The aortic knob index as a novel predictor of new-onset atrial fibrillation after off-pump coronary artery bypass grafting.

PURPOSE: To validate the predictive value of the aortic knob index for identifying new-onset postoperative atrial fibrillation (POAF) after off-pump coronary artery bypass grafting (OPCAB). METHODS: Among 156 patients who underwent isolated OPCAB, 138 consecutive patients without a history of atrial fibrillation were enrolled in this retrospective observational cohort study. The patients were divided into two groups based on the development of POAF. We compared the baseline clinical characteristics; preoperative radiographic characteristics of the aorta, including aortic knob measurements; and perioperative data, between the groups. Logistic regression analysis was performed to identify the predictors of new-onset POAF. RESULTS: New-onset POAF developed in 35 (25.4%) patients. Multivariate logistic regression analysis revealed that the aortic knob index was an independent predictor of POAF and yielded that the risk of POAF increased by 1.85 times when the aortic knob index increased by 0.1 (odds ratio, 1.853; confidence interval, 1.326-2.588; P < 0.001). Receiver operating characteristic analysis revealed that an aortic knob index of 1.364 constituted a cutoff value for new-onset POAF with 80.0% sensitivity and 65.0% specificity. CONCLUSIONS: The aortic knob index on preoperative chest radiography was a significant and independent predictor of new-onset POAF following OPCAB.

Abdominal Aortic Aneurysm with Essential Thrombocythemia: A Case Report Describing Perioperative Management in Open Surgery.

We report perioperative management and open surgery to treat a case of infrarenal abdominal aortic aneurysm with essential thrombocythemia (ET), a chronic myeloproliferative disorder associated with arterial or venous thrombosis, idiopathic bleeding, and heparin-resistant diathesis. Following careful preoperative management, including assessment of heparin resistance, open surgery was successfully performed to treat the aortic aneurysm of our patient. This report shows that optimal preparation for surgery is important to safely perform abdominal aortic aneurysm repair and prevent perioperative thrombosis and bleeding in patients with abdominal aortic aneurysm with ET.

Successful Management of Prolonged Thrombocytopenia After Surgery for Abdominal Aortic Aneurysm With Disseminated Intravascular Coagulation.

We report a case of an infrarenal abdominal aortic aneurysm that developed acute onset thrombocytopenia and disseminated intravascular coagulation (DIC) after a previous coronary artery bypass grafting. Open surgical intervention was successfully performed for the treatment of aortic aneurysm; however, thrombocytopenia and enhanced-fibrinolytic-type DIC were prolonged even after the surgery, and improved after Helicobacter pylori eradication therapy and medication with warfarin and oral tranexamic acid. Surgical intervention alone was not effective as a treatment for DIC associated with aortic aneurysm, and multidisciplinary management was necessary for the optimization of the coagulation and fibrinolytic systems, even after successful surgery.

Usefulness of Cardiovascular Magnetic Resonance Imaging in a Patient with Cardiac Involvement of Systemic Sclerosis.

A 72-year-old Japanese woman with systemic sclerosis was admitted to our hospital because of symptoms of heart failure. Cardiovascular magnetic resonance (CMR) imaging had shown that extensive myocardial fibrosis secondary to systemic sclerosis was the main cause of heart failure. One month after CMR, she had complete atrioventricular (AV) block. It was suggested that the progression of fibrosis to the AV node caused complete AV block. This case report has clinical implications in highlighting the fact that CMR is useful for not only evaluating the present pathophysiology but also predicting future adverse events in patients with systemic sclerosis.

Systolic anterior motion of the mitral valve associated with acute type A aortic dissection: a case report describing one-step surgery of ascending aortic replacement and interventricular septal myectomy.

BACKGROUND: Systolic anterior motion of the mitral valve associated with acute type A aortic dissection is rare in daily clinical practice. The prevention of systolic anterior motion is important, because once it occurs, the hemodynamics may become unstable, leading to a critical situation. In the surgical procedure to treat systolic anterior motion, the prevention of new iatrogenic aortic intimal tears is important in the context of acute type A aortic dissection. CASE PRESENTATION: We present a case of systolic anterior motion in a 68-year-old woman with an acute type A aortic dissection and suspected acute relative adrenal insufficiency. Preoperative transthoracic echocardiography revealed left ventricular outflow tract obstruction due to systolic anterior motion without left ventricular hypertrophy and interventricular septal bulging due to a narrow aorto-mitral angle. We successfully performed a one-step surgery for ascending aortic replacement and interventricular septal myectomy using the needle stick technique for the treatment of systolic anterior motion. CONCLUSIONS: Concomitant interventricular septal myectomy using the needle stick technique with thoracic aortic replacement is a safe and feasible technique. Interventricular septal myectomy may be effective in preventing postoperative unstable hemodynamics due to systolic anterior motion in the management of acute aortic dissection.

Double Inferior Vena Cava with Azygos Continuation and Retroaortic Left Renal Vein Associated with Juxtarenal Abdominal Aortic Aneurysm Surgery.

The combination of a double inferior vena cava (IVC), a retroaortic left renal vein, and azygos continuation of the IVC is extremely rare. Here we report the case of a 74-year-old man with this complex venous anomaly associated with a juxtarenal abdominal aortic aneurysm (AAA), who underwent a successful graft implantation with left renal artery reconstruction without injuring the retroaortic venous system. The venous anomaly was diagnosed using preoperative contrast-enhanced computed tomography (CT). Thus, contrast-enhanced CT can provide sufficient information on AAA and anomalous venous anatomy to avoid fatal complications during AAA surgery.

Removal of prostaglandin E2 and increased intraoperative blood pressure during modified ultrafiltration in pediatric cardiac surgery.

OBJECTIVE: We investigated the relationship between serum prostaglandin E(2) and intraoperative blood pressure in pediatric cardiac surgery with modified ultrafiltration. METHODS: In 35 consecutive patients (31.6 +/- 26.8 months, 0.4-111 months, 10.9 +/- 5.5 kg, 2.9-23.8 kg) who underwent cardiac surgery with modified ultrafiltration, we measured intraoperative serum prostaglandin E(2) changes and effluent prostaglandin E(2), assessed the relationship between serum prostaglandin E(2) and intraoperative hemodynamic parameters, and performed subset analyses to compare patients with low (<10 kg, n = 18) and high (>10 kg, n = 10) weights. RESULTS: During cardiopulmonary bypass, systolic blood pressure decreased from 80.8 +/- 15.2 to 60.5 +/- 11.3 mm Hg (P = .00000002979) and serum prostaglandin E(2) increased from 16.6 +/- 8.7 to 58.8 +/- 53.3 pg/mL (P = .002). During modified ultrafiltration, although central venous pressure and catecholamine dosage transited at the same levels, systolic blood pressure increased from 60.5 +/- 11.3 to 83.4 +/- 14.1 mm Hg (P = .00000002979) and serum prostaglandin E(2) decreased from 58.8 +/- 53.3 to 21.1 +/- 11.6 pg/mL (P = .001), with negative correlation between serum prostaglandin E(2) and systolic blood pressure (R = -0.392, P = .0000277723) and 15,700 +/- 10,700 pg (1790 +/- 2230 pg/kg) prostaglandin E(2) removed during modified ultrafiltration. Decrease in serum prostaglandin E(2) was significantly higher in low-weight patients (51.8 +/- 58.4 pg/mL) than in high-weight patients (15.7 +/- 30.1 pg/mL). CONCLUSION: Removal of prostaglandin E(2) is one reason for increased blood pressure during modified ultrafiltration, with the effect more marked in low-weight patients.

Molecular diagnosis of prosthetic valve endocarditis with aorto-right atrial fistula.

Definite diagnosis of infective endocarditis is impossible when all blood cultures are negative under antibiotic treatment. In this case, Streptococcus canis was identified using polymerase chain reaction from preoperative whole blood and excised valve tissue, and considered as the pathogen for infective endocarditis, despite negative blood cultures. This information was useful for diagnosis and selection of antibiotics.

Inhibition of platelet aggregation by combined therapy with aspirin and cilostazol after off-pump coronary artery bypass surgery.

BACKGROUND: Although off-pump coronary artery bypass (OPCAB) has become an increasingly common surgical procedure, recent concerns have been raised regarding the existence of a hypercoagulable or prothrombotic state associated with OPCAB. To determine the optimal antiplatelet regimen after OPCAB, we investigated the effects of aspirin alone and of combined therapy with aspirin + cilostazol on platelet aggregation in patients after OPCAB. MATERIAL AND METHODS: Twenty patients scheduled to undergo OPCAB were randomized to one of two antiplatelet regimens: aspirin alone (n=10) and aspirin + cilostazol (n=10). Anti-platelet agents had not been received for at least 1 week before surgery and were initiated on the afternoon of postoperative day 1. Platelet aggregability and hemostatic parameters were evaluated at four time points: before and 3, 7, and 14 days after OPCAB. We measured agonist-and shear stress-induced platelet aggregation (SIPA) using a modified cone-plate viscometer. RESULTS: No complications resulting from postoperative antiplatelet therapy-related bleeding were seen in either group. Collagen-and arachidonate-induced platelet aggregation and SIPA were significantly inhibited in the aspirin + cilostazol group compared with the aspirin-alone group (collagen-and arachidonate-induced aggregation, p<0.0001; SIPA, p=0.0367). Adding cilostazol to aspirin augmented the inhibitory effects on platelet aggregation induced by collagen and arachidonate. adenosine diphosphate (ADP)-induced platelet aggregation tended to be inhibited in the aspirin + cilostazol group compared with the aspirin-alone group (p=0.0534). CONCLUSION: The results of this study suggest that combined therapy with aspirin + cilostazol is more effective than aspirin monotherapy in reducing platelet aggregation in patients after OPCAB. This combination therapy may represent a new therapeutic option for an anti-thrombotic regimen in patients after OPCAB.

Locally applied cilostazol suppresses neointimal hyperplasia and medial thickening in a vein graft model.

BACKGROUND: Pathological changes in vein grafts begin immediately after arterial circulation is applied to the grafts. Chemical mediator stimulation and mechanical strain induce neointimal hyperplasia and medial thickening of the vein grafts, resulting in their failure. We investigated the inhibitory effect of locally applied cilostazol, an inhibitor of cyclic adenosine monophosphate phosphodiesterase III, on neointimal hyperplasia and medial thickening of the grafts. METHODS AND RESULTS: We established a distal anastomotic stricture model of femoral vein-abdominal aorta interposition grafting in rats. In this model, neointimal hyperplasia was observed not only at the distal anastomotic sites, but also in the graft body at postoperative day 14 and was markedly progressed at day 28. A strong expression of tenascin-C was found in the media and neointima of the graft body. In the grafts around which cilostazol was administered locally using Pluronic gel, neointimal hyperplasia was significantly suppressed compared with control grafts treated with the gel alone, with the mean neointimal cross-sectional area reduced by 87.1% for the graft body and by 78.9% for the distal anastomotic sites and mean medial cross-sectional area of the graft body reduced by 54.2% at day 28 versus the control. Cilostazol treatment decreased cell proliferation and the number of tenascin-C-producing cells seen by in situ hybridization, but the expression of tenascin-C protein was not suppressed. CONCLUSION: We concluded that a single perivascular application of cilostazol inhibits neointimal hyperplasia and medial thickening of vein grafts in a rat model.

Congenital pulmonary vein stenosis with anomalous pulmonary venous connection.

An 11-month-old boy with congenital pulmonary vein stenosis, partial anomalous pulmonary venous connection, and ventricular septal defect is described. Angiocardiography demonstrated stenosis between the right upper pulmonary vein and high superior vena cava and obstruction of the right lower pulmonary vein. For pulmonary vein stenosis, we performed transverse sutured plasty for the right upper pulmonary vein, followed by right lower lobectomy. In some patients, combined management for pulmonary vein stenosis is effective.

Tenascin-C synthesized in both donor grafts and recipients accelerates artery graft stenosis.

OBJECTIVE: Tenascin-C, an extracellular matrix glycoprotein, is thought to play an important role in neointimal hyperplasia of artery bypass grafts. In this study, the direct contribution of tenascin-C to neointimal hyperplasia of free artery grafts and the origin of tenascin-C-producing cells were examined using tenascin-C transgenic mice. METHODS AND RESULTS: Abdominal aorta-to-carotid artery interposition grafting was performed in mice. When grafts from wild-type mice were transplanted to wild-type, neointimal hyperplasia was observed in the grafts at days 14 and 28. Immunohistochemical staining showed strong expression of tenascin-C in the media and neointima of the grafts. Much less neointimal hyperplasia was seen when grafts from tenascin-C-deficient mice were transplanted to tenascin-C-deficient mice. In tenascin-C-deficient grafts transplanted to wild-type mice, tenascin-C deposition was observed only in the neointima. In the reverse combination, deposition was seen in the media and neointima. The source of the tenascin-C-producing cells was analyzed using heterozygous mice that identically express both tenascin-C and LacZ. While LacZ-positive cells were seen only in the neointima of artery grafts from wild-type transplanted to mutant mice, positive cells were detected in both the neointima and media in grafts from mutant to wild-type mice. CONCLUSIONS: We presented direct evidence that tenascin-C is a crucial molecule in neointimal hyperplasia in free artery grafts, and that tenascin-C-producing cells are derived from both donor grafts and recipients.

Temporary axillo-femoral bypass for abdominal aortic aneurysm repair in high risk patients.

Abdominal aortic aneurysm (AAA) is sometimes associated with coronary artery and valvular disease. We report the successful treatment of a 76-year-old woman diagnosed with an infrarenal AAA, associated with severe mitral regurgitation and double-vessel coronary artery disease. First, AAA repair, using temporary axillo-femoral bypasses on both sides was done. Second, after 77 days, we simultaneously undertook coronary artery bypass grafting (CABG) and mitral valve repair. This staged operation achieved an excellent result. This rarely used abdominal aortic surgical procedure contributed to minimizing variations in afterload, an important consideration in high risk cardiac patients.

Successful surgical treatment of Takayasu's arteritis associated with pyoderma gangrenosum.

Pyoderma gangrenosum is rarely associated with Takayasu's arteritis. We report the successful surgical treatment of a 34-year-old woman who was diagnosed with pyoderma gangrenosum associated with thoracic aortic aneurysm and dissection due to Takayasu's arteritis. She underwent graft replacement of the thoracic aortic aneurysm under cardiopulmonary bypass, with perioperative management using prednisolone and cyclosporine A. She has had no evidence of the development of skin lesions or the progression of Takayasu's arteritis.

Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years' experience.

BACKGROUND: Transluminal stent-graft placements (TSGPs) are a new, less invasive procedure now recognized as the choice for aortic disease repair. Treatment of aortic dissections with TSGPs has resulted in good early results, but the long-term results and changes in the false lumen have not been elucidated in detail. METHODS AND RESULTS: TSGPs were performed in 49 patients with primary tears in their descending aortas, and the follow-up period ranged from 4 months to 6 years. The patients were divided into 32 acute-onset and 17 chronic dissections; of the acute-onset cases, there were 15 Stanford type A retrograde dissections. Periodic enhanced spiral CT was conducted after TSGP. The false lumen in the ascending aorta in 14 (93%) of the Stanford type A cases was obliterated completely within 3 months. The CT study was continued for >2 years for 17 acute-onset dissection and 11 chronic dissection patients. The average false lumen diameters of the proximal, middle, and distal descending aorta before treatment were 15.9, 16.2, and 15.6 mm in the acute-onset dissection group and 28.1, 25.2, and 21.0 mm in the chronic dissection group, respectively. The false lumen diameters 2 years after treatment were 3.0, 3.7, and 3.1 mm in the acute-onset dissection group and 10.6, 10.5, and 11.9 mm in the chronic dissection group, respectively. Two years after TSGPs, the false lumen of the thoracic aorta totally disappeared in 76% of the acute-onset dissection group and 36% of the chronic dissection group. No cases showed rupture after TSGP. CONCLUSIONS: Complete obliteration of the false lumen is more likely in acute-onset cases than in chronic cases.

Successful surgical treatment for an adult case of double aortic arch.

We present the case of a 39-year-old male who had complaints of dysphagia and throat pain. Computed tomography (CT), 3 dimensional CT and aortography revealed a double aortic arch (Edwards type IA). The patient underwent exploration through a left-sided thoracotomy and the left arch was divided at the distal site of the left subclavian artery, which completely relieved the esophageal compression.