Efficacy and Safety of Non-Vitamin K Antagonist Oral Anticoagulants for Japanese Patients With Venous Thromboembolism　- The Primary Results From the KUROSIO Study.

BACKGROUND: Direct oral anticoagulants (DOACs) are recommended as the first-choice anticoagulation therapy in the acute phase of venous thromboembolism (VTE). However, there is limited real-world data for Japanese VTE patients.Methods and Results: The KUROSIO study (UMIN000023747) was a prospective long-term observational study comprising 1,017 patients with concurrent acute symptomatic pulmonary thromboembolism and proximal deep vein thrombosis (DVT) or isolated calf DVT initially treated with DOACs. After excluding 24 patients, 993 (mean age, 66.3±15.1 years; 58.6% females) were analyzed. The incidences of recurrent symptomatic VTE and major bleeding for up to 52 weeks after diagnosis were 3.2% and 2.2%, respectively. Multivariate analyses revealed chemotherapy and anemia as significant risk factors associated with recurrent symptomatic VTE and major bleeding, respectively. CONCLUSIONS: The efficacy and safety of DOACs in Japanese patients with VTE were determined in this real-world observational study.

[Total Arch Replacement Using Bilateral Axillary Artery Perfusion].

OBJECTIVES: The selection of arterial cannulation site is an important decision to avoid cerebral complication for total arch replacement(TAR). We report the surgical outcome of TAR using bilateral axillary artery perfusion in our hospital. METHODS: Between January 2012 and June 2020, 97 patients who underwent elective TAR for atherosclerotic aneurysms were enrolled in this study. Among them, bilateral axillary artery perfusion was used for 81 patients, and frozen elephant trunk( FET) procedure were used for 34 patients. In the case of FET procedure, translocated TAR was performed with distal anastomosis between the left common carotid artery and the left subclavian artery. The left subclavian artery was reconstructed by rerouting the graft used for the left axillary artery perfusion. RESULTS: There were no perioperative cerebral infarction and no hospital deaths. The mean operation time was 420 minutes. Compared to the conventional elephant trunk method, the FET method significantly reduced the operation time to 381 minutes. CONCLUSIONS: Bilateral axillary artery perfusion could contribute to reduce the cerebral infarction in TAR and facilitate the FET procedure.

Severe aortic regurgitation with intimal intussusception secondary to Debakey type I aortic dissection.

Aortic regurgitation (AR) with intimal intussusception, secondary to aortic dissection, is relatively rare and the images are interesting findings. We report a typical case of severe AR with intimal intussusception, secondary to DeBakey type I aortic dissection, detected by contrast-enhanced computed tomography (CECT) and transesophageal echocardiography (TEE). Since there are three types of aortic regurgitation with aortic dissection, it is imperative to consider the most appropriate intervention for AR. The combination of CECT, TEE, and surgical findings may play an important role in determining the optimum surgical procedure for AR with aortic dissection.

Functional assessment of improvement of myocardial ischemia using coronary flow velocity reserve after coronary artery bypass surgery in hemodialysis.

BACKGROUND: In patients with end-stage renal disease requiring hemodialysis (HD patients), myocardial ischemia after coronary artery disease is a major cause of mortality. Coronary pathophysiology, namely myocardial microvascular dysfunction, appears to differ from patients not requiring HD (non-HD patients). OBJECTIVES: We compared functional improvement of myocardial ischemia after coronary artery bypass surgery (CABG) between HD and non-HD patients by transthoracic coronary flow velocity reserve (CFVR). METHODS: We retrospectively reviewed isolated CABG patients from between 2008 and 2017. Finally, 161 patients were enrolled; each underwent pre- and postoperative CFVR assessment, and left anterior descending (LAD) artery revascularization with "in-situ" internal mammary artery (IMA). Graft patency was confirmed, and after successful CABG, postoperative CFVR improvement between the two groups was compared. RESULTS: Preoperative CFVR value in group H was 1.81 ± 0.52, group N was 1.93 ± 0.66. There was no significant difference between the groups. IMA to LAD grafts were patent in postoperative evaluation in all patients. Postoperative CFVR in group H was 2.48 ± 0.72 and group N was 2.83 ± 0.73 (P = .042). Significant difference was observed. CONCLUSION: In both groups, CFVR values improved after successful CABG, but postoperative CFVR values were significant different. In younger populations CFVR values are generally higher. Our HD group was significantly younger than the non-HD group, but CFVR values were postoperatively significantly lower. CFVR values are reportedly affected by both epicardial and microcoronary circulation. In this study population, as all grafts to the LAD were patent, the lower CFVR value in the HD group was considered to have resulted in microvascular disorders.

Repair of an adult aorto-pulmonary artery fistula associated with a ruptured aortic arch aneurysm using a frozen elephant trunk technique.

We describe the repair of an acute aorto-pulmonary artery fistula in a 82-year-old patient with a ruptured aortic arch aneurysm using a frozen elephant trunk technique.

Reoperation for pseudoaneurysm of the thoracic aorta after cardiovascular surgery.

PURPOSE: Pseudoaneurysms of the thoracic aorta after cardiovascular surgery are rare, but life-threatening complications. We herein describe the clinical outcomes of pseudoaneurysms of the thoracic aorta arising after cardiovascular surgery. METHODS: We retrospectively reviewed 14 patients (mean age 64 years) who underwent reoperation for a pseudoaneurysm of the thoracic aorta between January 1997 and December 2010. RESULTS: Pseudoaneurysms of the thoracic aorta were detected incidentally during routine follow-up in 11 asymptomatic patients, whereas symptoms or signs indicating an aortic pseudoaneurysm were present in three patients. The mean intervals between repeat and previous cardiovascular surgeries and the follow-up were 167 and 62 months, respectively. The aortic pseudoaneurysms were located in the proximal and distal suture lines in six patients, and at aortotomy sites in four. These locations accounted for about 70 % of all aortic pseudoaneurysms. None of the patients died in the hospital. Postoperative complications, such as a need for permanent pacemaker implantation or groin-related issues, occurred in five patients. However, no major postoperative complications, aorta-related events or a need for reoperation developed during the follow-up period. CONCLUSIONS: Regular follow-up, including imaging modalities and physical examinations, is mandatory to detect aortic pseudoaneurysms after cardiovascular surgery.

Tricuspid leaflet augmentation with an autologous pericardial patch for recurrent severe tricuspid regurgitation that occurred after suture annuloplasty.

We, herein, report the use of tricuspid leaflet augmentation with an autologous pericardial patch to treat a patient with severe tricuspid regurgitation (TR) that occurred after suture annuloplasty. The patient underwent mitral valve replacement for rheumatic mitral disease and tricuspid suture annuloplasty for moderate TR 23 years ago. She developed right-sided heart failure associated with severe TR. Leaflet augmentation with an autologous pericardial patch and ring annuloplasty were applied at redo surgery. Postoperative echocardiography showed trivial TR with significant improvement of the patient's symptoms. We have now performed this technique on three cases of severe recurrent TR that occurred after suture annuloplasty, and excellent early results were obtained in each case.

[Outcomes after total arch replacement using antegrade selective cerebral perfusion under right axillary artery perfusion].

Although the outcomes of total arch replacement have been improving, the prevention of cerebral infarction is still an important consideration in aortic arch surgery. Herein, we reviewed our experience with total arch replacement using antegrade selective cerebral perfusion under right axillary artery perfusion. Between January 2002 and March 2013, total arch replacement was performed for 125 patients including 31 patients with acute aortic dissection. An 8 mm polyester grafts was sutured to the axillary artery through the right subclavicular incision and was connected to cardiopulmonary bypass circuit. Antegrade selective cerebral perfusion under hypothermic circulatory arrest was initiated using right axillary artery perfusion. Postoperative cerebral infarction occurred in 5.6% of patients. Hospital mortality rate was 3.2%. The 5-year rate of freedom from aortic event was 83%. The 5-year survival rate was 75%. We consider that right axillary artery perfusion is advantageous for preventing cerebral infarction in total arch replacement.

Bilateral Axillary Artery Perfusion in Total Arch Replacement.

BACKGROUND: The site of arterial cannulation is an important consideration in the prevention of cerebral infarction after total arch replacement. We compared the outcomes of cannulation of the bilateral axillary artery, the femoral artery, and central cannulation in total arch replacement. METHODS: Enrolled were 242 patients, categorized into three groups according to the arterial cannulation site used: bilateral axillary artery group, 124 patients; femoral artery group, 88 patients; central cannulation group, 30 patients. Selective cerebral perfusion was used for brain protection in all patients. Surgical outcomes, including the incidence of postoperative cerebral infarction, were compared between the groups. RESULTS: Cardiopulmonary bypass time and lower-body circulatory arrest time were significantly shorter in the bilateral axillary artery group. Frozen elephant trunk procedure was performed in 54% of the bilateral axillary artery group (P < .001), and concomitant coronary artery bypass graft surgery was performed in 40% of the central cannulation group (P < .01). Hospital mortality in the bilateral axillary artery group was 1.6%, compared with 1.1% in the femoral artery group, and 0% in the central cannulation group (P = .72). The incidence of permanent neurologic deficit was significantly lower in the bilateral axillary artery group (0.8%) than in the central cannulation group (13%; P = .02). Logistic regression analysis indicated that bilateral axillary artery perfusion was a significant factor in the prevention of permanent neurologic deficit (odds ratio 0.10, P = .03). CONCLUSIONS: Recent technical advances using bilateral axillary artery perfusion and frozen elephant trunk technique were associated with shortening cardiopulmonary bypass time and prevention of postoperative cerebral infarction in total arch replacement.

Successful treatment for infected aortic aneurysm using endovascular aneurysm repairs as a bridge to delayed open surgery.

Management of infected aortic aneurysms, which can be life-threatening, remains challenging. Open surgical treatments, including debridement of the infected aorta and the surrounding tissue and either in situ reconstruction or extra-anatomic bypass covering with omentum or muscle flap, are the mainstay of therapy. However, increasing advances in technology have made endovascular treatment of infected aneurysms feasible. The present study describes the first clinical report of successful treatment of an infected aneurysm using endovascular techniques in the acute phase, followed by delayed open surgery.

Serum Cystatin C Level as a Biomarker of Aortic Plaque in Patients with an Aortic Arch Aneurysm.

AIM: During surgery for an aortic arch aneurysm, aortic plaque in the descending aorta should be evaluated, but there are currently no suitable biomarkers for it. Surgeons should be especially aware of cerebral embolism from femoral perfusion and of peripheral embolism from stent graft deployment. Cystatin C is a known useful marker of renal dysfunction with a role as a biomarker for severity of coronary artery disease. In the absence of a suitable biomarker for aortic plaque in the descending aorta, we examine cystatin C as a candidate. METHODS: In all, 75 patients who underwent surgery for an aortic arch aneurysm were enrolled. They were divided into two groups, depending on whether they had chronic kidney disease or not. The serum cystatin C value and creatinine value were evaluated preoperatively. The aortic plaque volume ratio and components in the descending aorta were calculated from preoperative enhanced computed tomography. RESULTS: The soft plaque volume ratio was higher in patients with chronic kidney disease than in patients without it. Cystatin C positively correlated with the total aortic plaque volume ratio in all cases, and it positively correlated with the soft plaque volume ratio in both groups. Creatinine had no correlation with any type of plaque volume ratio in either group. In patients without chronic kidney disease, the soft plaque volume ratio was higher in patients with higher cystatin C levels than in patients with normal levels. CONCLUSION: The preoperative serum cystatin C level could be a biomarker of aortic plaque in the descending aorta in patients with an aortic arch aneurysm.

Impact of instantaneous wave-free ratio on graft failure after coronary artery bypass graft surgery.

BACKGROUND: We aimed to assess an impact of instantaneous wave-free ratio (iFR) on a graft failure after coronary artery bypass grafting (CABG). METHODS AND RESULTS: A total of 131 coronary arteries from 88 patients who underwent invasive coronary angiography, intracoronary pressure measurements, CABG, and scheduled follow-up coronary computed tomography angiography within one year were investigated. All studied arteries had FFR <0.80. The rate of graft failure was significantly higher in vessels with negative iFR (>0.89) than in those with positive iFR (<0.89) (25.7% vs. 7.3%, p = 0.012). The graft failure rates increased as the preoperative iFR values rose (iFR <0.80, 3.3%; iFR: 0.80-0.84, 5.6%; iFR: 0.85-0.89, 16.0%; iFR: 0.90-0.94, 28.0%; and iFR: 0.95-1.00, 50.0%; p = 0.002). A cut-off value of iFR to predict graft failures was determined as 0.84 by receiver-operating characteristic curve analysis with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 88%, 62%, 25%, 97%, and 66%, respectively. CONCLUSIONS: The risk of graft failure becomes higher, as the preoperative iFR increases. The graft failure is significantly more frequent when a bypass graft is anastomosed on vessels with negative iFR than those with positive iFR.

Staged hybrid aortic procedure for chronic type B aortic dissection in two patients with Marfan syndrome.

We here report two patients with Marfan syndrome treated by a combination of surgical grafting and endovascular repair in our hospital. One was a 32-year-old woman who underwent thoracoabdominal aortic replacement for a Crawford type III dissected aortic aneurysm. Subsequently, the Bentall procedure and total arch replacement was performed for an aortic root and arch aneurysm. Finally, thoracic endovascular aortic repair bridging implanted grafts was performed. The second was a 67-year-old woman with Stanford type A acute aortic dissection who underwent the Bentall procedure and total arch replacement at the age of 64. Subsequently, she underwent thoracoabdominal replacement for a dilated dissected aortic aneurysm and finally, bridging endovascular aortic repair was performed. This procedure is less invasive than open repair for patients with Marfan syndrome.

Usefulness of routine use of bilateral axillary artery perfusion in total arch replacement.

OBJECTIVES: To avoid cerebral infarction for aortic arch aneurysm and malperfusion for acute aortic dissection, the site of cannulation during total arch replacement remains important. Recently, we have used bilateral axillary artery perfusion in total arch replacement and in acute aortic dissection. Herein, we report the surgical outcomes. METHODS: Seventy-eight patients with aortic arch aneurysm and 45 patients with acute aortic dissection were enrolled in this study. During surgery, translocation of the total arch was performed on 67 patients using a 'frozen elephant trunk technique'. RESULTS: In patients with aortic arch aneurysm, there was no postoperative cerebral infarction. New postoperative cerebral infarction was observed in only one patient who underwent acute aortic dissection. Two patients who had aortic arch aneurysm and 2 patients who had acute aortic dissection died at the hospital. Complications related to bilateral axillary perfusion were not observed. CONCLUSIONS: The routine use of bilateral axillary artery perfusion in total arch replacement for aortic arch aneurysm to avoid cerebral infarction has the potential to be a useful procedure. It can facilitate the frozen elephant trunk procedure in acute aortic dissection.

A biodegradable microneedle sheet for intracorporeal topical hemostasis.

Management of bleeding is critical for improving patient outcomes. While various hemostatic products are used in daily practice, technical improvement is still needed. To addresses this problem, we newly developed a microneedle hemostatic sheet based on microneedle technology. We demonstrated the unique features of this microneedle hemostatic sheet, including reduced hemostatic time, biodegradable polymer composition that allows intracorporeal use without increasing infectious risk incorporation of microneedles to fix the sheet to the wound even on the left ventricular wall of a swine while beating, and a mesh structure with flexibility comparable to that of bonding surgical tape and sufficient rigidity to penetrate human aorta tissue and swine left ventricular wall. One potential application of the microneedle hemostatic sheet is intracorporeal topical hemostasis for parenchymatous organs, large vessels, and heart wall during trauma or surgery, in addition to new, widespread applications.

Effect of coronary artery bypass grafting on blood pressure response to head-up tilting.

Blood pressure response to head-up tilt (HUT) in 7 healthy subjects and 9 patients before and after coronary artery bypass grafting (CABG) was measured during supine and 15-min 60° HUT. Stroke volume (SV) and ejection fraction (EF) were assessed by echocardiography. Baseline mean arterial pressure (MAP) and heart rate (HR) in patients before CABG were similar to healthy subjects. MAP in patients decreased by 6 (4-9) mmHg [median (1st-3rd quartiles)] during 7-12 mmHg of HUT with decreased cardiac output (CO = SV × HR) while HR remained unchanged. MAP in healthy subjects remained unchanged during HUT with increased HR. Body weight decreased by 3.5 (2.5-3.7) kg and MAP decreased by 6 (2-13) mmHg during the last 3-min HUT while HR increased after CABG. Decreases in SV and CO during HUT disappeared after CABG. Blood pressure decreased during HUT in patients before and after CABG regardless of HR response.

Functional Evaluation of the Myocardial Ischemia After Coronary Artery Bypass Surgery Using Coronary Flow Velocity Reserve in Left Ventricular Hypertrophy.

Patients with left ventricular hypertrophy (LVH) have reportedly higher than normal mortality and incidences of cardiovascular events. Coronary microvascular pathophysiology also appears to differ from other populations. Such coronary microcirculation dysfunctions are considered strong causes of cardiac events. We compare the functional improvement of myocardial ischemia between LVH patients and other patients after successful coronary artery bypass surgery (CABG) using coronary flow velocity reserve (CFVR) by transthoracic echo cardiography. Patients who underwent isolated coronary artery bypass surgery, including left anterior descending artery (LAD) revascularization via "in situ" internal thoracic artery (ITA) between June 2008 and July 2017 (n = 155), were retrospectively reviewed. ITA grafts were patent in postoperative graft evaluation in all patients. CFVR was evaluated pre- and postoperatively, and data were compared between patients with severe LVH group and those without (non-LVH group). Preoperative mean CFVR was 1.77 ± 0.75 in LVH group and 1.91 ± 0.63 in non-LVH group (P = 0.188). After the operation, ITA to LAD graft patency was confirmed in all patients. Postoperative CFVR was 2.23 ± 0.70 in LVH group and 2.85 ± 0.71 in non-LVH group, respectively (P = 0.002). Significant difference was observed between the 2 groups. CFVR values improved after ITA to LAD bypass grafting in both LVH and non-LVH groups, but postoperative CFVR was significantly lower in patients with severe LVH than in patients without. Myocardial ischemia may exist in patients with LVH, despite patent graft, due to microvascular dysfunction. Comprehensive treatment, including long-term oral medication to improve microvascular dysfunction, is necessary for patients with LVH.