Hemolytic anaemia due to graft kinking progression and aortic stenosis exacerbation after aortic arch replacement: A case report.

INTRODUCTION: Hemolytic anaemia from graft kinking is a rare complication after aortic surgery, typically treated by graft replacement. This case highlights hemolytic anaemia caused by the interaction of aortic stenosis and a kinked graft, successfully managed with transcatheter aortic valve replacement (TAVR). PRESENTATION OF CASE: A 75-year-old male developed hemolytic anaemia 2 years after total aortic arch replacement for a saccular aneurysm, with a worsening graft kink and aortic stenosis. Phase-contrast MRI confirmed abnormal blood flow at the kink. Due to his frail condition from prostate cancer, TAVR was performed, resolving the anaemia. DISCUSSION: Factors contributing to graft kinking include intraoperative graft length determination, natural aortic elongation with ageing, and graft type. To determine the cause of hemolysis, we needed to evaluate whether it was due to the kinked graft, aortic stenosis, or their combined effect. Hemolytic anaemia appeared at a low pressure gradient of 15.5 mmHg across the aortic valve, making it unlikely that the valve alone was the cause of the hemolysis. Using phase-contrast cardiovascular magnetic resonance, we observed abnormally accelerated blood flow caused by aortic stenosis impinging on the kinked graft. Possible causes include an increased pressure gradient at the kink due to accelerated blood flow, as well as physical collisions that may have resulted in shear stress on the red blood cells. CONCLUSION: TAVR resolved hemolytic anaemia caused by aortic stenosis and graft kinking after aortic arch replacement. In high-risk patients, less invasive treatment of the primary condition may effectively resolve hemolytic anaemia.

Patch aortoplasty for supravalvular aortic stenosis in an adult patient: A case report.

INTRODUCTION: Supravalvular aortic stenosis (SVAS) is an uncommon congenital abnormality that presents with intimal thickening of the aortic media at the sinotubular junction. Given the congenital nature of the disease, patients usually become symptomatic in childhood. PRESENTATION OF CASE: A 48-year-old man developed symptomatic SVAS in middle age. A patch aortoplasty with a bovine pericardial patch was performed. His postoperative course was uneventful, and echocardiography revealed a significant decrease in peak velocity and pressure gradient. DISCUSSION: SVAS, a congenital heart disease with an incidence of 1 in 20,000 live births, is often linked to Williams syndrome but can also occur independently. Isolated SVAS is generally less severe and may not show symptoms in childhood. Its narrowing often stabilizes after growth, but in this middle-aged patient, symptoms appeared later in life. SVAS usually presents as discrete thickening above the sinuses of Valsalva or as diffuse narrowing along the ascending aorta. Surgical relief is the common treatment, with flap plasty using various patch techniques. This patient, having discrete stenosis and intact aortic valve function, underwent single-patch expansion. Key to this surgery is avoiding coronary artery stenosis, by considering coronary orifice location and other cardiac anomalies. A bovine pericardial patch was chosen for its bleeding control benefits. CONCLUSION: Although SVAS progression in middle age is quite rare, it can be successfully corrected with detailed and selected surgical procedures.

A Case Report of Inhaled Nitric Oxide for Transfusion-Related Acute Lung Injury.

Transfusion-related acute lung injury (TRALI) is an acute respiratory distress syndrome (ARDS) occurring during or within six hours after transfusion. On the other hand, while inhaled nitric oxide (iNO) temporarily improves arterial oxygenation with selective pulmonary vasodilation, there is no evidence of mortality reduction in ARDS. We herein report a case in which TRALI was diagnosed with severe hypoxemia during cardiovascular surgery, and extracorporeal membrane oxygenation (ECMO) was avoided by using iNO for respiratory management. Administering iNO to patients with acute respiratory failure may be useful as a bridging therapy to help patients recover. However, further evidence is needed before this treatment can become standard practise.

An adolescent with Behçet's aortitis mimicking infective endocarditis: a case report.

BACKGROUND: Aortic valve involvement is rare in patients with Behçet' s disease (BD); however, recurrent prosthetic valve detachment after valve surgery has frequently been reported. We report a rare case of Behçet's aortitis involving the aortic valve, mimicking active infective endocarditis (IE) with perivalvular abscess. CASE SUMMARY: A 16-year-old boy, with an unknown case of BD, presented with pyrexia of unknown origin, severe aortic valve regurgitation, vegetation, and perivalvular abscess in the aortic valve. All cultures tested negative for microorganisms. As we suspected IE, aortic valve replacement was performed. After the initial surgery, recurrent prosthetic valve detachment and pseudoaneurysm formation occurred, which resulted in the diagnosis of BD. The patient underwent a modified Bentall procedure, in which the valve conduit was proximally sutured to the left ventricular outflow tract instead of the aortic annulus. Immunosuppressive therapy was initiated on the 10th postoperative day. His condition became stable, and additional surgery was not required. DISCUSSION: The echocardiographic findings of Behçet's aortitis involving the aortic valve resemble those of aortic valve IE. Modified Bentall procedure, combined with effective immunosuppressive therapy, may be useful in preventing prosthetic valve detachment.

[Mitral Valve Repair in a Patient with Two Aneurysms of the Mitral Valve Due to Infective Endocarditis;Report of a Case].

Echocardiography revealed 2 aneurysms in the mitral valve with mitral regurgitation and aortic regurgitation,in a 42-years-old man. He had had infective endocarditis due to Streptococcus 9 months before. A prolapse in the right coronary cusp without vegetation and 2 aneurysms in the anterior mitral leaflet were found intraoperatively. Aortic valve was replaced, and then mitral aneurysms were resected and repaired using his own pericardium. There has been almost no regurgitation or recurrence of infection over 3 years.

Diagnostic features of cardiac cavernous hemangioma in the right ventricle on magnetic resonance imaging.

Cardiac tumors are rare; however, with recent advances in imaging techniques, they are being diagnosed more frequently with cardiac magnetic resonance (CMR) imaging. We report a case of a cardiac cavernous hemangioma in the right ventricle. This case was diagnosed with CMR imaging based on the characteristic features of peripheral nodular contrast enhancement and progressive centripetal fill-in. CMR imaging also provided useful preoperative anatomical information, showing the relationships among the tumor, tricuspid valve, and right ventricular anterior wall.

Preserved autoregulation of coronary flow after off-pump coronary artery bypass grafting: retrospective assessment of intraoperative transit time flowmetry with and without intra-aortic balloon counterpulsation.

BACKGROUND: Intra-aortic balloon pumping (IABP) markedly increases graft flow after coronary artery bypass grafting (CABG) with cardiopulmonary bypass. We sought to delineate the effects of IABP on graft flow after off-pump CABG (OPCAB). METHODS: The clinical records of 32 patients (25 male, 7 female; mean age: 70 ± 9 years) who underwent OPCAB with IABP between January 2011 and May 2015 were retrospectively reviewed. Thirteen patients (41%) had a history of myocardial infarction, and 13 patients (41%) had a history of percutaneous coronary intervention. In total, there were 76 bypass grafts with 102 distal anastomoses. These included 50 in situ or pedicled grafts and 26 aortocoronary grafts. After completion of the anastomoses, the heart was positioned normally, and graft flow with IABP was measured using transit-time flowmetry under stable circulation. Then, IABP was turned off for 30 s to a few minutes, until graft flow was constant, for measurement of flow off IABP. RESULTS: The angiographic patency rate was 100% (47/47). Overall, graft flow was 55 ± 36 ml/min on IABP and 53 ± 36 ml/min off IABP (p = 0.37). The pulsatility index was 4.1 ± 2.1 on IABP and 2.7 ± 1.5 off IABP (p < 0.001). There was no significant difference in graft flow between on and off IABP for aortocoronary bypass or in situ grafts. Graft flow was 57 ± 36 ml/min on IABP and 55 ± 37 ml/min off IABP (p = 0.41) in in situ grafts and 52 ± 34 ml/min on IABP and 49 ± 35 off IABP (p = 0.41) in aortocoronary grafts. Graft flow on IABP was more than 5 ml/min greater in 28 (37%) bypass grafts, and more than 5 ml/min lower in 20 (26%) bypass grafts. CONCLUSION: In contrast to previous reports for conventional CABG, graft flow after OPCAB was not necessarily increased by IABP, regardless of elevated diastolic arterial pressure. It is suggested that preserved autoregulation of coronary flow contributes to a lower impact on the heart and early functional recovery, and consequently, greater perioperative safety of OPCAB.

Comparison of early haemodynamics of 19-mm aortic valve bioprostheses in patients with a small aortic annulus.

OBJECTIVES: A potential problem in aortic valve replacement (AVR) for patients with a small aortic annulus is prosthesis-patient mismatch (PPM). Although larger size prostheses have been well studied, the haemodynamics of 19-mm bioprostheses has been reported in only a small number of patients. The Trifecta valve is a novel bioprosthesis and its unique design is conceived to increase effective orifice area (EOA) and prevent PPM. This study aims at comparing the early haemodynamics of the new Trifecta valve with that of other conventional 19-mm valves. METHODS: We retrospectively evaluated 128 consecutive patients who underwent AVR with 19-mm bioprosthesis (39 Trifecta valve, 67 Magna Ease valve and 22 Mosaic Ultra valve) at Saitama International Medical Center between April 2012 and December 2014. Haemodynamics was evaluated by transthoracic echocardiography at 1 month after discharge and at 1-year follow-up. RESULTS: The average body surface area of all patients was 1.37 m(2). There was no difference in postoperative clinical outcomes between the three groups. Among the three groups, the mean pressure gradient (MPG) was the smallest (10.6 ± 4.3 mmHg, P < 0.001) and the EOA was the largest (1.63 ± 0.36 cm(2), P < 0.001) in the Trifecta group at 1 month after discharge. In the Trifecta group, PPM was not observed (P < 0.001), the MPG was the smallest (12.8 ± 3.6 mmHg, P < 0.001) and the EOA was the largest (1.50 ± 0.30 cm(2), P < 0.001) at the 1-year follow-up. CONCLUSIONS: The new 19-mm Trifecta valve showed favourable early haemodynamics compared with the conventional valves and may be useful for preventing PPM in patients with a small aortic annulus.

Impacts of intraoperative flow on graft patency of sequential and individual saphenous vein grafts.

OBJECTIVE: We sought to delineate the predictor of saphenous vein graft (SVG) failure and to evaluate the impact of sequential grafting of SVG on graft flow as the significant predictor of patency. METHODS: Angiograms and clinical records of 439 patients who underwent coronary artery bypass grafting with aortocoronary SVG were reviewed. Of these, 708 distal anastomoses were created by 480 SVGs. Of 349 patients who underwent isolated coronary artery bypass grafting, operation was performed with an off-pump technique in 347 patients (99%). For 90 patients, a combined procedure on cardiopulmonary bypass was performed. A postoperative angiography was performed in 230 SVGs for clinical reasons. Insufficient flow (IF) was defined as a graft flow of 20 mL/min or less, measured by transit-time Doppler flowmetry during operation. RESULTS: In 480 SVGs, 44 (9.2%) presented IF, and 24 SVGs presented partial or total occlusion. Six of the nine failed individual SVG had IF, whereas none of the failed sequential SVG was associated with IF. Univariate and multivariate logistic regression analyses demonstrated that IF (P = 0.002; odds ratio, 6.63) and sequential grafting (P = 0.004; odds ratio, 2.51) were significantly correlated with a failure of the SVG. The patency rate of sequential SVG to the most distal target was 78/93 (83.9%), which was significantly lower than 9/139 (93.5%) of the individual SVG (P = 0.02) and 7/113 (93.8%) of the sequential SVG to proximal targets (P = 0.02). CONCLUSIONS: When both targets seem to have sufficient demand, avoidance of sequential grafting would be reasonable. Moreover, the important target should be grafted by individual grafting or sequential proximal anastomosis.

[Surgery for Ventricular Tachycardia Arising from Left Ventricular Aneurysm in a Patient with Dilated Cardiomyopathy；Report of a Case].

A left ventricular aneurysm (LVA) generally results from myocardial infarction, but rarely LVA can be associated with dilated cardiomyopathy (DCM). We herein report a surgical case of malignant ventricular tachycardia (VT) in a patient with LVA associated with DCM. A 57-year-old woman was diagnosed with DCM and LVA when she 1st presented with sustained VT. She had anti-arrhythmic medical therapy and implantable cardiac defibrillator. Subsequently, she presented with recurrent monomorophic VT arising from the LVA. Because anti-arrhythmic medical therapy and endocardial ablation were not effective, the patient was performed left ventricular aneurysmectomy and encircling endocardial cryoablation and could achive good arrhythmic control and clinical outcome.

Predictors and prevention of flow insufficiency due to limited flow demand.

BACKGROUND: We investigated the impacts of flow demand and native coronary stenosis on graft flow and patency. METHODS: We reviewed the angiograms of 549 bypass grafts in 301 patients who underwent off-pump coronary artery bypass grafting since 2007. Grafts consisted of 237 internal thoracic artery to left anterior descending artery; 97 internal thoracic artery and 52 saphenous vein grafts to left circumflex artery; and 109 gastroepiploic artery and 54 saphenous vein grafts to right coronary artery. We selected only individual bypass grafts created as the sole bypass graft to the coronary vascular region. Flow insufficiency was defined as ≤ 20 ml/min measured intraoperatively. When a significant difference in the incidence of flow insufficiency or "not functional" occurred between higher and lower values rather than the particular minimal luminal diameter value, the highest value was defined as the cut-off minimal luminal diameter. Distal lesions were defined as stenosis at segment #4, 7, 8, 12, 13, 14, or 15. RESULTS: Flow insufficiency was found in 112/549 (20.4%) bypass grafts. For internal thoracic artery to left circumflex artery grafts, the cut-off minimal luminal diameter for proximal and distal lesions was 1.25 mm and 0.75 mm, respectively. For gastroepiploic artery to right coronary artery grafts, the cut-off minimal luminal diameter was 0.82 mm for proximal lesions (p = 0.005), while 10 (71%) of 14 gastroepiploic artery grafts for distal lesions presented with flow insufficiency. Univariate and multivariate analysis identified a distal lesion (odds ratio (OR): 3.12, p < 0.0001); minimal luminal diameter greater than the cut-off value (OR: 3.64, p < 0.0001); right coronary artery (OR: 18.2, p = 0.0002) and left circumflex artery (OR; 2.29, p = 0.009) grafting; and a history of myocardial infarction in the grafted region (OR: 2.21, p = 0.02) as significant predictors of flow insufficiency. CONCLUSIONS: Both competitive flow and insufficient flow demand cause graft failure. For distal lesions, more severe stenosis is necessary to avoid graft failure, compared with proximal lesions. A revascularization strategy for distal lesions should be discussed separately from that for proximal lesions.

[New surgical approach for acute type A aortic dissection; combining classic surgery with descending stent grafting].

The outcome of surgical repair of acute type A dissection has substantially improved, but patients with residual dissection in the descending aorta are facing a risk of late complications such as aneurysm formation and rupture, and often require redo surgery. To minimize late complications, the combined approach with hemi-arch replacement and simultaneous descending stent grafting (SG) was applied and compared with conventional surgery. Between April 2007 and April 2010, 70 consecutive patients with acute type A dissection underwent operation, and 8 with DeBakey type II and 9 undergoing total-arch replacement were excluded from the study. 38 patients (71.7%) underwent combined surgery with SG and 15 (28.3%) underwent conventional surgery. Computed tomography (CT) was performed during the follow-up. Patency, width of the false lumen and the maximal diameter of the descending aorta were compared between these 2 groups. In early CT, the thoracic true lumen was wider than the false lumen in 28 patients (80%) in the SG group and 7 (50%) in the conventional group (p = 0.04). In mid-term CT, dilatation of the thoracic aorta occurred in 5 patients (16.1%) in the SG group and 5 (45.5%) in the conventional group (p < 0.05). This approach is technically feasible and offers the chance of thrombosis and reduction of the distal false lumen.

Anomalous right subclavian artery with ascending aortic aneurysm: a case report.

We report a rare case of the ascending aortic aneurysm with an anomalous origin of the right subclavian artery. The right subclavian artery branched from the aorta as the fourth major vessel and ran behind the esophagus. Moreover, the left and right coronary arteries arose ectopically from the posterior and the left aortic sinus, respectively.

Early angiographic results of multivessel off-pump coronary artery bypass grafting.

OBJECTIVES: Recently off-pump coronary artery bypass grafting (CABG) is being widely used for coronary revascularization. However, there is some evidence that off-pump surgery increases the risk of recurrent angina and the need for reintervention, suggesting poor graft quality or incomplete revascularization. We describe our experience to demonstrate the feasibility of multiple coronary revascularization in off-pump CABG (OPCAB). PATIENTS AND METHODS: From January 2002 to March 2003, 168 patients underwent OPCAB at our institute. In 16 of them, 6 to 9 vessels were revascularized in each patient. There were 14 males and 2 females with a mean age of 66 years (47 to 74 years). All patients had triple-vessel disease. Ten patients received in situ arterial grafts only which were harvested with the skeletonization technique using an ultrasonic scalpel. We used the Starfish heart positioner to expose lateral, posterior, and inferior walls of the heart with minimal hemodynamic compromise. RESULTS: All patients were discharged from the hospital without any serious complications. Postoperative angiography was performed in 87.5% within 1 month after operation. The patency rate was 96.6%. CONCLUSION: These results indicate that complete revascularization can be achieved in OPCAB in patients with diffuse coronary arterial disease. Complete revascularization with in situ arterial conduits only is technically feasible and yields a high early graft patency, even in the off-pump situation.

Experimental assessment of the drainage capacity of small silastic chest drains.

Recently, flexible fluted small silicone drains have been used widely as chest drains after cardiac surgery. Despite the clinical advantages of using smaller silastic chest drains over conventional chest tubes, an experimental comparison of the drainage capacity between these two drain tubes has not yet been performed. The drainage capacity of 19F silicone drains and 28F conventional tubes was tested. In an in vitro study, both tubes were set in a water bath and drained at a pressure of 10 mm Hg. In an in vivo study, the drains were inserted into the hemithorax in 8 adult pigs. Blood was infused at 20 mL x min(-1) into both chest cavities and the tubes were drained at 15 cm H(2)O for 30 min. In the in vitro study, the drainage capacity of the conventional chest tube was 9-times higher than that of the smaller silicone drain (103.8 vs. 11.6 L x hr (-1)). However, in the in vivo study, there was no difference in drainage capacity between the two different tubes over time. This experiment demonstrated that the smaller silastic chest drain has sufficient drainage capacity, almost identical to the conventional chest tube, in the clinical setting.