Two Cases of Surgical Correction of Recurrent Mitral Regurgitation due to Failed Catheter- Delivered Mitral Clip (MitraClip).

From April 2018 to February 2021, 150 patients underwent MitraClip implantation for severe functional mitral regurgitation (MR) at our hospital. Two of our patients, an 85-year-old man and an 84-year-old woman, developed a single leaflet device attachment in the acute phase after the implantation and had severe residual MR requiring surgical correction. The recurrent MR was first pointed out on day 5 and day 4, and the duration between MitraClip implantation and surgery was 13 and 55 days, respectively. Due to strong adhesions with the clips and severe valve damage after MitraClip implantation, both cases underwent mitral valve replacement with a good postoperative course. In patients with a high-risk baseline profile, surgical mitral valve replacement after failed MitraClip implantation should be considered at an optimal timing, and a detailed echocardiographic follow-up is required.

A Case of Acute Type A Aortic Dissection after Coronary Artery Bypass Grafting.

The patient was a 69-year-old man who underwent emergency surgery for acute aortic dissection that developed 5 months after coronary artery bypass grafting. The left internal thoracic artery (LITA) graft anastomosed to the left descending artery was not affected by the aortic dissection, and during the ascending aortic replacement, the artery was not identified for clamping. Although fully sufficient cardioplegia was not achieved due to the patent LITA graft, the patient's postoperative cardiac function was good. The two anastomotic sites of the vein grafts to the ascending aorta were excised along with a remnant of the aortic wall in an island fashion and were reimplanted onto the artificial graft. Based on the site of intimal tear, we speculated that partial clamping during the previous surgery had caused the dissection.

Association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery.

OBJECTIVE: To examine whether there is an association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery. METHODS: A retrospective cohort study using a national clinical database in Japan was conducted. Patients who underwent emergency thoracic aortic surgery from January 1, 2014, to December 31, 2016, were included. Patients with type B dissection were excluded. A multilevel logistic regression analysis was performed to examine the association between prehospital transfer distance and surgical mortality. In addition, an instrumental variable analysis was performed to address unmeasured confounding. RESULTS: A total of 12,004 patients underwent emergency thoracic aortic surgeries at 495 hospitals. Surgical mortality was 13.8%. The risk-adjusted mortality odds ratio for standardized distance (mean 12.8 km, standard deviation 15.2 km) was 0.94 (95% confidence interval, 0.87-1.01; P = .09). Instrumental variable analysis did not reveal a significant association between transfer distance and surgical mortality as well. CONCLUSIONS: No significant association was found between surgical mortality and prehospital transfer distance in emergency thoracic aortic surgery cases. Suspected cases of acute thoracic aortic syndrome may be transferred safely to distant high-volume hospitals.

Midterm Results of Thoracic Endovascular Aortic Repair with Reentry Closure for Chronic Type B Aortic Dissection with Aneurysmal Dilatation.

Objectives: This study aims to discuss the midterm results of thoracic endovascular aortic repair (TEVAR) with reentry closure for chronic type B aortic dissection (CTBAD). Materials and Methods: This retrospective study analyzed 13 patients with CTBAD who underwent TEVAR with reentry closure between July 2014 and December 2020. We evaluated the false lumen (FL) cross-sectional area using computed tomography images of the descending aorta at the level of the bronchial bifurcation, Valsalva sinus, celiac artery, and infrarenal abdominal aorta pre- and postoperation. The study endpoints were technical and clinical success rates, freedom from additional aortic reintervention or surgery, and survival. Results: Technical success was obtained in 12 patients (92.3%) with no hospital mortality and neurological complications. The postoperative observation period was 49.2±21.5 months. The clinical success rate was 76.9% (10 cases), and a postoperative reduction of the FL cross-sectional area was obtained in 53.8% of patients. The 5-year overall survival rate was 64.8% with no aortic-related deaths while the 5-year freedom from additional aortic surgery rate was 66.7%. Conclusions: TEVAR with reentry closure suggests preventing FL dilatation or rupture in CTBAD, but the revision of our devices and further research with more patients and longer follow-up periods are required.

A superior vena cava to right pulmonary artery shunt for severe right ventricular outflow tract stenosis caused by an unresectable cardiac tumor.

We report the case of a 47-year-old man who was diagnosed with severe right ventricular outflow tract (RVOT) stenosis due to a space-occupying lesion; the diagnosis was made using computed tomography. He underwent mass reduction, pulmonary valve replacement, and RVOT reconstruction with a bovine pericardial patch. The pathological diagnosis was undifferentiated pleomorphic sarcoma originating from the myocardium. As the mass resection was incomplete, he received heavy particle therapy. He did not want to receive adjuvant chemotherapy. Four months later, severe RVOT stenosis recurred because the residual mass had invaded the prosthetic valve in the pulmonic position and one of the cusps was fixed in the closed position. He presented with dyspnea and marked lower leg edema. We performed superior vena cava (SVC) to right pulmonary artery (RPA) shunting as a palliative operation to improve his heart failure symptoms. After surgery, his symptoms improved; his hemodynamics have been stable for one year. SVC-RPA shunting is a palliative operation but can be used to effectively treat severe RVOT stenosis caused by unresectable cardiac tumors. .

Emergent Transcatheter Arterial Embolization via a Transpopliteal Approach for Internal Iliac Artery Injury during Lumbar Disk Surgery in the Prone Position.

This report describes a successful case of transcatheter arterial embolization for a critical vascular injury during lumbar disk surgery that resulted in a large retroperitoneal hematoma in a 72-year-old woman. A 4-Fr long sheath was inserted via the right popliteal artery in the prone position. Pelvic angiography revealed a pseudoaneurysm in the right internal iliac artery, which was managed with coil embolization. The patient underwent laparotomy because of abdominal compartment syndrome and was discharged in good condition after rehabilitation. The transpopliteal endovascular approach in the prone position may thus provide the best chance to treat this rare but critical condition.

First Database Comparison Between the United States and Japan: Coronary Artery Bypass Grafting.

BACKGROUND: International collaboration has an interest in health care quality evaluation. We compared characteristics and surgical outcomes between Asian patients in the United States and Japanese patients who undergo adult cardiac surgery. METHODS: Using the Japan Adult Cardiovascular Surgery Database (JCVSD) and The Society of Thoracic Surgeons (STS) National Database, we compared Asian patients undergoing isolated coronary artery bypass graft surgery between 2013 and 2016 in Japan and the United States. The STS had 16,903 Asian patients among 573,823 patients of all races undergoing isolated coronary artery bypass graft surgery (2.95%); the JCVSD had 55,570 patients, almost all of whom are Japanese. Descriptive statistics were analyzed independently, then the data were aggregated for comparison. RESULTS: The JCVSD patients were older (69 vs 65 years) with a smaller body surface area (1.65 m2 vs 1.81 m2) and body mass index (24 kg/m2 vs 26 kg/m2). The proportion of males (79% vs 78%), prevalence of chronic lung disease (82% vs 86%), and diabetes mellitus (54% vs 60%) were similar. The JCVSD had higher prevalence of renal disease requiring dialysis (11% vs 6%). The numbers of anastomoses were similar (3.1 vs 3.3); off-pump procedures and the usage of right internal mammary artery were more prevalent (60% vs 15% and 38% vs 7%, respectively) in the JCVSD. The unadjusted operative mortality was 2.7% in the JCVSD and 2.1% in the STS database. CONCLUSIONS: Comparisons of coronary artery bypass graft surgery characteristics and outcomes were conducted between the STS National Database and the JCVSD to illustrate the value of international collaboration on adult cardiac surgery databases.

Complete resection of a giant calcifying fibrous tumor of myocardial origin.

A calcifying fibrous tumor (CFT) is a rare, benign tumor that commonly develops in the internal viscera. It is histologically characterized by hyalinized collagenous tissue with calcifications and lymphoplasmacytic infiltrates. There have been few reports of CFTs occurring in the heart. and the therapeutic approach of such cases has not been well established; however, complete surgical resection appears to be the best treatment option for cardiac CFT, since this lesion can cause cardiac symptoms and recurrence has been recently noted. To our knowledge, this report describes the largest cardiac CFT for which complete surgical resection was successfully performed.

Significant impact of left ventricular assist device models on the value of flow-mediated dilation: effects of LVAD on endothelial function.

The precise physiological changes associated with the use of left ventricular assist device (LVAD) are not well characterized. We examined the impact of changes in hemodynamic state using LVAD on endothelial function. We measured flow-mediated vasodilation (FMD) to evaluate endothelial vasodilator function of the brachial artery in 53 patients (dilated cardiomyopathy: 39, ischemic cardiomyopathy: 4, and others: 10) with an implanted LVAD (DuraHeart, EVAHEART, or HeartMate II). We found that FMD value in the HeartMateII LVAD group (9.3% ± 2.9%) was significantly higher than those in the other two groups (EVAHEART: 6.7% ± 2.8% and DuraHeart: 6.2% ± 4.0%). Other factors that affected the FMD value were age (r = - 0.31, p = 0.026), Brinkman index (r = - 0.30, p = 0.029); however, aortic opening, aortic regurgitation, and other hemodynamic parameters such as cardiac index or pulmonary capillary wedge pressure did not correlate with FMD. Multivariate analyses revealed that the difference among the LVAD models most significantly affected the FMD values after adjusting for age and smoking status (t = 2.6, p = 0.014). Event free survival rate of death and cerebral infarction was not significantly different according to the value of FMD. The difference among the LVAD groups most significantly affected the state of endothelial function and it had more impact than other clinical factors.

Long-term support by left ventricular assist device for arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heart muscle disorder characterized by right ventricular enlargement, right heart failure (HF), and ventricular arrhythmias which lead to sudden death especially in young adults. Current recommendations for management of patients with ARVC are antiarrhythmic medications, catheter ablation, and implantable cardioverter defibrillator therapy to prevent sudden cardiac death. However, despite these treatments, few patients suffer from recurrent ventricular arrhythmias or HF unresponsive to conventional management. Heart transplantation (HTx) is a preferred treatment for these cases, but because of a persistent donor heart shortage in Japan, ventricular assist device (VAD) support has become an important option for a management of the end-stage ARVC. Previous articles reported 4 cases of a successful management by left ventricular assist device (LVAD), but the longest interval of LVAD support was only 333 days. We present 3 cases of ARVC patients who were successfully managed by LVAD implantation for more than a year. These 3 cases are unconventional examples of ARVC patients, considering the nature of the disease. The novelty of these cases should be taken in the context of the extremely long waiting period for HTx in Japan.

Emergency percutaneous coronary intervention for left main trunk thrombus following orthotopic heart transplantation.

Heart transplantation (HTx) is the gold standard therapy to improve quality and quantity of life in end-stage heart failure patients. However, recipients are at risk of experiencing allograft rejection and post-transplant complications, in the acute as well as chronic phase. A 43-year-old man with a history of left ventricular non-compaction underwent orthotopic HTx. On Day 7, transthoracic echocardiography showed a sudden decrease in cardiac function with hypokinesis in a left ventricular anterior wall distribution. Coronary angiography revealed a large thrombus in the left main trunk. With intra-aortic balloon pump support, emergency percutaneous coronary intervention was performed. Endomyocardial biopsy showed no rejection. A left main trunk thrombus is rare in the early phase after HTx, but it can be a life-threatening complication. Transthoracic echocardiography is well known to be important in the management of heart transplant recipients, and coronary angiography as well as myocardial biopsy should be considered when left ventricular wall motion is impaired.

A tale of two sisters with hypertrophic cardiomyopathy and recurrent embolism: When is the optimal timing of the intervention for left atrial appendage?

Hypertrophic cardiomyopathy (HCM) is an extremely heterogeneous genetic disease that affects the left ventricle (LV) and has a varied clinical course and phenotypic expression. Here, we report a case of two sisters with HCM who developed a massive refractory left atrial appendage (LAA) thrombus and recurrent embolism. The older sister, who was at a high surgical risk due to progressive LV systolic dysfunction with an ejection fraction of 19%, underwent LAA plication in combination with implantation of an LV assist device after progression to treatment-refractory heart failure at the age of 49. The younger sister underwent surgical thrombectomy, LAA plication, and Maze surgery before deterioration of heart failure at the age of 47. She was free from embolism and atrial fibrillation for 2years after surgery. Individualized therapeutic approaches targeting the LAA at a relatively early stage are required in the subgroups of HCM patients with left atrial dysfunction.

[Implantable Ventricular Assist Device].

For patients with "stage D refractory heart failure" as stated by the The Japanese Circulation Society (JCS) 2017/The Japanese Heart Failure Society (JHFS) 2017 Guidelines for Diagnosis and Treatment of Acute and Chronic Heart Failure, extensive therapeutic methods including implantation of ventricular assist device (VAD) and/or heart transplantation, as well as terminal care. An implantable VAD is a device designed to support patients for a long term of several years. This device has its most part buried in the body with its driveline penetrated out through the skin to connect with a controller and butteries. In Japan, implantable VADs started to be used in 2011, and now 3 devices are available in a commercial basis, that is, EVAHEART 2, HeartMate II and Jarvik 2000. They are available when a patient has been listed as a candidate for heart transplantation, and recently the usage of implantable VAD as destination therapy that is applied for patients who are not eligible for heart transplantation but would get benefit from circulatory support, enough to be free from hospital-bound status and enjoy high quality of life. If this device can prove to improve heart failure patients' symptoms, resulting in decreasing medical expense, surely it would be widely accepted as a promising therapy to treat heart failure.

Coronary Artery Aneurysm Caused by a Stent Fracture.

Coronary stent fracture (SF) is rare as a complication of percutaneous coronary intervention (PCI), and its adverse events are increasingly being recognized with the development in devices of PCI. The major adverse events caused by SFs are in-stent restenosis due to neointimal overgrowth caused by poor drug delivery.1,2) A coronary artery aneurysm (CAA) is a rare complication of SF, but may lead to lethal events such as acute coronary syndrome or rupture of the CAA further leading to cardiac tamponade.3-5) However, the management of CAAs is controversial with or without SF.6) Herein, we report a case of a CAA caused by an SF and discuss the management of CAA complicated with SF, along with a literature review. We suggest that surgical treatment should be considered the higher-priority strategy in the cases of CAA with SF as compared to CAA without SF.

Cardiac Sarcoidosis Diagnosed by Incidental Lymph Node Biopsy.

Cardiac involvement in systemic sarcoidosis sometimes provokes life-threatening ventricular tachyarrhythmia. Steroid administration is one of the fundamental anti-arrhythmia therapies. For an indication of steroid therapy, a definitive diagnosis of sarcoidosis is required.1) However, cases that are clearly suspected of cardiac sarcoidosis based on their clinical courses sometimes do not meet the current diagnostic criteria and result in the loss of an appropriate opportunity to perform steroid therapy.Here we report a case that was diagnosed as sarcoidosis by incidental biopsy of an inguinal lymph node during cardiac resuscitation for cardiac tamponade.2) While the inguinal lymph node was not swollen on computed tomography, a specimen obtained from an incidental biopsy during the exposure of a femoral vessel for the establishment of extracorporeal cardio-pulmonary resuscitation showed a non-caseating granuloma.This findings suggest a non-swelling lymph node biopsy might be an alternative strategy for the diagnosis for sarcoidosis if other standard strategies do not result in a diagnosis of sarcoidosis.

Implantation of a Left Ventricular Assist Device for Danon Cardiomyopathy.

This is the first report of Danon cardiomyopathy managed with a left ventricular assist device (LVAD). Danon disease is an X-linked dominant inheritance disorder. Heart failure with Danon cardiomyopathy results in a poor prognosis, and heart transplantation is the treatment of choice. We present two cases of successful implantation of an LVAD for Danon cardiomyopathy. Patient 1 was in the dilatated phase of hypertrophic cardiomyopathy (HCM) with Danon cardiomyopathy, and she underwent LVAD implantation. She is waiting for transplantation. Patient 2 had dilatated cardiomyopathy with Danon cardiomyopathy and received transplantation 990 days after LVAD implantation without myopathy or intellectual disability.

Successful management of apical abscess after Nipro left ventricular assisted device explantation by removal of apical cuff and omentopexy.

Nipro-Toyobo-paracorporeal pulsatile flow VAD (Nipro VAD; Nipro, Osaka, Japan) has been used most commonly as a paracorporeal VAD (p-VAD) in Japan. There are few reports describing clinical course of post LVAD explantation and its complication. We herein present two cases of apical abscess after the explantation of the device. SSI is a main risk factor of formation of the apical abscess at the time of LVAD explantation. It is mandatory to perform sufficient debridement and closure of the layers including abdominal muscle and anterior abdominal fascia at exit sites in the explantation surgery. Omentopexy is also helpful for prevention from infection. Routine removal of apical cuff and outflow graft could be considered as one of the options when LVAD is explanted as bridge to recovery.

[Beating-heart Mitral Valve Surgery].

Cardiac surgeries have become complicated, although the procedures have been sophisticated as well as anesthetic management and postoperative care. Cardiac surgery team's main concerns include how to preserve cardiac function after aortic cross-clamp and chemical cardiac arrest, which cause myocardial edema and reperfusion injury. These days beating-heart surgery for mitral valve diseases is reported. Patients of mitral disease with low cardiac function due to ischemic cardiomyopathy or dilated cardiomyopathy as well as patients of mitral disease with functional coronary bypass graft might be good candidates for beating-heart mitral valve surgery, via either median sternotomy or right thoracotomy approach. Beating-heart surgery with aortic cross-clamp and coronary perfusion and that without aortic cross-clamp are available. Of great importance during beating-heart surgery without aortic crossclamp is to vent the left ventricle enough and maintain aortic root pressure, resulting in constant closure of aortic valve. The equivalent results are reported compared to conventional mitral valve surgery with cardiac arrest, and the beating- heart mitral surgery could be an alternative for patients with low ejection fraction and patients with previous sternotomy.