Role of Helicopter Transfer and Cloud-Type Imaging for Acute Type A Aortic Dissection.

BACKGROUND: This study explored if long-distance transfer was safe for patients suffering from acute aortic dissection type A (AADA) and also analyzed the effectiveness of helicopter transfer and cloud-type imaging transfer systems for such patients in northern Hokkaido, Japan. METHODS AND RESULTS: The study included 112 consecutive patients who underwent emergency surgical treatment for AADA from April 2014 to September 2020. The patients were divided into two groups according to the location of referral source hospitals: the Asahikawa city group (group A, n = 49) and the out-of-the-city group (group O, n = 63). Use of helicopter transfer (n = 13) and cloud-type telemedicine (n = 20) in group O were reviewed as subanalyses.Transfer distance differed between groups (4.2 ± 3.5 km in group A vs 107.3 ± 69.2 km in group O; p = 0.0001), but 30-day mortality (10.2% in group A vs 7.9% in group O; p = 0.676) and hospital mortality (12.2% in group A vs 9.5% in group O; p = 0.687) did not differ. Operative outcomes did not differ with or without helicopter and cloud-type telemedicine, but diagnosis-to-operation time was shorter with helicopter (240.0 ± 70.8 vs 320.0 ± 78.5 minutes; p = 0.031) and telemedicine (242.0 ± 75.2 vs 319.0 ± 83.8 minutes; p = 0.007). CONCLUSION: We found that long-distance transfer did not impair surgical outcomes in AADA patients, and both helicopter transfer and cloud-type telemedicine system could contribute to the reduction of diagnosis-to-operation time in the large Hokkaido area. Further studies are mandatory to investigate if both the systems will improve clinical outcomes.

[Early Outcomes and Indications for Surgical Intervention of Preoperative Atrial Fibrillation].

BACKGROUND: This study investigates short-term outcomes following surgical interventions for atrial fibrillation (Af), including the Cox-maze Ⅳ procedure (maze procedure) and pulmonary vein isolation (PVI), performed concurrently with other cardiac surgeries. Additionally, we aim to determine the indications for surgical intervention for Af. METHOD: We retrospectively studied a total of 1,580 patients, out of which 274 had preoperative Af, that underwent cardiac surgery between January 2015 and April 2023. Patients who underwent emergency surgery, died in the hospital postoperatively, or received pacemaker implantation were excluded. Patients were first divided into two groups:the intervention group (n=135, 53.6%) and the non-intervention group( n=117, 46.4%), further categorized by whether they were in sinus rhythm at discharge. The intervention group was then subdivided into the maze procedure group( n=54), and the PVI group (n=76). RESULTS: Within the maze procedure group, significant differences were observed between the sinus rhythm and non-sinus rhythm groups in terms of age, preoperative Af duration, and aortic valve intervention status. In the PVI group, patients with persistent Af, longer preoperative Af duration, and larger left atrium diameter( LAD) were less likely to return to sinus rhythm. Smaller LAD was also a significant factor for returning to sinus rhythm in the non-intervention group. Multivariate analysis for all patients revealed that an LAD smaller than 50 mm was the strongest predictor for returning to sinus rhythm post operation( p<0.01). CONCLUSION: For patients with persistent Af, the maze procedure is favored over PVI as a surgical intervention. When LAD exceeds 50 mm, the likelihood of returning to sinus rhythm is diminished.

Interventional Bridging Therapy for Radical Cardiac Surgery in a Patient Seemed to be Inoperable Due to Very Poor Left Ventricular Function: A Case Report.

Cases that are inoperable owing to poor preoperative conditions are sometimes encountered. However, there are some cases that are led to radical treatment by performing bridge therapy. Here, we presented a case of a patient with complex cardiac disease in an inoperable state who underwent bridging therapy that led to successful surgical treatment. A 73-year-old male who received hemodialysis treatment and had severe aortic valve stenosis and coronary artery disease planned surgical treatment. However, he was deemed inoperable owing to his low cardiac function and hemodynamic instability. Therefore, to escape from a fatal condition, we first performed balloon aortic valvuloplasty and percutaneous coronary intervention as palliative procedures. Subsequently, his cardiac function and hemodynamic stability remarkably improved; therefore, after 1 month, we performed a successful radical surgical treatment. Even in inoperable patients, bridging therapy leading to radical treatment is possible.

Proximalized Total Arch Replacement Can Be Safely Performed by Trainee.

BACKGROUND: The aim of the present study was to validate safety of total arch replacement (TAR) using a novel frozen elephant trunk device, operated by trainees as surgical education. METHODS: Sixty-four patients including 19 patients (29.6%) with acute aortic dissection type A (AADA) underwent TAR in our institute between April 2014 and March 2019 were retrospectively analyzed. Twenty-nine patients were operated by trainees (group T) and 35 patients were operated by attending surgeons (group A). RESULTS: Patient characteristics did not differ between groups. Operative time (409.4 ± 87.8 vs. 468.6 ± 129.6 minutes, p = 0.034), cardiopulmonary bypass time (177.7 ± 50.4 vs. 222.9 ± 596.7 minutes, p = 0.019), and hypothermic circulatory arrest time (39.5 ± 13.4 vs. 54.5 ± 18.5 minutes, p = 0.001) were significantly shorter in group A than in group T, but aortic clamping time did not differ between groups (115.3 ± 55.7 vs. 114.2 ± 35.0 minutes, p = 0.924) because the rate of concomitant surgery was higher in group A (37.1 vs. 10.3%, p = 0.014). Thirty-day mortality was 3.1% in the entire cohort. Although operation time was longer in group T, there were no significant difference in postoperative results between the groups, and the experience levels of the main operator were not independent predictors for in-hospital mortality + major postoperative complications. There was no difference in late death and aortic events between groups. CONCLUSIONS: The present study demonstrated that TAR can be safely performed by trainees, and suggests TAR as a possible and safe educational operation.

Examination of Anterior Leaflet Pseudoprolapse Causing Severe Mitral Regurgitation and Its Ideal Surgical Procedure.

BACKGROUND: The aim of this study is to evaluate severe mitral regurgitation caused by so called atrial leaflet "pseudoprolapse" and verify the effect of simple annular stabilization. METHODS: One-hundred-twenty-two patients underwent surgery for severe mitral regurgitation at our institute between January 2015 to July 2018. Of those, 32 cases diagnosed as anterior leaflet prolapse that underwent mitral repair were analyzed. Ten cases with pseudoprolapse, which is defined as anterior leaflet prolapse without dropping into the left atrium beyond the annular line causing eccentric regurgitation flow directed to the posterior atrium, were classified as the Pseudoprolapse Group. The other 22 cases had obvious anterior leaflet prolapse dropping into the left atrium; these cases were classified as the True Prolapse Group. We compared clinical findings between the 2 groups and reviewed pseudoprolapse cases. RESULTS: Patients in the Pseudoprolapse Group had lower ejection fraction and lower regurgitation volume than those in the True Prolapse Group. A2 lesion as main inflow of regurgitation was more included in the Pseudoprolapse Group. All but one patient in the Pseudoprolapse Group received only simple annuloplasty, and all patients in the True Prolapse Group received leaflet repair and annuloplasty. In both groups, mid-term regurgitation grade and the reoperation rate were satisfactory. In the Pseudoprolapse Group, 6 cases were clarified as atrial functional mitral regurgitation, and 4 cases were considered to have focal posterior leaflet tethering. CONCLUSIONS: Pseudoprolapse cases could be characterized by low ejection fraction, low regurgitation volume, and A2 prolapse. For most cases with pseudoprolapse, simple annuloplasty may be enough, however further study is needed.

[Tricuspid Valve Aneurysm Preoperatively Diagnosed with Right Atrial Tumor;Report of a Case].

A 79-year-old woman visited a hospital with coronary vasospastic angina and supraventricular tachycardia. Periodic inspection of echocardiography suggested a right atrial tumor which was not pointed out 6 months ago, but magnetic resonance imaging suggested a valve aneurysm. These findings were contradictory. We preoperatively diagnosed a cardiac tumor because of its new onset and mobility. Tumor resection and valve repair was planned in consideration of the risk of embolism. As a result, we finally diagnosed tricuspid valve aneurysm from the intraoperative findings and histopathological findings. We assumed that valve aneurysm was formed in the healing process of subclinical infective endocarditis. It was inferred that preoperative diagnosis of valve aneurysm is very difficult.

Papillary muscle rupture after myocardial infarction during left ventricular assist device support.

We report a rare case of papillary muscle rupture due to myocardial infarction during left ventricular assist device support. A 69-year-old woman with cardiogenic shock due to acute myocardial infarction requiring venoarterial extracorporeal membrane oxygenation support was transferred for further surgical intervention. Six days after the event, extracorporeal membrane oxygenation was decannulated, and an extracorporeal left ventricular assist device was implanted. On postoperative day 11, she suffered from sudden onset hypoxia due to pulmonary edema. Transesophageal echocardiography showed new onset severe mitral regurgitation. No further surgical intervention was performed according to the family's wishes, and she passed away on the 22nd postoperative day. Autopsy findings revealed papillary muscle rupture. Although the left ventricle is unloaded by the left ventricular assist device, papillary muscle rupture should be recognized as a possible complication after myocardial infarction.

[Mitral Valvuloplasty of Infective Endocarditis During Pregnancy].

This report describes a case in which we treated a patient who developed infective endocarditis in the mitral valve at 28 weeks' gestation. The condition was resolved by performing mitral valvuloplasty 2 days after an emergency cesarean section. Although the patient was in a relatively stable period at 32 weeks' gestation, the mother had an extremely high risk of embolism;thus, emergency surgery was required. We believe that an accurate diagnosis in a timely manner and a valvuloplasty shortly after cesarean section saved the life of the mother and child.

A case of minimum invasive debranch thoracic endovascular aortic repair for isolated left vertebral artery: complete revascularization without artificial vessels via a single small incision.

Isolated left vertebral artery (ILVA) is one of the most frequent vertebral abnormalities. When performing thoracic endovascular aortic repair (TEVAR), the ILVA may have to be closed depending on the position of the stent graft; in these cases, the decision to reconstruct the ILVA depends on the state of cerebral blood flow. Here, we report a case of a 68-year-old male, in whom the Willis arterial circle was incomplete; we therefore performed a reconstructive method during zone 2-landing TEVAR that ensured ILVA and left subclavian artery blood flow without the use of artificial vessels. Only one supraclavicular incision was required for reconstruction. This method has some procedural difficulties; however, it does not use artificial blood vessels and can be performed with a single incision.

A case of non-bacterial thrombotic endocarditis on the aortic valve following coronary angiography.

Nonbacterial thrombotic endocarditis (NBTE) on the aortic valve involves fibrin and platelet aggregate formation, potentially leading to embolic events. We present a case of NBTE on the aortic valve following coronary angiography (CAG) in a 54-year-old man with multiple comorbidities. Surgical thrombectomy was performed owing to acute cerebral infarcts. This case highlights the significance of considering that mechanical trauma from catheterization during CAG can trigger thrombus formation.

[Revascularization surgery for isolated unilateral absence of the right pulmonary artery].

We describe a baby girl with isolate absence of the right pulmonary artery. She had tachypnea just after birth. Several examinations showed absence of the right pulmonary artery and an aortopulmonary collateral artery. After follow-up, cardiac catheterization was performed the age of 14 months. It showed mild pulmonary artery hypertension. The posterior wall of right pulmonary artery was reconstructed with U-shaped in situ pulmonary artery flap and the anterior wall was reconstructed with autologous pericardium patch. Enhanced computed tomography was performed on postoperative day 9 showed occlusion of the right pulmonary artery by a thrombus. Emergency catheterization and thrombolytic therapy was performed with no success. Then, we successfully performed thrombectomy by open surgery. Cardiac catheterization performed at 6 months after the operation showed patency of the right pulmonary artery and improvement of pulmonary artery hypertension.

Proximal and extended aortic arch replacement in acute DeBakey type I aortic dissection.

Objective: This study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection. Subjects: From April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta. Methods: Of the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed. Results: The duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p < 0.01). The overall operative mortality rate was 10.3% in the proximal repair group and 14.7% in the extended repair group (p = 0.379). The mean follow-up period was 31.1 ± 26.7 months in the proximal repair group and 35.3 ± 26.8 months in the extended repair group. During follow-up, the cumulative survival and freedom from reintervention rates at 5 years were 66.4% and 92.9% in the proximal repair group, and 76.1% and 72.6% in the extended repair group, respectively (p = 0.515 and p = 0.134). Conclusions: No significant differences were found in the rates of long-term cumulative survival and freedom from aortic reintervention between the two surgical strategies. These findings suggest limited aortic resection achieves acceptable patient outcomes.

Staged revascularization and multi-modal mechanical circulatory supports in a patient with severe cardiogenic shock due to acute-on-chronic coronary syndrome.

Acute coronary syndrome with cardiogenic shock is a life-threatening condition, but with planned staged treatment combined with coronary revascularization and mechanical circulatory supports its management is increasingly possible. Here, we present our successful life-saving case. A 76-year-old male patient was diagnosed with ST-elevation myocardial infarction with cardiogenic shock due to severe stenosis of the left main coronary artery based on the severe triple vessel disease. We initially introduced Impella CP and performed a percutaneous coronary intervention without stenting on the patient. We maintained hemodynamics with Impella CP and performed coronary artery bypass grafting after a week. Intraoperatively, Impella CP was left to function as a left ventricular vent. The patient required upgrading to Impella 5.5 plus veno-arterial extracorporeal membrane oxygenation postoperatively, but his condition gradually improved, all mechanical circulatory supports could be weaned off, and he eventually survived.

Two-stage repair for DeBakey type II acute aortic dissection and distal aortic arch aneurysm in a nonagenarian patient.

Although total arch replacement would be performed in a patient with acute type A aortic dissection and concomitant aortic aneurysm in the distal aortic arch, total arch replacement may be too invasive in elderly patients with significant morbidities. A 92-year-old female with acute type II DeBakey aortic dissection and concomitant distal aortic arch aneurysm was successfully treated with hemi-arch replacement followed by thoracic endovascular aortic repair. Hybrid two-stage repair of DeBakey type II aortic dissection complicated by distal arch aneurysm using thoracic endovascular aortic repair after hemi-arch replacement may be effective.

Modified turn-up technique for proximal anastomosis in acute aortic dissection type A has potential to facilitate stable outcomes for low-volume early-career surgeons.

Objective: Secure proximal anastomosis is an essential part of surgical treatment for acute aortic dissection type A (AADA). This study aimed to investigate the effectiveness of the modified turn-up technique for proximal anastomosis in AADA and compare this technique with other techniques. Methods: We divided 57 patients who underwent ascending aorta replacement for AADA into the modified turn-up technique group (group A: 36 patients) and the other technique group (group B: 21 patients). Intraoperative and postoperative course data were compared between groups A and B. In group A, we also compared early-career surgeons (practicing for <10 years after graduation) and aged surgeons (practicing for ≥10 years after graduation). Results: Preoperative patient characteristics did not differ between groups. There was a tendency toward shorter operation time in group A than in group B without statistical significance (p = 0.12), and the length of intensive care unit stay was significantly shorter (p < 0.01); the occurrence of cerebral infarction was lower (p < 0.01) in group A than in group B, whereas mortality and major complications other than the cerebral infarction rate did not differ between the groups. In group A, 13 patients were operated on by early-career surgeons, while 23 patients were operated on by surgeons with more than 10 years of experience. Aortic clamp time and circulatory arrest time were significantly longer in patients operated on by early-career surgeons, but outcomes were comparable. Conclusions: The modified turn-up technique was comparable to other techniques. Even for less skilled surgeons (e.g., early-career surgeons), the use of this technique may lead to stable outcomes.

Case of rapid aortic remodeling after thoracic endovascular aortic repair for retrograde type A aortic dissection.

The proper surgical strategy for retrograde type A aortic dissection (RTAD) is still controversial, and some studies have reported the efficacy of frozen elephant trunk and thoracic endovascular aortic repair (TEVAR). A 68-year-old man was diagnosed with acute type A aortic dissection using enhanced computed tomography. The false lumen at the arch and ascending aorta was thrombosed, and the primary entry was placed in the descending aorta. In addition, there were malperfusions of the right renal artery and both iliac arteries. We performed TEVAR using the right femoral artery combined with the petticoat technique. At 11 days postoperatively, we observed rapid aortic remodeling at the arch and ascending aorta. The patient was discharged uneventfully after 14 days. We believe that TEVAR for RTAD is effective in appropriate patients. However, the accumulation of the number of cases and accurate strategies for patient selection are in demand.

Edge-to-edge repair of the systolic anterior motion of mitral valve and cardiac myectomy of the abnormally positioned papillary muscles in an infant with COL4A1 mutation.

Surgical treatment is challenging in pediatric patients with left ventricular outflow tract (LVOT) stenosis (LVOTS). We herein present the case of a 2-year-old male patient with porencephaly who was diagnosed with LVOTS accompanied by moderate mitral valve regurgitation (MR) with systolic anterior motion (SAM). Edge-to-edge mitral valve reconstruction and myectomy of the abnormal cardiac muscle were performed, with an uneventful postoperative course. LVOT myectomy and edge-to-edge mitral valve repair may be considered as a safe and acceptable approach with good clinical outcomes in pediatric patients with LVOTS accompanied by MR with SAM.

A case of TEVAR for acute aortic dissection after MICS AVR and retroperitoneal tumor resection.

If multiple treatments are performed within a short time, when something occurs, it is difficult to identify its cause. Here, we present a case of thoracic endovascular aortic repair (TEVAR) for acute aortic dissection (AAD) after multiple treatments. A 76-year-old woman underwent minimally invasive aortic valve replacement, transcatheter lumbar artery embolism and retroperitoneal tumor resection within a short period of time. After a series of procedures, the patient experienced sudden back pain, and computed tomography revealed an AAD Type B. Her back pain persisted; therefore, we performed TEVAR, and the post-operative course was uneventful. In this case, the relationship between AAD and treatment before AAD was unclear, but AAD should considered when performing treatments that may cause AAD.

Descending aortic transection for recurrence of a pseudoaneurysm previously treated with a stent graft after extra-anatomical bypass for aortic coarctation: a case report.

BACKGROUND: In adult patients with primary or recurrent coarctation of the aorta (CoA), extra-anatomic bypass grafting (EABG) has been widely used as a surgical treatment option. However, there have been few reports on pseudoaneurysms (PAs) of the distal anastomotic sites after extra-anatomic bypass for CoA. CASE PRESENTATION: A 51-year-old man with hemoptysis was transferred to our hospital. Twenty years ago, he had undergone EABG from the ascending to the descending aorta (ascending-to-descending EABG) for CoA with right aortic arch. Eight years ago, he underwent thoracic endovascular aortic repair (TEVAR) for the ruptured PA on the distal anastomotic site of the EABG. Contrast-enhanced computed tomography scans revealed recurrent ruptured PA on the distal anastomotic site of the EABG. Therefore, we decided to replace the descending aorta, followed by end-to-side anastomosis of the EABG to the replaced descending aorta. However, due to massive adhesion of the lung to the EABG and PA, we performed transection of the descending aorta to decompress the PA. The postoperative course was uneventful, and the patient is doing well 5 months after surgery. CONCLUSIONS: Aortic transection between the CoA and the distal anastomosis site may be a useful additional procedure in patients previously treated with TEVAR for PAs in the distal anastomosis site after EABG.

Feasibility of the AtriClip Pro Left Atrium Appendage Elimination Device via the Transverse Sinus in Minimally Invasive Mitral Valve Surgery.

BACKGROUND: Achieving external access to and manual occlusion of the left atrial appendage (LAA) during minimally invasive mitral valve surgery (MIMVS) through a small right thoracotomy is difficult. Occlusion of the LAA using an epicardial closure device seems quite useful compared to other surgical techniques. METHODS: Fourteen patients with atrial fibrillation underwent MIMVS with concomitant surgical occlusion of the LAA using double-layered endocardial closure stitches (n=6, endocardial suture group) or the AtriClip Pro closure device (n=8, AtriClip group) at our institution. The primary safety endpoint was any device-related adverse event, and the primary efficacy endpoint was successful complete occlusion of blood flow into the LAA as assessed by transthoracic echocardiography at hospital discharge. The primary efficacy endpoint for stroke reduction was the occurrence of ischemic or hemorrhagic neurologic events. RESULTS: All patients underwent LAA occlusion as scheduled. The cardiopulmonary bypass and aortic cross-clamp times in the endocardial suture group and the AtriClip group were 202±39 and 128±41 minutes, and 213±53 and 136±44 minutes, respectively (p=0.68, p=0.73). No patients in either group experienced any device-related serious adverse events, incomplete LAA occlusion, early postoperative stroke, or neurologic complication. CONCLUSION: Epicardial LAA occlusion using the AtriClip Pro during MIMVS in patients with mitral valve disease and atrial fibrillation is a simple, safe, and effective adjunctive procedure.