Propensity score-matched comparison of total arterial off- and on-pump coronary artery bypass with complete revascularization.

Little is known regarding the long-term (> 10 years) outcomes and risk factors of total arterial coronary artery bypass grafting (CABG). This study evaluated the long-term outcomes and risk factors for all-cause mortality and major adverse cardiac and cerebrovascular events (MACCEs) following total arterial on-pump CABG (ONCAB) or off-pump CABG (OPCAB) with complete revascularization. This retrospective cohort analysis enrolled patients with stable angina who underwent total arterial CABG with complete revascularization in our institute between July 2000 and June 2019. The endpoints were all-cause mortality and MACCE incidence, including a comparison between OPCAB and ONCAB. Long-term (10-year) outcomes were analyzed using propensity score-matched pairs, and risk factors were evaluated using univariate and multivariate analyses. Overall, 401 patients who underwent primary total arterial CABG were classified into the OPCAB (n = 269) and ONCAB (n = 132) groups. Using propensity score matching (PSM), 88 patients who underwent OPCAB were matched with 88 patients who underwent ONCAB. The mean follow-up period was 7.9 ± 6.3 years. No significant difference in all-cause mortality (hazard ratio, 1.04; 95% confidence interval, 0.53-2.04; p = 0.9138) and MACCE incidence (hazard ratio, 1.06; 95% confidence interval, 0.68-1.65; p = 0.7901) was observed between the two groups. Renal failure requiring dialysis was a significant risk factor for mortality (p < 0.0001) and MACCEs (p = 0.0003). Long-term outcomes of total arterial OPCAB and ONCAB with complete revascularization showed similar findings using PSM. Renal failure requiring dialysis was a significant risk factor for mortality and morbidity.Journal standard instruction requires an unstructured abstract; hence the headings provided in abstract were deleted. Kindly check and confirm.Thank you for your kindness.Clinical registration number 5598, Tokyo Women's Medical University Hospital.

Trans-cuff leakage in bio-Bentall operation.

We have reported a case of trans-cuff leakage that occurred in a composite graft of bio-Bentall operation. The leakage resolved several months after surgery, similar to the trans-cuff leakage seen in simple aortic valve replacement. We have proposed hypotheses on the mechanism of trans-cuff leakage during a bio-Bentall operation and suggested ways to prevent it from occurring.

[Introduction and Activities of Nurse Practitioner in Japan in a University Hospital].

Nurse practitioner (NP) is widely known to be an essential position of medical team in the United States, but has not yet been established as an official qualification in Japan. NP in Japan (NP-J) is accepted instead of NP, but they are not the same. We summarized the actual activities of NP-J at our hospital and had an insight into the roles of NP-J in a university hospital and the problems of introduction of NP in the future. The benefits of working as a NP-J at a university hospital are the safe acquisition of procedures at an educational institution and the involvement of various departments. In the future, the education of NP-J in a university hospital may lead to the training of NP-J working in public and private hospitals. The problem of introduction of NP in the future is the legislation. The importance of task shifting and education of NP-J in a university hospital may lead to the spread of NP in the future in Japan.

Gerbode defect and left ventricular-aortic discontinuity in prosthetic valve endocarditis.

Communication between the left ventricle and right atrium is known as the Gerbode defect. The defect is usually congenital but can be acquired secondary to infective endocarditis. Left ventricular-aortic discontinuity is another serious complication of extensive infective endocarditis. Here, we report a rare case of prosthetic valve endocarditis complicated with both acquired Gerbode defect and left ventricular-aortic discontinuity. We successfully performed reconstructive surgery involving patch closure of the Gerbode defect and reconstruction of the circumferential left ventricular outflow tract with a xenopericardial patch, followed by supra-annular aortic valve replacement with the Solo Smart bovine pericardial stentless valve.

Solo Smart stentless bioprosthesis for redo aortic valve replacement.

BACKGROUND: In the redo aortic valve replacement (AVR), removal of the previously implanted damaged prosthesis may result in a native aortic annulus defect, making it difficult to reimplant a stented prosthesis. The Solo Smart valve, a relatively new stentless bioprosthesis, is designed for the supra-annular implantation into the wall of the sinus of Valsalva and may be a useful alternative to redo-AVR. CASE REPORT: We report a successful case of redo-AVR using the Solo Smart valve. CONCLUSION: The unique feature of the Solo Smart valve is the supra-annular implantation procedure in the sinus of Valsalva without annular stitches. This bioprosthesis can be a useful alternative for redo-AVR in patients with a defect of the native aortic annulus.

Harvest of the right gastroepiploic artery graft using a novel hybrid ultrasonic/bipolar energy device.

BACKGROUND: The right gastroepiploic artery (RGEA) is a useful in-situ graft, and skeletonization is effective to prevent spasm and achieve good patency. To harvest the skeletonized RGEA easily, ultrasonic scalpel has been widely used, but the tip shape of conventional ultrasonic device was not optimal for this procedure. Recently, a novel hybrid ultrasonic/bipolar energy device (THUNDERBEAT Open Fine Jaw [TOFJ]) has been developed and is widely used in general surgery. SURGICAL TECHNIQUE: The operator holds forceps in left hand and TOFJ in right hand, incises the anterior layer of the omentum, and extends the incision distally along the RGEA. The side branches and satellite veins were sealed and cut. Because the tip of the TOFJ is well-designed to easily grasp and peel off the tissue, there is no need to change instruments throughout the procedure. After the dissection was advanced distally, the proximal side was subsequently dissected. CONCLUSIONS: This novel device is useful for harvesting skeletonized RGEA.

Pulmonary infiltration shadows associated with acute aortic dissection mimicking coronavirus pneumonia.

BACKGROUND: In acute aortic dissection, various findings can be found in computed tomography. However, pulmonary infiltration is rarely observed. CASE REPORT: A 57-year-old man was diagnosed with acute aortic dissection (AAD), but had marked infiltration shadows in his right lung. Intraoperative findings showed that large subadventitial hematomas had spread from the ascending aorta to the right pulmonary artery, which may have caused the infiltration of the lung. CONCLUSIONS: Subadventitial hematoma must be considered in rare cases of AAD with pulmonary infiltration.

[Pleuro-peritoneal Shunt for Intractable Pleural Effusion Complicated with Unresectable Cardiac Tumor].

We present a case of palliative pleuro-peritoneal shunt for refractory hydrothorax complicated with unresectable cardiac tumor. The patient was a 77-year-old woman, who was admitted to our hospital for evaluation of intractable pleural effusion. It was attributed to severe diastolic dysfunction associated with cardiac tumor. The cardiac tumor occupied a large area of the anterior surface of the right atrium, and curative surgical resection was difficult. Therefore, we planned multidisciplinary staged treatment with chemotherapy followed by tumor excision. Persistent intractable bilateral pleural effusion necessitated repeat chest drainage. To maintain the patient's quality of daily life, bilateral pleuro-peritoneal shunts were inserted. Then, the problem of pleural effusion was resolved and her symptoms were improved. However, she expired 3 months later, due to deterioration of general condition. Pleuro-peritoneal shunting is a useful palliative approach to improve quality of life in patients with refractory hydrothorax.

[Patch Closure of Posterior Type Ventricular Septal Perforation with Posterior Left Ventricular Aneurysm through Right Ventricular Incision].

We report a case of patch closure of posterior type ventricular septal perforation (VSP) with posterior left ventricular aneurysm (PLVAN) through right ventricular incision. A 70-year-old man was transferred to our hospital because of persistent epigastric pain. He was diagnosed with inferior acute myocardial infarction, and percutaneous coronary intervention was performed to the right coronary artery[ atrio-ventricular(AV)]. After 2 weeks, he developed congestive heart failure and was treated with inotropic support and intra-aortic balloon pumping. Echocardiography and computed tomography (CT)showed posterior type VSP between PLVAN and the right ventricle. The operation was performed via standard median sternotomy and under cardiopulmonary bypass. After right ventricle incision parallel to the left anterior descending artery, there was VSP (20×20 mm) behind the trabecular septmarginalis (TSM). We closed VSP with a 2-layer patch (40×40 mm) consisted of Dacron and bovine pericardial patches. Postoperative echocardiography showed no residual shunt, and postoperative CT showed no enlargement of PLVAN. He was discharged home on foot without right heart failure and has been well without major complications.

Axillary venous drainage in redo aortic root surgery.

The axillary artery is an established alternative cannulation site for peripheral cardiopulmonary bypass (CPB). However, axillary vein cannulation is not as common. Here, we present our experience with an axillo-axillary CPB combined with a femoro-femoral CPB in redo aortic root replacement. The full-flow bypass was obtained with vacuum-assisted drainage and excellent decompression of the heart was achieved without left heart venting. Although only adhesions around the aortic root graft were dissected, a comfortable surgical field could be obtained with our CPB strategy. Axillary vessels were easy to expose with a small single skin incision. Cerebral protection could be achieved in both antegrade and retrograde fashion when the circulatory arrest was required for an additional arch procedure. Our strategy based on axillo-axillary and femoro-femoral CPB was effective and feasible in redo aortic root replacement. We consider that it simplified the complex aortic reoperation.

Atypical Kawasaki disease: A patient with coronary, brain, and internal mammary arteritis.

Here we report a rare case of atypical Kawasaki disease (KD) in a patient presenting with systemic arteritis affecting the coronary arteries, brain, and internal mammary arteries (IMAs). A 25-year-old man was referred to our institute with angina pectoris. Coronary angiography revealed coronary artery aneurysms and triple-vessel disease. Three-dimensional brain computed tomography showed multiple small saccular aneurysms on the vertebral and posterior inferior cerebellar arteries. Off-pump coronary artery bypass (OPCAB) grafting ​​​​​​was performed; however, the bilateral IMAs were tightly adhered and not patent. OPCAB was completed using the bilateral radial and gastroepiploic arteries. This is the first report of KD involving the IMA.

Modified Commando operation using stentless aortic bioprosthesis.

Operations necessitating intervalvular fibrous body reconstruction in patients with extensive endocarditis are referred to as "Commando operations," an indicator of the procedure's difficulty. Aortic root replacement is inevitable when performing the Commando operation for extensive aortic annular defect after radical debridement. We performed a modified Commando operation, in which supra-annular aortic valve replacement with the Solo Smart stentless bioprosthesis was employed instead of aortic root replacement. Supra-annular implantation can spare damaged annular structures. This modification is expected to render complex reconstructive surgery technically less demanding.

Solo Smart Stentless Bioprosthesis for Infective Valve Endocarditis with Aortic Annular Abscess.

So far, there is still controversy regarding the optimal prosthetic valve for patients with active infective valve endocarditis with annular abscess. Here, we report the case of a 65-year-old woman who was diagnosed with infective endocarditis associated with extensive annular abscess. The patient underwent debridement of the abscess cavity followed by aortic valve replacement using a Solo Smart (SS) stentless bioprosthesis. Postoperative recovery was uneventful, with no signs of recurrent infection. Since the SS valve is designed for supra-annular and subcoronary implantation, it is considered to be an alternative to conventional prosthetic valves in patients with infective endocarditis with aortic annular abscess.

[Successful Pregnancy Outcome in a Woman Undergoing Aortic Valve Replacement Using a Mechanical Valve which Allows Reduced Anticoagulation].

Pregnant women undergoing mechanical valve replacement are at a considerable risk of thromboembolic events, bleeding, and fetotoxicity associated with the administration of vitamin K antagonists and some other anticoagulants. We present our clinical experience of pregnancy and childbirth in a young woman who underwent aortic valve replacement (AVR) with a mechanical valve. A young woman underwent AVR with a bioprosthetic valve for a diagnosis of aortic regurgitation and bicuspid aortic valve at age 23. Four years later, structural valve deterioration(SVD) of the prosthetic valve necessitated redo AVR with bioprosthesis. Three years after the redo AVR, she developed recurrent SVD of the bioprosthesis, and the 3rd AVR operation was performed using an On-X mechanical valve, which allows reduced anticoagulation. She conceived 5 months after AVR using the On-X valve. Anticoagulation therapy was administered with a low-dose vitamin K antagonist combined with heparin infusion during pregnancy. No anticoagulation-induced maternal and fetal complications occurred throughout the pregnancy. The On-X valve, which allows lower levels of anticoagulation is useful in women wishing to get pregnant.

[Clinical Experience of Endovascular Stent-graft Treatment for Stanford Type A Acute Aortic Dissection].

BACKGROUNDS: Recently, thoracic endovascular aortic repair (TEVAR) is widely accepted and performed in patients with complicated and uncomplicated Stanford type B aortic dissection. However, TEVAR for Stanford type A aortic dissection is not commonly performed even in the endovascular era. This report describes patients who underwent TEVAR for Stanford type A dissection. PATIENTS: Since 2016, 5 patients underwent TEVAR for retrograde acute Stanford type A dissection. A covered stent-graft was placed in the descending aorta for primary entry coverage. An additional bare-stent was placed in the narrowed true lumen of the downstream aorta. A thrombosed false lumen was observed in 4 and a partially thrombosed lumen in 1 patient. No patient showed pericardial effusion, aortic insufficiency, or persistent back pain. Four of 5 patients were asymptomatic, and only 1 patient developed multiorgan malperfusion. Repetitive computed tomography (CT) was performed postoperatively. RESULTS: All patients underwent successful TEVAR without the need for additional intervention, and no operative mortality and morbidity were observed. The patient with multiorgan malperfusion recovered uneventfully without any complication. Follow-up CT revealed complete disappearance of the false lumen in the ascending aorta in all patients. CONCLUSIONS: Although TEVAR of the descending aorta was performed with acceptable mortality and morbidity rates in strictly selected patients with retrograde Stanford type A dissection, conceptual and technical issues remain unresolved in patients with ascending aortic stent-graft placement. Technological advances would lead to the development of innovative disease-specific endovascular devices and solutions in the future for TEVAR in patients with Stanford type A dissection.

[Acute Pancreatitis after Thoracoabdominal Aortic Aneurysm Repair in Patient Having a History of Pancreaticoduodenectomy;Report of a Case].

A 76-year-old man who have a history of pancreaticoduodenectomy was admitted to our hospital for surgical treatment of pararenal abdominal aortic aneurysm. He underwent thoracoabdominal aortic aneurysm repair through the Stoney's thoracoabdominal incision under partial cardiopulmonary bypass. Postoperatively, laboratory examination showed elevated pancreatic amylase and computed tomography revealed acute pancreatitis. Pancreatitis was successfully treated by giving IV protease inhibition and the patient went well thereafter. In patients with a history of pancreaticoduodenectomy, gentle surgical maneuver around the residual pancreas and adequate perfusion of celiac artery during thoracoabdominal aortic aneurysm repair were considered mandatory.

[Surgical Experience of Mitral Valve Plasty in Patient with Persistent Left Superior Vena Cava;Report of a Case].

A 45-year-old man diagnosed with severe mitral regurgitation was admitted to our hospital for surgical treatment. Preoperative computed tomographic imaging revealed a persistent left superior vena cava. At operation, cardiopulmonary bypass was established with ascending aortic and bicaval cannulation. In addition to 2 venous cannulas, we directly cannulated to the left superior vena cava for sufficient venous drainage. Mitral valve plasty consisted of triangular resection of P2 segment was performed through the right side left atriotomy. Postoperative course was uneventful and echocardiography 3 months after the operation showed trivial mitral regurgitation. Precise preoperative evaluation concerning the persistent left superior vena cava should be mandatory for appropriate management of cardiopulmonary bypass.

Surgical management of proximal coronary arteriovenous fistulas using intraoperative fluorescence imaging.

We report the use of intraoperative fluorescence imaging to assist in the surgical management of proximal coronary arteriovenous fistulas in four patients.

[Excision of a Left Ventricular Papillary Fibroelastoma via Right Thoracotomy with a Small Skin Incision].

A 75-year-old woman was referred to our hospital for surgical treatment of a left ventricular mass. Echocardiography demonstrated a mobile left ventricular mass originating from the apex of the anteroseptal wall. Cardiac magnetic resonance imaging showed low signal intensity on T1 images and high signal intensity on T2 images. A right 4th intercostal thoracotomy with a small skin incision was performed, and cardiopulmonary bypass was established via the right femoral artery and vein and the right jugular vein. After cardiac arrest, we approached the tumor through the mitral valve via a left atrial incision. Resection of the tumor was difficult owing to its deep location;however, we could successfully resect it using an endoscope. Histopathological diagnosis confirmed a papillary fibroelastoma. Postoperative course was uneventful. A papillary fibroelastoma originating from the left ventricular wall is rare. Although a right thoracotomy is a useful approach for the management of a cardiac mass, careful planning is needed to obtain access to a mass in deep location.

[Surgical Experience of Distal Aortic Arch Aneurysm Suspected to be Associated with Pre-existing Coarctation of the Aorta].

A 45 year-old-man who had undergone ventricular septal defect repair during childhood presented with hoarseness. He was diagnosed as having a distal aortic arch aneurysm by using computed tomography, and was referred to our hospital for surgical treatment. The operation was performed via a 4th intercostal thoracotomy in the right lateral position. The aortic aneurysm occupied the upper pleural cavity. The aortic arch was pressed up by the aortic aneurysm, so visual identification and clamping of the proximal aorta and the left subclavian artery were extremely difficult. Extracorporeal circulation was established via the right femoral artery and vein. Aneurysmal resection and graft replacement were performed using the open proximal method and retrograde cerebral circulation. The aneurysmal wall and proximal aorta were fragile and the proximal aorta was narrow, although the distal aorta was normal. The difference in diameters between the proximal and distal aorta suggested the presence of coarctation of the aorta.