Impact of tricuspid annuloplasty on postoperative changes in the right ventricular systolic and diastolic function: A retrospective cohort study.

OBJECTIVES: To elucidate the impact of regulation of tricuspid regurgitation (TR) using tricuspid annuloplasty on postoperative changes in right ventricular (RV) systolic and diastolic functions. METHODS: We enrolled 69 patients who underwent aortic or mitral valve surgery between July 2016 to March 2018 without recurrence. Patients with concomitant coronary artery bypass grafting or a history of previous cardiovascular surgery were excluded, remaining 45 patients enrolled. Patients were divided into two groups according to concomitant tricuspid annuloplasty (T: n = 12 vs non-T: n = 33). RV global longitudinal strain (RVGLS), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), and early tricuspid inflow velocity/early diastolic tricuspid annular velocity ratio (tricuspid E/e') were assessed as functional indices at preoperative, postoperative and 1-year follow-up periods. RESULTS: RVFAC deteriorated postoperatively but recovered at follow-up in group T, whereas that in group non-T showed gradual deterioration overtime. RVGLS and TAPSE showed similar temporary deterioration and recovery between groups. Tricuspid E in group T increased postoperatively and showed significant difference, which was kept until follow-up period. Tricuspid e' decreased postoperatively, and recovered slightly in both groups. As a result, postoperative RV diastolic function (tricuspid E/e') showed significant difference between groups. This difference was maintained until follow-up. CONCLUSIONS: RV systolic function deteriorated postoperatively, but there was a tendency to improve at follow-up regardless of tricuspid annuloplasty. RV diastolic function may potentially be impaired when TR was regulated by tricuspid annuloplasty.

[Aortic Valve Translocation for Severe Prosthetic Valve Endocarditis with Aortic Annular Abscess].

We report a case of successful aortic valve translocation in a 71-year-old man with severe prosthetic valve endocarditis and an aortic annular abscess. Six years earlier, the patient had undergone aortic valve replacement for aortic regurgitation and coronary artery bypass grafting to the left anterior descending artery with a saphenous vein. Moreover, 4 years earlier, he had undergone total arch replacement for chronic aortic dissection. He was admitted to our hospital with suspected urinary tract infection. Despite antibiotic therapy, the patient developed a high fever. Transthoracic echocardiography revealed a rocking motion of the prosthetic aortic valve, and an emergency operation was performed. An annular abscess surrounding the prosthetic aortic valve was observed, and the valve was detached. For destruction of the entire aortic annulus, we performed an aortic valve translocation procedure. Revascularization of the left coronary artery was performed by interposing an 8 mm artificial graft between the proximal anastomosis site of the previous venous graft and the composite tube graft. Revascularization of the right coronary artery was performed using a saphenous vein graft. The patient was discharged uneventfully at postoperative day 29 and doing well 1 year after surgery.

[Experiences of Cardioaortic Surgery with Small Anterior Mediastinal Mass on Preoperative Computed Tomography].

Computed tomography(CT) is indispensable for diagnostic imaging. During preoperative assessment for cardioaortic surgery, a CT examination is performed not only for diagnostic purposes but also to decide the surgical strategy. In some cases, CT demonstrates a small abnormal mass in the adipose tissue of the anterior mediastinum. Sometimes radiologists diagnose the image and send the diagnostic report to cardiologists or cardiovascular surgeons. However, they tend to limit their focus to their field of specialty. Thus, they might overlook or underestimate an abnormal mass. Anterior mediastinal masses, though small, may include malignant tumors. Thus, we reviewed 12 cases in which anterior mediastinal masses were found on preoperative CT. Two of these patients were finally diagnosed with malignant tumors. We should pay attention to not only cardiovascular assessment but also mediastinal masses on preoperative CT. In some cases, concomitant surgery for cardioaortic disease and an anterior mediastinal tumor is effective.

Multiple Spontaneous Iliac and Femoral Arteriovenous Fistulas.

An arteriovenous fistula (AVF) in a limb involves an abnormal connection between a limb artery and vein. It can be due to trauma or iatrogenic injury. Traumatic AVFs can be caused by penetrating or gunshot injuries to the limb, whereas iatrogenic causes include catheter intervention to the groins or open surgery of the inguinal space. By contrast, the occurrence of multiple spontaneous AVFs is rare. We report a case of endovascular therapy for multiple spontaneous AVFs between the iliac artery and the vein, common femoral artery and the vein, superficial artery and the saphenous vein, and deep femoral artery and the vein.

Popliteal Artery Pseudoaneurysm Caused by Osteochondroma.

A 16-year-old boy developed pulsating pain and dysesthesia in his right knee. Computed tomography showed a large aneurysm in the right upper popliteal artery and a spiked bone tumor arising from the right distal femoral shaft. Pseudoaneurysm due to osteochondroma was suspected, and the patient underwent emergency surgery. A 2-mm pinhole was detected in the arterial wall behind the tumor. After resection of the tumor, the damaged arterial wall was removed, and the defect was repaired using a saphenous vein patch. We suggest that patch repair is preferable to direct closure or end-to-end anastomosis to prevent recurrent pseudoaneurysm at a later time, even if the defect is small.

[Impact of Patent False Lumen at the Descending Aorta after Total Aortic Replacement for Acute type A Aortic Dissection].

OBJECTIVE: Acute type A aortic dissection remains one of the most challenging diseases facing cardiovascular surgeons. It is associated with high mortality and morbidity. However, prevention of disease process progression in the residual dissected aorta is an important aspect of the patient's long-term outcome. The aim of this study was to examine the impact of patent false lumen at the descending aorta after total arch replacement for acute type A aortic dissection. METHODS: Between December 1994 and August 2014, a total of 145 patients underwent total arch replacement for acute type A aortic dissection. The hospital mortality was 5.5%.Of these 145 patients, 33 had patent false lumen at the descending aorta after surgery, and 94 had thrombosed false lumen. The perioperative variables and late results were statistically analyzed. RESULTS: The incidence of residual thoracic patent false lumen was 26.0%.No significant difference was observed in the cumulative survival rate between groups. The patent false lumen group was associated with significant higher risk of the descending aortic event than the thrombosed group. By multivariate analysis, younger age and non-resection of the primary tear were significant prospective factors for the patent false lumen at the descending aorta. CONCLUSIONS: The patent false lumen at the descending aorta was associated with the late aortic critical events after total arch replacement for aortic dissection.

Blood flow dynamic improvement with aneurysm repair detected by a patient-specific model of multiple aortic aneurysms.

Aortic aneurysms may cause the turbulence of blood flow and result in the energy loss of the blood flow, while grafting of the dilated aorta may ameliorate these hemodynamic disturbances, contributing to the alleviation of the energy efficiency of blood flow delivery. However, evaluating of the energy efficiency of blood flow in an aortic aneurysm has been technically difficult to estimate and not comprehensively understood yet. We devised a multiscale computational biomechanical model, introducing novel flow indices, to investigate a single male patient with multiple aortic aneurysms. Preoperative levels of wall shear stress and oscillatory shear index (OSI) were elevated but declined after staged grafting procedures: OSI decreased from 0.280 to 0.257 (first operation) and 0.221 (second operation). Graftings may strategically counter the loss of efficient blood delivery to improve hemodynamics of the aorta. The energy efficiency of blood flow also improved postoperatively. Novel indices of pulsatile pressure index (PPI) and pulsatile energy loss index (PELI) were evaluated to characterize and quantify energy loss of pulsatile blood flow. Mean PPI decreased from 0.445 to 0.423 (first operation) and 0.359 (second operation), respectively; while the preoperative PELI of 0.986 dropped to 0.820 and 0.831. Graftings contributed not only to ameliorate wall shear stress or oscillatory shear index but also to improve efficient blood flow. This patient-specific modeling will help in analyzing the mechanism of aortic aneurysm formation and may play an important role in quantifying the energy efficiency or loss in blood delivery.

Late complications and pathological findings of the arterial switch operation.

We describe aortic root dilatation, severe aortic regurgitation, and pulmonary artery stenosis that were accidentally diagnosed 23 years after the arterial switch operation for transposition of the great arteries in situs inversus. We successfully performed the modified Bentall procedure and pulmonary artery reconstruction. The pathology of the dilated aortic root revealed intimal atherosclerosis and linear necrosis of the tunica media, suggesting the vulnerability of the pulmonary artery to systemic pressure.

Dual aortic aneurysms with coronary artery and multiple cerebrovascular stenoses.

Total debranching thoracic endovascular aortic repair is useful for avoiding neurological complications in cases where cardiopulmonary bypass is difficult and for devising an intraoperative cervical branch reconstruction method.

Rupture of a dissecting thoracoabdominal aortic aneurysm due to Citrobacter freundii infection.

We describe a case of an elderly man with Citrobacter freundii-associated infectious rupture of a dissecting thoracoabdominal aortic aneurysm. We performed an emergency thoracoabdominal aortic replacement using a rifampicin-soaked prosthetic graft and omental flap wrapping. The patient was discharged on postoperative day 255, although he experienced pseudomembranous enteritis and paraplegia.

Mid-term functional recovery after tricuspid annuloplasty concomitant with left-sided valve surgery.

BACKGROUND: To elucidate the impact of tricuspid annuloplasty concomitant with left-sided valve surgery on the right ventricular (RV) function in patients with mild or more tricuspid regurgitation (TR). METHODS: We enrolled 136 patients with mild or more TR who underwent left-sided valve surgery. Seventy-three patients underwent left-sided valve surgery alone (group non-T) and 63 underwent concomitant tricuspid annuloplasty (group T). The echocardiographic data at the latest follow-up (mean 1019 days) were compared using multiple regression analysis to adjust cofounding factors. Propensity score was calculated and included in the analysis as a covariate. In addition, propensity score matching was used for sensitive analysis (12 pairs). RESULTS: In group non-T, there were more aortic valve surgeries, and fewer mitral valve surgeries. At baseline, body surface area, New York Heart Association class, and prevalence of atrial fibrillation were significantly different between groups. On preoperative echocardiography, left and right atrial diameter, RV diameter, and tricuspid annular diameter were larger in group T, whereas there was no significant difference in RV fractional area change. In multiple regression analyses, RV diameter in diastole was significantly lower and RV fractional area change was significantly higher at the follow-up period in group T. These results were not attenuated even in subgroup analysis in patients with only mild TR or mitral valve surgery alone. CONCLUSION: Among patients with mild or more TR, RV dimensional and functional recovery was not obtained with left-sided valve surgery alone. Adding tricuspid annuloplasty may potentially achieve both outcomes.

Annular excursion contributes to efficient cardiac output: a three-dimensional echocardiographic approach.

BACKGROUND AND AIM OF THE STUDY: The heart produces an efficient cardiac output by repeating diastole and systole. With the evolution of three-dimensional (3D) echocardiography, it is possible to evaluate cardiac motion using detailed 3D morphologic echocardiography. The study aim was to evaluate mitral and aortic annulus excursions towards the apex of the left ventricle, using 3D echocardiography. Measurements of the angle variation between the mitral and aortic valve throughout the cardiac cycle were performed to determine the effects of annulus excursion on cardiac function. METHODS: Seven healthy adolescents (five males, two females; mean age 15.9 +/- 1.1 years; Group H) and seven patients with dilated cardiomyopathy (seven males; mean age 63.6 +/- 12.9 years; Group D) were selected. All subjects underwent 3D echocardiography between November 2007 and June 2008. Annulus excursion (AE) was defined as the annular motion towards the apex. The Ex-Ratio A (%) and Ex-Ratio M (%) were defined as the ratios of aortic or mitral excursion, respectively, to the maximal distance from the annulus to the left ventricular apex. The annulus was defined simply as a flat round disc, and the annular area calculated as the annular distance between the anterior and posterior annulus as a circle diameter. The annulus excursion volume (AEV) was calculated by multiplying the annular area by AE, and determined for each valve of each patient. The total AEV was the summation of the mitral and aortic AEVs. The ratio of AEV to left ventricular diastolic volume was expressed as AEV/EDV. Angular variation between the valves was measured during the cardiac cycle with the following values: maximal angle (Dmax), minimal angle (Dmin), and the difference between Dmax and Dmin (Dmax-min). RESULTS: In all cases, the apex was in a fixed position. The AE was significantly greater for group H than for group D. While AEV did not differ between groups, AEV/EDV(A) and AEV/EDV(M) were greater for group H than for group D. The angle between the mitral and aortic annulus changed throughout the cardiac cycle. The Dmax-min value was significantly greater for group H than for group D. CONCLUSION: Annulus excursion contributes to an efficient cardiac output. The angle variation was measured during the cardiac cycle and found to be greater in healthy adolescents. 3D echocardiography represents a useful modality for clarifying 'motional cardiac morphology'.

The frozen elephant trunk technique for acute retrograde type A aortic dissection: preliminary results.

OBJECTIVES: Our goal was to determine the early and midterm outcomes after total arch replacement with the frozen elephant trunk (FET) technique compared to those of the conventional elephant trunk (ET) technique for acute retrograde type A aortic dissection. METHODS: Between 2012 and 2019, a total of 49 patients had total arch replacement for acute retrograde type A aortic dissection. Patients were divided into the conventional ET (n = 17) and FET (n = 32) groups. The false lumen status was evaluated using enhanced computed tomography (CT) 1 week postoperatively. The diameter of the downstream aorta was evaluated annually using CT. The median follow-up period was 29 months. RESULTS: Preoperative data and neurological complications were not significantly different in the 2 groups. The diameter and length of the ET prosthesis were significantly larger and longer in the FET group. The overall early mortality rate was 10.2% (5/49) with no differences between the 2 groups. The mean follow-up period was significantly longer in the conventional ET group. The rates of freedom from aortic events at 3 years were significantly lower in the FET group. At the level of the distal arch, postoperative false lumen patency was significantly lower and the follow-up aortic diameter was significantly smaller in the FET group. CONCLUSIONS: The FET technique facilitates false lumen thrombosis and aortic remodelling at the distal arch level, with fewer adverse aortic events during the follow-up period with acceptable early outcomes; however, these findings are exploratory and require investigation.

The outcome of patients undergoing abdominal aortic aneurysm repair with and without cardiac disease.

PURPOSE: We report the outcome of abdominal aortic aneurysm (AAA) repair with and without cardiac disease. In patients with cardiac disease, we compared staged procedures and simultaneous operations. MATERIAL AND METHODS: A total of 217 patients underwent scheduled AAA repair from 1994 to 2005. When the AAA with cardiac disease was 5.0 cm or less in diameter, we performed a staged procedure. When it was more than 5.0 cm in diameter, we performed a simultaneous operation. Forty-two patients underwent simultaneous operations, and 15 had staged procedures. RESULTS: No occurrence of major cardiac complication was detected in any patient postoperatively. There were no hospital deaths in either the no-cardiac-disease group or the staged-procedure group. There were two hospital deaths in the simultaneous group. The estimated actuarial 10-year survival rates were 58.9 +/- 9.9% and 68.2 +/- 1.5% for the no-cardiac-disease group and the with-cardiac-disease group, respectively (P = 0.85). The 10-year survival rates were 71.2 +/- 1.6% and 74.8 +/- 1.3% for the one-stage-operation group and the staged-operation group, respectively (P = 0.35). There was no significant difference with regard to hospital deaths and late mortality rate among the groups. CONCLUSION: The simultaneous operation method is a useful technique in patients having both a large AAA and cardiac disease.

Cadherin-6 is required for zebrafish nephrogenesis during early development.

We performed functional analyses of cadherin-6 (cdh6) in zebrafish nephrogenesis using antisense morpholino oligonucleotide (MO) inhibition combined with in situ hybridization. We have cloned a zebrafish homolog (accession number AB193290) of human K-cadherin (CDH6), which showed 6063% identity and 7678% similarity to the human, mouse, chicken and Xenopus homologs. Whole-mount in situ hybridization showed that cdh6 is expressed in the pronephric ducts and nephron primordia in addition to the central and peripheral nervous systems. Expression of cdh6 in the pronephric ducts was first detected at 14 hours post-fertilization (hpf) and increased to 24 hpf. Embryos injected with MOs directed against cdh6 (cdh6MOs) showed developmental defects, including a small head, body axis curvature, short yolk extension and a short bent tail by 30 hpf and edema appeared in the thorax by 42 hpf. Such defects and edema became more marked by 52 hpf and most of the affected embryos died by 5 days post-fertilization. Embryos injected with cdh6MOs were subjected to in situ hybridization with probes for the pronephric markers, wt1 and pax2.1, to examine disturbed development of the anterior region of the pronephric ducts and the nephron primordia. Histological studies showed malformation of the pronephros as abnormally fused glomerulus primordia, fused or abnormally bent pronephric tubule anlagen and coarctated pronephric ducts. These results suggest that cdh6 plays pivotal roles in the development of the pronephros in zebrafish embryos.

Surgicel® packing remnants mimicking mediastinitis after adult cardiac surgery.

Surgicel® is one of the most commonly used bioabsorbable topical haemostatic agents. Some articles have reported that Surgicel® remnants might be misdiagnosed as an abscess. However, the number of reports in the cardiothoracic surgical field is limited. Herein, we report a 65-year-old woman who was suspected of having mediastinitis on computed tomography after redo-Bentall operation. Reoperation revealed that internal accumulation of Surgicel® remnants mimicked mediastinitis. It is important to share the use and location of Surgicel® with radiologists. If mediastinitis cannot be ruled out, the next step of reoperation or magnetic resonance imaging should be promptly taken.

Off-pump resection of a giant inflamed epicardial cyst.

BACKGROUND: Epicardial cysts are rarer benign tumors than pericardial cysts. There have been few reports on surgical management for epicardial cysts. CASE PRESENTATION: A 73-year-old woman with dyspnea on exertion had a giant cyst (12 × 10 cm in diameter) on preoperative computed tomography. Compression of the left atrium and ventricle by the cyst was considered to be the cause of her symptoms. The cyst was diagnosed with an epicardial cyst intraoperatively. Although the cyst adhered to surrounding tissues, it was successfully resected with off-pump surgery by using a heart positioner and an ultrasonic scalpel. CONCLUSIONS: Surgeons should consider off-pump surgery as an alternative to video-assisted thoracoscopic surgery and on-pump surgery for complicated epicardial cysts.

Effect of tricuspid annuloplasty concomitant with left heart surgery on right heart geometry and function.

OBJECTIVES: To elucidate the effect of tricuspid annuloplasty concomitant with left-sided valve surgery on the right heart in patients with mild or more tricuspid regurgitation (TR). METHODS: We enrolled 78 patients with mild or more TR who underwent left-sided valve surgery. Forty-three patients underwent only left-sided valve surgery (group non-T) and 35 underwent concomitant tricuspid annuloplasty (group T). Echocardiographic changes between the preoperative and 1-year follow-up periods were compared. Propensity score matching was used to obtain risk-adjusted outcome comparisons (16 pairs). RESULTS: In group non-T, there were more operations for aortic stenosis and concomitant coronary artery bypass grafting, and fewer operations for mitral regurgitation. The prevalence of atrial fibrillation was higher in group T. In preoperative echocardiography, there were no significant differences in left ventricular and right ventricular (RV) dimensions and functions. Tricuspid valve annular diameter and TR-related parameters were significantly larger in group T. Left ventricular dimensions and TR-related parameters significantly improved in both groups 1 year after operation. RV diameter was significantly reduced in only group T. In analysis of variance, RV diameter in systole and diastole showed significant interaction, whereas left heart dimensions and function, tricuspid valve tethering height, and RV fractional area change did not show interaction. These results were not attenuated even after propensity-matching analyses. CONCLUSIONS: Among patients with mild or more TR, RV reverse remodeling was not obtained with left-sided valve surgery alone. Additional use of tricuspid annuloplasty might potentially achieve favorable TR regulation as well as RV reverse remodeling.