Aortic Remodeling After Thoracic Endovascular Aortic Repair for Nonacute Uncomplicated Type B Aortic Dissection.

BACKGROUND: Entry closure with thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD) results in aortic remodeling recently. This study aimed to evaluate the relationship between aortic diameter or timing of surgical intervention from onset and remodeling after TEVAR for uncomplicated nonacute TBAD. METHODS: Between April 2014 and December 2021, 83 consecutive patients underwent TEVAR for TBAD at our center. Forty patients with subacute and chronic uncomplicated TBADs with a patent false lumen, who could be followed up for at least 6 months, were included in this study. Indications for TEVAR included aortic diameter enlargement and preemptive treatment to prevent future aneurysmal changes in patients at risk of aortic diameter enlargement. Aortic remodeling was accessed, and data between the remodeling and nonremodeling groups were compared. RESULTS: The technical success rate was 97.5%, with a type Ia endoleak remaining in 1 patient. No operative or in-hospital mortality occurred. Paraparesis occurred in only 1 patient (2.5%). Follow-up was completed at a median of 53.5 months. Late death occurred in 3 cases, but there were no aortic-related deaths. Late aortic remodeling was achieved in 22 patients (55%). The preoperative maximum aortic diameter (PMAD) in the thoracic aortic region was 51.5 mm in the nonremodeling group, significantly larger than 42.5 mm in the remodeling group (P < 0.0001). The cutoff value of the PMAD for predicting aortic remodeling was 45 mm (area under the curve, 0.917; P = 0.028). The remodeling group had an earlier time from onset to intervention than the nonremodeling group, with a cutoff value of 6.3 months (area under the curve, 0.743; P = 0.021). CONCLUSIONS: TEVAR for nonacute uncomplicated TBAD resulted in a late aortic remodeling rate of 55%. This study suggested that a PMAD of >45 mm or a period >6.3 months between dissection onset and surgery hinders aortic remodeling after TEVAR.

Impact of frailty and prefrailty on the mid-term outcomes and rehabilitation course after cardiac surgery.

PURPOSE: This study examined the impact of frailty and prefrailty on mid-term outcomes and rehabilitation courses after cardiac surgery. METHODS: A total of 261 patients (median age: 73 years; 30% female) who underwent elective cardiac surgery were enrolled in this study. The Japanese version of the Cardiovascular Health Study Frailty Index classified 86, 131, and 44 patients into frailty, prefrailty, and robust groups, respectively. We examined the recovery of walking ability, outcomes at discharge, mid-term all-cause mortality, and rehospitalization related to major adverse cardiovascular and cerebrovascular events (MACCE) across the three cohorts. RESULTS: The 3-year survival rates in the frailty, prefrailty, and robust groups were 87%, 97%, and 100%, respectively (p = 0.003). The free event rates of all-cause mortality and re-hospitalization related to MACCE were 59%, 79%, and 95%, respectively (p < 0.001), with a graded elevation in adjusted morbidity among patients in the prefrailty (hazard ratio [HR], 4.57; 95% confidence interval [CI], 1.08-19.4) and frailty (HR, 9.29; 95% CI 2.21-39.1) groups. Patients with frailty also experienced a delayed recovery of walking ability and a reduced number of patients with frailty were discharged home. CONCLUSION: Frailty and prefrailty adversely affect the mid-term prognosis and rehabilitation course after cardiac surgery.

Bypass Grafting to Circumflex: Left Internal Thoracic Artery versus Saphenous Vein.

BACKGROUND: This study aimed to compare the short- and long-term outcomes of saphenous vein grafts (SVGs) and in situ left internal thoracic artery (LITA) grafts to the left circumflex artery (LCX) territory. METHODS: This study included 678 patients who underwent LITA-left anterior descending (LAD) + SVG-LCX grafts and 286 patients who underwent right internal thoracic artery (RITA)-LAD + in situ LITA-LCX grafts from January 2002 to December 2020. Short-term and long-term clinical outcomes were compared using inverse probability of treatment weighting adjustment to reduce selection bias. RESULTS: In-hospital mortality was significantly higher for the SVG-LCX group (p = 0.008), whereas deep sternal wound infection was significantly higher in the LITA-LCX group (p = 0.013).Survival rates at 5 and 10 years were 83.12 and 71.45% in the SVG-LCX group, whereas 75.24 and 65.54% in the LITA-LCX group (log-rank p = 0.114). Rates of freedom from cardiac events at 5 and 10 years were 92.82 and 85.24% in the SVG-LCX group, whereas 94.89 and 89.46% in the LITA-LCX group (log-rank p = 0.179).Univariate and multivariate logistic regression analysis showed that proximal severe stenosis was significantly protective against graft dysfunction before discharge (odds ratio, 0.43; 95% confidence interval, 0.23-0.81). CONCLUSION: Deep sternal wound infection was significantly higher for LITA to LCX bypass whereas in-hospital mortality was higher for SVG to LCX. In situ LITA to LCX bypass grafting exhibited similar long-term outcomes with SVG to LCX bypass grafting in adjusted patient cohorts. Proximal severe stenosis of LCX was protective against graft dysfunction.

Dynamic changes in insulin requirements with post-operative time using bedside artificial pancreas to maintain normoglycemia without hypoglycemia after cardiac surgery.

It is difficult to manage postoperative blood glucose levels without hyperglycemia and hypoglycemia in cardiac surgery patients even if continuous intravenous insulin infusion is used. Therefore, the insulin requirements for maintaining normoglycemia may be difficult to evaluate and need to be elucidated. In this single-center retrospective study, 30 adult patients (age 71.5 ± 9.0 years old, men 67%, BMI 22.0 ± 3.1 kg/m2, diabetes 33%) who underwent cardiac surgery and used bedside artificial pancreas (STG-55) as a perioperative glycemic control were included. We investigated the insulin and glucose requirements to maintain normoglycemia until the day after surgery. The bedside artificial pancreas achieved intensive glycemic control without hypoglycemia under fasting conditions for 15 h after surgery (mean blood glucose level was 103.3 ± 3.1 mg/dL and percentage of time in range (70-140 mg/dL) was 99.4 ± 2.0%). The total insulin requirement for maintaining normoglycemia differed among surgical procedures, including the use of cardiopulmonary bypass during surgery, while it was not affected by age, body mass index, or the capacity of insulin secretion. Moreover, the mean insulin requirement and the standard deviation of the insulin requirements were variable and high, especially during the first several hours after surgery. Treatment using the bedside artificial pancreas enabled intensive postoperative glycemic control without hypoglycemia. Furthermore, the insulin requirements for maintaining normoglycemia after cardiac surgery vary based on surgical strategies and change dynamically with postoperative time, even in the short term.

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.

[Disruption of Matsui-Kitamura Stent-graft Six Years after Treatment for Rupture of Thoracic Aortic Aneurysm].

Matsui-Kitamura stent-graft (MKSG) is a home-made device for thoracic endovascular aortic repair (TEVAR) developed in Japan. A 76-year-old man who had been treated by TEVAR (zone 3) with a MKSG for ruptured thoracic aortic aneurysm was diagnosed as having type Ia endoleak caused by suture disruption and aneurysmal sac expansion 6 years later. He underwent TEVAR (zone 1) with debranching and type Ia endoleak disappeared. MKSG had been the effective device especially for acute aortic emergencies in the descending thoracic aorta until the stent-grafts became commercially available, but careful observation and appropriate re-intervention is mandatory for the continued life-saving contribution.

[Early and Long Term Outcomes of Surgery for Acute Type A Aortic Dissection Complicated with Organ Malperfusion].

OBJECTIVE: The purpose of this study was to evaluate early and long term outcomes of surgery for acute type A aortic dissection complicated with organ malperfusion. METHOD: From January 2001 to October 2015, 336 consecutive patients (mean age 68.6±12.2, male 172) underwent surgery for acute type A aortic dissection at out center. Early and late outcomes were compared between patients accompanied with and without organ malperfusion. RESULTS: Preoperative organ malperfusion was observed in 76 patients( 22.6%). That consisted of 38 neurological systems, 13 coronary, 8 visceral, and 26 extremities. Nine patients had 2 organ malperfusion. In-hospital mortality was 22.4% and 6.5% in patients with and without organ malperfusion, respectively. Multivariate logistic analysis showed preoperative organ malperfusion was a significant risk factor for in-hospital mortality (Odds ratio 3.59, 95% confidence interval 1.56~8.28, p<0.01). Five year survival rate of hospital survivors were 84.5±5.5% and 80.9±3.3% with and without organ malperfusion (p=0.51). CONCLUSIONS: Although organ malperfusion is still associated with high mortality, however, acceptable long term outcomes could be obtained if organ malperfusion is treated appropriately. Ischemic organ oriented approach might be very important to improve surgical outcomes of these critically ill conditions.

Double-patch repair by a bilateral ventriculotomy for postinfarction ventricular septal defect.

OBJECTIVES: Repair of a postinfarction ventricular septal defect (VSD) is a challenging procedure with a high risk of postoperative residual shunt and subsequent mortality. This retrospective study aimed to assess a modified infarct exclusion technique with a biventricular approach. METHODS: Nineteen consecutive patients who underwent the infarct exclusion procedure for VSD between 2002 and 2011 were reviewed. A biventricular approach (B group: 6 patients) and a left ventricular approach (L group: 13 patients) were studied by univariate analysis. RESULTS: The overall 30-day mortality was 15.8%, and was not different between the two groups (p=0.94). Postoperative residual shunt was not observed in the B group (p=0.21). The overall five-year survival rate was 79%, and there were no late deaths in the B group (p=0.14). CONCLUSION: The repair of postinfarction VSD can be safely performed by the infarct exclusion technique with a biventricular approach. This technique seems to reduce surgical mortality and prevents recurrence of the VSD.

Left ventricular restoration for cardiac sarcoidosis: report of two cases.

Although sarcoidosis may involve the myocardium, there is little available information on its treatment, especially in cases requiring surgery, such as left ventricular restoration or mitral valve repair. This report presents two surgical cases with cardiac sarcoidosis treated by left ventricular restoration and mitral valve repair for a ventricular aneurysm and dilated cardiomyopathy with mitral regurgitation.

False aneurysm with an aorto-superior vena cava fistula after replacement of the ascending aorta: report of a case.

A 58-year-old female presenting with congestive heart failure due to a fistula between an aortic false aneurysm and the superior vena cava (SVC) is described. She had a history of Takayasu's arteritis (TA) and she had undergone aortic valve and ascending aorta replacement and coronary artery bypass grafting 6 years before. The false aneurysm had occurred 1 year after the surgery, and she had been conservatively managed. The operation revealed that the cause of the false aneurysm was the detachment of the two proximal saphenous vein anastomoses to the ascending aortic graft. After the surgery, the patient made an uneventful recovery. A false aneurysm of the ascending aorta is one of the most serious complications after replacement of the ascending aorta for patients with TA (Miyata et al. in J Vasc Surg 27:438-445, 1998). We herein present the exceptional case of a fistula between an aortic false aneurysm and the SVC that occurred after ascending aorta graft replacement.

Mid-term echocardiographic comparison of chordal preservation method of mitral valve replacement in patients with mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: The efficacy of chordal-preserved mitral valve replacement (MVR) on left ventricular function was investigated in patients with mitral stenosis. METHODS: Eighty patients (25 males, 55 females; mean age 64.5 +/- 8.7 years) with pure mitral stenosis who underwent MVR between January 1999 and May 2008 were studied retrospectively. Of these patients, 20 had total chordal-preserved MVR (group I), 36 had posterior leaflet-preserved MVR (group II), and 24 had MVR without chordal preservation (group III). Echocardiographic assessments were performed preoperatively and at four years postoperatively. RESULTS: Both, preoperatively and intraoperatively, there were no significant differences between the three groups. Mid-term echocardiography showed significant improvements in the left ventricular ejection fraction (LVEF) of the chordal preservation groups (group I, 55 +/- 12% to 60 +/- 7%, p = 0.017; group II, 56 +/-10% to 61 +/- 8%, p = 0.025), whereas the LVEF was significantly decreased after non-chordal-preserved MVR (group III, 56 +/- 7% to 49 +/- 11%, p = 0.036). Furthermore, the non-chordal preservation group demonstrated a significant increase in left ventricular volumes (end-diastolic volume, from 92 +/- 15 ml/m2 to 107 +/- 23 ml/m2, p = 0.005, end-systolic volume, from 43 +/- 7 ml/m2 to 58 +/- 20 ml/m2, p < 0.001) and a spherical change in left ventricular geometry (sphericity index, from 1.6 +/- 0.2 to 1.3 +/- 0.2, p < 0.001). CONCLUSION: Chordal preservation during MVR resulted in an improved ejection performance and the maintenance of left ventricular volume in mitral stenosis. However, these hemodynamic advantages were similar after total chordal preservation and posterior leaflet preservation.

Rapidly progressive infective endocarditis after MitraClip therapy: A rare complication of transcatheter edge-to-edge mitral valve repair.

Infective endocarditis (IE) is a rare, life-threatening complication of MitraClip (Abbott, Abbott Park, IL, USA) therapy. We report a case of an 84-year-old male who underwent transcatheter edge-to-edge mitral valve (MV) repair using MitraClip (Abbott, Abbott Park, IL, USA) 4 weeks prior for ventricular functional mitral regurgitation (MR) and returned with unstable hemodynamics and high-grade fever. Transthoracic echocardiography (TTE) on emergency admission showed thickening of the anterior mitral leaflet (AML) without apparent MR deterioration. TTE and transesophageal echocardiography (TEE) performed the next day showed severe MR due to rapidly progressing AML degeneration with aneurysmal formation. During the TEE examination, exacerbated heart failure due to severe MR caused cardiogenic shock and subsequent ventricular fibrillation, necessitating emergency extracorporeal cardiopulmonary resuscitation. Considering the positive findings of methicillin-resistant Staphylococcus aureus (MRSA) in blood cultures and degenerative MV findings, MitraClip-related IE was diagnosed; finally, MV replacement was performed. Retrospective consideration suggested that the potential causes of this MitraClip-related IE were valve injuries caused by multiple full-close procedures and insufficient prophylaxis for preoperatively detected MRSA. MitraClip-related IE has destructive characteristics that necessitate surgical intervention despite high risks; therefore, we should prevent procedure-related MV injuries and implement preoperative infection precautions to prevent catastrophic complications, particularly in patients with preoperative nasal MRSA-positive findings. Learning objectives: MitraClip-related infective endocarditis (IE) is a rare but fatal condition. IE caused by methicillin-resistant Staphylococcus aureus (MRSA), in particular, has an inferior prognosis with high mortality rates due to its destructive nature. Therefore, interventionalists should consider preventive strategies to avoid procedure-related valve injuries and adequately prepare for prophylaxis of patients who are carriers of MRSA to prevent MitraClip-related IE caused by MRSA.

Endovascular Repair for Ascending Aortic Graft Side Branch Pseudoaneurysm: A Report of Two Cases.

Introduction: A pseudoaneurysm arising from the side branch of the prosthesis, following ascending aortic replacement, is extremely rare. Re-intervention usually involves open surgery, replacement of the ascending aorta, or ligation of the side branch. Redo surgery with an additional sternotomy carries the risk of cardiac and vascular injuries, and endovascular treatment can reduce such adverse events. Report: This study describes the successful thoracic endovascular aortic repair (TEVAR) of two cases of pseudoaneurysms arising from the side branch after ascending aortic replacement. Case 1 involved a 79 year old man who underwent ascending aortic replacement and omentopexy for a ruptured tuberculous aortic aneurysm 13 years ago. The pseudoaneurysm was mushroom shaped with a 30 mm protrusion. Case 2 involved an 83 year old man who underwent ascending aortic replacement for Stanford type A acute aortic dissection 11 years ago. The pseudoaneurysm was rod shaped with a 27 mm protrusion. In both cases, the pseudoaneurysm arising from the side branch was not noted on computed tomography (CT) until one year earlier and was first identified at a routine follow up examination. The pseudoaneurysms required surgical repair because of the risk of rupture; however, TEVAR was selected considering the risks of redo surgery and the patients' ages. It was performed via a femoral artery approach without adverse events using a commercially available thoracic aortic device. Post-operative CT scan showed complete exclusion of the pseudoaneurysm. Discussion: Although TEVAR is usually not indicated for ascending aortic pathologies, if there is an anatomical indication and a compatible stent graft, TEVAR for the ascending aorta should be the first choice in patients who are inoperable, at high risk and undergoing redo surgery.

Very-long-term outcomes of mechanical valves in mitral position focusing on valve-related complications.

OBJECTIVES: This study aimed to examine very-long-term outcomes of a mechanical valve at the mitral position. METHODS: This study included all patients who underwent mitral valve replacement (MVR) using a mechanical valve including urgent operation at the Department of Cardiovascular Surgery, Hyogo Brain and Heart Center, Himeji, from January 1987 to December 2015. RESULTS: Five hundred and eighty-three patients (277 men [47.51%]; age, 61 [54-67] years) were included in this study. The implanted valve models were as follows: SJM, 221 (37.91%); ATS, 35 (6.00%); On-X, 68 (11.66%); and Carbomedics 194, (33.28%).The median clinical follow-up duration was 13.3 (7.4-19.6) years. The survival rates at 10, 15, 20 and 25 years were 81.42%, 69.27%, 56.34% and 45.03%, respectively. Thromboembolism was observed in 38 patients, and the linearized ratio for each event was 0.626%/patient-year [95% confidence interval (CI), 0.443-0.859%]. Intracranial haemorrhage and gastrointestinal bleeding were observed in 26 and 9 patients, and the linearized ratio for each event was 0.425%/patient-year (95% CI, 0.277-0.006%) and 0.145%/patient-year (95% CI, 0.067-0.276%), respectively. Major paravalvular leak was observed in 32 patients, and the linearized ratio was 0.532%/patient-year (95% CI, 0.364%-0.751%). The cumulative incidence rate of major paravalvular leak at 10, 15, 20 and 25 years was 3.7%, 5.6%, 6.4% and 10.4%, respectively. Multivariable Cox regression analysis revealed that repeated MVR and male gender were associated with major paravalvular leak. CONCLUSIONS: Male gender and repeated MVR were risk factors for paravalvular leak after mechanical MVR. Paravalvular leak could have occurred regardless of postoperative period even at 25 years after implantation. Lifelong clinical follow-up is considered necessary.

Modes of the bioprosthetic valve failure of the porcine and pericardial valves in the mitral position.

OBJECTIVES: This study was conducted to examine the incidence and modes of the bioprosthetic valve failure of the porcine valve in the mitral position and compare them with those of the pericardial valve. METHODS: This study included 240 patients (116 men [48.3%]; mean age, 74.87 ± 6.61 years) who underwent mitral valve replacement using the St. Jude Medical Epic bioprosthesis (Epic) (N = 125) or Carpentier-Edwards Perimount (CEP) pericardial valve (N = 115) from January 2000 to December 2020. RESULTS: The median clinical follow-up durations in the Epic and CEP groups were 54.5 months (range, 0-111 months) and 81.5 months (range, 0-194 months), respectively. Structural valve degeneration (SVD) was observed in 9 patients (7.2%) in the Epic group and 11 patients (9.6%) in the CEP group. The rates of freedom from SVD at 3, 5 and 7 years were 97.7%, 90.5% and 75.5% in the Epic group and 100.0%, 96.1% and 90.0% in the CEP group, respectively. SVD reoperation was performed for 7 patients (5.6%) in the Epic group and 6 patients (5.2%) in the CEP group. The rates of freedom from SVD reoperation at 3, 5 and 7 years were 97.7%, 90.5% and 75.5% in the Epic group and 100%, 96.1% and 90.0% in the CEP group, respectively. Epic SVD was predominantly due to leaflet tearing, whereas CEP SVD was predominantly due to leaflet calcification and adhesion to the subvalvular apparatus. CONCLUSIONS: SVD of the porcine valve was predominantly due to leaflet tearing. The rate of reoperation for SVD was slightly higher for the porcine valve in the mitral position than for the pericardial valve at adjusted survival analysis.

A true aneurysm of posterior tibial artery.

True aneurysms of tibial artery are uncommon. We report a case of a 47-year-old woman who suffered from a distal embolism in the left toes. The surgical intervention involved an aneurysmectomy and the interposition of the posterior tibial artery using the saphenous vein graft. She has been doing well 22 months after the operation.

Giant pseudoaneurysm that developed seven years after surgical repair of a postinfarction ventricular septal defect.

Left ventricular pseudoaneurysm is a rare complication after myocardial infarction or cardiac surgery. An 88-year-old woman who developed a left ventricular pseudoaneurysm 7 years after the repair of a postinfarction ventricular septal defect was admitted to our hospital with a complaint of a pulsatile epigastric mass, which had persisted for a month. Enhanced computed tomography revealed a large left ventricular pseudoaneurysm that extended to the subcutaneous epigastric tissue through the supra-diaphragmatic space. Dehiscence of the patch on the lateral side, which was used during previous surgery, provided the entry site. Surgical repair with aneurysm exclusion patch plasty was successful, and the patient was discharged without any complications.

Acute Coronary and Cerebral Emboli From a Pedunculated Ascending Aorta Thrombus.

Hyperprolactinemia is a risk factor for thrombus formation. We present a rare case of a mobile ascending aorta thrombus leading to acute myocardial infarction and cerebral infarction in a patient with idiopathic hyperprolactinemia. (Level of Difficulty: Beginner.).