Utilizing a long sheath to minimize atheroma manipulation (minimal manipulation approach) during Zone 1 and 2 thoracic endovascular aortic repair with a shaggy aorta.

We have adopted a simple and reproducible approach, "minimal manipulation approach," since January 2021 in five patients to minimize the risk of thromboembolic events during Zone 1 and 2 thoracic endovascular aortic repair (TEVARs) with shaggy aorta. The approach consists of two parts: ① Use of a 65-cm-long sheath (dry seal) to deliver the endografts without touching the protruding atheroma. Covering the atheroma with the first endograft delivered at Zone 3 to the mid-descending aorta (paving the aorta), and second endograft insertion and deployment through the paved aorta with first endograft. ② Protection of the left subclavian artery using balloon catheter during TEVAR. No in-hospital mortality was recorded, and none of the patients had stroke, spinal cord ischemia, or distal embolic events.

Sufficient cardiac unloading by Impella 5.0 in left ventricular rupture following mitral valve replacement: a case report.

A 72-year-old woman presented with exertional dyspnea. Echocardiography revealed severe mitral valve stenosis; therefore, mitral valve replacement was performed using a bioprosthetic valve. However, left ventricular wall rupture occurred following mitral valve replacement. Under re-cardiac arrest, we found a left ventricular tear under the posterior annulus of the mitral valve. We repaired the left ventricular muscle using a bovine pericardial patch and implanted a bioprosthetic valve again. Postoperatively, we implanted an Impella 5.0 heart pump through the right axillary artery to ensure left ventricular wall unloading. Systemic blood flow depended almost completely on mechanical circulatory assistance until postoperative day 3. After the fourth postoperative day, we started weaning the patient from Impella 5.0. Finally, it was completely discontinued on the sixth postoperative day. After that, the patient's condition was stable, and she was discharged 44 days postoperatively. Impella 5.0 is a potentially beneficial device for left ventricular unloading in patients with left ventricular wall rupture following mitral valve replacement.

Effect of Left Ventricular Hyperenhancement in Magnetic Resonance Imaging on Reverse Remodeling After Mitral Valve Repair for Moderate Ischemic Mitral Regurgitation.

We aimed to investigate cardiac magnetic resonance imaging (MRI)-derived predictors of a lack of left ventricular (LV) reverse remodeling after undersized mitral annuloplasty (uMAP) for moderate ischemic mitral regurgitation (IMR). We retrospectively reviewed 31 patients who underwent uMAP for moderate IMR and cardiac MRI evaluation between 2004 and 2017. Cardiac MRI evaluation included cine MRI LV and right ventricular volumetric measurements and gadolinium-enhanced MRI assessment of myocardial scarring. LV dimensions were assessed preoperatively, postoperatively, and at follow-up using serial transthoracic echocardiography, and the mid-term (median, 49 months) predictors of a lack of LV reverse remodeling were analyzed. At the mid-term follow-up (mean follow-up period: 85 ± 40 months), 15 patients exhibited reverse LV remodeling. The relative reduction in LV dimension at follow-up was negatively correlated with the preoperative number of LV segments with myocardial infarction (MI) (defined as an LV segment with >25% enhancement). The optimal cut-off for predicting a lack of reverse LV remodeling at follow-up was >5 LV segments with MI, with a sensitivity and specificity of 92% and 92%, respectively. This cut-off value also predicted all-cause mortality at follow-up, with a sensitivity and specificity of 88% and 67%, respectively. The presence of >5 LV segments with MI on gadolinium-enhanced MRI might be a useful predictor of lack of reverse LV remodeling and all-cause mortality outcomes after undersized mitral annuloplasty for moderate IMR.

Impact of right ventricular volume and function evaluated using cardiovascular magnetic resonance imaging on outcomes after surgical ventricular reconstruction.

OBJECTIVES: This study aimed to evaluate whether cardiac magnetic resonance imaging (MRI)-derived right ventricular (RV) assessment can facilitate risk stratification among patients with ischaemic cardiomyopathy who underwent surgical ventricular reconstruction (SVR). METHODS: We retrospectively analysed 53 patients who underwent SVR. The patients were preoperatively evaluated using cardiac MRI. Cine-MRI was acquired for left ventricular (LV) and RV volume. Gadolinium-enhanced MRI was performed to evaluate LV scarring. The mid-term (median, 58 months) risk factors of all-cause mortality and major adverse cardiac events were analysed. RESULTS: A significant reduction in LV end-diastolic and end-systolic volume index and an increase in LV ejection fraction were observed early after SVR. RV end-diastolic volume index (RVEDVI) and RV end-systolic volume index (RVESVI) decreased after SVR (preoperative versus postoperative: RVEDVI, 71 ± 24 vs 62 ± 17 ml/m2, P = 0.006; RVESVI, 44 ± 26 vs 37 ± 16 ml/m2, P = 0.033), but RV ejection fraction did not change (preoperative versus postoperative: RV ejection fraction 40.8±14.6 vs 42.0±11.0%, P = 0.067). At follow-up, 25 deaths and 31 major adverse cardiac events occurred. After adjustment for age, creatinine level and preoperative mitral regurgitation grade, the Cox-hazard model indicated that RVEDVI [P = 0.006, hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01-1.05] and RVESVI [P = 0.007, HR 1.02, 95% CI 1.01-1.04] were significant predictors for all-cause mortality. As for major adverse cardiac events, RVEDVI (P = 0.007, HR 1.03, 95% CI 1.01-1.05), RVESVI (P = 0.002, HR 1.03, 95% CI 1.01-1.04) and RV ejection fraction (P = 0.018, HR 0.97, 95% CI 0.94-0.99) were significant. CONCLUSIONS: RV parameters were more sensitive than LV parameters for predicting worse outcomes following SVR. Preoperative assessment of RV volume and function using cardiac MRI may improve the risk stratification of SVR.

Ventricular volume and myocardial viability, evaluated using cardiac magnetic resonance imaging, affect long-term results after surgical ventricular reconstruction.

OBJECTIVES: We aimed to investigate the outcomes of surgical ventricular reconstruction (SVR) for ischaemic cardiomyopathy and to identify ideal candidates for this procedure using cardiac magnetic resonance imaging (MRI) studies. METHODS: We retrospectively examined 50 patients who underwent SVR and were preoperatively evaluated using cardiac MRI from 2004 to 2014. Cine MRI and gadolinium-enhanced MRI were performed to evaluate left ventricular (LV) volume and scarring. The midterm (median, 2.5 years) risk factors of cardiac death or major adverse cardiac events (MACEs) were analysed. Patients were divided into three groups-those with preoperative indexed LV end-systolic volume (LVESVI) of ≤100 ml/m2 (Group 1), those with LVESVI of >100 and ≤130 ml/m2 (Group 2) and those with LVESVI of >130 ml/m2 (Group 3)-and examined. RESULTS: In total, 17 patients exhibited MACEs at follow-up. Kaplan-Meier analysis showed that the 5-year rate of freedom from MACEs was 66%. The Cox hazard model indicated that preoperative LVESVI was the only significant predictor for MACEs (P = 0.006; hazard ratio, 1.02; 95% confidence interval, 1.01-1.04). Moreover, a significant reduction in LVESVI and an increase in LV ejection fraction (LVEF) were observed early after SVR (preoperative versus postoperative: LVESVI, 110 ± 44 vs 68 ± 28 ml/m2, P < 0.001; LVEF, 24.3 ± 10.3 vs 32.0 ± 10.4%, P < 0.001) and at follow-up (LVESVI, 61 ± 28 ml/m2, P < 0.001; LVEF, 36.5 ± 11.5%, P < 0.001). Although no difference was observed between the groups at follow-up, LVEF and LVESVI primarily improved in Group 2. LVEF improvement was significantly greater in Group 2 than in Group 1 (%increase in LVEF: Group 1, 6%; Group 2, 18%; P = 0.008). In patients with a preoperative LVESVI of >130 ml/m2, the number of non-viable segments was a significant risk factor for MACEs. CONCLUSIONS: Patients with preoperative LVESVI ranging from 100 to 130 ml/m2 had fairly better outcomes, and the percentage improvement in LVEF and the percentage reduction in LVESVI were more pronounced in these patients. Hence, accurate preoperative assessments of LV volume and viability testing using cardiac MRI studies are essential for better stratification of the SVR procedure.

Blood flow analysis of the aortic arch using computational fluid dynamics.

OBJECTIVES: To obtain predictive information regarding aortic disease, we evaluated how blood flow inside the aortic arch was influenced by thoracic aortic aneurysms. In addition, to reveal the optimal intraoperative management in these cases, we examined blood flow during right subclavian arterial (rSCA) perfusion using computational fluid dynamics (CFD). METHODS: Patient-specific models of the aortic arch were made with six different patterns based on the computed tomographic images. CFD models with finite volume methods were created to simulate the physiological pulsatile flow including the peripheral reflection wave, characteristic impedance and autonomous regulation system. Flow stream patterns, wall shear stress (WSS) and the oscillatory shear index (OSI) were calculated during one cardiac cycle. Furthermore, flow streamlines during rSCA perfusion were simulated under different perfusion flows. RESULTS: Aortic dilatation caused vortical disturbed flow in a dilated space, resulting in turbulent flow not only inside the aneurysm but also in the proximal and/or distal normal aortic portion. In patients with a dilated thoracic aorta, there was a helical spiral flow with a circumferential vortex in systole. In patients with an arch aneurysm, turbulent flow inside the aneurysm caused a high OSI at the tip of the aneurysm. A high OSI was detected at the orifice of the supra-aortic branches, sinotubular junction, posterior lateral side of the ascending aorta and lesser curvature of the proximal descending aorta. rSCA perfusion revealed that the right common carotid artery was perfused by blood flow from rSCA throughout the cardiac cycle. With 75% of the flow from the rSCA, blood flow from the heart reached the left common carotid and subclavian artery only during a short period during the peak of systole. CONCLUSIONS: A dilated aorta causes a turbulent flow pattern in the aortic arch. The high OSI site was similar to the favourite entry site for acute aortic dissection, indicating the causal relationship between mechanical stress and acute aortic dissection. rSCA cannulation might be cerebroprotective from ascending aortic plaque.