Use of a cutting stapler to excise a left atrial appendage in minimally invasive cardiac surgery.

PURPOSE: A cutting stapler is a well-established instrument in many surgical fields. However, its efficacy and safety have not been proven yet in resecting a left atrial appendage (LAA) in minimally invasive cardiac surgery (MICS). METHODS: A cutting stapler was used to resect the LAA in 98 consecutive patients who underwent MICS. Of these, 26 patients underwent aortic valve replacement, 72 mitral valve repair/replacement, 25 tricuspid annuloplasty, 7 closure of atrial septal defect, and 26 the Maze procedure (contains overlapping). The ascending aorta was elevated using a retractor, and a 12-mm shaft motor-driven cutting stapler was inserted through the transverse sinus. As a control group, 150 patients who underwent suture resection/closure of the LAA either from inside or outside were compared. RESULTS: There was one mortality in each group. They were not related to the LAA resection/closure. In the suture group, the LAA suture was taken down in one patient because of a suspected obstruction of the circumflex artery, and two patients had re-exploration for bleeding from the LAA. In the stapler group, there was no complication related with the LAA. The rate of complication did not reach a statistical difference. CONCLUSION: A cutting stapler is considered to be a useful instrument to resect the LAA in MICS.

Prognostic impact and periprocedural complications of chronic steroid therapy in patients following transcatheter aortic valve replacement: Propensity-matched analysis from the Japanese OCEAN registry.

OBJECTIVE: This study aimed to assess the effect of chronic steroid use on periprocedural complications and clinical outcomes after transcatheter aortic valve replacement (TAVR). BACKGROUND: Chronic steroid use increases the risk of periprocedural complications and mortality during surgery. METHODS: We investigated 1,313 consecutive patients with aortic stenosis who underwent transfemoral (TF)-TAVR using data from a Japanese multicenter registry. The baseline characteristics, periprocedural complications including vascular complications (VCs), access route related VCs, and clinical outcomes were compared between patients in the steroid group and nonsteroid group. RESULTS: Major VCs and access route VCs occurred more in the steroid group than in the nonsteroid group (13.4 vs. 5.8%, p = .019; 20.9% vs. 9.8%, p = .004). Especially in the surgical cut-down group, the rate of access route VCs was differed between the two groups (28.0% vs. 7.5%, p = .003). The 30-day mortality rates were similar between the two groups (0% vs. 1.4%, p = .39). In the propensity score-matched model, the higher incidence of major VCs in the steroid group was maintained, although early mortality was similar in the two groups. CONCLUSIONS: Although chronic steroid therapy is not associated with increased early mortality, chronic steroid use may affect periprocedural VCs and access route VCs mainly due to surgical cut-down in patients following TF-TAVR.

A novel 'two-window' technique to facilitate totally 3D-endoscopic mitral valve repair.

We describe our experience of a novel 'two-window' technique designed to assist in totally 3D-endoscopic mitral valve repair. A 10-mm trocar for a 3D-endoscope was inserted through the 4th intercostal space in the mid-axillary line. A main small incision (3 cm, 4th intercostal space) without rib spreading, and a second 1 cm incision (1-2 intercostal spaces above,) were made in the anterior axillary line. Soft tissue retractors were applied on both ports. A left atrial retractor, a left ventricular vent, and right-hand instruments were inserted through the main working port. A flexible aortic cross-clamp, an antegrade cardioplegia line, and left-hand instruments were inserted through the second port. Our two-window technique is safe, effective, and reproducible for totally endoscopic mitral valve repair.

Mild Systemic Hypothermic Circulatory Arrest Using a Frozen Elephant Trunk Graft with Endo-Balloon Occlusion for Total Arch Replacement.

BACKGROUND: Stroke and paraplegia are serious complications of total aortic arch replacement (TAR). Hypothermic circulatory arrest and cerebral perfusion reduce the risk of neurologic complications, but longer circulatory arrest time remains a risk factor for such complications. We utilized a frozen elephant trunk (FET) with endo-balloon occlusion under mild systemic hypothermia, which allowed us to shorten circulatory arrest time. METHODS: Between April 2007 and May 2020, 72 patients underwent elective TAR using antegrade cerebral perfusion (ACP). They were divided into 2 groups. 64 patients received conventional TAR with moderate systemic hypothermic (bladder temperature, 25-28°C) circulatory arrest (group C). We used a FET with endo-balloon occlusion and retrograde perfusion through the femoral artery for the newest 8 patients who had mild hypothermic (bladder temperature of 30°C) circulatory arrest (group B). RESULTS: The mean operation time (257.5 ± 42.1 versus 327.8 ± 84.9 min, P = .023), CPB time (144.4 ± 28.1 versus 178.2 ± 26.4 min, P = .003), cardiac arrest time (75.5 ± 21.2 versus 95.7 ± 56.4 min, P < .001), SCP time (100.8 ± 25.5 versus 124 ± 23.2 min, P < .001), lower body circulation arrest time (17.2 ± 4.2 versus 62.5 ± 19.3 min, P < .001) were significantly shorter in the endo-balloon occlusion group. There were no perioperative neurological and renal complications or mortality in FET group. The new technique enabled a decrease in mechanical ventilation time (8.6 ± 1.4 versus 13.9 ± 5.7 min, P = .015) and hospital length of stay (9.7 ± 1.8 versus 18.3 ± 4.6 min, P = .005). CONCLUSION: FET using an endo-balloon occlusion with mild hypothermia is a safe and an effective approach in TAR.

Biventricular Mural Endocarditis on the Intraventricular Septum.

Mural endocarditis is an inflammation and disruption of the nonvalvular endocardial surface of the cardiac chambers. We present a rare case of mural endocarditis on the intraventricular (IV) septum on both the left and right ventricular side with intact valvular annulus. This case highlights the complexity of the operative and postoperative management in an unprecedented case of biventricular mural endocarditis.

Surgical repair of Kommerell's diverticulum and an aberrant subclavian artery.

PURPOSE: The coexistence of Kommerell's diverticulum and an aberrant subclavian artery (ASCA) is a rare congenital variation of the vascular structure. We report our experience of treating aneurysms associated with these anomalies. METHODS: Between June 2007 and November 2011, five consecutive patients underwent repair of an aneurysm associated with Kommerell's diverticulum and an ASCA at Shiga University Hospital. Four of the five patients had a right-sided aortic arch associated with the ASCA. One patient underwent emergency surgery for a ruptured thoracic aneurysm. The operations performed were descending aorta replacement through right thoracotomy in one patient and total arch replacement through a median thoracotomy, under deep hypothermic circulatory arrest and selective cerebral perfusion, in four patients. No staged operation was required. RESULTS: One patient died of mediastinitis, subsequent to a ruptured Kommerell's diverticulum, 45 days postoperatively. There were no other deaths in the early or late (6-58 months) postoperative period. One patient required re-exploration for bleeding, but none of the patients suffered neurologic complications. CONCLUSIONS: Aortic disease with an ASCA and Kommerell's diverticulum can be repaired safely under elective conditions.

Transcatheter mitral valve repair for a patient with double inferior vena cava: case report.

Background: A transcatheter edge-to-edge repair (TEER) is disseminating gradually as a treatment for primary and secondary mitral regurgitation (MR) in patients with high surgical risk. In performing TEER, securing a safe access route is crucial. We report a case with a challenging access route due to the presence of a double inferior vena cava (IVC) and the patient's small body habitus. Case summary: An 84-year-old female presented with congestive heart failure due to severe MR. Despite receiving optimal medical therapy, her symptoms did not improve significantly. Transcatheter edge-to-edge repair was deemed challenging due to her extremely small body habitus [height: 131 cm; body surface area: 1.17 m2] and the presence of double IVC. However, considering her inoperable risk for surgical repair, she underwent TEER after a multidisciplinary heart team discussion. The steering guide catheter (SGC) encountered resistance, but gradual advancement and use of a bougie with a large bore sheath dilator successfully delivered the SGC to the right atrium. Following the TEER, there was a significant improvement in the symptoms. Discussion: Extremely small venous system in a small patient with double IVC presented a unique technical hurdle. Transcatheter edge-to-edge repair is potentially feasible even in such a patient by cautiously applying the technique described.

Left ventricular pseudoaneurysm after endoscopic mitral valve repair for active endocarditis.

A left ventricular pseudoaneurysm is a rare complication that can occur after infective endocarditis, possibly leading to serious complications such as cardiac tamponade, rupture and recurrent infective endocarditis. We report a case of a totally-endoscopic repair of a pseudoaneurysm after endoscopic mitral valve repair. A 48-year-old woman underwent endoscopic mitral valve repair for active infective endocarditis. A left ventricular pseudoaneurysm was found 2 weeks after the surgery. The pseudoaneurysm was repaired through a left thoracotomy with a totally endoscopic platform. The postoperative course was uneventful, and there was no recurrence at 18 months. Left ventricular pseudoaneurysm may be repaired with a left thoracotomy totally endoscopic approach.

Staged endoscopic mitral valve repair for active infective endocarditis with a mitral annular abscess.

The presence of an annular abscess complicates the operation for infective endocarditis. We report a case of a totally endoscopic repair of a mitral annular abscess using a staged strategy. A 28-year-old woman underwent endoscopic mitral valve repair for active infective endocarditis with Staphylococcus aureus. At the index operation, the mitral annular abscess was completely debrided, yielding an annular defect. The mitral valve was repaired with the autologous pericardial patch and an annuloplasty. Primary repair of the annular defect was not performed because of the fragility of oedematous tissues. Two weeks after index surgery, when the infection was under control, and the scar tissue had formed around the annulus, we performed the second stage operation involving repair of the annular abscess. The scar formation enabled annular reconstruction and additional repair of the mitral valve in a totally endoscopic fashion. The postoperative course was uneventful, and there was no recurrence at 5 months. An annular abscess may be repaired with staged surgery in select situations.

Endoscopic Aortic Valve Replacement: Initial Outcomes of Isolated and Concomitant Surgery.

BACKGROUND: The applicability of totally endoscopic surgical aortic valve replacement (AVR) in multivalve operations is unknown. This study describes an approach and perioperative outcomes of totally endoscopic isolated and concomitant AVR using various valve types. METHODS: A total of 216 patients (114 male; mean age, 71.3 ± 11.3 years) underwent totally endoscopic AVR from May 2017 to October 2022 in a tertiary care center. The 3-port technique was used: a 3- to 4-cm main port without rib spreading, a 10-mm 3-dimensional endoscopic port, and a 5-mm left-hand port with femoral cannulations. Sutures were hand tied with a knot pusher. Descriptive analyses compared perioperative outcomes between patients with or without concomitant procedures. RESULTS: Of 216 patients, concomitant surgery was performed in 33 (15.2%) patients. Of the 33, 21 (63.6%) had a concomitant mitral procedure. A stented bioprosthesis was implanted in 165 (76.3%) patients, a mechanical valve in 22 (10.2%) patients, and a rapid deployment or sutureless valve in 29 (13.4%) patients. Median operation time and aortic cross-clamp time were 175 minutes (interquartile range; 150-194 minutes) and 78 minutes (interquartile range; 67-92 minutes) for isolated AVR, respectively. Thirty-day mortality occurred in 1 patient (0.5%). Two patients (0.9%) had conversion to sternotomy. Major neurologic events occurred in 3 patients (1.4%). The major adverse event rate was similar between patients with or without concomitant procedures. CONCLUSIONS: Endoscopic AVR can safely address concomitant valve diseases.

Endoscopic mitral valve repair utilizing cavitron ultrasonic surgical aspirator for active endocarditis.

Mitral valve repair for endocarditis in an acute setting is still challenging due to difficulties in debriding friable tissue and in leaving enough non-infected tissue for reconstruction. Endoscopic approaches for complex mitral valve procedures via a minimally invasive approach have been reported from high-volume programs. However, the role of endoscopic mitral valve surgery for acute infective endocarditis has not been clearly defined. We report our technique of endoscopic mitral valve repair using the cavitron ultrasonic surgical aspirator system for active endocarditis. The cavitron ultrasonic surgical aspirator with a low power setting provides enough debridement of the infective tissue and leaves healthy tissue adequate for repair under a totally endoscopic vision.

Three-Dimensional Endoscopic-Assisted Concomitant Mitral and Aortic Valve Surgery.

Minimally invasive cardiac surgery is commonly used to treat degenerative mitral regurgitation. The totally endoscopic approach has emerged as an attractive alternative procedure especially for young patients and has been described in isolated mitral and aortic valve settings. The totally endoscopic double valve procedure, including mitral and aortic valves, extends this treatment option to a broader patient population. We describe our approach to performing a totally endoscopic concomitant aortic and mitral valve procedure that has overcome unique technical hurdles and has yielded favorable outcomes.

Midterm results after seamless patch mitral reconstruction.

Objectives: Some pathologies, including infective endocarditis or sclerotic changes of the mitral leaflet, make the conventional mitral valve repair challenging. Our previously described technique for reconstruction with a seamless pericardial patch makes the repair feasible in some of such difficult pathologies. However, the extent of mitral leaflet segments that could be safely repaired using this technique remains unknown. We investigated the association between the midterm outcome and the extent of mitral leaflet segments replaced by a pericardial patch. Methods: From January 2009 to January 2022, patients who underwent mitral valve repair with the seamless 1-patch reconstruction technique were included. The glutaraldehyde-treated pericardium was trimmed and anchored at the papillary muscle. The edge was sewn to the leaflet and the annulus. Results: A total of 49 patients (aged 60 ± 15 years) underwent mitral valve repair with this technique. The totally endoscopic approach was used in 27 patients (55%). No patient's repair was converted to valve replacement. No operative mortality or disabling stroke was observed during the early postoperative period. In the midterm follow-up, redo surgery was required in 9 patients (18%). Freedom from mitral valve reintervention rates at 1, 5, and 10 years were 84%, 82%, and 82% for all patients, respectively. Freedom from reoperation at 5 years was 100%, 92%, and 46% for commissural lesion, 1- to 2-segment involvement, and 3-segment involvement, respectively. There was a significant difference among the 3 groups with regard to mitral valve reoperation rate (P = .002). Conclusions: Mitral valve seamless patch reconstruction provides excellent midterm results if applied to commissural lesions or lesions involving up to 2 segments.

Syphilitic aortitis causing bilateral coronary ostial stenosis.

Coronary ostial stenosis in otherwise normal coronary vessels is a rare complication of syphilitic aortitis. A 47-year-old man with no coronary risk factors developed severe isolated ostial stenosis in the left main coronary artery and right coronary artery. He underwent coronary artery bypass grafting using the bilateral internal thoracic arteries and gastroepiploic artery and recovered uneventfully.

Surgical repair of a giant atrial septal aneurysm with patent foramen ovale.

Atrial septal aneurysm (ASA) is a rare occurrence. Many studies have established a correlation between ASA and both ischemic stroke of unidentified cause and cardiac embolism. We describe the case of a 59-year-old woman who had a giant ASA with patent foramen ovale. The aneurysm was successfully removed. Although the detailed mechanism involved in the degeneration of the atrial septum is unclear, we recommend that such damage be surgically repaired to reduce the risk of cerebral embolism or heart failure in symptomatic patients. Surgery is recommended for larger ASA.

Does off-pump bilateral internal thoracic artery grafting increase operative risk in dialysis patients?

BACKGROUND: We compared short-term outcomes of patients with chronic dialysis receiving bilateral internal thoracic artery (BITA) grafting with single internal thoracic artery (SITA) grafting using propensity score analysis. METHODS: Between 2002 and 2008, 656 consecutive patients underwent isolated coronary artery bypass grafting (99.1% off-pump). Of these, 56 patients with chronic dialysis and multivessel disease were retrospectively compared according to surgical technique, BITA (n = 32) or SITA (n = 23) grafting. In an attempt to minimize the selection bias, propensity scores were created based on 13 preoperative factors (C statistics, 0.914). RESULTS: There was no significant difference in age, left ventricular ejection fraction, prevalence of diabetes mellitus, and logistic euroSCORE between the 2 groups. All patients underwent revascularization using the off-pump technique without conversion to cardiopulmonary bypass. All arterial conduits were harvested using skeletonization technique. Except for 1 patient, all ITAs were used as in situ graft. Complete revascularization was achieved in all patients. There was no significant difference in occurrence of mediastinitis, impaired wound healing, and stroke between the 2 groups. The 30-day mortality was 6.3% in the BITA group and 13.0% in the SITA group (P = .64). After adjusting for propensity score, BITA grafting was not associated with impaired wound healing (odds ratio, 0.63; 95% confidence interval, 0.04 to 8.79; P = .73) and 30-day mortality (odds ratio, 0.60; 95% confidence interval, 0.05 to 6.82; P = .68). CONCLUSION: In situ skeletonized BITA grafting is safe and feasible in dialysis patients with multivessel disease.

[Acute type A aortic dissection, developed shortly after aortic valve replacement and coronary artery bypass grafting].

We experienced a case of acute type A aortic dissection shortly after a cardiac operation. A 73-year-old man underwent aortic valve replacement and coronary artery bypass grafting for aortic regurgitation and angina pectoris. Aortic valve was tricuspid and the ascending aorta was mildly dilated in preoperative studies. The postoperative computed tomography (CT) revealed aortic dissection, from the ascending aorta to the arch of aorta, although the patient was asymptomatic. Reoperation for the aortic dissection was performed on the 22nd post operative day. Re-do sternotomy was safely carried out prior to heparinization. Under hypothermic circulatory arrest with femoral arterial and venous cannulations, the ascending aorta was replaced and re-implantation of the saphenous vein graft was carried out. The postoperative recovery was uneventful and he was discharged on the 17th postoperative day.

Relapse of aortopulmonary window 41 years after patch closure.

In this study, we describe a rare case of a 45-year-old man with a recurrence of aortopulmonary window (APW) 41 years after the initial patch closure for an APW at the age of 4. He presented with persistent cough and exertional dyspnoea. Imagings revealed a recurrence of APW, ascending aorta saccular aneurysm, and severe mitral and tricuspid regurgitation. Re-patch closure, ascending aortic replacement, and mitral and tricuspid annuloplasties were performed, followed by an uneventful postoperative course. The relapse of APW in the remote postoperative period is extremely rare.

Hypo-attenuated leaflet thickening in surgically-implanted mitral bioprosthesis.

BACKGROUND: Hypo-attenuated leaflet thickening (HALT) in bioprosthetic aortic valve has been studied, but its equivalent in bioprosthetic mitral valve (bMV) remains uncharacterized. We sought to identify the prevalence, hemodynamic characteristics, and significance of anticoagulation therapy in bMV HALT. METHODS: A single-center cross-sectional study of 53 consecutive patients who underwent mitral valve replacement (MVR) with bMV between 2007 and 2017 was conducted. Cardiac-gated contrasted CT scans were obtained. Anticoagulant and antiplatelet therapy use were ascertained at the time of hospital discharge and CT scanning. Patient characteristics, postoperative stroke, and hemodynamic profile by echocardiogram were obtained to descriptively characterize the prevalence and characteristics associated with bMV HALT. RESULTS: Three patients (5.7%) were found to have a HALT on bMV. The mean time from index MVR to CT scan was 3.4 ± 0.8 years in HALT cohort and 3.4 ± 2.7 years in non-HALT cohort. Fifty patients (94.3%) were discharged on warfarin, and 37 patients (69.8%) were on warfarin at the time of CT scans. One patient with HALT was on therapeutic warfarin at the time of the CT scan that identified HALT. All three patients were asymptomatic at the time of CT scan. In patients with HALT, mean transmitral pressure gradient were 8, 5, and 2.7 mmHg, all with trivial or mild mitral regurgitation. CONCLUSIONS: In this study, the prevalence of HALT was low at 5.7%, all presenting without symptoms. One patient presented with HALT while on therapeutic oral anticoagulation, which may suggest thrombotic etiology may not adequately explain HALT.

Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery.

OBJECTIVES: To compare different configurations of the bilateral internal thoracic arteries for the left coronary system and examine early and late outcomes, including mid-term graft patency. METHODS: We reviewed 877 patients who underwent primary isolated coronary artery bypass grafting using in situ bilateral internal thoracic arteries [in situ right internal thoracic artery (RITA)-to-left anterior descending artery (LAD) grafting, n = 683; in situ left internal thoracic artery (LITA)-to-LAD grafting, n = 194]. We compared mid-term patency between the grafts. Propensity score matching was performed to investigate early and long-term outcomes. RESULTS: The 2-year patency rate for RITA-to-LAD and LITA-to-LAD grafts were similar. Multivariate analysis revealed that RITA-to-non-LAD anastomosis (P = 0.029), postoperative length of stay (P = 0.003) and chronic obstructive pulmonary disease (P = 0.005) were associated with graft failure. After statistical adjustment, 176 propensity-matched pairs were available for comparison. RITA-to-LAD grafting enabled a more distal anastomosis. Kaplan-Meier analysis revealed that the incidences of death, repeat revascularization and myocardial infarction were significantly higher in the LITA-to-LAD group among both the unmatched and matched samples (P = 0.045 and 0.029, respectively). CONCLUSIONS: The mid-term patency and outcomes of RITA-to-LAD grafting are good and reduces future cardiac event, in contrast to LITA-to-LAD grafting.