Safe and promising outcomes of in-hospital preoperative rehabilitation for coronary artery bypass grafting after an acute coronary syndrome.

OBJECTIVE: In patients with stable hemodynamic status after an acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) after preoperative investigations can provide outcomes comparable to those of emergency surgery. However, no established guidelines exist regarding the preparation period before surgery. We report the results of the use of an inpatient cardiac rehabilitation program followed by CABG after an ACS to improve post-operative outcomes and prognosis after discharge. METHODS: From 2005 to 2017, 471 patients underwent either isolated or combined CABG at our institution, and of those, the 393 who received isolated CABG were included in the analysis. Twenty-seven patients (6.9%) were admitted with ACS and underwent preoperative rehabilitation before undergoing CABG, with a subsequent review of surgical morbidity and mortality rates. Propensity score matching yielded a cohort of 26 patients who underwent preoperative rehabilitation (group A) and 26 controls (group B). Preoperative characteristics were similar between groups. RESULTS: The completion rate of the rehabilitation program was 96.3%. All programs were conducted with inpatients, with an average length of stay of 23 ± 12 days. All patients completed in-bed exercises, and 85% completed out-of-bed exercises. The 30-day postoperative mortality was 0% in both groups A and B, and the rate of postoperative major adverse cardiac or cerebrovascular events at 12 months did not differ significantly between groups (7.7% vs 3.9%, respectively; p = 1.0). The duration of mechanical ventilation (1.3 ± 0.3 vs 1.5 ± 0.3 days, respectively; p = 0.633), length of intensive care unit stay (4.4 ± 2.1 vs 4.8 ± 2.3 days, respectively; p = 0.584) and length of hospital stay (25 ± 13 vs 22 ± 9 days, respectively; p = 0.378) did not differ significantly between groups. CONCLUSIONS: No complications of preoperative rehabilitation were observed, suggesting that it is an acceptable option for patients who experience ACS and undergo CABG. These results are promising in offering more robust designs of future trials.

Iatrogenic aortic dissection during aortic root replacement in an older Loeys-Dietz syndrome type III patient with no family history of aortic disease: a case report.

BACKGROUND: Iatrogenic aortic dissection during cardiac surgery is a rare but critical complication. At present, no strategies have been developed to prevent it. We herein report a case of intraoperative aortic dissection during aortic root replacement in an older patient with Loeys-Dietz syndrome type III who had no family history of aortic disease. CASE PRESENTATION: A 60-year-old man was admitted to the hospital for Stanford type B acute aortic dissection and given conservative treatment. He was found to have aortic root dilatation and severe aortic regurgitation. Thus, elective Bentall procedure was performed. Postoperative computed tomography showed new Stanford type A aortic dissection that may have developed due to aortic cannulation during surgery. The patient was given conservative treatment and successfully discharged to home at postoperative day 34. Although he had no family history of aortic disease, a genetic test revealed an unreported SMAD3 frameshift mutation (c.742_749dup, p. Gln252ThrfsTer7), and the patient was diagnosed with Loeys-Dietz syndrome type III. CONCLUSION: In patients with connective tissue disorder, aortic manipulations may become the cause of critical complications. Avoiding the use of invasive techniques, such as cannulation and cross-clamping, and implementing treatment strategies, such as perfusion from other sites than the aorta and open distal anastomosis, can prevent these complications, and may be useful treatment modalities. The possibility of connective tissue disease should be considered even if the patient is older and has no family history of aortic disease.

Surgical treatment for saphenous vein graft aneurysm without redo sternotomy.

BACKGROUND: Saphenous vein graft aneurysm (SVGA) is a rare complication after coronary artery bypass grafting; however, it may lead to fatal conditions. A redo sternotomy poses a high risk of injury to the patent graft. CASE REPORT: A 59-year-old man with chest pain was diagnosed with a giant SVGA (67 mm) anastomosed to the right coronary artery (RCA) and compressing the right atrium. Considering the high risk of injury to a patent graft through the sternum, a surgical procedure was planned without redo sternotomy. Through an upper midline abdominal incision, redo bypass grafting was performed to the distal RCA using the right gastroepiploic artery, followed by resection of the aneurysm using the right anterior lateral thoracotomy approach. The postoperative course was uneventful. CONCLUSION: In patients with an SVGA anastomosed to the right coronary system, our surgical strategy may be a useful alternative to redo sternotomy to avoid injury to the patent graft.

The use of prophylactic intra-aortic balloon pump in high-risk patients undergoing coronary artery bypass grafting.

OBJECTIVE: Intra-aortic balloon pump (IABP) is one of the most commonly used mechanical circulatory assist devices for high-risk patients undergoing cardiac surgery. In an effort to validate previously reported clinical outcomes, we describe the preoperative characteristics and outcomes of patients who underwent prophylactic IABP in high-risk patients undergoing coronary artery bypass grafting (CABG). DESIGN: A prospective observational study. METHODS: From 2005 to 2017, 471 patients underwent either isolated or combined CABG at our institution. Of those, 393 patients underwent isolated CABG and were included for the analysis. Eighty-five patients (22%) were considered high-risk and underwent prophylactic IABP, with subsequent review of surgical morbidity and mortality rates. RESULTS: The 30-day postoperative mortality (prophylactic IABP group vs non prophylactic IABP group: 0% vs 1.6%, p = 0.589) and major adverse cardiac or cerebrovascular events (5.9% vs 3.3%, p = 0.333) were not significantly different between the two groups. Prolonged mechanical ventilation (>72 hours) (12.5% vs 4.2%, p = 0.014) occurred more frequently in the prophylactic IABP group. CONCLUSIONS: No IABP-related complications were noted, emphasizing that the use of prophylactic IABP in high-risk patients undergoing CABG is an acceptable option.

[Clinical characteristics of biliary tract infection and acalculous cholecystitis after cardiovascular surgery].

Biliary tract infection (BTI) including acalculous cholecystitis is a rare but life-threatening complication after cardiovascular surgery. The objective of our study was to describe epidemiology, clinical characteristics, and risk factors of BTI after cardiovascular surgery. From January 2007 to December 2011, 586 consecutive patients(age68±11;397 men,189 women)were enrolled in this study. BTI was diagnosed according to Centers for Disease Control and Prevention (CDC) surveillance criteria for healthcare associated infection. Data collection included preoperative, intraoperative, and post-operative variables. The overall incidence of BTI was 3.9%. The mortality in BTI group was significantly higher than that in non-BTI group (17.1% vs 5.5%, p<0.05). Multi-logistic analysis revealed that operation of the thoracic aorta( p<0.05) and massive transfusion(p<0.01) were independent risk factors for BTI after cardiovascular surgery.

[Left ventricular outflow tract obstruction after mitral valve plasty; report of a case].

A 65-year-old female was admitted to our hospital with mitral regurgitation (MR). Transthoracic echocardiography showed severe mitral valve prolapse and subaortic septal hypertrophy with no pressure gradient. Mitral valve plasty consisted of artificial chorda implantation and ring annuloplasty was performed. During intensive care unit( ICU) stay after operation, systolic murmur and low cardiac output syndrome were noted and echocardiography revealed left ventricular outflow tract obstruction (LVOTO) without systolic anterior motion and MR. Cessation of catecholamine, volume administration, beta-blocker and negative inotropic drug like cibenzoline rapidly reduced LVOTO and the hemodynamic condition was improved. Even in a case of subaortic septal hypertrophy with no pressure gradient, emergence of LVOTO should be considered when new systolic murmur and low cardiac output syndrome appeared.

[Procalcitonin as a marker of the postoperative infection in cardiovascular surgery].

BACKGROUND: Procalcitonin( PCT) is a new diagnostic marker of severe bacterial infection and sepsis. PURPOSE: To evaluate the usefulness of PCT in patients with suspicion of bacterial infection after cardiovascular surgery. METHODS: From January 2012 to December 2012, 150 consecutive patients after cardiovascular surgery were studied retrospectively. Postoperative infection was diagnosed under Centers for Disease Control and Prevention (CDC) guideline for healthcare associated infection, and biomarker levels and microbiological specimen were evaluated. RESULTS: Only blood stream infection group revealed higher PCT levels( median 5.0 ng/ml) than non blood stream infection group( median 0.1 ng/ml)[p<0.01]. CONCLUSION: PCT is the best biomarker available for the clinical diagnosis of blood stream infection after cardiovascular surgery.

[Modified warden procedure for partial anomalous pulmonary venous connection in an adult].

A 46-year-old woman was admitted to our hospital because of congestive heart failure and atrial fibrillation. She had undergone atrial septal defect repair at the age of 7 years. Computed tomography( CT)scan revealed right upper pulmonary vein returned to superior vena cave and the left upper pulmonary vein returned to the innominate vein. Cardiac catheterization showed Qp/Qs of 2.6. Pulmonary venous drainage repair and right-sided maze procedure was planned. The right upper pulmonary vein was led to the left atrium using the modified Warden Procedure. The left upper pulmonary vein was divided and anastomosed to the left atrial appendage. Concomitantly right-sided maze procedure was performed. Postoperative course was uneventful and CT scan revealed no stenosis at anastomotic sites. Sinus rhythm was retained and she was discharged on postoperative day 30.

[Aortic valve replacement after percutaneous transcatheter aortic valvuloplasty for severe aortic stenosis].

BACKGROUND: Aortic valve replacement( AVR) is a definitive treatment in patients with severely calcified aortic stenosis (AS). However, elderly patients with multiple comorbidities are considered to be unsuitable for AVR. Percutaneous transcatheter aortic valvuloplasty( PTAV) has been performed as a palliative option to relieve symptoms or to be a bridge use toward definitive therapy. This study aimed to examine the effectiveness and clinical outcome of surgical AVR subsequent to PTAV. PATIENTS AND METHODS: Since 2010, 5 symptomatic patients have undergone AVR after PTAV in our institution. PTAV was performed as a bridge to definitive AVR in 2 patients. Other 2 patients developed symptomatic aortic valve restenosis during a follow-up, and required AVR. In the last patient,AVR was carried out after successful noncardiac surgery subsequent to PTAV. RESULTS: AVR improved cardiac hemodynamics in all patients. There was no operative death. Postoperative course was uneventful and all patients were discharged on foot except for 1 patient in whom metastatic liver tumor from advanced gastric cancer was noted. CONCLUSION: AVR might be performed safely even in high-risk patients with the history of PTAV. PTAV is useful as a palliation or a bridge to definitive therapy for treatment of patients with severe AS unsuitable for surgery.

[Aortopulmonary fistula caused by aortic arch aneurysm rupture presenting severe left to right shunt and congestive heart failure].

A 74-year-old female was admitted to our hospital due to hyperkinetic congestive heart failure. Noninvasive positive pressure ventilation, continuous hemodialysis and inotropic support were needed preoperatively. Computed tomography revealed saccular aortic arch aneurysm with aortopulmonary fistula toward the left pulmonary artery. Cardiac catheterization revealed severe left to right shunt with the pulmonary flow/systemic flow (Qp/Qs) ratio of 6.2.Emergency operation was performed under hypothermic circulatory arrest followed by selective cerebral perfusion and lower body perfusion. The aortopulmonary fistula was directly closed, reinforced with the aneurysmal wall, and total arch replacement was performed. Although the patient temporarily recovered by endoscopic suction of the blood from the lungs and continuous hemodialysis filtration, she died because of multiple organ failure due to mesenteric ischemia on postoperative day 34.

[Bilateral pulmonary artery banding for complex congenital heart disease in a patient with trisomy 13; report of a case].

We described a case of a neonate of 13 trisomy with hypoplastic aortic arch and multiple ventricular septal defect (VSD). The patient presented symptoms of congestive heart failure due to pulmonary high flow. Because of ductal patency without prostaglandin infusion, bilateral pulmonary artery banding was performed for regulation of pulmonary high flow. Surgical intervention improved the clinical symptoms of the patient and permitted the patient to be discharged. We concluded that palliative surgery for the patient contributes to improve the quality of life both the patient and the family. This is the 1st report of bilateral pulmonary artery banding for a patient with 13 trisomy.

[Effectiveness of simultaneous cardiac resynchronization therapy in surgical valvular patients with severe heart failure].

BACKGROUND: Cardiac resynchronization therapy (CRT)has been accepted broadly as an alternative to medical treatment in managing severe heart failure patients. Despite advance in CRT, the presence of a significant valvular heart disease was currently specific exclusion criteria and a response to this therapy remains unclear. The purpose of this study was to determine the effectiveness of CRT in heart failure patients undergoing valvular operation simultaneously. PATIENTS AND METHODS: Between July 2010 and May 2012, 8 heart failure patients who underwent CRT in conjunction with valvular surgery were experienced. Right and left ventricular and atrial epicardial leads were implanted after completion of valvular procedures. In patients with chronic atrial fibrillation(Af),maze procedure was performed in order to eliminate Af. To evaluate the improvement of ventricular mechanical dyssynchrony, the echocardiographic assessment was repeated on admission and 1 month after the CRT implantation. RESULTS: There was no operative death. One patient of ischemic cardiomyopathy died of sustained ventricular tachycardia 2 months after the operation. Postoperative course of severe heart failure patients was uneventful and all patients except 1 discharged on foot with improved New York Heart Association (NYHA) class. Echocardiographic parameters of dyssynchrony did not reach to statistical significance, but several parameters, left ventricular( LV)-pre-ejectionperiod( PEP) and interventricular mechanical delay (IVMD) showing time delay of cardiac contraction, tended to be improve, suggesting contribution to satisfactory postoperative course. CONCLUSION: The acceptable outcome was demonstrated with our concept to recover the intraventricular and atrioventricular synchrony. Although it might be difficult to establish the patient selection criteria for concomitant CRT and valvular surgery, our strategy is considered to be a feasible procedure to improve the morbidity and mortality in patients with severe heart failure due to valvular disease.

[Successful repair of descending aortic aneurysm with narrowed elephant trunk after total arch replacement; report of a case].

A 40-year-old man had undergone total arch replacement using the elephant trunk technique. Three years after the initial operation, stenosis of the elephant trunk due to enlargement of a false lumen was detected. Replacement of the descending thoracic aorta was performed. A narrow segment of the elephant trunk was compressed by old hematoma and lapped around the connective tissue. A new graft was anastomosed to the narrow segment of the elephant trunk in an end-to-side fashion. Postoperative course was uneventful, and he was discharged 18 days after the operation.

[Pericardial defect incidentaly noticed during off-pump coronary artery bypass grafting; report of a case].

We experienced a rare case of congenital pericardial defect incidentally found during off-pump coronary artery bypass grafting (CABG)[OPCAB]. We performed off-pump for a 61-year-old man. He was asymptomatic but was noted to have an abnormal chest X-ray showing the enlarged heart. He had right ventricule lifting upward and apex shifting far to left side. Partial absence of the left pericardium was found. The surgery was technically more demanding than usual, because of heart rotation and inadequate pericardial stitch.

[Minimally invasive cardiac surgery with the aid of three-dimensional computed tomography(3DCT) image projection on the body surface].

Port-access minimally invasive cardiac surgery (MICS) is complicated by limited skin incision and surgical field. In order to optimize the set-up and port placement in this surgery, we have employed image overlay technique prior to operation consisted of three-dimentional computed tomography (3DCT)image projection on the patient surface. With the aid of this technique, we successfully performed port-access MICS in 12 patients and mitral valve replacement in 1 patient with severe mediastinal displacement after previous pneumonectomy. Image overlay projection could allow surgeons to view underlying anatomical structures virtually and obtain a good operative field. Our proposed technique would be expected to make port-access MICS easier and probably safer in this particular circumstance.

[Successful surgical treatment for aortic valve regurgitation and thoracoabdominal aortic aneurysm in a patient with homozygous familial hypercholesterolemia; report of a case].

A 46-year-old woman with homozygous familial hypercholesterolemia was referred due to aortic regurgitation. The patient was introduced selective low density lipoprotein cholesterol(LDL)apheresis 20 years ago. Echocardiogram revealed severe aortic regurgitation, and computed tomography revealed thoracoabdominal aortic aneurysm. We considered 2 staged operations were necessitated. Firstly, aortic valve replacement was performed. Emergent coronary artery bypass grafting was also done because intraoperative myocardial ischemia was strongly suspected from left ventricular hypokinesis. One year later, replacement of thoracoabdominal aorta was performed. Post-operative course was uneventful and the patient was discharged at post-operative day 21. The patients with homozygous familial hypercholesterolemia must be strictly followed up because systemic atherosclerosis frequently exacerbates despite selective LDL apheresis.

[Intraoperative cerebral malperfusion complicated with axillary artery cannulation].

To minimize the risk of malperfusion, axillary arterial cannulation which avoids retrograde flow, has been widely used in patients undergoing operations for various types of aortic pathologies. Despite several advantages of this technique, cerebral malperfusion is getting known and might be due to newly developed arterial damage or dissection. Eighty-four patients underwent cannulation of the axillary artery in recent 5 years. Malperfusion occurred in 3 patients with significant regional cerebral oxygen desaturation during operation. Axillary arterial perfusion was stopped and oxygen saturation was elevated immediately. The perfusion was switched to the femoral artery and following procedure was completed. Although axillary arterial cannulation is an attractive alternative, neither axillary nor femoral arterial perfusion is perfect to avoid the cerebral malperfusion. Whichever perfusion site is used, special care should be taken for intraoperative finding and appropriate use of each techniques.

[Redo ascending aorta replacement using a homograft for graft infection caused by methicillin-resistant Staphylococcus aureus; report of an emergently air-transferred case just after Great East Japan Earthquake].

We describe a case of replacement with a cryopreserved homograft for graft infection. A 48-year-old man had been performed ascending aorta replacement using woven dacron graft for type A aortic dissection. Two months ago, methicillin-resistant Staphylococcus aureus infection was suspected because of high-grade fever. Computed tomography (CT) scan revealed abscess formation around the prosthetic graft and redo operation using cryopreserved homograft was scheduled to avoid re-infection into mediastinum at Tohoku University Hospital, an institute cooperating with University of Tokyo tissue bank. However, Catastrophic Great East Japan Earthquake occurred the day before the scheduled date, and the patient could not have an operation at the institution. He was transferred to our hospital by helicopter. Then homograft was successfully implanted in ascending aorta after complete excision of infectious graft.

[Re-do operation for coronary stenosis after Cabrol procedure; report of a case].

The Cabrol technique has been used to reimplant coronary arteries at the time of aortic root replacement. We describe a case of coronary stenosis after Cabrol procedure. A 42-year-old female with Marfan syndrome and chronic type B dissection who underwent aortic root replacement with Cabrol procedure complained of chest pain. Computed tomography( CT) showed extended thoraco-abdominal aortic aneurysm. Angiography revealed bilateral Cabrol limb stenosis at anastomotic sites. Re-do operation was performed under median re-sternotomy. Pannus around the coronary anastomosis was resected and patch extension using bovine pericardium was performed. Reconstruction of coronary arteries was completed by Piehler procedure and total arch replacement with elephant trunk technique was concomitantly performed. Post-operative course was uneventful. CT revealed the release from coronary stenosis.

[Our technical modification of aortic valve sparing operation focused on standardization and reproducibility].

BACKGROUND: The aortic valve-sparing operation has been accepted as an ideal procedure for the treatment of aortic root aneurysm, especially in young patients. However, this operation is thought to be technically difficult due to lack of conceptual understanding of the procedure for many surgeons. In order to overcome the surgical problem, we have developed a simple valve-sparing aortic root replacement focused on standardization and reproducibility. METHODS: Seven consecutive patients underwent the aortic valve-sparing operation in our institution.Our surgical strategy to restore valvular competency is based on the concept of inserting a dilated aortic annulus into small sized graft. Regardless of annular diameter, the Valvalva graft of 26 mm was used in all patients. Proximal end of the graft is secured on the outside of the left ventricular outflow tract with 12 mattress sutures. The 3 commissures are suspended upward inside the graft as possible. The remnants of aortic sinuses are sutured to the graft in U-shaped manner using continuous suture line. If necessary, aortic cusp repair was performed. Coronary arteries are reconstructed by Piehler's method. RESULTS: There was no operative death. Valve-sparing procedure was completed without conversion to valve replacement and no significant postoperative aortic insufficiency was noted. CONCLUSIONS: The excellent outcome was demonstrated with our simple modification. Although we recommend this technique of the aortic valve-sparing procedure which is reproducible and technically less demanding, close observation would be mandatory concerning with valvular durability in this particular circumstance.