Coronary Artery Bypass Grafting for a Young Female Patient With Chronic Active Epstein-Barr Virus Infection.

A 24-year-old woman with chronic active Epstein-Barr virus (CAEBV) infection successfully underwent coronary artery bypass grafting for triple coronary arteries with chronic total occlusion and aneurysms. This case underscores the importance of accurate assessment and treatment of coronary artery lesions in patients with CAEBV infection.

Right Ventricular Dysfunction in Patients With Concomitant Tricuspid Regurgitation Undergoing Transcatheter Aortic Valve Implantation.

BACKGROUND: This study investigated the impact and predictive factors of concomitant significant tricuspid regurgitation (TR) and evaluated the roles of right ventricle (RV) function and the etiology of TR in the clinical outcomes of patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).Methods and Results: We assessed grading of TR severity, TR etiology, and RV function in pre- and post-TAVI transthoracic echocardiograms for 678 patients at Keio University School of Medicine. TR etiology was divided into 3 groups: primary TR, ventricular functional TR (FTR), and atrial FTR. The primary outcomes were all-cause and cardiovascular death. At baseline, moderate or greater TR was found in 55 (8%) patients and, after adjustment for comorbidities, was associated with increased all-cause death (hazard ratio [HR] 2.11; 95% confidence interval [CI] 1.19-3.77; P=0.011) and cardiovascular death (HR 2.29; 95% CI 1.06-4.99; P=0.036). RV dysfunction (RVD) also remained an independent predictor of cardiovascular death (HR 2.06; 95% CI 1.03-4.14; P=0.042). Among the TR etiology groups, patients with ventricular FTR had the lowest survival rate (P<0.001). Patients with persistent RVD after TAVI had a higher risk of cardiovascular death than those with a normal or recovered RV function (P<0.001). CONCLUSIONS: The etiology of TR and RV function play an important role in predicting outcomes in concomitant TR patients undergoing TAVI.

Natural History of Leaflet Thrombosis After Transcatheter Aortic Valve Replacement: A 5-Year Follow-Up Study.

Background Subclinical leaflet thrombosis, characterized by hypoattenuated leaflet thickening (HALT) on multidetector computed tomography, is common after transcatheter aortic valve replacement (TAVR). Because little is known about the long-term natural history of subclinical HALT, we aimed to investigate this in patients who underwent TAVR without using additional anticoagulation. Methods and Results We retrospectively evaluated patients who underwent TAVR with the Edwards SAPIEN-XT at our institute between October 2013 and December 2015. Patients were grouped according to the presence or absence of HALT within 1 year after TAVR (HALT and No-HALT groups). The primary outcome, defined as the composite of all-cause mortality, heart failure readmission, and ischemic stroke, was compared. Valve performance was assessed over time by transthoracic echocardiography. Among 124 patients (men: 29.1%; median age, 85 years), 27 (21.8%) showed HALT on multidetector computed tomography within 1 year after TAVR. No patient required additional anticoagulation for treating HALT because of the absence of valve-related symptomatic deterioration. During the median follow-up period of 4.7 years (interquartile range, 4.0-5.6), the rate of primary outcome and valve performance was not statistically different between the 2 groups (37.0% versus 38.1%; log-rank test P=0.92; mean pressure gradient, 9 mm Hg [8-14 mm Hg] versus 10 mm Hg [7-15 mm Hg]; P=0.51, respectively). Conclusions Approximately 20% of patients after TAVR had HALT within 1 year; however, that did not change the risk of subsequent adverse cardiovascular events or the valve performance with statistical significance for up to 5 years despite no additional anticoagulation therapy.

Outcomes of pulmonary valve replacement using a bioprosthetic valve and polytetrafluoroethylene bicuspid valve for pulmonary valve regurgitation after intracardiac repair of tetralogy of Fallot.

BACKGROUND: Excellent results have been reported regarding pulmonary valve replacement (PVR) for pulmonary valve regurgitation (PR) after intracardiac repair (ICR) in patients with tetralogy of Fallot (TOF). However, there are apparently no reports comparing the following procedures: PVR using a bioprosthetic valve and PVR using a polytetrafluoroethylene (PTFE) bicuspid valve. Herein, we retrospectively analyzed the outcomes of PVR for PR after ICR of TOF in our institution and assessed which of the two PVR procedures was better. METHODS: From June 2008 to December 2017, we performed PVR for PR after ICR of TOF in 34 patients. Patients with the right ventricle to the pulmonary artery conduits were excluded. Preoperative and postoperative cardiac magnetic resonance imagings (cMRIs) were performed in all patients. The patients were divided into the bioprosthetic valve group (BV group, n = 17) and the PTFE bicuspid valve group (PTFE group, n = 17). RESULTS: There were no significant differences in the preoperative cMRI data and perioperative factors between the two groups. There were no deaths in either group. Postoperative cMRI showed that the PR fraction and the right ventricular end-diastolic volume index (RVEDVI)/left ventricular end-diastolic volume index ratio were significantly improved in both groups. However, RVEDVI was significantly improved only in the BV group. Re-PVR was required in four patients in the PTFE group. CONCLUSION: PVR using a bioprosthetic valve was more effective for PR treatment after ICR of TOF than PVR using a PTFE bicuspid valve.

Saphenous vein valve assessment utilizing upright CT to potentially improve graft assessment for bypass surgery.

Saphenous veins (SVs) are frequently employed as bypass grafts. The SV graft failure is predominantly seen at the valve site. Avoiding valves during vein harvest would help reduce graft failure. We endeavored to detect SV valves, tributaries, and vessel size employing upright computed tomography (CT) for the raw cadaver venous samples and in healthy volunteers. Five cadaver legs were scanned. Anatomical analysis showed 3.0 (IQR: 2.0-3.0) valves and 13.50 (IQR: 10.00-16.25) tributaries. The upright CT completely detected, compared to 2.0 (IQR: 1.5-2.5, p = 0.06) valves and 9.5 (IQR: 7.5-13.0, p = 0.13) tributaries by supine CT. From a total of 190 volunteers, 138 (men:75, women:63) were included. The number of valves from the SF junction to 35 cm were significantly higher in upright CT than in supine CT bilaterally [upright vs. supine, Right: 4 (IQR: 3-5) vs. 2 (IQR:1-2), p < 0.0001, Left: 4 (IQR: 3-5) vs. 2 (IQR: 1-2), p < 0.0001]. The number of tributaries and vessel areas per leg were also higher for upright compared with supine CT. Upright CT enables non-invasive detection of SV valves, tributaries, and vessel size. Although not tested here, it is expected that upright CT may potentially improve graft assessment for bypass surgery.

Intramyocardial Transplantation of Human iPS Cell-Derived Cardiac Spheroids Improves Cardiac Function in Heart Failure Animals.

The severe shortage of donor hearts hampered the cardiac transplantation to patients with advanced heart failure. Therefore, cardiac regenerative therapies are eagerly awaited as a substitution. Human induced pluripotent stem cells (hiPSCs) are realistic cell source for regenerative cardiomyocytes. The hiPSC-derived cardiomyocytes are highly expected to help the recovery of heart. Avoidance of teratoma formation and large-scale culture of cardiomyocytes are definitely necessary for clinical setting. The combination of pure cardiac spheroids and gelatin hydrogel succeeded to recover reduced ejection fraction. The feasible transplantation strategy including transplantation device for regenerative cardiomyocytes are established in this study.

Dysphagia Aortica Caused by Congenitally Angulated Descending Aorta.

Dysphagia aortica is a rare pathology primarily caused by an aortic aneurysm or Kommerrell's diverticulum. Herein, we describe an extremely rare case of dysphagia aortica due to a congenitally angulated descending aorta in a 50-year-old woman successfully treated by open surgery. The woman underwent David procedure for aortic regurgitation 5 years previously, with the same anatomy of an angulated descending aorta without symptoms. She has difficulty in swallowing solid food from 1 month. Total aortic arch replacement using the elephant trunk technique and secondary descending aortic replacement released the esophageal compression by the abnormal aorta and completely improved her symptom.

No-touch saphenous vein graft harvesting technique for coronary artery bypass grafting.

OBJECTIVES: Although the patency of internal artery grafts in coronary artery bypass grafting (CABG) is superior to that of saphenous vein grafts (SVGs), good long-term patency rates have been reported with SVGs harvested using the no-touch technique. Here, we report the early results of CABG with no-touch SVGs (NT-SVGs) along with the precautions required while handling these grafts. METHODS: This retrospective study included 41 patients who underwent CABG with NT-SVGs between May 2016 and March 2018. NT-SVGs were harvested with minimal electric scalpel use, and post-harvesting vascular overdilation with a syringe was not performed. Blood with heparinized saline was used to prevent vascular endothelial damage. A drain was inserted into the SVG harvest site, which was closed with a single interrupted suture, and elasticated bandage and compression stockings were used to prevent fluid retention and avoid delayed wound healing. RESULTS: There was no case of postoperative thoracotomy due to bleeding or myocardial infarction, and postoperative graft assessment confirmed graft patency in all patients, with a little mismatch between the diameters of SVG and the anastomotic vessel. Delayed wound healing at the graft harvest site seemed to improve after introducing the above procedures. CONCLUSIONS: Early results of CABG with NT-SVGs were good. Some precautions must be taken during harvesting and anastomosis. Taking precautions described in this study may help reduce the risk of perioperative complications and make the no-touch technique the standard procedure for harvesting SVGs for CABG.

Superior trans-septal approach for minimally invasive mitral valve surgery via right small thoracotomy.

Minimally invasive mitral valve surgery (MIMVS), despite its challenges, is not a rare procedure. However, MIMVS via a right small thoracotomy must be performed using long-shafted surgical instruments and thoracotomy instruments specialized for minimally invasive cardiac surgeries. We have performed 12 cases of MIMVS via right small thoracotomy using the superior trans-septal approach and secured a surgical visual field that easily allows a finger to reach the mitral valve annulus without using special instruments for minimally invasive cardiac surgery. We named this technique the "drawer-case technique." In conclusion, MIMVS via right thoracotomy using the superior trans-septal approach can be performed easily and safely, similar to mitral valve surgery performed via median sternotomy.

Multiple papillary fibroelastomas attached to left ventricular side and aortic side of the aortic valve: A report of new case and literature review.

The aortic valve (AV) is the most commonly affected site in multiple papillary fibroelastomas, but the frequency of embolism caused by the attachment side of the AV has not been elucidated. According to the review of the previous literature, 16 cases have been found attached to the AV. Of these, 6 of these have been found to be attached on the aortic side and 4 on the left ventricular side, 1 was bilateral, and 5 cases were unknown. Of the cases found on the aortic side, embolism occurred in 3 of them, and of the left ventricular side cases, embolism occurred in 2 of them. The frequency of embolism is equivalent even if papillary fibroelastoma attached to either side of the AV.

Development of a transplant injection device for optimal distribution and retention of human induced pluripotent stem cell‒derived cardiomyocytes.

BACKGROUND: Induced pluripotent stem cell (iPSC)‒based regenerative therapy is a promising strategy for cardiovascular disease treatment; however, the method is limited by the myocardial retention of grafted iPSCs. Thus, an injection protocol that efficiently introduces and retains human iPSC-derived cardiomyocytes (hiPSC-CMs) within the myocardium is urgently needed. The objective of the present study was to develop a method to improve the retention of hiPSCs in the myocardium for cardiac therapy. METHODS: We efficiently produced hiPSC-CM spheroids in 3-dimensional (3D) culture using microwell plates, and developed an injection device for optimal 3D distribution of the spheroids in the myocardial layer. Device biocompatibility was assessed with purified hiPSC-CM spheroids. Device effectiveness was evaluated in 10- to 15-month-old farm pigs (n = 15) and 5- to 24-month-old micro-minipigs (n = 20). The pigs were euthanized after injection, and tissues were harvested for retention and histologic analysis. RESULTS: We demonstrated an injection device for direct intramyocardial transplantation of hiPSC-CM spheroids from large-scale culture. The device had no detrimental effects on cell viability, spheroid shape, or size. Direct epicardial injection of spheroids mixed with gelatin hydrogel into beating porcine hearts using this device resulted in better distribution and retention of transplanted spheroids in a layer within the myocardium than did conventional needle injection procedures. CONCLUSIONS: The combination of the newly developed transplant device and spheroid formation promotes the retention of transplanted CMs. These findings support the clinical application of hiPSC-CM spheroid‒based cardiac regenerative therapy in patients with heart failure.

Midterm Results of 2-Stage Hybrid Arch Repair for Extensive Aortic Arch Aneurysms.

BACKGROUND: This report evaluated the perioperative and midterm results of the 2-stage hybrid arch procedure. This procedure involves total arch replacement with an elephant trunk as the first stage and thoracic endovascular aortic repair as the second stage for patients with extended aortic arch pathology. METHODS: Between April 2010 and April 2017, 55 consecutive patients (age, 74.2 ± 6.4 years) with extended aortic arch atherosclerotic pathology involving the aortic arch and descending aorta underwent first-stage total arch replacement with the elephant trunk procedure. The second stage was completed for 53 (96.4%) of the 55 patients. The mean duration between the 2 procedures was 2.4 ± 2.2 months. Postoperative follow-up was completed after a mean of 36.6 ± 24.9 months. RESULTS: The in-hospital mortality rate for the first stage was 0%. Two patients died during the interval between surgeries. The in-hospital mortality rate for the second stage was 0%. Two (3.6%) of the 55 first-stage patients and none of the 53 second-stage patients experienced a postoperative stroke. No spinal cord dysfunction occurred during the first-stage and second-stage procedures. The 3- and 5-year survival rates were 88.2% and 67.0%, respectively. The 5-year thoracic aortic intervention-free rate was 95.5%. CONCLUSIONS: Extended aortic arch aneurysms were repaired using a 2-stage hybrid arch repair. Perioperative mortality and midterm results were acceptable. Use of an elephant trunk provided a secure landing zone for thoracic endovascular aneurysm repair. This 2-stage hybrid procedure is an alternative approach to extended aortic arch pathology.

Preserved Vasoconstriction and Relaxation of Saphenous Vein Grafts Obtained by a No-Touch Technique for Coronary Artery Bypass Grafting.

BACKGROUND: To obtain a saphenous vein graft (SVG) for coronary artery bypass grafting (CABG), the benefit of using a no-touch (NT) technique in vascular function has not been fully investigated. Methods and Results: The pathological and physiological functions of human SVGs with a NT technique to preserve the perivascular adipose tissue (PVAT) and ones obtained by using a conventional (CON) technique removing PVAT, were examined. Immunohistochemistry of the section of SVGs showed that the phosphorylation of endothelial nitric oxide synthase in the endothelium of the NT group was more responsive to vascular endothelial growth factor. A myograph of SVGs showed greater contraction with phenylephrine in the NT group. However, the strong contraction was eliminated in SVGs taken by electrocautery. In the 10 patients whose SVGs were taken without electrocautery, endothelial-dependent relaxation with bradykinin was apparently increased in the CON group more than in the NT group. Smooth muscle relaxation with nitroprusside was higher in the CON group at the lower concentrations; however, the relaxation became greater in the NT group at the high concentrations. Therefore, the effect of neutralizing PVAT-released factors in the both groups was further examined. After medium of NT and CON were exchanged in half, relaxation of SVGs was immediately restored in the NT group. CONCLUSIONS: The results suggest that the NT technique preserves the functions of vasoconstriction and relaxation. Also, the presence of PVAT-released vasoconstrictive factors was suspected.

Stonehenge technique is associated with faster aortic clamp time in group of minimally invasive aortic valve replacement via right infra-axillary thoracotomy.

BACKGROUND: Trans-right axillary aortic valve replacement (TAX-AVR) remains uncommon. We developed a special method to pull the heart closer to the right chest wall to make the surgery as easy and safe as aortic valve replacement via median sternotomy. Because the retraction sutures lifting the ascending aorta and aortic root are arranged circularly around the wound, we named this technique "Stonehenge technique". METHODS: We examined 47 patients who underwent aortic valve replacement through a small right infra-axillary thoracotomy as the initial surgical therapy. These patients were divided into two groups: the conventional TAX-AVR group that underwent AVR via the conventional small right axillary incision approach (n = 20) and the TAX-AVR with SH group that underwent AVR with the Stonehenge technique (n = 27). RESULTS: The aortic cross-clamp and the extracorporeal circulation time were significantly shorter in the TAX-AVR with SH group than in the conventional TAX-AVR group (conventional TAX-AVR group: 125.5 ± 47.9; TAX-AVR with SH group: 96.0 ± 14.0, p = 0.004, and conventional TAX-AVR group: 163.8 ± 55.9; TAX-AVR with SH group: 140.0 ± 16.8, p = 0.04). CONCLUSION: The outcomes of this technique depend on the site of the retraction sutures in the opened pericardium, direction of pull, amount of force applied, and precautions taken. If performed correctly, the ascending aorta and the root can be pulled from the wound to within the surgeon's fingers' reach, thereby reducing aortic cross-clamp and extracorporeal circulation times in group of minimally invasive aortic valve replacement via right infra-axillary thoracotomy.

Causes of repair failure for degenerative mitral valve disease and reoperation outcomes.

OBJECTIVES: This study aimed to evaluate the causes of initial mitral valve (MV) repair failure, the details of reoperation and the long-term outcomes of mitral valve re-repair (Re-MVP). METHODS: We retrospectively reviewed 86 patients who underwent reoperation after MV repair for MR due to degenerative disease from October 1991 to December 2015. First, we analysed the initial MV repair data, causes of MV repair failure, reoperation data and long-term outcomes including survival. Second, the patients were classified into 2 groups based on valve related failure or procedure related failure , and the differences between the groups were analysed. RESULTS: Leaflet prolapse at the initial operation affected the bilateral leaflets in 37 (43%) patients, the anterior leaflet in 30 (35%) patients and the posterior leaftlet in 19 (22%) patients. Median duration from first operation to reoperation was 47.5 (interquartile range 4.8-85.8) months. Reoperation indication included recurrent mitral regurgitation alone in 59 patients, haemolysis combined with recurrent mitral regurgitation in 15 patients, infectious endocarditis combined with recurrent mitral regurgitation in 8 patients, mitral stenosis in 2 patients and left ventricular pseudoaneurysm in 2 patients. The cause of MV repair failure was valve-related in 61 (71%) patients, procedure-related in 20 (23%) patients and both in 5 (6%) patients. Re-MVP was successful in 23 (27%) patients. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Freedom from all-cause death was significantly better after Re-MVP. The 5-year freedom from reoperation after Re-MVP was 95.7%. CONCLUSIONS: Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Durability of re-repaired MVs and survival of re-repaired patients were acceptable.

Thoracic Endovascular Aortic Repair for Pseudoaneurysm after Interrupted Aortic Arch Repair.

Here we describe the case of a 33-year-old woman who was diagnosed with interrupted aortic arch (IAA) type A and who underwent radical surgery in her infancy. She developed a 42-mm anastomotic pseudoaneurysm in the distal aortic arch. We decided to perform thoracic endovascular aortic repair because of the patient's special request to avoid open surgery. We selected a reversed taper-type leg stent graft for the iliac artery and successfully implanted it without problems. However, the long-term outcomes of the stent graft in young people remain unclear, and careful regular follow-up for a long period is mandatory.

Comparison of aortic arch repair using the endovascular technique, total arch replacement and staged surgery†.

OBJECTIVES: We evaluated the operative and long-term outcomes of various approaches for aortic arch repair. METHODS: A total of 436 consecutive patients who underwent aortic arch repair from January 2001 to March 2016 in our centre were evaluated. Of these, 276 underwent conventional total arch replacement (TAR), and 118 underwent thoracic endovascular repair (TEVAR). The remaining 42 patients underwent staged thoracic endovascular repair (STEVAR). A total of 72 patients in the TEVAR group were matched to 72 patients who underwent open surgery including TAR or STEVAR by using propensity score analysis. RESULTS: Surgical outcomes showed shorter ICU and hospital stay in the TEVAR group ( P < 0.001 and P < 0.001, respectively). The 30-day mortality and neurologic dysfunction showed no significant difference among the three groups (2.8 and 5.4% in TAR group, 1.7 and 8.5% in TEVAR group and 0 and 2.4% in STEVAR group; P = 0.500 and P = 0.297, respectively). Long-term survival was not significantly different among the three groups (78% in TAR group, 67% in TEVAR group and 81% in STEVAR group at 5 years; P = 0.123). Freedom from aortic reintervention was lower in the TEVAR group than in other groups (98% in TAR, 92% in TEVAR and 97% in STEVAR at 5 years, P = 0.040). CONCLUSIONS: Operative outcomes showed no significant differences between the groups except for early recovery after TEVAR. Long-term survival was similar between groups; however, TEVAR had inferior reintervention free rate.

Ten-Year Experience of Coronary Endarterectomy for the Diffusely Diseased Left Anterior Descending Artery.

BACKGROUND: Coronary endarterectomy (CE) is a surgical option for a diffusely diseased coronary artery. This study evaluated the clinical and angiographic outcomes of CE for a diffusely diseased left anterior descending artery (LAD) using the internal thoracic artery (ITA). METHODS: From September 2004 to September 2014, 188 patients (163 men; mean age, 66.1 years) underwent coronary artery bypass grafting with CE for a diffusely diseased LAD. Forty patients (21.3%) had unstable angina, and 55 (29.3%) were at Canadian Cardiovascular Society class 3 or 4. Mean ejection fraction was 0.55. Endarterectomy was performed under direct vision through a long arteriotomy in all patients. Angiographic evaluation was performed before discharge and at 1 year after the operation. RESULTS: Mean arteriotomy length was 6.1 ± 1.8 cm. The endarterectomized LAD was reconstructed using the left ITA in 179 (95.2%) or the right ITA in 9 (4.8%). The operation was conducted off pump in 185 patients (98.4%). The 30-day mortality was 1.1%. Perioperative myocardial infarction occurred in 17 patients (9.0%). The patency rate of the ITA and LAD at early postoperative and follow-up angiography was 91.6% and 96.6%, respectively. Optical coherence tomography performed in 8 patients revealed that the endarterectomized LAD was completely endothelialized and that the surface of the reconstructed lumen had become homogeneous within 1 year after the operation. The median follow-up period was 5.8 years. At 5 years, freedom from all-cause death was 89.3% ± 2.4% and freedom from major adverse cardiac and cerebrovascular events was 74.0% ± 3.3%. CONCLUSIONS: CE for a diffusely diseased LAD using the ITA provides satisfactory clinical outcomes with favorable rates of angiographic patency.