Surgical strategy of IgG4-related inflammatory abdominal aortic aneurysm with preoperative steroid therapy: A case report.

Immunoglobulin G4 (IgG4)-related disease, characterized by high serum IgG4 concentrations and IgG4-positive plasma cell infiltration, often presents as an inflammatory aneurysm. We herein report the case of a 78 year-old man, presenting with elevated inflammatory markers and IgG4 concentrations, who was diagnosed with IgG4-related inflammatory abdominal aortic aneurysm with dense perianeurysmal fibrosis. Before the surgical intervention, steroid therapy was administered to resolve his perianeurysmal inflammatory fibrosis. Half a year after the initiation of steroid therapy, there was an improvement in serum inflammatory markers and IgG4 concentrations, and the perianeurysmal fibrosis had regressed. Thus, we performed a surgical intervention including resection of the aneurysm and interposition with a prosthetic graft. Histopathological examination demonstrated few IgG4-positive plasma cells were distributed in the adventitia, which was suspected to be associated with the preoperative steroid therapy. This case study suggests preoperative steroid therapy is a useful therapeutic strategy for IgG4-related abdominal aortic aneurysm because it allows the use of open surgical procedures with reduced surgical risk.

Surgical Management of Incidental Profunda Femoris Artery Aneurysm: A Case Report.

Profunda femoris artery aneurysm is a rare vascular disorder, which is often diagnosed incidentally on identification of synchronous aneurysms. Herein, we report the case of a 63-year-old man, presenting with a hepatic cyst, who had left profunda femoris artery and left internal iliac artery aneurysms. We performed surgical intervention, including resection of the aneurysm and reconstruction of the profunda femoris artery using a prosthetic graft. The postoperative course was uneventful, and computed tomography revealed good graft patency. We believe surgical reconstruction of the profunda femoris artery should be completed except in complicated cases, such as rupture or aneurysm in the distal segment of the profunda femoris artery.

Undifferentiated intimal sarcoma mimicking a mycotic aneurysm.

Intimal sarcoma of arteries is a rare malignant tumor, which often mimics other vascular disorders; therefore, preoperative diagnosis is often challenging. We herein report a 71-year-old man who presented with fever and elevated inflammatory markers who had a mass in the left internal iliac artery with rapid growth. Based on clinical findings, a diagnosis of mycotic aneurysm was made. We performed surgical intervention, including resection of the affected vessels with omentopexy, although intraoperative findings were not typical of a mycotic aneurysm. Microscopic and immunohistochemical examination demonstrated undifferentiated intimal sarcoma. The patient died of multiorgan failure two months after the surgery. The vascular surgeon should consider the possibility of a diagnosis of intimal sarcoma for patients with atypical findings and the importance of histological and immunohistochemical examination for precise diagnosis in surgical vascular cases.

Short- and long-term results of radial artery and saphenous vein grafts in the right coronary system: a propensity-matched study.

PURPOSE: The selection of optimal grafts for the right coronary artery remains controversial. This study aims to evaluate the short- and long-term results of radial artery (RA) grafts and saphenous vein grafts (SVGs) to the right coronary artery. METHODS: We reviewed, retrospectively, isolated coronary artery bypass grafts, placed between 1997 and 2007, and compared the long-term results of patients who received RA (n = 110) grafts with those of patients who received SVGs (n = 264) using propensity-score matching for risk. The preoperative predictors of graft occlusion were investigated on a per case basis. RESULTS: Superior survival was noted in the unmatched RA group, but late outcomes after propensity-score matching yielded 91 patient pairs that were similar in the two groups. Graft failure was not correlated with mortality, but showed strong correlation with cardiac events in all patients. The predictors of graft occlusion in the RA group were mild proximal stenosis and low indexing glomerular filtration rates for body surface area, whereas those in the SVG were female gender and off-pump coronary artery bypass grafting. CONCLUSIONS: There were no significant differences in long-term outcomes between the RA and SVG groups. Predictors of graft occlusion differed between the groups. Notably, renal dysfunction impaired radial patency, emphasizing the importance of careful graft selection.

Cardiac calcified amorphous tumor in a hemodialysis patient.

We present a case of cardiac calcified amorphous tumor, a rare intracardiac non-neoplastic tumor, in a hemodialysis patient. A 72-year-old woman with no history of thromboembolic, malignant, or inflammatory disease presented with dyspnea. Echocardiography revealed a highly echoic, slightly mobile mass with an acoustic shadow originating from the mitral subvalvular apparatus, extending to the left ventricular outflow tract. She underwent surgical resection of the mass through the aortic valve, which was easily excised from the papillary muscle and chordae tendineae. Histopathologic examination revealed nodular calcium deposits on a background of amorphous degenerated fibrin material, consistent with calcified amorphous tumor.

Mitral valve regurgitation after atrial septal defect repair in adults.

BACKGROUND AND AIM OF THE STUDY: Mitral valve regurgitation (MR) is known to deteriorate following adult atrial septal defect (ASD) repair in the mid to long-term. The study aim was to identify the risk factors for this deterioration. METHODS: Between 1995 and 2011, a total of 93 consecutive patients (aged > or = 18 years) underwent ASD repair at the authors' institution. Patients who underwent concomitant procedures, other than tricuspid annuloplasty or maze procedure, were excluded; hence, 74 patients were enrolled in the study. MR was evaluated by transthoracic echocardiography shortly after surgery and subsequently on a regular basis in the outpatient clinic. Risk factors for the deterioration of MR were estimated using Cox proportional hazards regression. RESULTS: The mean patient age at surgery was 48.0 +/- 17.1 years, and 20 patients (27%) had atrial fibrillation (AF) preoperatively. The mean follow up was 6.9 +/- 5.5 years. The degree of MR was not unchanged or not improved in 54 patients (73.0%) (group 1), but was increased by one grade in 12 patients (16.2%) (group 2), and by two or more grades in eight patients (10.8%) (group 3). At surgery, all patients in group 3 were aged > 50 years. In group 3, on echocardiography, the average end-diastolic left ventricular dimension was increased from 41.8 mm to 51.8 mm (p = 0.027), and enlargement of the mitral annulus was noted in seven patients. Four of the group 3 patients required reoperation for MR after ASD repair. The Cox proportional hazards model revealed preoperative AF (p = 0.045, hazard ratio (HR): 11.68, 95% confidence interval (95% CI): 1.05-129.48) and Qp/Qs > or = 2.8 (p = 0.015, HR: 9.19, 95% CI :1.53-55.04) to be independent risk factors of new-onset or aggravated MR (by two or more grades) after ASD repair. CONCLUSION: An earlier repair of ASD would be preferable in terms of MR aggravated after ASD repair. For elderly patients with a preoperative high Qp/Qs and AF, mitral valve annuloplasty with ASD repair should considered.

A Case of Adventitial Cystic Disease of the Popliteal Artery Progressing Rapidly after Percutaneous Ultrasound-guided Aspiration.

Adventitial cystic disease is a rare non-atherosclerotic vascular disease. We report a 36-year-old man with right intermittent claudication by adventitial cystic disease. computed tomography (CT) and magnetic resonance imaging (MRI) revealed an ovoid cystic mass compressing the right popliteal artery and causing severe stenosis of the lumen. Percutaneous aspiration was performed, which improved his symptoms. However, he complained of identical intermittent claudication two weeks later. Radiographic findings revealed that the cystic lesion had progressed rapidly. The cystic lesion was resected and the affected arterial segment was interposed. We consider that conventional surgical intervention remains the favored treatment option in the management of adventitial cystic disease.

Early outcomes and hemodynamics after implantation of the Trifecta aortic bioprosthesis.

OBJECTIVE: The Trifecta valve is a recent, newly designed high performance valve, with few studies on the clinical and hemodynamic data. The purpose of this study was to evaluate the early clinical and echocardiographic results of the Trifecta valve. METHODS: Between April 2012 and December 2012, 23 consecutive patients underwent aortic valve replacement with the Trifecta valve in our institution. Clinical and hemodynamic data were prospectively recorded and hemodynamic performance was assessed by transthoracic echocardiography. RESULTS: Nine patients were male and the overall mean age was 75 ± 9 years. Twenty patients suffered aortic stenosis, and 3 suffered aortic insufficiency. Prosthesis sizes implanted were: 19 mm (n = 4), 21 mm (n = 12), and 23 mm (n = 7). There were no 30-day deaths and no valve-related events during follow-up, except for 1 postoperative stroke. The mean postoperative transprosthetic pressure gradient was 10.0 ± 1.4, 9.6 ± 3.6, and 7.1 ± 3.6 mmHg, and the effective orifice area was 1.45 ± 0.13, 1.68 ± 0.16, and 1.90 ± 0.28 cm(2), for valve sizes 19, 21, and 23 mm, respectively. One patient had moderate prosthesis-patient mismatch. No moderate to severe aortic regurgitation was observed. The mean pressure gradient in aortic stenosis patients decreased significantly from 49.9 ± 20.7 to 8.9 ± 3.6 mmHg (p < 0.001). Left ventricular mass index in all patients decreased significantly from 142.0 ± 33.6 to 115.4 ± 26.4 g/m(2) (p < 0.001). CONCLUSIONS: The Trifecta aortic bioprosthesis provided satisfactory early outcomes and hemodynamic function.

Mid-long-term results after aortic arch repair using a four-branched graft with antegrade selective cerebral perfusion.

BACKGROUND AND AIM OF THE STUDY: The purpose of this study is to evaluate mid-long-term results of aortic arch replacement. METHODS: Between 1992 and 2012, 263 consecutive patients underwent aortic arch repair in our institution. Follow-up rate was 92%, and 243 patients were enrolled in this study. Two hundred twelve patients (87%) underwent total arch replacement using a four-branched graft with antegrade selective cerebral perfusion. Ninety-nine patients (41%) were operated on for acute aortic dissection. RESULTS: Hospital mortality was 13.2%. The mean follow-up duration was 3.6 ± 3.7 (0-19) years. Late mortality occurred in 38 patients, 4.3 ± 3.2 (0.3-14.1) years after surgery. The survival rates were 85%, 70%, and 50% at one, five, and 10 years. In the acute type A aortic dissection group, survival rate at one and five years was 86% and 79%. In the nonacute type A dissection group, one- and five-year survivals were 85% and 62% (log-rank test: p=0.0027). The causes of late mortality were respiratory failure in five, aortic aneurysm rupture in six, cancer in four, stroke in eight, others in seven, and unknown in eight. Twenty-six patients had another aortic intervention 3.6 ± 6.0 (0.04-19.6) years after arch repair. Seven patients had stroke after discharge 6.5 ± 3.9 (1.9-13.0) years after repair. CONCLUSIONS: Mid-long-term results after aortic arch repair with antegrade selective cerebral perfusion were satisfactory. Acute type A aortic dissection did not negatively influence the mid-long-term survival.

Transaortic edge-to-edge mitral valve repair and left ventricular myectomy.

Systolic anterior motion of mitral anterior leaflet is a serious clinical condition and it is hard to control medically. Alfieri edge-to-edge repair has been thought one of the useful techniques to improve abnormal anterior systolic motion with hypertrophic obstructive cardiomyopathy. Here, we present a 71-year-old lady who had the left ventricular outflow tract obstruction, severe mitral valve regurgitation with systolic anterior motion. The patient had a history of aortic valve replacement 5 years ago. She was successfully treated with transaortic edge-to-edge mitral valve plasty and myectomy of the left ventricle. Postoperative course was uneventful.

Mechanical valve evaluation with four-dimensional computed tomography.

BACKGROUND AND AIM OF THE STUDY: Echocardiography or cinefluoroscopy are standard modalities for evaluating implanted mechanical valve prostheses. The aim of the present study was to evaluate the validity of multidetector computed tomography (MDCT) with three-dimensional image reconstruction in a cine mode (four-dimensional (4D)-CT) for evaluating the functional and morphological findings of implanted mechanical valves. METHODS: A total of 37 patients who had received 45 implanted mechanical valves was studied using electrocardiogram-gated (16- or 256-row) MDCT. The mean age of patients at the MDCT examination was 65.1 +/- 10.1 years (range: 0.5-85 years). The series included 18 aortic and 27 mitral mechanical valves, in addition to 36 bileaflet valves and nine monoleaflet valves. Fifteen patients had atrial fibrillation, and seven had permanent pacemaker implantation. Volume-rendering 3D and multiplanar reformations were obtained, and valve leaflet movement was evaluated using reformatted images in a cine mode (4D images). The quality of mechanical valve leaflet visualization was scored on a four-grade scale (Leaflet index), and the level of artifact was also scored (Artifact index). RESULTS: There were two stuck-valve patients who required emergency surgery. Stuck mechanical leaflets could be visualized using 4D-CT. In all of the bileaflet mechanical valves the valve leaflet motions were visualized with 4D images. In contrast, in four of nine valves with monoleaflet valves the opening and closing angles could not be visualized because of radio-opacity of the leaflet. The median Leaflet index was 3.7 +/- 0.8, and the median Artifact index 3.0 + 0.8. The Leaflet and Artifact indices were significantly lower in monoleaflet valves (p < 0.0001, p = 0.0037, respectively). When using 256-row MDCT the Artifact index was superior to that achieved with 16-row MCDT, but was without statistical difference (p = 0.0654). CONCLUSION: Functional and morphological evaluations of mechanical valves with 4D-MDCT is promising in patients with bileaflet mechanical valves. However, the evaluation of monoleaflet valves is limited.

Efficacy of landiolol hydrochloride for prevention of atrial fibrillation after heart valve surgery.

The goal of this prospective study was to examine the effects of landiolol hydrochloride on prevention of atrial fibrillation and on hemodynamics in the acute postoperative phase after heart valve surgery. The subjects were 60 patients who underwent valve surgery at our hospital from April 2008 to July 2010. The patients were randomly divided into two groups: the landiolol group (30 patients) and the control (no landiolol) group (30 patients). In the landiolol group, continuous intravenous landiolol was initiated immediately on admission to the intensive care unit at a dose of 10 µg/kg/ minute. Occurrence of atrial fibrillation was compared between the groups over an observation period of 72 hours after surgery. Atrial fibrillation occurred in 6 patients (20%) in the landiolol group and 16 (53.3%) in the control group during the observation period. Landiolol hydrochloride significantly reduced the occurrence of atrial fibrillation in the acute postoperative phase after heart valve surgery. Heart rate was significantly decreased by landiolol, but aggravation of hemodynamics was not observed. These results suggest that landiolol is a useful drug for prevention of atrial fibrillation after valve surgery.

Mitral bioprosthetic valve stenosis in a patient with antiphospholipid antibody syndrome and systemic lupus erythematosus.

A 45-year-old woman with antiphospholipid antibody syndrome (APS) and systemic lupus erythematosus was admitted because of severe dyspnea. She had undergone mitral valve replacement (MVR) using a Mosaic bioprosthesis for infective endocarditis 9 years previously. She developed congestive heart failure secondary to mitral bioprosthetic valve stenosis resulting from relatively early structural valve deterioration. She underwent a second MVR using a mechanical valve prosthesis. The explanted bioprosthesis showed marked pannus formation and mineralization with fibrin thrombus formation, especially on the outflow surfaces of the leaflets. After the second operation, she was discharged without APS-related thromboembolic events under meticulous anticoagulant and antiplatelet therapies.

Aortic arch repair with antegrade selective cerebral perfusion using mild to moderate hypothermia of more than 28°C.

BACKGROUND: The temperature at circulatory arrest during open distal anastomosis is the most significant issue for aortic arch repair. In many institutions, there has been trend toward raising the temperature during circulatory arrest. METHODS: Between 2004 and 2011, 164 consecutive patients underwent aortic arch repair with antegrade selective cerebral perfusion (ASCP) and moderate hypothermia. The patients were divided into two subsets (n = 84 each): group A (circulatory arrest at less than 27.9°C) and group B (at more than 28°C). RESULTS: In group A compared with group B, mean temperature at circulatory arrest was 26° ± 1.0°C vs 29° ± 1.0°C, mean ASCP time was 72 ± 23 minutes vs 67 ± 17 minutes, and mean circulatory arrest time was 47 ± 21 minutes vs 44 ± 13 minutes. The 30-day mortality was 6.1% in both groups. Permanent neurologic deficit occurred in 8 patients (9.8%) in group A and in 5 (6.1%) in group B (p = 0.39). The incidence of renal failure requiring hemodialysis was 14.6% in group A and 3.6% in group B (p = 0.02). Postoperative respiratory failure requiring mechanical ventilation exceeding 3 days occurred in 12.2% of patients in group A and in 7.3% in group B (p = 0.04). CONCLUSIONS: The temperature during ASCP can be safely increased to more than 28°C without increasing the rate of mortality and morbidity. ASCP with moderate hypothermia offered sufficient cerebral and distal organ protection.

Very-low-dose continuous drip infusion of landiolol hydrochloride for postoperative atrial tachyarrhythmia in patients with poor left ventricular function.

Three patients with poor left ventricular function (left ventricular ejection fraction <30 %) developed postoperative atrial tachyarrhythmia in intensive care. Case 1 was a 64-year-old man who underwent a modified Bentall procedure and mitral valve annuloplasty. Case 2 was a 63-year-old woman who underwent quintuple coronary artery bypass grafting. Case 3 was a 65-year-old man who underwent mitral valve replacement. Preoperative intra-aortic balloon pumping was required in Cases 2 and 3. Excellent heart rate control with no hemodynamic deterioration was achieved in all three cases by very-low-dose continuous drip infusion of landiolol hydrochloride (2-5 µg/kg/min). Very-low-dose continuous drip infusion of landiolol hydrochloride is a safe and useful alternative for the control of perioperative atrial tachyarrhythmias in patients with poor left ventricular function.

Aortic valve translocation for treatment of a deteriorated stentless valve.

A 54-year-old woman was admitted to our hospital with recurrent chest pain for 1 month. She had a history of aortic root replacement with a stentless valve following aortic valve replacements done twice 12 years ago, and coronary artery bypass grafting 6 years ago. The stentless valve was implanted with the full-root technique. After admission, she was diagnosed with a saphenous vein graft aneurysm in the proximal anastomotic site and severe aortic regurgitation due to stentless valve deterioration. These lesions were successfully treated using aortic valve translocation. The advantage of this procedure is that it avoids dissection and removal of the stentless valve implanted using the full-root technique. Aortic valve translocation can be one of useful alternatives for stentless valve reoperation.

Evaluation of risk factors for hospital mortality and current treatment for poststernotomy mediastinitis.

PURPOSE: Poststernotomy mediastinitis (PSM) following cardiovascular surgery remains an intractable complication associated with considerable mortality. It is therefore necessary to assess the risk factors associated with hospital mortality and evaluate the surgical treatment options for PSM. METHODS: We identified 59 (2.2%) patients who developed PSM after cardiovascular surgery between January 1991 and January 2010. PSM was defined as deep sternal wound infection requiring surgical treatment. In all, 31 patients were infected with methicillin-resistant Staphylococcus aureus (MRSA); and 14 patients died in hospital from PSM. A total of 51 patients were treated by simple closure or tissue flap reconstruction after débridement (traditional treatment), and 8 underwent closure or reconstruction after negative-pressure wound therapy (NPWT). The risk factors for in-hospital mortality due to PSM were analyzed by comparing the characteristics of survivors and nonsurvivors. The available surgical treatments for mediastinitis were also assessed. RESULTS: Univariate analysis identified age, sex, pulmonary disease, MRSA infection, prolonged mechanical ventilation and prolonged intensive care unit stay as risk factors for in-hospital mortality (P < 0.05). Multiple logistic regression analysis identified MRSA infection (odds ratio 20.263, 95% confidence interval 1.580-259.814; P = 0.0208) as an independent risk factor for hospital mortality. NPWT was associated with significantly less surgical failure than traditional treatment (P = 0.0204). There were no deaths as a result of PSM in patients who underwent NPWT irrespective of the presence of MRSA infection. CONCLUSION: MRSA infection was an independent risk factor for PSM-related in-hospital mortality. NPWT may improve the prognosis for patients with MRSA mediastinitis.

[Hybrid repair of thoracoabdominal aortic aneurysm in high-risk patients using a quadrifurcated graft].

Surgical treatment for thoracoabdominal aortic aneurysm is still challenging and is associated with a high risk of paraplegia. Hybrid repair with stent graft insertion for the thoracoabdominal aorta excluding the branches of the lumbar and visceral arteries and bypass grafting to the visceral branches has been introduced as a less invasive treatment that reduces the risk of paraplegia. For hybrid repair, it is important to have appropriate management of the revascularized grafts to the 4 visceral arteries with sufficient inflow. We have recently adopted a knitted quadrifurcated graft applied inversely from the abdominal aorta or the iliac artery to the 4 visceral arteries; the celiac, superior mesenteric, and bilateral renal arteries. To date, we have used the graft in hybrid repair of thoracoabdominal aortic aneurysm in 2 high-risk elder patients who had disseminated intravascular coagulopathy and severe renal failure, respectively. We found that a knitted quadrifurcated graft was easy to handle and useful for reducing the number of anastomoses, which were expected to shorten the operation time. Postoperative courses were uneventful without paraplegia in either patient. Postoperative computed tomography showed excellent patency of the inversely applied quadrifurcated graft without any endoleak or migration in the thoracoabdominal stent. In conclusion, revascularization of 4 visceral arteries using a quadrifurcated graft should be considered a preferable option in hybrid treatment for thoracoabdominal aortic aneurysm.