Angiotensin Receptor-Neprilysin Inhibitor Suppresses Renin-Angiotensin-Aldosterone System Activation After Cardiac Surgery Using Cardiopulmonary Bypass.

BACKGROUND: Sacubitril/valsartan, being both a neprilysin inhibitor and angiotensin receptor blocker, exhibits a renin-angiotensin-aldosterone system (RAAS) inhibitory effect. However, no study has investigated the administration of sacubitril/valsartan in patients early after surgery using cardiopulmonary bypass. METHODS AND RESULTS: This was a prospective observational study of 63 patients who underwent open heart surgery and were treated with sacubitril/valsartan. No serious adverse events occurred. Among the 63 patients, sacubitril/valsartan was discontinued in 13 due to hypotension (n=10), renal dysfunction (n=2), and dizziness (n=1). Atrial natriuretic peptide concentrations increased significantly from Day 3 of treatment (P=0.0142 vs. Postoperative Day 1) and remained high thereafter. In contrast, plasma renin activity was significantly suppressed from Day 3 onwards (P=0.00206 vs. Postoperative Day 1). A decrease in creatinine concentrations and an increase in the estimated glomerular filtration rate were observed on Day 3; this improvement in renal function was not observed in the historical control group, in which patients did not receive sacubitril/valsartan. New postoperative atrial fibrillation was less frequent in the study group compared with the historical control (12.7% vs. 38.0%; P=0.0034). CONCLUSIONS: Sacubitril/valsartan administration was safe immediately after open heart surgery in patients without postoperative hypotension. It enhanced serum atrial natriuretic peptide concentrations and suppressed RAAS activation.

Safety and Effectiveness of Acceleration Training as Cardiac Rehabilitation Immediately After Open Heart Surgery　- A Pilot Study.

BACKGROUND: We examined the safety and efficacy of acceleration training (AT) in patients immediately after cardiac surgery. METHODS AND RESULTS: This randomized controlled study included patients who underwent open-heart surgery using cardiopulmonary bypass. Of these patients, 31 received regular cardiac rehabilitation (CR) and 39 received AT in addition to regular CR (AT group). AT was provided using a vibration platform (Power Plate®Pro7TMand Power plate®personal; Performance Health System, Chicago, IL, USA). The AT group performed 5 static resistance training sessions: squats, wide stance squats, toe stands, banded squats, and front lunges. Each vibration session lasted 30 s. We evaluated the short physical performance battery, anterior mid-thigh thickness, maximum voluntary isometric contraction of the knee extensors, and serum intercellular adhesion molecule (ICAM-1) and vascular cell adhesion molecule (VCAM-1) concentrations as indicators of endothelial function. The observation period was during hospitalization and lasted approximately 20 days. No adverse events occurred during AT. Ultrasound revealed a significantly lower reduction in muscle mass at discharge in the AT group. No significant differences were observed in ICAM-1 and VCAM-1 concentrations between the 2 groups preoperatively, postoperatively, or at discharge. CONCLUSIONS: AT is considered safe and effective for patients immediately after open-heart surgery. AT, along with regular CR, may prevent skeletal muscle mass loss, muscle weakness, and physical function loss immediately after open-heart surgery.

Aortic annular enlargement techniques using an original patch for prosthetic valve endocarditis.

BACKGROUND: Prosthetic valve endocarditis (PVE) is a serious complication, and it is difficult to treat marked adhesion and infectious tissue. CASE PRESENTATION: There were four patients with aortic PVE, whose ages ranged from 59 to 80 years. In all patients, transoesophageal echocardiography revealed periannular abscess formation. We applied aortic annular enlargement techniques using a composite three-layer patch to repair the defects after radical debridement of the abscesses, and then replaced the prosthetic valves on the reconstructed annuli. All patients received antibiotics after surgery and recovered well without recurrence. CONCLUSIONS: The aortic annular enlargement techniques provided a good field of vision at the complicated annulus, and our original patch was useful for repairing the aortic annulus and its surrounding apparatus.

Surgical Fenestration for Lower Limb Ischemia Developing from Chronic Type B Aortic Dissection: A Report of 2 Cases.

Lower limb ischemia caused by type B aortic dissection typically presents with a leg-threatening condition in the acute phase. However, in some cases, lower limb ischemia symptom develops as intermittent claudication in the chronic phase. Although surgical fenestration has been used for treating ischemic complications of aortic dissection, it has recently become an alternative option for such cases because of the significant advance of endovascular treatments. We report 2 cases of chronic type B aortic dissection complicated by lower limb ischemia. Two male patients aged 57 and 43 years presented with intermittent claudication more than 2 weeks after the onset of the disease. On the basis of anatomic condition of the dissected aorta, we successfully performed surgical fenestration through a median laparotomy. In the current endovascular era, surgical fenestration remains an effective and durable option for treating lower limb ischemia caused by chronic type B aortic dissection.

The Konno Procedure in Redo Aortic Valve Replacement after the Nicks Procedure.

A case is reported of successful surgery using the Konno procedure seven years after the patient had undergone aortic valve replacement (AVR) with the Nicks procedure. A 79-year-old woman with aortic stenosis and a small aortic annulus had undergone previous AVR with a 17-mm mechanical prosthesis and aortic annular enlargement by the Nicks procedure. Redo surgery was performed using a 19-mm bioprosthesis with the Konno procedure, to replace a valve that had become stuck due to pannus formation. As intense adhesion was present around the heart, especially behind the posterior aortic wall where the Nicks procedure had been performed, the Konno procedure provided the advantage of a good field of vision at the aortic annulus. This procedure may be less invasive when applied to adults, because the septal incision in adults would be relatively smaller than in children. As well as being used in children, the Konno procedure could be an effective option for redo AVR in adults with a small aortic annulus.

Endovascular Repair of a False Aneurysm Developing from IgG4-Related Periaortitis during Corticosteroid Therapy.

Immunoglobulin G4 (IgG4)-related disease is a systemic autoimmune disease that can affect various organs. Corticosteroid therapy is generally an effective treatment; however, IgG4-related aortic lesions pose a risk of aortic rupture related to corticosteroid use. Here, we report a case of IgG4-related periaortitis complicated with a false aneurysm during corticosteroid therapy. Although endovascular repair was successfully performed, autoimmune pancreatitis and sclerosing cholangitis emerged after surgery. The multiple lesions associated with IgG4-related disease were resolved through continuous corticosteroid therapy. Our case suggests that both appropriate surgical intervention and continuous corticosteroid therapy are essential for the treatment of IgG4-related periaortitis.

Popliteal venous aneurysm with deep venous thrombosis in the contralateral calf: report of a case.

Although a popliteal venous aneurysm is a rare entity, it is an important cause of pulmonary embolism (PE), which is occasionally life-threatening. We herein report a case of a popliteal venous aneurysm with deep venous thrombosis (DVT) in the contralateral calf. A 65-year-old male, who presented with sudden onset palpitation and dyspnea, was transferred to our hospital. Enhanced computed tomography revealed PE and a venous aneurysm of the left popliteal vein. The popliteal venous aneurysm was saccular and had an intramural thrombus. Furthermore, duplex scanning detected DVT in the contralateral calf. The patient underwent a tangential aneurysmectomy with lateral venorraphy. The surgery and postoperative course were uneventful. The PE and calf DVT disappeared with perioperative anticoagulant therapy. It is recommended that, in the treatment of popliteal venous aneurysms, special attention should be given to the condition of the venous vessels of the contralateral leg, because this can influence the therapeutic strategy.

Collapse of zone 0 landing TEVAR (Najuta) and the development of higher brain dysfunction.

Although thoracic endovascular repair (TEVAR)-specific complications often develop, stent-graft collapse is a rare, but fatal complication that requires attention. A 62-year-old male underwent TEVAR for a saccular distal arch aortic aneurysm. After the placement of the Gore TAG (W. L. Gore & Associates, Inc., Newark, DE, USA) from zones 2 to 4, a Najuta endograft (Kawasumi Laboratories, Inc., Tokyo, Japan) was deployed from zone 0. Neither intraoperative angiography nor postoperative contrast-enhanced computed tomography (CT) showed endoleaks or migration. On day 12 after surgery, the patient suddenly lost consciousness during rehabilitation, and CT revealed the collapse of the Najuta endograft. In emergency surgery, the Najuta endograft was removed and the TAG was sutured to the aorta. Although the patient survived, he developed irreversible higher brain dysfunction. The cause of the collapse was examined by the manufacturer and only a slight bird-beak configuration was noted. There were no other findings to indicate the cause of the collapse. The Najuta endograft is a semi-customized system that is created according to the three-dimensional morphology of each individual aortic arch and, thus, is expected to follow the flexion of this vessel. Nevertheless, the risk of collapse needs to be considered.

Utility of growth differentiation factor-15 as a predictor of cardiovascular surgery outcomes: Current research and future directions.

In a world increasingly confronted by cardiovascular diseases (CVDs) and an aging population, accurate risk assessment prior to cardiac surgery is critical. Although effective, traditional risk calculators such as the Japan SCORE, Society of Thoracic Surgeons score, and EuroSCORE II may not completely capture contemporary risks, particularly due to emerging factors such as frailty and sarcopenia. These calculators often focus on regional and ethnic specificity and rely heavily on evaluations based on age and underlying diseases. Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine that has been identified as a potential biomarker for sarcopenia and a tool for future cardiac risk assessment. Preoperative plasma GDF-15 levels have been associated with preoperative, intraoperative, and postoperative factors and short- and long-term mortality rates in patients undergoing cardiac surgery. Increased plasma GDF-15 levels have prognostic significance, having been correlated with the use of cardiopulmonary bypass during surgery, amount of bleeding, postoperative acute kidney injury, and intensive care unit stay duration. Notably, the inclusion of preoperative levels of GDF-15 in risk stratification models enhances their predictive value, especially when compared with those of the N-terminal prohormone of brain natriuretic peptide, which does not lead to reclassification. Thus, this review examines traditional risk assessments for cardiac surgery and the role of the novel biomarker GDF-15. This study acknowledges that the relationship between patient outcomes and elevated GDF-15 levels is not limited to CVDs or cardiac surgery but can be associated with variable diseases, including diabetes and cancer. Moreover, the normal range of GDF-15 is not well defined. Given its promise for improving patient care and outcomes in cardiovascular surgery, future research should explore the potential of GDF-15 as a biomarker for postoperative outcomes and target therapeutic intervention.

Impella - Current issues and future expectations for the percutaneous, microaxial flow left ventricular assist device.

The importance of temporary mechanical circulatory support for treating acute heart failure with cardiogenic shock is increasingly recognized, and Impella (Abiomed, Danvers, MA, USA) has received particular attention in this regard. Impella is an axial flow left ventricular assist device (LVAD) built into the tip of a catheter. It is inserted via a peripheral artery and implanted into the left ventricle. Although the morphology of Impella is different from a typical LVAD, it has similar actions and effects as an LVAD in terms of left ventricular drainage and aortic blood delivery. Impella increases mean arterial pressure (MAP) and systemic blood flow, thereby improving peripheral organ perfusion and promoting recovery from multiple organ failure. In addition, left ventricular unloading with increased MAP increases coronary perfusion and decreases myocardial oxygen demand, thereby promoting myocardial recovery. Impella is also useful as a mechanical vent of the left ventricle in patients supported with veno-arterial extracorporeal membrane oxygenation. Indications for Impella include emergency use for cardiogenic shock and non-emergent use during high-risk percutaneous coronary intervention and ventricular tachycardia ablation. Its intended uses for cardiogenic shock include bridge to recovery, durable device, heart transplantation, and heart surgery. Prophylactic use of Impella in high-risk patients undergoing open heart surgery to prevent postcardiotomy cardiogenic shock is also gaining attention. While there have been many case reports and retrospective studies on the benefits of Impella, there is little evidence based on sufficiently large randomized controlled trials (RCTs). Currently, several RCTs are now ongoing, which are critical to determine when, for whom, and how these devices should be used. In this review, we summarize the principles, physiology, indications, and complications of the Impella support and discuss current issues and future expectations for the device.

Minimally invasive cardiac surgery via bilateral thoracotomy in treatment of left ventricle aneurysm: a case report.

BACKGROUND: Left ventricle aneurysm (LVA) as a sequela to myocardial infarction or iatrogenic injury is required surgical treatment with full median sternotomy. Herein, we report a case of successful surgical treatment of left ventricle aneurysm performed by minimally invasive cardiac surgery (MICS). CASE PRESENTATION: We describe a case of a LVA treated by minimally invasive cardiac surgery in an 82-year-old woman who reported to the hospital with the complaint of chest pains at rest. Computed tomography (CT) coronary angiography revealed a left ventricle apical aneurysm. The aneurysm was suspected to be a pseudoaneurysm caused by a previous myocardial infarction. Surgery was performed under general anesthesia, with the patient in a supine position. A small incision was made in the 3rd intercostal space through which an aortic root vent cannula and aortic clamp were inserted, followed by exposing the aneurysm via incision of the left 6th intercostal space. The aneurysm was resected and pathologically examined, revealing it to be a "true" aneurysm. The left ventricle wall was closed using polypropene mattress sutures. Postoperative CT scan revealed successful resection of the aneurysm. Usually, a surgical treatment with full median sternotomy and left ventriculostomy is indicated for LVA. We decided to treat the LVA with bilateral thoracotomy MICS. We preferred to perform this procedure under cardiac arrest to ensure safe and secure closure of the aneurysm. The right small thoracotomy was necessary for aortic cross-clamping and aortic root venting. CONCLUSIONS: The procedure was safe and simple and yielded excellent postoperative outcomes. Therefore, we speculate that this method can be applied to the management of larger aneurysms.

Overview of mechanical circulatory support for the management of post-myocardial infarction ventricular septal rupture.

Post-myocardial infarction ventricular septal rupture (PIVSR) is becoming increasingly rare in the percutaneous coronary intervention era; however, the mortality rates remain high. Surgical repair is the gold standard treatment for PIVSR but is associated with surgical difficulty and high mortality. Therefore, the timing of surgery is controversial (i.e. either undertake emergency surgery or wait for resolution of organ failure and scarring of the infarcted area). Although long-term medical management is usually ineffective, several mechanical circulatory support (MCS) devices have been used to postpone surgery to an optimal timing. Recently, in addition to venous arterial extracorporeal membrane oxygenation (VA-ECMO), new MCS devices, such as Impella (Abiomed Inc., Boston, MA, USA), have been developed. Impella is a pump catheter that pumps blood directly from the left ventricle, in a progressive fashion, into the ascending aorta. VA-ECMO is a temporary MCS system that provides complete and rapid cardiopulmonary support, with concurrent hemodynamic support and gas exchange. When left and right heart failure and/or respiratory failure occur in cardiogenic shock or PIVSR after acute myocardial infarction, ECpella (Impella and VA-ECMO) is often introduced, as it can provide circulatory and respiratory assistance in a shorter period. This review outlines the basic concepts of MCS in PIVSR treatment strategies and its role as a bridge device, and discusses the efficacy and complications of ECpella therapy and the timing of surgery.

[Investigation of rescued cases with cardiac rupture caused by blunt trauma].

The mortality of cardiac rupture by blunt trauma is so high that quick diagnosis and appropriate treatment are essential for saving patients. Based on 8 such cases rescued in our hospital and on 70 other rescued cases reported in Japan, we review its treatment strategy. Ultrasound examination, particularly focused assessment with sonography for trauma (FAST), was useful for diagnosing traumatic cardiac rupture. It was, however, impossible to detect the exact site of rupture before surgery. Three quarters of the rescued cases suffered from right cardiac rupture and more than 95% of those were treated successfully without extracorporeal circulation. All the cases with multiple cardiac rupture needed cardiopulmonary bypass or percutaneous cardiopulmonary support (PCPS) for their surgeries. And so did a quarter of the cases with left cardiac rupture. The standard treatment strategy seems to be as follows:to release cardiac tamponade as slowly as possible, to set up an extracorporeal circulation for surgery, and to repair the ruptured heart via median sternotomy.

Thymoma with a feeding vessel from coincident coronary-pulmonary artery fistulas.

We report a rare case of a 68-year-old man with thymoma and coronary-pulmonary artery fistulas. The thymoma was 66 × 51 × 88 mm in size and accompanied by a feeding vessel originating from the coronary-pulmonary artery fistulas. We performed total thymectomy and resection of coronary-pulmonary artery fistulas at the same time, which has not been reported in the literature. The fistulas along with the left main trunk were successfully resected while temporarily transecting the main pulmonary artery. This strategy was a useful option for obtaining a good field of vision around the left main trunk behind the main pulmonary artery.

Impella support as a bridge to heart surgery in patients with cardiogenic shock.

OBJECTIVES: In patients with cardiogenic shock, delayed surgery after stabilization of haemodynamics and improvement in end-organ function by mechanical circulatory support is known to yield better outcomes than emergency surgery. We aimed to investigate the effectiveness of Impella (Abiomed, Danvers, MA, USA) as a bridge to cardiac surgery in patients with cardiogenic shock. METHODS: We reviewed 7 patients with cardiogenic shock who underwent Impella support as a bridge to cardiac surgery using cardiopulmonary bypass at our institution between April 2018 and August 2021. RESULTS: Cardiogenic shock was caused by ventricular septal rupture in 3 patients, papillary muscle rupture in 1 and acute myocardial infarction in 3. Cardiac surgery was delayed by 1-7 (3.9 ± 2.5) days with Impella support after the diagnosis of cardiogenic shock, during which the hepatic and renal function of the patients improved significantly. Device-related or operation-related adverse events included re-exploration for bleeding in 3 patients, acute limb ischaemia due to thromboembolism in 1 and intraoperative aortic dissection in 1. Thirty-day mortality was 14.3%, and the cumulative survival was 71.4% at 1 year. The survival tended to be better than that in historical control group in which extracorporeal membrane oxygenation was used as a bridge to surgery (P = 0.0992). CONCLUSIONS: Impella is an effective tool for bridging patients with cardiogenic shock to surgery. This strategy may improve surgical outcomes in patients with cardiogenic shock. However, prolonged Impella support may increase significant adverse events, and further investigation is required to determine the optimal duration of support before surgery.

Immunoglobulin G4-related inflammatory pseudotumor of the right ventricle with right coronary artery occlusion.

Immunoglobulin G4-related inflammatory pseudotumors are usually benign. Such tumors of cardiac origin are extremely rare, with no primary cardiac tumors reported to date. We report a case of a 77-year-old woman, with a medical history of diabetes, hypertension, and hyperlipidemia, who was diagnosed with a malignant cardiac tumor on preoperative imaging and had a confirmed pathological diagnosis of immunoglobulin G4-related inflammatory pseudotumor. She was examined for atherosclerosis obliterans, and coronary computed tomography revealed obstruction of the right coronary artery and a cardiac tumor in the right atrium. A suspected malignant tumor measuring 40 mm (maximum standardized uptake value: 12.2) bordering the right atrium was detected using 18F-fluorodeoxyglucose positron emission tomography. Her tumor was in contact with the heart, making biopsy impossible. She was diagnosed with malignancy on preoperative imaging and underwent tumor resection, tricuspid valve replacement, right atrial and right ventricular plasty, coronary artery bypass, lung resection, and diaphragmatic repair. However, the final pathological diagnosis was immunoglobulin G4-related inflammatory pseudotumor. Preoperative diagnosis of immunoglobulin G4-related inflammatory pseudotumor is extremely difficult; however, if the condition is diagnosed preoperatively, chemotherapy or steroid therapy should be administered, and patients who do not respond to chemotherapy should be considered for surgical treatment. Learning objective: Immunoglobulin G4-associated inflammatory pseudotumor is extremely rare. Preoperative imaging diagnosis of immunoglobulin G4-associated inflammatory pseudotumor is extremely difficult, and pathology with biopsy is the only definitive diagnosis. However, if we could make an accurate preoperative diagnosis, patients should be treated with chemotherapy or steroids, and surgical treatment should be considered for patients who do not respond to chemotherapy or steroids.

Prosthetic Valve Function after Aortic Valve Replacement for Severe Aortic Stenosis by Transcatheter Procedure versus Surgery.

Background This study compared the clinical outcomes of transcatheter (TAVR) and surgical (SAVR) aortic valve replacements, focusing on postoperative valvular performance assessed by echocardiography. Method and Results A total of 425 patients who underwent TAVR (230 patients) or SAVR (195 patients) were included. Postoperative effective orifice area index (EOAI) was higher in the TAVR group (1.27 ± 0.35 cm2/m2) than in the SAVR group (1.06 ± 0.27 cm2/m2, p < 0.001), and patient−prosthesis mismatch (PPM) was more frequent in the SAVR group (22.6%) than in the TAVR group (8.7%, p < 0.001). Mild or greater paravalvular leakage (PVL) was more frequent in the TAVR group (21.3%) than in the SAVR group (0%, p < 0.001). Moreover, there was no difference in freedom from all-cause death, stroke, or rehospitalization between the groups. Patients with moderate or greater PPM (EOAI < 0.85 cm2/m2) had lower freedom from composite events than those without this PPM criterion (p = 0.008). Patients with mild or greater PVL also had lower freedom from composite events than those without this PVL criterion (p = 0.017). Conclusions Postoperative valvular performance of TAVR was superior to that of SAVR in terms of EOAI. This merit was counterbalanced by the significantly lower rates of PVL in patients who underwent SAVR. The overall clinical outcomes were similar between the study groups.

Reducing the dose of contrast medium in angiography by use of a highly sensitive receiver and synchrotron radiation system.

OBJECTIVE: Contrast medium causes side effects such as contrast-induced nephropathy, and the dose of contrast medium is a risk factor in their occurrence. To reduce doses of contrast medium, we developed an angiographic system with high definition and high sensitivity and reviewed its effectiveness. The system entails synchrotron radiation, which is characterized by high photon density and straightness of beam that together result in high resolution, and a high-gain avalanche rushing amorphous photoconductor receiver, which is 100 times more sensitive than conventional charge-coupled device cameras. MATERIALS AND METHODS: Diluted contrast medium was administered, and angiography of rat hindlimbs was performed with synchrotron radiation and the high-gain photoconductor receiver. The difference in gray-scale value between the background and contrast medium was calculated. Images were evaluated by counting of arteries. RESULTS: The difference in contrast at low levels was detected with the high-gain photoconductor receiver but not with the charge-coupled device camera. The photon density of synchrotron radiation with the high-gain photoconductor receiver was one-fifth that with the charge-coupled device camera. The high-gain photoconductor receiver had approximately 5 times the sensitivity of the charge-coupled device camera. CONCLUSION: Use of the synchrotron radiation and high-gain photoconductor receiver makes it possible to perform angiography with an extremely low concentration of contrast medium.

[Comparative study between landiolol and amiodarone for therapeutic efficacy after open heart surgery].

Tachyarrhythmia, especially atrial fibrillation, remains as a common complication after open heart surgery and sometimes leads to fatal condition. Many reports showed that landiolol (ultra short-acting beta one blocker) and amiodarone were effective against postoperative atrial fibrillation (POAF). However, there were few comparative studies between these 2 drugs as prophylactic agents, and no report mentioned the therapeutic efficacy. Our study suggests that landiolol be the 1st choice for rate control of tachyarrhythmia because of easy dose adjustment and mild side effects. Amiodarone may be useful for the patients whose left ventricular function is poor.

Mediastinal Abscess Caused by an Expanded Polytetrafluoroethylene Membrane.

A 76-year-old man who had undergone tricuspid annuloplasty 13 years earlier was admitted to our hospital because of a high fever. Although he was treated with antibiotics for pneumonia, a mild fever persisted. Computed tomography and gallium scintigraphy revealed a mediastinal abscess with an expanded polytetrafluoroethylene (ePTFE) membrane. There were no positive cultures or sternal changes indicating poststernotomy mediastinitis. The membrane was removed by a left parasternal approach without resternotomy, and its total removal was essential for the patient's recovery. This is the first reported case of sterile mediastinal abscess caused by an ePTFE membrane after a cardiac operation.