[On-pump Beating Minimally Invasive Cardiac Surgery Valve Plasty for Infective Endocarditis Located in the Tricuspid Valve:Report of a Case].

The patient is a 50-year-old man. He was healthy by nature, had fever in the 38 ℃ range for about a week, blood culture identified methicillin-sensitive Staphylococcus aureus( MSSA), and ultrasoundcardiography(UCG) showed a 10 mm vegetation adherent to the tricuspid valve, which led to the diagnosis of infective endocarditis. The patient was transferred to our hospital for surgery because UCG showed severe tricuspid regurgitation and the vegetation enlarged to 20 mm in size. We resected the posterior apex with vegetation attachment and performed tricuspid valve plasty using the Kay stitches, and the regurgitation disappeared. The patient continued additional antimicrobial therapy and was discharged without any complications at 30 days after operation. Tricuspid valve surgery was considered to be a safe procedure that could be performed at minimally invasive cardiac surgery.

Effect of nadir hematocrit during cardiopulmonary bypass on the early outcomes after surgical repair of acute type A aortic dissection.

OBJECTIVE: Although hemodilution during hypothermic cardiopulmonary bypass (CPB) had been thought to improve microcirculation and reduce blood viscosity, there has been no report investigating the effect of low nadir hematocrit (Hct) values caused by severe hemodilution on the surgical outcomes of patients with acute type A aortic dissection (ATAAD). METHODS: We retrospectively reviewed 112 consecutive patients who emergently underwent emergency surgical repair of ATAAD at our institution. The patients were classified into the high Hct (nadir Hct ≥ 21% during CPB; n = 51) and low Hct (nadir Hct < 21% during CPB; n = 61) groups. After propensity score matching of preoperative characteristics, surgical outcomes were compared between the groups. RESULTS: Although there was no difference in the surgical procedure, longer CPB time and more blood transfusion during surgery were needed in the low Hct group than in the high Hct group. After surgery, estimated glomerular filtration rate was significantly lower (p = .015), lactaic acid was higher (p = .045), and intubation time was longer (p = .018) in the low Hct group than in the high Hct group, although there was no difference in hospital mortality between the groups. The AUC of the nadir Hct during CPB as a prognostic indicator of prolonged postoperative ventilator support was 0.8, with the highest accuracy at 16.7% (sensitivity 88%, specificity 76.9%). In all cohorts, female sex was an independent risk factor for a lower nadir Hct value of <21% during CPB. CONCLUSION: A lower nadir Hct value of <21% during CPB may be associated with postoperative renal dysfunction and prolonged ventilator support in patients with ATAAD.

Aortic Agatston score correlates with the progression of acute type A aortic dissection.

Aortic calcification in the tunica media is correlated with aortic stiffness, elastin degradation, and wall shear stress. The study aim was to determine if aortic calcifications influence disease progression in patients with acute type A aortic dissection (ATAAD). We retrospectively reviewed a total of 103 consecutive patients who had undergone surgery for ATAAD at our institution between January 2009 and December 2019. Of these, 85 patients who had preoperatively undergone plain computed tomography angiography (CTA) for evaluation of their aortic calcification were included. Moreover, we assessed the progression of aortic dissection after surgery via postoperative CTA. Using a classification and regression tree to identify aortic Agatston score thresholds predictive of disease progression, the patients were classified into high-score (Agatston score ≥ 3344; n  =   36) and low-score (<3344; n  =   49) groups. Correlations between aortic Agatston scores and CTA variables were assessed. Higher aortic Agatston scores were significantly correlated with the smaller distal extent of aortic dissection (p < 0.001), larger true lumen areas of the ascending (p  =  0.009) and descending aorta (p =   0.002), and smaller false lumen areas of the descending aorta (p =  0.028). Patients in the high-score group were more likely to have DeBakey type II dissection (p =  0.001) and false lumen thrombosis (p  =  0.027) than those in the low-score group, thereby confirming the correlations. Aortic dissection in the high-score group was significantly less distally extended (p < 0.001). A higher aortic Agatston score correlates with the larger true lumen area of the ascending and descending aorta and the less distal progression of aortic dissection in patients with ATAAD. Interestingly, the findings before and after surgery were consistent. Hence, aortic Agatston scores are associated with aortic dissection progression and may help predict postoperative residual dissected aorta remodeling.

[Rapid Growing Thoracic Aortic Aneurysm in a Patient with Relapsing Polychondritis].

A 26-year-old man with relapsing polychondritis was admitted for the treatment of multiple thoracic aortic aneurysms in the ascending and descending aorta. Descending thoracic aortic aneurysm showed rapid expansion, therefore, the patient underwent an extended thoracic aortic repair from the ascending aorta to the descending aorta via anterolateral thoracotomy and partial sternotomy. Although postoperative course was uneventful, aortic root enlargement and severe aortic insufficiency progressed over the next two years. He and his family refused redo surgical intervention and the patient died of heart failure. Careful perioperative follow-up may be mandatory in a patient with relapsing polychondritis complicated by cardiovascular disease.

[Revascularization of the Right Common Carotid Artery Prior to Central Repair for Stanford Type A Acute Aortic Dissection with Brain Malperfusion:Report of a Case].

A 67-year-old woman had sudden loss of consciousness and chest and back pain. She was transported by ambulance about two hours later. Computed tomography (CT) showed dissection of the aorta, the brachiocephalic artery and the right common carotid artery (RCCA). RCCA was completely obstructed. Emergency surgery was conducted one hour later. RCCA's blood flow was reestablished prior to hemi-arch replacement. Postoperative CT revealed diminishment of the false lumen and recovery of the blood flow of RCCA, and she was discharged on foot without any complications.

Physical activities and surgical outcomes in elderly patients with acute type A aortic dissection.

OBJECTIVE: Although elderly patients undergoing surgery for acute type A aortic dissection (ATAAD) is increasing, their physical activities are not fully understood. We report the physical activities and surgical outcomes in elderly patients who underwent ATAAD. METHODS: From 2009 to 2019, 103 consecutive patients underwent surgery for ATAAD at our institution. Surgical outcomes along with pre- and postoperative physical activities in 52 elderly patients (≥70 years old) were compared with those in 51 younger patients (<70 years old). Postoperative walking difficulty was defined as taking ≥30 days to regain the ability to walk 200 m postoperatively or as the inability to walk at discharge. RESULTS: It took longer for elderly patients to regain the ability to walk 100 or 200 m postoperatively. ROC analysis revealed the AUC of the duration for walking 200 m postoperatively as a prognostic indicator for late deaths was 0.878, with the highest accuracy at 30 days (sensitivity = 83.3%, specificity = 91.8%). Hospital mortality within 30 days was 3.8%, and 1-, 3-, and 5-years survival rates were 92%, 84.7%, 84.7%, respectively, for elderly patients, with no significant differences between groups. Cox proportional hazard analysis showed postoperative walking difficulty was an independent risk factor for late mortality in all cohorts (p = .017). CONCLUSIONS: Elderly patients undergoing surgical ATAAD repair showed acceptable surgical outcomes. However, they were more likely to decrease their physical activities postoperatively. Postoperative difficulty in walking was an independent risk factor for the late mortality in patients with ATAAD.

[Patch Repair by Anterolateral Thoracotomy with Partial Sternotomy for Saccular Aortic Arch Aneurysm with Severe Thoracic Deformity:Report of a Case].

An 87-year-old male was referred to our hospital for surgery of saccular aortic arch aneurysm. As he had a history of thoracoplasty on his left side due to pulmonary tuberculosis, his aortic arch adhered to the apex of the left thorax. Total arch replacement(TAR) via median sternotomy was considered difficult, and anterolateral thoracotomy with partial sternotomy (ALPS) was performed. During surgery, we considered TAR difficult even with ALPS approach. Taking account of his age, aneurysmectomy and patch repair were chosen instead of TAR to shorten operation time. Although he suffered from diffuse cerebral infarction, he was discharged without neurological deficit at 39 days after operation.

Forced expression of miR-143 and -145 in cardiomyocytes induces cardiomyopathy with a reductive redox shift.

BACKGROUND: Animal model studies show that reductive stress is involved in cardiomyopathy and myopathy, but the exact physiological relevance remains unknown. In addition, the microRNAs miR-143 and miR-145 have been shown to be upregulated in cardiac diseases, but the underlying mechanisms associated with these regulators have yet to be explored. METHODS: We developed transgenic mouse lines expressing exogenous miR-143 and miR-145 under the control of the alpha-myosin heavy chain (αMHC) promoter/enhancer. RESULTS: The two transgenic lines showed dilated cardiomyopathy-like characteristics and early lethality with markedly increased expression of miR-143. The expression of hexokinase 2 (HK2), a cardioprotective gene that is a target of miR-143, was strongly suppressed in the transgenic hearts, but the in vitro HK activity and adenosine triphosphate (ATP) content were comparable to those observed in wild-type mice. In addition, transgenic complementation of HK2 expression did not reduce mortality rates. Although HK2 is crucial for the pentose phosphate pathway (PPP) and glycolysis, the ratio of reduced glutathione (GSH) to oxidized glutathione (GSSG) was unexpectedly higher in the hearts of transgenic mice. The expression of gamma-glutamylcysteine synthetase heavy subunit (γ-GCSc) and the in vitro activity of glutathione reductase (GR) were also higher, suggesting that the recycling of GSH and its de novo biosynthesis were augmented in transgenic hearts. Furthermore, the expression levels of glucose-6-phosphate dehydrogenase (G6PD, a rate-limiting enzyme for the PPP) and p62/SQSTM1 (a potent inducer of glycolysis and glutathione production) were elevated, while p62/SQSTM1 was upregulated at the mRNA level rather than as a result of autophagy inhibition. Consistent with this observation, nuclear factor erythroid-2 related factor 2 (Nrf2), Jun N-terminal kinase (JNK) and inositol-requiring enzyme 1 alpha (IRE1α) were activated, all of which are known to induce p62/SQSTM1 expression. CONCLUSIONS: Overexpression of miR-143 and miR-145 leads to a unique dilated cardiomyopathy phenotype with a reductive redox shift despite marked downregulation of HK2 expression. Reductive stress may be involved in a wider range of cardiomyopathies than previously thought.

Risk factors for spinal cord injury in patients undergoing frozen elephant trunk technique for acute aortic dissection.

BACKGROUND: The purpose of this study was to evaluate the risk factors for spinal cord injury (SCI) in patients with acute aortic dissection undergoing surgery with frozen elephant trunk technique (FET). METHODS: From December 2014 to February 2018, 17 patients with acute aortic dissection underwent surgical treatment of the aortic arch with FET. SCI occurred in 3 patients. Risk factors for SCI were evaluated. RESULTS: Mean age of the patients was 56 years and 88.2% were male. The ratio of true lumen to total aortic diameter at the level of carina (before: 0.48 vs. after: 0.75, P < 0.001), aortic valve (before: 0.47 vs. after: 0.67, P = 0.001), and celiac artery (before: 0.48 vs. after: 0.68, P = 0.003) increased after surgery. There were no significant differences in perioperative minimum hemoglobin level and postoperative mean arterial pressure between patients with and without SCI. However, patients with SCI had higher creatinine level before surgery (SCI: 1.32 mg/dL vs. no SCI: 0.81 mg/dL, P = 0.023). Although there was no difference in number of patent intercostal arteries before surgery, those originating from the true lumen were fewer in patients with SCI (SCI: 2.7 vs. no SCI: 8.6, P = 0.021). Furthermore, with entry closure, significant decrease in patency was observed in intercostal arteries originating from the false lumen (before: 3.1 vs. after: 1.0, P < 0.001). CONCLUSION: FET was useful in entry closure. However, FET in patients with higher creatinine level and those who may have significant spinal cord perfusion from the false lumen could be a risk factor for postoperative SCI.

Off-pump coronary artery bypass grafting via left anterior thoracotomy from the 4th costal space in a patient with total laryngectomy and a permanent tracheostoma.

Median sternotomy is the standard approach for coronary artery bypass grafting. Herein, we performed off-pump coronary artery bypass grafting via left anterior thoracotomy from the 4th costal space in an unstable angina pectoris patient with total laryngectomy and a permanent tracheostoma. In this patient, median sternotomy had high risks of surgical-site infection and tracheal injury. To avoid these risks, we selected left anterior thoracotomy. Initially, it was difficult to expose the ascending aorta and postdescending branch. With extension of the skin incision to the median area and division of the 5th and 6th ribs and costal arch, we could expose the anastomotic sites, including the ascending aorta and postdescending branch, without median sternotomy conversion. We performed multiple coronary artery bypass graft procedures safely. This approach might be an additional surgical option in patients with total laryngectomy and a permanent tracheostoma.

[Pseudoaneurysm with Infective Endocarditis Ten Years After the Resection of Pseudoaneurysm Complicated with Myocardial Infarction;Report of a Case].

A 76-year-old female was referred to our hospital for fever and chillness. She was diagnosed with pneumonia and sepsis, and methicillin-resistant Staphylococcus aureus (MRSA)was detected by the sputum culture. Echocardiography showed mobile vegetation and left ventricular pseudoaneurysm at the apex. As she had a history of ventricular pseudoaneurysmectomy 10 years before, we considered the patient had developed infective endocarditis at the surgical site. Surgical treatment was needed because of the rapidly growing pseudoaneurysm despite the use of antibacterial agents. She successfully underwent resection of the pseudoaneurysm and MRSA was also detected in the culture of the previous vascular graft patch. Antibacterial agents were administrated for 6 weeks, and she was discharged at 53 days after operation.

Surgical outcomes of acute type A aortic dissection in dialysis patients.

BACKGROUND: Acute type A aortic dissection (ATAAD) is relatively uncommon in dialysis patients, and characteristics and repair outcomes are not fully understood. PATIENTS AND METHODS: Patients with ATAAD (n = 960) were divided into a dialysis group (n = 19) and non-dialysis group (n = 941), depending on whether they required dialysis for preoperative end-stage renal disease (ESRD). Hospital charts and imaging data were reviewed, and characteristics and outcomes were compared between the groups. Segmental aortic wall or intima/media flap calcification in the thoracic and abdominal aorta was assessed in the dialysis patients. RESULTS: The leading primary causes of ESRD were polycystic kidney disease (n = 5) and chronic glomerulonephritis (n = 5). There were no significant differences (dialysis group vs. non-dialysis group) in age (60.5 vs. 64.5 years), preoperative hemodynamics, or organ ischemia. Dialysis patients were more likely to have an entry tear in the aortic arch (42% vs. 15%, p = 0.003). These patients showed moderate-to-severe calcification (multiple focal or single focal calcification > 10 mm) in the ascending aorta (17%), aortic arch (61%), descending aorta (67%), and abdominal aorta (83%). Arch replacement was common in this group (37% vs. 18%, p = 0.030). Although in-hospital mortality was increased in this group (21% vs. 7%, p = 0.059), morbidities did not differ significantly. Six-year survival was 60.3 ± 13.4% and 78.8 ± 1.6%, respectively (p = 0.01). CONCLUSIONS: Dialysis patients tend to have aortic calcification and a primary tear in the aortic arch. Outcomes are acceptable.

[Combined Thoraco-abdominal Aortic Aneurysm Repair and Coronary Artery Bypass Grafting through a Left Thoracotomy].

Approximately 40% of the patients with aortic aneurysm have coronary artery disease(CAD), which is an important factor contributing to early mortality associated with aneurysm surgery. Combined coronary artery bypass grafting (CABG)and aortic aneurysm repair of the ascending aorta to the aortic arch is often performed through a median sternotomy due to a good surgical exposure. However, treatment strategy of thoraco-abdominal aortic aneurysm(TAAA) combined with CAD is often controversial. We report a successful case of a 69-year-old man who underwent TAAA repair and CABG through a left thoracotomy. Left thoracotomy via the 5th intercostal space with para-rectal incision provides a good surgical exposure of the thoraco-abdominal aorta and the left anterior descending artery(LAD). LAD was revascularized with a saphenous vein graft which was anastomosed to the descending aorta, followed by TAAA repair. The postoperative course was uneventful and the patient was discharged on 13th postoperative day without any complications.

Characteristics of Abdominal Aortic Aneurysm in Japanese Patients Aged 50 Years or Younger.

Objective: We investigated the characteristics and surgical outcomes of abdominal aortic aneurysm (AAA), which typically occurs in elderly persons, in Japanese patients aged 50 years or younger. Materials and Methods: Clinical records of 999 patients who underwent open or endovascular repair for AAA at our hospital between 2007 and 2015 were reviewed to identify the clinical characteristics and surgical outcomes of young patients with AAA. The cohort included 14 patients aged 50 years or younger (mean, 40.4 years; young group) and 985 patients aged older than 50 years (mean, 72.8 years; old group). Results: Marfan syndrome, prior aortic dissection, and a history of aortic surgery were more prevalent in the young group, and 50% of the patients in the young group had dissecting aneurysms. All patients in the young group underwent open repair. Overall in-hospital mortality rates were 7.1% (1/14) and 1.9% (19/985) in the young and old groups, respectively (P=0.67). Seven-year survival and aortic event-free survival rates in the young group were 82.5%±11.5%, and 71.2±14.5%, respectively. Conclusion: AAA in patients aged 50 years or younger tended to be associated with Marfan syndrome, a history of aortic surgery, and prior aortic dissection. Early outcomes of AAA among young patients are acceptable, but close postoperative monitoring is important.

[Total Aortic Arch Replacement by Minimally Invasive Approach in a Patient with Permanent Tracheostomy;Report of a Case].

Standard full median sternotomy for total aortic arch replacement in patients with tracheostomy has higher risks for mediastinitis and graft infection. To avoid surgical site infection, it is necessary to keep a sufficient distance between the tracheostomy and the site of surgical skin incision. We herein report a case of a 74-year-old man with permanent tracheostomy after total laryngectomy, who underwent total aortic arch replacement for an aneurysm. Antero-lateral thoracotomy in the 2nd intercostal space with lower partial sternotomy( ALPS approach) provided an enough distance between the tracheostomy and the surgical field. It also provided a good view for surgical procedure and enabled the standard setup of cardiopulmonary bypass with ascending aortic cannulation, venous drainage from the right atrium and the left ventricular venting through the upper right pulmonary vein. The operation was completed in 345 minutes and the patient was discharged on the 11th postoperative day without any complications.

Efficacy of multiple arterial coronary bypass grafting in patients with diabetes mellitus.

OBJECTIVES: Use of the left internal mammary artery in patients with diabetes mellitus and multivessel coronary artery disease is known to improve survival after coronary artery bypass grafting (CABG); however, the survival benefit of multiple arterial grafts (MAGs) in diabetic patients is debated. We investigated the efficacy of CABG performed with MAGs in diabetic patients. METHODS: The overall patient group comprised 2618 consecutive patients who underwent isolated CABG at our hospital between 1990 and 2014. Perioperative characteristics, in-hospital outcomes and long-term outcomes were compared between diabetic (n = 1110) and non-diabetic patients (n = 1508). The long-term outcomes of diabetic and non-diabetic patients were analysed between those who received a single arterial graft (SAG) and those who received MAGs. Both full unmatched patient population and propensity-matched patient population analyses (diabetic cohort = 431 pairs, non-diabetic cohort = 577 pairs) were performed. RESULTS: Preoperative comorbidities were much more common in the diabetic patients than in the non-diabetic patients; however, comorbidities were not associated with in-hospital outcomes (diabetes versus non-diabetes group, in-hospital mortality: 2.2 vs 1.5%; deep sternal wound infection: 2.2 vs 1.8%, P > 0.05). Although survival and freedom from major cardiac and cerebrovascular events (MACCEs) at 15 years were lower in the diabetes group than in the non-diabetes group (survival: 48.6 vs 55.0%, P = 0.019; MACCE-free survival: 40.8 vs 46.1%, P = 0.02), cardiac death-free survival at 15 years was similar (81.7 vs 83.9%, P = 0.24). Overall, 12-year survival was higher in both diabetic and non-diabetic patients treated with MAGs than in those treated with an SAG (64.9 vs 56.8%, P = 0.006, and 71.9 vs 60.5%, P < 0.001). Propensity-matched patient cohort analysis revealed improved 12-year survival with MAGs versus SAG in both the diabetes group (64.9 vs 58.8%, P = 0.041) and non-diabetes group (71.4 vs 63.8%, P = 0.014). Similarly, MACCE-free survival was improved in both groups. CONCLUSIONS: A long-term survival advantage, with no increase in perioperative morbidity, is conferred with the use of multiple arterial bypass grafts not only in non-diabetic patients but also in diabetic patients.

Urgent Surgical Management of Deep Femoral Artery Aneurysm in a Patient with Pre-Vasculo-Behcet Status.

We report a case of deep femoral artery (DFA) aneurysm associated with pre-vasculo-Behcet status. A 34-year-old man with a history of recurring oral and genital ulcers was admitted complaining of worsening left thigh pain over the previous 30 days. Computed tomography showed a left DFA aneurysm (60 mm × 70 mm), concomitant aneurysms in the popliteal and carotid arteries, and deep vein thrombosis. Active pre-vasculo-Behcet status was diagnosed, and DFA ligation was performed urgently. Remission was achieved with postoperative prednisolone and colchicine without vascular complications. DFA aneurysm and vascular pathologies were successfully managed by ligation surgery and medical therapy.

[Valve replacement after omentum flap for medicastinitis;report of a case].

A 71-year-old woman presented with heart failure due to aortic and mitral valve regurgitation. She had developed midiastinitis and graft infection, 15 months before, following replacement of the ascending aorta for acute aortic dissection. Omentum flap operation had been performed and the infection had been controlled. This time, she underwent re-thoracotomy, and replacement of ascending aorta, aortic valve replacement and mitral valve plasty were performed. The omenal tissue was exfoliated without any damage to the heart or the great vessels by using an ultrasonic scalpel. As the omental tissue was viable, it was placed back in the mediastinal space.

[Mitral Valve Replacement under Ventricular Fibrillation through Right Thoracotomy for Severe Mitral Regurgitation with Low Left Ventricular Function after Coronary Artery Bypass Grafting；Report of a Case].

A 64-year-old woman had undergone coronary artery bypass grafting (CABG:left internal thoracic artery-left anterior descending artery, right internal thoracic artery-1st diagonal branch, saphenous vein graft-posterior descending artery) 5 years before. However, she was referred to us due to worsening of dyspnea. Severe mitral regurgitation with tethering and tricuspid regurgitation were observed by echocardiography, and low left ventricular function with ejection fraction of 32.6% was noted. Coronary artery computed tomography revealed patency of all grafts, and the right internal thoracic artery ran across the front of the ascending aorta. To avoid injuring the patent grafts, mitral valve replacement under ventricular fibrillation and tricuspid annuloplasty were performed with a right thoracotomy approach. The postoperative course was uneventful, and she was discharged in an improved state on hospital day 28. This method appears safe and useful for avoiding secondary injuries in patients with severe mitral regurgitation with low left ventricular function after CABG.

Reoperation for enlargement of the distal aorta after initial surgery for acute type A aortic dissection.

OBJECTIVE: We investigated the long-term outcomes of repair for acute type A aortic dissection on the basis of false lumen status and assessed treatment modalities for the enlarged downstream aorta. METHODS: Between January 1990 and March 2013, 534 patients underwent surgery for acute type A aortic dissection. In-hospital mortality was 9.3% (50/534), and follow-up was 98% (472/484). Of the 472 hospital survivors, 451 (96%) underwent contrast-enhanced computed tomography within 1 month of surgery. Risk-adjusted survival and distal aortic events were investigated in these 451 patients. Surgical outcomes of distal reoperations were assessed in 37 patients. RESULTS: Postoperative false lumen patency was 62% (280/451). Eighteen patients died of aortic rupture, 17 (94%) with a patent false lumen. A patent false lumen decreased survival (hazard ratio [HR], 1.70; P = .012) and increased distal aortic events (HR, 4.11; P = .001). Other predictors identified were age (HR, 1.07; P < .001) and male sex (HR, 1.89; P = .002) for late mortality, and Marfan syndrome (HR, 6.6; P < .001), distal aortic diameter greater than 45 mm (HR, 4.4; P < .001), and nonresection of the primary entry (HR, 2.3; P = .005) for distal aortic events. Distal reoperations comprised open repair of the arch (n = 13), descending aorta (n = 16), or thoracoabdominal aorta (n = 7) or thoracic endovascular aortic repair (n = 7), with no in-hospital death or paraplegia. Although thoracic endovascular aortic repair yielded false lumen thrombosis around the stent graft in 80% of patients (4/5), complete false lumen thrombosis was achieved in 20% (1/5). CONCLUSIONS: False lumen patency influences the late outcomes of acute type A aortic dissection repair. Outcomes of distal reoperation were acceptable; thus, careful follow-up and timely reoperation may improve the late outcomes.