Antegrade thoracic endovascular aneurysm repair via the ascending aorta.

PURPOSE: We performed antegrade thoracic endovascular aneurysm repair via the ascending aorta in selected high-risk patients scheduled for open surgery, in whom an iliofemoral or abdominal aortic approach was not feasible. We present our initial experience with this approach. METHODS: Of 16 consecutive patients who underwent antegrade endovascular aneurysm repair via the ascending aorta at our institution, 3 had an emergency intervention for rupture and 3 had an urgent intervention for impending rupture or complicated aortic dissection. The procedure was scheduled in 10 patients. The median patient age was 77 years. In 13 patients, one or more concomitant procedures were performed. In 6 patients, vascular access for endovascular aneurysm repair was obtained via a branch of the replacement graft. In 10 patients, direct cannulation of the ascending aorta was carried out using 2 pursestring sutures. RESULTS: The initial success rate was 100%. Early mortality occurred in 2 (12.5%) patients because of multiple organ failure in one and heart failure in the other. No patient required a second intervention during follow-up. The mean duration of follow-up was 19 months. CONCLUSION: The antegrade approach is a useful alternative in patients with no access suitable for endovascular aneurysm repair and who are not appropriate candidates for open conventional thoracic aortic surgery. This approach is applicable to selected patients.

Impact of concomitant tricuspid regurgitation on long-term outcomes in severe aortic stenosis.

AIMS: Tricuspid regurgitation (TR) has been reported to be associated with worse survival in various heart diseases, but there are few data in aortic stenosis (AS). METHODS AND RESULTS: In the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) Registry enrolling 3815 consecutive patients with severe AS, there were 628 patients with moderate or severe TR (TR group) and 3187 patients with no or mild TR (no TR group). The study patients were subdivided into the initial aortic valve replacement (AVR) stratum (n = 1197) and the conservative stratum (n = 2618) according to treatment strategy. The primary outcome measure was a composite of aortic valve-related death or hospitalization due to heart failure. The 5-year freedom rate from the primary outcome measure was significantly lower in the TR group than in the no TR group (49.1% vs. 67.3%, P < 0.001). Even after adjusting for confounders, the excess risk of TR relative to no TR for the primary outcome measure remained significant [hazard ratio (HR): 1.25, 95% confidence interval (CI): 1.06-1.48; P = 0.008]. The trend for the excess adjusted risk in the TR group was consistent in the initial AVR and the conservative strata (HR 1.55, 95% CI: 0.97-2.48; P = 0.07; HR 1.22, 95% CI: 1.02-1.46; P = 0.03, respectively). In the initial AVR stratum, the 5-year freedom rate from the primary outcome measure was not different between the two groups with (n = 56) or without (n = 91) concomitant tricuspid annuloplasty (61.5% vs. 72.1%, P = 0.48). CONCLUSION: The presence of clinically significant TR concomitant with severe AS is associated with a poor long-term outcome, regardless of the initial treatment strategy.

Early Surgery vs. Surgery After Watchful Waiting for Asymptomatic Severe Aortic Stenosis.

BACKGROUND: There is no large-scale study comparing postoperative mortality after aortic valve replacement (AVR) for asymptomatic severe aortic stenosis (AS) between initial treatment with AVR vs. eventual AVR after conservative management. Methods and Results: We analyzed data from a multicenter registry enrolling 3,815 consecutive patients with severe AS. Of 1,808 asymptomatic patients, 286 patients initially underwent AVR (initial AVR group), and 377 patients were initially managed conservatively and eventually underwent AVR (AVR after watchful waiting group). Mortality after AVR was compared between the 2 groups. Subgroup analysis according to peak aortic jet velocity (Vmax) at diagnosis was also conducted. There was no significant difference between the 2 groups in 5-year overall survival (OS; 86.0% vs. 84.1%, P=0.34) or cardiovascular death-free survival (DFS; 91.3% vs. 91.1%, P=0.61), but on subgroup analysis of patients with Vmax ≥4.5 m/s at diagnosis, the initial AVR group was superior to the AVR after watchful waiting group in both 5-year OS (88.4% vs. 70.6%, P=0.003) and cardiovascular DFS (91.9% vs. 81.7%, P=0.023). CONCLUSIONS: Asymptomatic severe AS patients who underwent AVR after watchful waiting had a postoperative survival rate similar to those who initially underwent AVR. In a subgroup of patients with Vmax ≥4.5 m/s at diagnosis, however, the AVR after watchful waiting group had worse postoperative survival rate than the initial AVR group.

Long-Term Survival After Coverage With Prevertebral Fascia for Abdominal Aortic Stump Closure.

Abdominal aortic graft-enteric fistula is an uncommon but grave complication. Acceptable early results of its management have been reported in recent years, but aortic stump disruption remains a dreaded problem in the remote period. This report describes a case of a 71-year-old male with graft-enteric fistula following after a distant abdominal aortic aneurysm repair. The patient underwent 1-stage operation with extra-anatomic bypass preceding the complete removal of the infected aortic graft and intestinal repair. For coverage of the aortic stump closure, the prevertebral fascia was harvested as a flap and was successfully used to buttress the closure. Additionally, omental wrap was secured around the stump and around the area after complete graft removal. Postoperative intravenous antibiotic with meropenem was administered for 8 weeks, followed by suppression with ongoing oral antibiotic with trimethoprim-sulfamethoxazole for 6 months. Although sigmoidectomy and the left ureteral reconstruction were required, the patient is doing well without recurrent infection and without stump disruption after 8 years of follow-up.

Seamless adaptive servo-ventilation therapy after triple-valve surgery.

A 70-year-old man with severe multivalvular disease, atrial fibrillation, and kyphoscoliosis, had Cheyne-Stokes respiration with central sleep apnea. After triple-valve surgery with the maze procedure, adjunctive adaptive servo-ventilation therapy was initiated on the first postoperative day and continued seamlessly in the postoperative period. Seamless adaptive servo-ventilation therapy as an adjunct to triple-valve surgery is more likely to prevent heart failure remodeling without worsening of pulmonary hypertension and recurrence of atrial fibrillation.

Surgical repair of an acute Stanford type A aortic dissection in a patient with a retrosternal gastric tube.

Cardiovascular surgery in patients with a retrosternal gastric tube (RGT) remains rare despite improvements in the prognosis of oesophageal cancer. A 75-year old woman with a history of total thoracic oesophagectomy with RGT reconstruction required emergency aortic arch replacement for an acute Stanford type A aortic dissection. We opted for a median sternotomy approach involving complete dissection of the RGT from surrounding tissues and retraction for surgical access to the dissection. Enhanced computed tomography was useful for the diagnosis and planning of the emergency surgery.

Small right vertical infra-axillary incision for minimally invasive port-access cardiac surgery: a moving window method.

Port-access cardiac surgery has been developed to minimize skin incision and improve cosmetic outcomes. Using this method, a skin incision is generally made just above where the thoracotomy will be placed, horizontally along the intercostal space at the anterolateral submammary position. However, this type of incision can affect the frontal view and shape of the breast. Here, we report our experience with minimally invasive cardiac surgery using a port-access approach via a small vertical right infra-axillary incision and a moving window method. Twenty patients underwent surgical procedures with this approach from December 2010 to January 2012. Thirteen patients underwent mitral valvuloplasty, four mitral valve replacement, one mitral and tricuspid valve replacement and atrial septal defect closure and two atrial septal defect closure. All surgical procedures were completed using this minimally invasive method. All patients had an uneventful recovery and indicated that they were satisfied with the cosmetic results during the follow-up. Our experience suggests that this technique can effectively minimize skin incision and improve cosmetic outcomes.

[Acute aortic dissection with anomalous coronary artery].

A 38-year-old man was diagnosed with acute type A aortic dissection and severe aortic regurgitation, and taken immediately to the operating room for repair of the ascending aorta using the Bentall procedure. The presence of the anomalous right coronary artery was revealed at the time of the procedure, and was repaired with single coronary button technique. Some case reports have described anomalous coronary artery in association with acute myocardiac infarction or angina pectoris. This report describes a case of anomalous coronary artery diagnosed during an emergency operation for aortic dissection.

Early and late results of surgical treatment for ventricular septal rupture with and without use of the infarction exclusion technique--experience with two- and three-sheet modification.

BACKGROUND: Ventricular septal rupture (VSR) is an infrequent but life-threatening situation. Although outcomes have improved with the introduction of infarction exclusion, we have experienced difficulty in determining the optimal patch size and shape for obtaining good outcomes. Therefore, we modified the infarction exclusion technique. Herein, we review our experience on the basis of early closure of VSR with and without use of the infarction exclusion technique. METHODS: We retrospectively analyzed the hospital records of 33 patients who underwent surgical treatment for VSR. We employed Dagget's method from 1982 to 1995, and then introduced the infarction exclusion technique in 1995. We have developed two modifications: the two-sheet single-patch technique and the three-sheet double-patch technique. RESULTS: Overall hospital mortality was 41.9% and that of the infarction exclusion group was significantly lower than the hospital mortality rate of the noninfarction exclusion group (21% and 63%, respectively, p = 0.0266). Late mortality of survivors was low in all groups during the observation period. The three-sheet double-patch group showed no residual shunt. This difference in outcomes between the single-patch and double-patch groups was statistically significant (p = 0.0174). CONCLUSIONS: The two-sheet method facilitates the restoration of ventricular geometry. A double-patch using the three-sheet method may be useful for reducing residual shunt.

Successful closure of a patent ductus arteriosus using an aortic stent graft.

Closure of patent ductus arteriosus (PDA) in the elderly is a high-risk procedure due to the fragility of the aorta and aneurysmal changes in the ductus. Stent grafting has emerged as a method for treating aortic disease. We describe a case in which this endovascular technique was successfully performed for closure of a PDA with aneurismal change in a high-risk patient. This approach may comprise the armamentarium for treating this pathology in adults.

Congestive heart failure due to coral reef thoracoabdominal aorta.

Acquired coarctation due to coral reefs is a rare and unique entity characterized by extensively calcified thrombus of the entire aorta. There are few reports of coral reef aorta resulting in severely congestive heart failure in the literature. We describe a 60-year-old female with acute heart failure. Computed tomography (CT)-scan and magnetic resonance imaging (MRI) revealed that the cause of the heart failure was cardiac after-load mismatch due to serious stenosis of the aorta. In order to prevent cardio-respiratory failure, an axillofemoral bypass was performed to release the cardiac after-load mismatch. This diminished the pressure gradient between upper and lower blood pressure that caused cardiac dysfunction.

Usefulness of a partial median sternotomy for acute infectious endocarditis in patients with tracheostoma.

Infectious endocarditis patients occasionally need emergency cardiac surgery even if they have a tracheostoma. However, a median full-sternotomy approach carries increased risk for sternal infection and lethal mediastinitis in cardiac surgery for patients with tracheostomas. We successfully performed valve replacement procedures using a lower partial median sternotomy approach in 6 infectious endocarditis patients with tracheostomas. There were neither operative deaths nor complications related to wound infection in these cases. The partial sternotomy approach represents a safe alternative in cardiac surgery for acute infectious endocarditis patients with tracheostomas who need emergent surgery.

Natural killer cells recognize friend retrovirus-infected erythroid progenitor cells through NKG2D-RAE-1 interactions In Vivo.

Natural killer (NK) cells function as early effector cells in the innate immune defense against viral infections and also participate in the regulation of normal and malignant hematopoiesis. NK cell activities have been associated with early clearance of viremia in experimental simian immunodeficiency virus and clinical human immunodeficiency virus type 1 (HIV-1) infections. We have previously shown that NK cells function as major cytotoxic effector cells in vaccine-induced immune protection against Friend virus (FV)-induced leukemia, and NK cell depletion totally abrogates the above protective immunity. However, how NK cells recognize retrovirus-infected cells remains largely unclear. The present study demonstrates a correlation between the expression of the products of retinoic acid early transcript-1 (RAE-1) genes in target cells and their susceptibility to killing by NK cells isolated from FV-infected animals. This killing was abrogated by antibodies blocking the NKG2D receptor in vitro. Further, the expression of RAE-1 proteins on erythroblast surfaces increased early after FV inoculation, and administration of an RAE-1-blocking antibody resulted in increased spleen infectious centers and exaggerated pathology, indicating that FV-infected erythroid cells are recognized by NK cells mainly through the NKG2D-RAE-1 interactions in vivo. Enhanced retroviral replication due to host gene-targeting resulted in markedly increased RAE-1 expression in the absence of massive erythroid cell proliferation, indicating a direct role of retroviral replication in RAE-1 upregulation.

[Application of partial median sternotomy in cardiac surgery in patients with tracheostoma].

Median full-sternotomy carries a risk of sternal infection and lethal mediastinitis in cardiac surgery. We performed open-heart surgery through partial median sternotomy in 5 patients with tracheostomy. Coronary artery bypass grafting (CABG) was performed in 3 patients, aortic valve replacement in 1, and mitral valve replacement in 1. No operative deaths or complications related to wound infection occurred. Partial sternotomy represents a safe alternative in cardiac surgery in patients with tracheostoma.

Successful one-stage operation of aortoesophageal fistula from thoracic aneurysm using a rifampicin-soaked synthetic graft.

Aortoesophageal fistula secondary to thoracic aneurysm is rare, but is usually lethal, and few survivors have been reported. We report successful surgery for aortoesophageal fistula in a one-stage operation. Repair involved in situ replacement of the thoracic aneurysm using a rifampicin-soaked graft, primary repair of the esophagus, omental wrap and tube jejunostomy. This is the original report of the surgical repair of aortoesophageal fistula using a rifampicin-soaked graft.

Massive progression of annuloaortic ectasia in a patient with Takayasu aortitis.

A 52-year-old woman with Takayasu aortitis had undergone coronary artery bypass grafting and left subclavian artery reconstruction two years before admission to the Kinki University Medical Hospital (Osaka, Japan). On this admission, marked annuloaortic ectasia with severe aortic regurgitation was noted on echocardiography and aortography. Because of refractory heart failure, a modified Bentall operation was performed. Considering the serious cardiovascular complications of Takayasu aortitis, such as aneurysmal dilation of the aortic root, coronary artery ostial stenosis and, frequently, the need for surgical intervention, patients should be monitored closely.

Surgical repair for atrial septal defect associated with myotonic dystrophy.

Myotonic dystrophy is a well-known hazard of anesthesia for various kinds of surgery. A 47-year-old male who had an increased CTG repeat of approximately 700 copies in the 3'-untranslated region of the myotonic dystrophy protein kinase gene underwent closure of an atrial septal defect under normothermic beating heart. A strong correlation between reduced left ventricular ejection fraction and stroke volume, and the number of CTG repeats, has been reported. Because this correlation is not completely understood, even if the preoperative cardiac function is normal, it is important to check the number of CTG repeats and the patients who have a large number of them should be carefully treated.

Cardiac tamponade due to a ruptured solitary mediastinal varix: a case report.

Mediastinal varix is rare. Some reports have noted that the mediastinal vein can become varicose in cases of portal hypertension or obstruction of the vena cava. However, solitary mediastinal varices without portal hypertension or obstruction of the vena cava are very rare. Mediastinal varicose veins have been problematic as pseudotumors, as no symptoms have been described in the literature. We encountered a case of cardiac tamponade due to a ruptured solitary mediastinal varicose vein. To the best of our knowledge, this is the first report of sustained symptomatic mediastinal varicose vein.