of (-)-DHMEQ on p50 and p52 inhibition. These data indicate that DSE-FRET can be used for high throughput screening of anticancer drugs targeted to DNA-binding proteins.

[Extended total arch replacement with coronary artery bypass grafting( CABG) via left thoracotomy;report of a case].

The operative procedure of extensive aortic aneurysm with ischemic coronary artery disease is controversial. We report a case of arch and descending thoracic aortic aneurysm replacement with coronary artery bypass grafting(CABG)via left thoracotomy. A 70-year-old man followed up by hepatic disease was diagnosed with expanding aortic thoracic aneurysm at the other hospital. He had admission to our hospital for surgical intervention. Computed tomography(CT)revealed arch and descending thoracic aortic aneurysm, and coronary arteriography (CAG) revealed #7 90% and #13 75% stenosis. We performed arch and descending thoracic aortic aneurysm replacement with CABG via left thoracotomy. Replaced synthetic graft and bypass grafts were patent on the postoperative CT. He was discharged at 15th postoperative day with no morbidity.

[Mitral valve repair for papillary muscle rupture; report of a case].

Papillary muscle rupture associated with acute myocardial infarction (AMI) is well known, but it's incidence is rare. We report a case of mitral valve repair with artificial chordae for partial papillary muscle rupture after AMI. A 75-year-old man underwent percutaneous coronary intervention(PCI) for right coronary artery because of AMI about 2 months ago at another hospital, and suffered from dyspnea 1 week after PCI. He had emergency admission to our hospital for cardiac failure. Echo-cardiogram revealed severe mitral regurgitation due to posterior papillary muscle rupture. We performed mitral valve repair with neochorda implantation to left ventricular wall of papillary muscle rupture site and ring annuloplasty. Mitral regurgitation was well controlled on postoperative echo-cardiogram. He was discharged at 25th postoperative day with no morbidity.

Extended replacement of the thoracic aorta.

OBJECTIVES: We present our experience of total aortic arch replacement. METHODS: Twenty-nine patients (21 males and 8 females; mean age 63.3 ± 13.3 years) with extended thoracic aortic aneurysms underwent graft replacement. The pathology of the diseased aorta was non-dissecting aneurysm in 11 patients, including one aortitis and aortic dissection in 18 patients (acute type A: one, chronic type A: 11, chronic type B: six). Five patients had Marfan syndrome. In their previous operation, two patients had undergone the Bentall procedure, three had endovascular stenting, one had aortic root replacement with valve sparing and 12 had hemi-arch replacement for acute type A dissection. Approaches to the aneurysm were as follows: posterolateral thoracotomy with rib-cross incision in 16, posterolateral thoracotomy extended to the retroperitoneal abdominal aorta in seven, mid-sternotomy and left pleurotomy in three, anterolateral thoracotomy with partial lower sternotomy in two and clam-shell incision in one patient. Extension of aortic replacement was performed from the aortic root to the descending aorta in 4, from the ascending aorta to the descending aorta in 17 and from the ascending to the abdominal aorta in eight patients. Arterial inflow for cardiopulmonary bypass consisted of the femoral artery in 15 patients, ascending aorta and femoral artery in seven, descending or abdominal aorta in five and ascending aorta in two. Venous drainage site was the femoral vein in 10, pulmonary artery in eight, right atrium in five, femoral artery with right atrium/pulmonary artery in four and pulmonary artery with right atrium in two patients. RESULTS: The operative mortality, 30-day mortality and hospital mortality was one (cardiac arrest due to aneurysm rupture), one (rupture of infected aneurysm) and one (brain contusion), respectively. Late mortality occurred in three patients due to pneumonia, ruptured residual aneurysm and intracranial bleeding. Actuarial survival at 5 years after the operations was 80.6 ± 9.0%. Freedom from the subsequent aortic events was 96.0 ± 3.9% at 5 years. CONCLUSIONS: Our treatment method for extensive thoracic aneurysms achieved satisfactory results using specific strategies and appropriate organ protection according to the aneurysm extension in the selected patients.

Effect of atherothrombotic aorta on outcomes of total aortic arch replacement.

OBJECTIVE: The effect of an atherothrombotic aorta on the short- and long-term outcomes of total aortic arch replacement, including postoperative neurologic deficits, remains unknown. We evaluated this relationship and also elucidated the synergistic effect of multiple other risk factors, in addition to an atherothrombotic aorta, on the neurologic outcome. METHODS: A group of 179 consecutive patients undergoing total aortic arch replacement were studied. An atherothrombotic aorta was present in 34 patients (19%), more than moderate leukoaraiosis in 71 (39.7%), and significant extracranial carotid artery stenosis in 27 (15.1%). In-hospital deaths occurred in 2 patients, 1 (2.9%) of 34 patients with and 1 (0.7%) of 145 patients without an atherothrombotic aorta (P = .26). Permanent neurologic deficits occurred in 4 (2.2%) and transient neurologic deficits in 17 (9.5%) patients. Multivariate analysis demonstrated that the risk factors for transient neurologic deficits were an atherothrombotic aorta (odds ratio, 4.4), extracranial carotid artery stenosis (odds ratio, 5.5), moderate/severe leukoaraiosis (odds ratio, 3.6), and cardiopulmonary bypass time (odds ratio, 1.02). To calculate the probability of transient neurologic deficits, the following equation was derived: probability of transient neurologic deficits = {1 + exp [7.276 - 1.489 (atherothrombotic aorta) - 1.285 (leukoaraiosis) - 1.701 (extracranial carotid artery stenosis) - 0.017 (cardiopulmonary bypass time)]}(-1). An exponential increase occurred in the probability of transient neurologic deficits with presence of an atherothrombotic aorta and other risk factors in relation to the cardiopulmonary bypass time. Survival at 3 years after surgery was significantly reduced in patients with vs without an atherothrombotic aorta (75.0% ± 8.8% vs 89.2% ± 3.1%, P = .01). CONCLUSIONS: Patients with an atherothrombotic aorta and associated preoperative comorbidities might be predisposed to adverse short- and long-term outcomes, including transient neurologic deficits.

Early and late results of graft replacement for dissecting aneurysm of thoracoabdominal aorta in patients with Marfan syndrome.

BACKGROUND: When treating dissecting aneurysm of the thoracoabdominal aorta surgically in patients with Marfan syndrome, we have usually performed graft replacement- including the entire thoracoabdominal aorta and reconstruction of all visceral branches, even if dilatation is mild in some segments-to avoid further aortic operations in the follow-up period. METHODS: From October 1999 through July 2011, 20 consecutive patients with Marfan syndrome underwent repair of dissecting aneurysm of the thoracoabdominal aorta (median age, 45 years; range, 19-65 years). All patients underwent surgical intervention with cerebrospinal fluid (CSF) drainage and distal aortic and selective organ perfusion. Deep hypothermia was used in 13 patients for spinal cord protection. RESULTS: No in-hospital mortality was observed. One patient had temporary spinal cord ischemia but was fully recovered by discharge. Other complications included exploration for bleeding (n=1), prolonged ventilation (n=1), and graft infection (n=1). At a mean follow-up of 54 months (range, 9-129 months), 1 patient had died of interstitial pneumonia at 38 months postoperatively. Survival at 8% years was 91.2±9.0%. Two patients required additional aortic procedures (total arch replacement and aortic valve-sparing surgery). Actuarial rate of freedom from aortic operations at 8 years was 83.9%±10.5%, but no patient needed required repeated thoracotomy for an aortic procedure. Neither false nor patch aneurysms were observed using computed tomography (CT) during follow-up surveillance. CONCLUSIONS: Graft replacement for dissecting aneurysm of the thoracoabdominal aorta in Marfan syndrome offers good early and long-term results. We believe total aortic replacement including the entire thoracoabdominal aorta and reconstruction of all visceral arteries should be recommended for selected patients with Marfan syndrome.

Short and midterm outcomes of elective total aortic arch replacement combined with coronary artery bypass grafting.

BACKGROUND: This study was performed to investigate the early and late outcomes of total aortic arch replacement (TAR) with or without coronary artery bypass grafting (CABG). METHODS: From October 1999 to December 2010, 200 consecutive patients underwent elective TAR for nondissecting aneurysm through a median sternotomy. Of this number, 131 (65.5%) had isolated TAR (TAR group) and 69 (34.5%) underwent concomitant CABG (TAR/CABG group). Patients in the TAR/CABG group were older and had more advanced chronic kidney disease and higher additive/logistic European System for Cardiac Operative Risk Evaluation and Japan scores than patients in the TAR group. RESULTS: Overall 30-day mortality was 0.5% (1 of 200) and hospital mortality was 3.5% (7 of 200). Hospital mortality was 1.5% (2 of 131) in the TAR group and 7.2% (5 of 69) in the TAR/CABG group (p=0.036). Multivariate analysis showed that operation time (odds ratio [OR] 1.01, p=0.013) was a risk factor for hospital mortality, but failed to demonstrate concomitant CABG as a risk factor. Cox proportional hazard analysis showed that age (OR 1.08, p=0.05), female sex (OR 3.58, p=0.0004), chronic kidney disease (OR 7.70, p<0.0001), and operation time (OR 1.01, p=0.0002) were risk factors for midterm mortality, whereas concomitant CABG was not (OR 0.92, p=0.87). There was a significant difference in midterm survival and freedom from major cerebrocardiovascular events in the TAR group versus the TAR/CABG group. CONCLUSIONS: Concomitant CABG was not a risk factor for hospital morality with TAR. However, patients with concomitant CABG have more preoperative comorbidities, which may adversely affect outcomes, and which may therefore deserve special attention.

[Repair versus replacement of mitral valve for treating severe functional mitral regurgitation].

BACKGROUND: The purpose of this study is to compare mitral valve replacement (MVR) to anuloplasty (MAP) in patients with severe functional mitral regurgitation (FMR). METHODS: Data of 43 patients with significant chronic FMR who underwent mitral valve operations from November 1999 through May 2011 were retrospectively analyzed. This reference group included patients who underwent MVR (n = 18) and MAP (undersized restrictive annuloplasty, n = 25). The mitral valve is replaced sparing the continuity between mitral valve and subvalvular apparatus. All patients had severe FMR, and 71.4% had New York Heart Association (NYHA) III or IV symptoms of heart failure, and 20% had preoperative intraaortic balloon pumping (IABP) insertion. The MVR group had significantly higher risk patients with complex jet and advanced coaptation depth (13.3 +/- 2.1 versus 11.1 +/- 2.3 mm, p = 0.04). RESULTS: Hospital mortality was 9.3%. No statistical difference was found between the 2 groups in term of intraoperative data. Kaplan-Meier survival estimates at 1, 5 years was 82.6, 72.3% in MVR group, and 77.8, 69.7% in MAP group (p = 0.98). Freedom from Cardiac-related event at 5 years was 62.7% for MVR compared to 56.8 % for MAP (p = 0.75). At the last follow-up, recurrence of MR II or greater was present in 4 (14.8%) patients in the MAP group and only one patient required re-operation because of worsening heart failure. In multivariable analysis, independent predictor of increased cardiac-related event was associated with residual pulmonary hypertension (HR, 3.0: p = 0.021). CONCLUSIONS: In high-risk patients with severe FMR. MVR seems to be a reasonable option.

Aortic regurgitation after valve-sparing aortic root replacement: modes of failure.

BACKGROUND: Despite the positive clinical results of valve-sparing aortic root replacement, little is known about the causes of reoperations and the modes of failure. METHODS: From October 1999 to June 2010, 101 patients underwent valve-sparing aortic root replacement using the David reimplantation technique. The definition of aortic root repair failure included the following: (1) intraoperative conversion to the Bentall procedure; (2) reoperation performed because of aortic regurgitation; and (3) aortic regurgitation equal to or greater than a moderate degree at the follow-up. Sixteen patients were considered to have repair failure. Three patients required intraoperative conversion to valve replacement, 3 required reoperation within 3 months, and another 8 required reoperation during postoperative follow-up. At initial surgery 5 patients had moderate to severe aortic regurgitation, 6 patients had acute aortic dissections, 3 had Marfan syndrome, 2 had status post Ross operations, 3 had bicuspid aortic valves, and 1 had aortitis. Five patients had undergone cusp repair, including Arantius plication in 3 and plication at the commissure in 2. RESULTS: The causes of early failure in 6 patients included cusp perforation (3), cusp prolapse (3), and severe hemolysis (1). The causes of late failure in 10 patients included cusp prolapse (4), commissure dehiscence (3), torn cusp (2), and cusp retraction (1). Patients had valve replacements at a mean of 23 ± 20.9 months after reimplantation and survived. CONCLUSIONS: Causes of early failure after valve-sparing root replacement included technical failure, cusp lesions, and steep learning curve. Late failure was caused by aortic root wall degeneration due to gelatin-resorcin-formalin glue, cusp degeneration, or progression of cusp prolapse.

Left atrial extension of metastatic lung tumor via pulmonary vein: report on the first case of Ewing sarcoma.

Extension of metastatic lung tumors into the left atrium via pulmonary veins is rare. Here, we report the first case of Ewing sarcoma exhibiting such extension. A 31-year-old man with pulmonary metastasis from Ewing sarcoma presented with a mass in the left lung, extending to the left atrium through the left inferior pulmonary vein. As the patient was considered to be at risk of tumor embolism, the mass was excised surgically.