Two-Year Results of the 17-mm Avalus Aortic Valve in the PERIGON Japan Trial.

BACKGROUND: The PERIcardial SurGical AOrtic Valve ReplacemeNt (PERIGON) Japan Trial was developed to assess the safety and effectiveness of the 17-mm Avalus bioprosthesis (Medtronic, Minneapolis, MN, USA) in patients undergoing surgical aortic valve replacement.Methods and Results:The primary endpoint in the trial was the percentage of patients achieving the composite of at least 1 class improvement in New York Heart Association (NYHA) functional class at 1 year compared with baseline and effective orifice area index (EOAI) of 0.6 cm2/m2or greater at 1-year after implantation, compared with a performance goal of 60%. The present study reports outcomes through 2 years. Eleven patients were implanted (10 [91%] female, median age 78.3 years). From baseline to 1 year, 10 subjects (91%) showed an improvement in NYHA classification. At 1 year, mean (±SD) EOAI was 0.82±0.17 cm2/m2, with 10 patients (91%) having an EOAI ≥0.6 cm2/m2. As such, 9 of 11 patients (82%) successfully met the primary endpoint. One death occurred between the 1- and 2-year follow-up visits, unrelated to the valve. There were no valve reinterventions, explants, or device deficiencies through 2 years. CONCLUSIONS: The PERIGON Japan Trial met its primary endpoint. Surgical implantation of the 17-mm Avalus aortic bioprosthesis can be performed with an acceptable incidence of device-related adverse events, and the valve performs effectively based on echocardiographic findings.

Relationship of oral conditions to the incidence of infective endocarditis in periodontitis patients with valvular heart disease: a cross-sectional study.

OBJECTIVES: Infective endocarditis (IE) is a life-threatening infectious disease, but the pathogenesis of the disease remains uncertain. The objective of this study was to examine whether oral infectious conditions are associated with the occurrence of IE in valvular heart disease (VHD) patients. MATERIALS AND METHODS: A total of 119 periodontitis (P) patients with or without VHD were enrolled, and cross-sectional analyses were performed. Patients were classified as follows: (1) mild-to-moderate P without VHD, (2) mild-to-moderate P with VHD, (3) severe P without VHD, or (4) severe P with VHD. A total of 78 VHD patients were classified as (1) VHD without IE or (2) VHD with IE. Conditional logistic regression analysis was performed to compute the odds ratio (OR) and 95% confidence interval (CI). RESULTS: No significant differences were observed between patients with or without VHD in oral conditions. A significant increase in the percentage of alveolar bone loss in VHD patients with IE was observed compared with that of patients without IE. The ratio of both Porphyromonas gingivalis (Pg) IgG titer > 1.68 and Pg fimA type II genotype in patients with IE was significantly higher than in patients without IE. There was a significant correlation between the occurrence of IE and clinical oral findings (number of remaining teeth: OR, 0.17; rate of alveolar bone loss > 40%: OR, 11.8). CONCLUSIONS: VHD patients with IE might have severe periodontitis compared with patients without IE, although further investigation will be needed because this is based on only 7 VHD patients with IE. CLINICAL RELEVANCE: The patients with IE had fewer remaining teeth, more advanced bone resorption compared with those of patients without IE. These findings suggest a possible association between the occurrence of IE and periodontal infection.

[Strategy to Avoid Reoperation after Ascending Aortic Replacement for DeBakey Typeâ Acute Aortic Dissection].

When ascending aortic replacement (AAR) is performed in patients with DeBakey typeⅠ acute aortic dissection( AAD), residual false lumen of the aortic arch after AAR is a risk factor of remote aortic reoperation. We have principally considered entry resection as a surgical policy for AAD, but since 2013, for cases of re-entry in the brachiocephalic artery, reconstruction of the brachiocephalic artery has been added. We verified whether brachiocephalic artery reconstruction contributes to the thrombus closure of the false lumen of the aortic arch after the operation. Of 68 patients who underwent AAR for DeBakey typeⅠ AAD within a 12 year period, 17 had re-entry in the brachiocephalic artery on preoperative computed tomography (CT). Six patients who underwent brachiocephalic artery reconstruction were assigned to group A, and 11 patients who did not were assigned to group B. We compared the 2 groups. Aortic clamp and selective cerebral perfusion times were significantly longer in group A. By postoperative CT, false lumen of the aortic arch was not found in any case (0%) in group A, but was found in 10( 90.9%) of the 11 cases in group B( p=0.0006). The risk of residual false lumen of the aortic arch significantly decreased in group A. In conclusion, in cases where re-entry is found in the brachiocephalic artery, a false lumen often remains in the aortic arch after AAR. However, by reconstructing the dissected brachiocephalic artery, the false lumen of the aortic arch can be obliterated, which contributes to avoidance of reoperation in a chronic phase.

[Distal Stentgraft-induced New Entry Developed after Surgery for Aortic Dissection].

We experienced 2 cases with distal stentgraft-induced new entry (distal SINE) after thoracic endovascular aortic repair( TEVAR) for type B aortic dissection and 1 case after total arch replacement and frozen elephant trunk method for type A dissection. We successfully performed additional TEVAR in all cases. If the stent graft is bent at deployment, distal SINE may occur on the great curvature side of the aorta by the spring back force. Therefore, we must pay attention to appropriate device selection, and even when remodeling of the aorta is good, meticulous follow-up is necessary.

[Patch plasty of intraoperative acute aortic dissection in a patient with severe aortic valve stenosis;report of a case].

Intraoperative aortic dissection is a rare complication, but is associated with a high mortality. We report a case of 79-year-old woman with severe aortic valve stenosis who underwent aortic valve replacement(AVR). After cardiopulmonary bypass(CPB) was established, aortic dissection started at the inflow cannulation site. Because hemodynamics were stable, we performed AVR as scheduled. After declamping, excessive bleeding from the arterial cannulation site continued. CPB was reestablished by placing the arterial cannula in the left femoral artery. The ascending aorta was opened at the site of cannulation under deep hypothermic circulatory arrest. The entry tear was successfully repaired by entry resection and Hemashield patch plasty. The postoperative course was uneventful, and the patient was discharged on the 22nd postoperative day. Patch plasty may be useful for the management of intraoperative aortic dissection.

Repair of insufficient aortic valve and single coronary artery with intramural course.

We report about a patient with severe bicuspid aortic valve insufficiency and a single coronary artery with an intramural course. Aortic valve repair with double plication and coronary translocation was satisfactory.

Reoperative aortic valve replacement after bio-Bentall using a double sewing ring technique.

We report an 89-year-old haemodialysis patient with a structural valve deterioration following a Bentall-de Bono operation with a tissue valve using the double sewing ring technique. The bioprosthesis was extracted easily, and the aortic valve replacement was performed without any complications in a high-risk patient. This procedure may be feasible given the prospects of reoperation.

A case of aortoduodenal fistula presenting with postoperative lymphatic leakage.

INTRODUCTION AND IMPORTANCE: Secondary aortoduodenal fistula (sADF) is a complication of prosthetic graft replacement of the abdominal aorta which often follows a fatal course. This report details our experience with a case of lymphatic fistula that developed after sADF repair. The fistula was refractory to conservative treatment but ultimately responded to lipiodol lymphangiography. CASE PRESENTATION: A 75-year-old man had undergone prosthetic graft replacement to treat an abdominal aortic aneurysm in 2012 and a thoracic aortic aneurysm in 2015. Upper gastrointestinal endoscopy was performed in 2020, and examination for worsening anemia revealed that the abdominal aortic graft had eroded into the horizontal duodenum. The patient was treated with prosthetic graft replacement and duodenectomy. A refractory lymphatic fistula was noted after surgery, which made ascites accumulation difficult to control, but the patient's condition rapidly improved following therapeutic lymphangiography. CLINICAL DISCUSSION: Surgery is the first-line therapy for sADF, but clinicians must stay vigilant for infection recurrence and aortoenteric fistulae after a repair, and this requires patient-specific postoperative management. Our modifications, intended to minimize contamination of the operative field in the present case, also facilitated our ability to subsequently treat a refractory lymphatic fistula, which is a rare postoperative complication of the procedure. CONCLUSION: Procedural modifications to sADF repair aimed at minimizing perioperative contamination are crucial for preventing infection recurrence. Given the extent of invasion, the surgery can cause various postoperative complications, requiring individualized strategies for management and treatment. Therapeutic lymphangiography is one such approach, which holds promise as a first-line treatment for refractory lymphatic fistula.

[Left coronary ostial stenosis and aortic regurgitation associated with syphilitic aortitis; report of a case].

We report a surgical case of severe left coronary ostial stenosis and aortic regurgitation associated with syphilitic aortitis. A 46-year-old man was referred to our hospital for further examination of effort angina pectoris. Coronary angiography and echocardiography showed severe left coronary ostial stenosis and aortic regurgitation. We initiated treatment with penicillin G injections and an emergency surgery was performed 8 days later. Aortic valve replacement (SJM #23) and coronary artery bypass grafting were also performed. We used in situ left internal thoracic artery (ITA) and right gastroepiploic artery (GEA) to prevent stenosis of the proximal anastomotic site in the late postoperative period. The postoperative course was uneventful.

[Bleeding complication from the elephant trunk graft at the 2nd stage operation of the total aortic replacement].

We described a rare complication that occurred during the 2nd stage of a total aortic replacement. The patient was a 72-year-old male who presented with type B acute aortic dissection complicated by distal arch aneurysm. Following the replacement of the total arch aorta with an elephant trunk graft (22 mm Gelweave graft), the descending and abdominal aorta enlarged rapidly. After about 3 months, he was scheduled for the 2nd operation. Through the 8th intercostal space and under partial cardiopulmonary bypass, the descending and the abdominal aorta was replaced with a 20 mm Gelweave-Coselli graft. The 12th intercostal artery, celiac trunk, superior mesenteric artery (SMA), and bilateral renal arteries were reconstructed. During the operation, severe bleeding began from the entire elephant trunk graft. After heparin neutralization and a massive transfusion of blood, fresh frozen plasma, and platelet-rich plasma, the bleeding was controlled. However, paraplegia occurred probably because of severe intraoperative hypotension. Careful attention should be paid during the 2nd stage of an elephant trunk operation.

[Aortic dissection after aortic valve replacement for bicuspid aortic valve complicated with ascending aortic dilatation; report of a case].

Congenital bicuspid aortic valve (BAV) is known to be a predisposing factor for aortic aneurysms and dissection because of intrinsic weakness of the aortic wall. We report here a case of 58-year-old man who developed type A aortic dissection 40 months after aortic valve replacement (AVR) for a congenital BAV. The ascending aorta diameter was 48 mm at the time of AVR. Computed tomography revealed ascending aortic dilatation (maximum diameter 64 mm) complicated with aortic dissection. We performed aortic root replacement and total arch replacement successfully. He has been doing well after the operation. In patients of congenital BAV with a baseline ascending aortic diameter of >40 mm, especially in young patients, complete replacement of the ascending aorta at the time of AVR should be considered in order to prevent future aortic complications.

Outcomes of valve replacement with mechanical prosthesis versus bioprosthesis in dialysis patients: A 16-year multicenter experience.

OBJECTIVE: To evaluate the long-term outcomes of heart valve replacement with mechanical prosthesis (MP) versus bioprosthesis (BP) in patients on dialysis. METHODS: A retrospective review was performed at 7 hospitals. Patients on dialysis who underwent valve replacement were included. Survival, reoperation, bleeding, and embolic events were compared across the MP and BP groups. RESULTS: Between April 2000 and April 2016, 312 patients on dialysis were enrolled in our study (MP: 94 patients [30.1%], BP: 218 patients [69.9%]). Mean follow-up was 3.4 ± 3.6 years. Five-year and 10-year survival rates were similar in both groups (MP: 57.4 ± 5.5% at 5 years and 46.3 ± 6.4% at 10 years, BP: 50.2 ± 4.1% at 5 years and 38.8 ± 4.5% at 10 years, P = .305). Multivariate Cox hazard analysis demonstrated that diabetic nephropathy (hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.31-2.73, P < .001), New York Heart Association functional classification ≥III (HR, 2.16; 95% CI, 1.37-3.35, P = .001), and mitral valve replacement (HR, 2.36; 95% CI, 1.58-3.49, P < .001) were significant risk factors for late death. Valve selection was not a significant risk factor. Freedom from valve-related embolic event at 5 years was significantly lower in the MP group (MP: 88.3 ± 4.3% at 5 years, BP: 97.2 ± 1.6% at 5 years, P = .007). Freedom from valve-related reoperation or hemorrhagic events was similar across both groups. CONCLUSIONS: Valve selection was not associated with late survival outcomes in patients on dialysis. However, BP may have an advantage in preventing embolic events without increasing the incidence of valve-related reoperation when compared with MP.

Simultaneous cusp-sparing aortic root replacement and coarctectomy with total arch replacement from the midline incision.

Four cases of simultaneous surgery for aortic root aneurysm with aortic regurgitation and coarctation of the aorta were presented. Age at surgery ranged from 18 to 37 years and all were male. All had annuloaortic ectasia and dilatation of the ascending aorta, 3 had bicuspid aortic valve and 1 had acute localized aortic dissection. Preoperative grade of aortic regurgitation was trivial in 1, moderate in 2 and severe in 1. Three had aortic valve-sparing root replacement with reimplantation technique and 1 had plication of the sinotubular junction. All patients had total arch replacement, coarctectomy and orthogonal anastomosis to the descending aorta. Antegrade cerebral perfusion was used for brain protection. All patients survived and postoperative pressure difference between the upper and lower extremities disappeared. Postoperative aortogram was satisfactory.

Resection of an azygos vein aneurysm with thrombosis.

Aneurysm of the azygos vein is rare. We describe the case of a 51-year-old nonsmoking woman with a posterior mediastinal mass caused by a giant azygos vein aneurysm with subtotal thrombosis. Surgical resection of the azygos vein was offered to our patient as a treatment option owing to theoretical risks of rupture and pulmonary embolism. After taping the azygos vein proximally and distally, the aneurysm was resected with video-assisted thoracoscopy. Approximately 30 cases have been reported in the literature to date. Dynamic computed tomography and a videoassisted approach were useful for the diagnosis and treatment for this abnormality.

Unexpectedly large aortoesophageal fistula inconsistent with CT imaging due to the thrombus working as the tamponade.

A 69-year-old woman with a history of graft replacement of descending aortic aneurysm was referred to our hospital due to massive hematemesis with shock status. Additionally, the deterioration of respiratory status made us start the management under mechanical ventilation. The emergent gastrointestinal endoscopy by a general practitioner showed ulcer-like lesion of the upper esophagus and arterial bleeding. A contrast-enhanced computed tomography showed thoracic aortic aneurysm surrounded by low density mass and contrast medium protruding from the aneurysm. The findings suggested that thoracic aortic aneurysm perforated into esophagus and made an aortoesophageal fistula. Hemodynamic deterioration rapidly progressed and she passed away 4 days after her hospitalization. Autopsy showed that a new thoracic aortic aneurysm arose from the proximal site of the graft. The aneurysm ruptured to esophagus with 6.0 cm x 5.0 cm sized fistula. The fistula was filled with a large thrombus. The large thrombus filling with the fistula worked as the tamponade and prevented her from the fatal exsanguinations and sudden death. The mechanism of the sentinel bleeding and the fatal exsanguinations known as Chiari's triad was revealed in our report.