New-Generation Transcatheter Aortic Valves in Patients With Small Aortic Annuli　- Comparison of Balloon- and Self-Expandable Valves in Asian Patients.

BACKGROUND: Asian patients have smaller aortic annuli. Although 20-mm balloon-expandable (BE) transcatheter heart valves (THV) are manufactured for transcatheter aortic valve implantation (TAVI) in these cases, the supra-annular design of self-expandable (SE) THV is considered more suitable; however, real-world comparative data are scarce.Methods and Results:Consecutive TAVI cases (n=330) in a single Japanese center were reviewed. Based on the cutoff for the new-generation 20-/23-mm BE-THV, a small aortic annulus was defined as <330 mm2. A considerable number of patients had small annuli: 49/302 (16%). Of these, 33 BE-THV and 13 SE-THV using new-generation valves were compared. Although the SE-THV group had smaller annulus area (median 297 (interquartile range, 280-313) vs. 309 (303-323) mm2(P=0.022)), it had more favorable post-procedural parameters; for SE-THV and BE-THV, respectively, effective orifice area (EOA), 1.5 (1.3-1.6) vs. 1.1 cm2(0.9-1.3) (P=0.002); mean pressure gradient, 7.6 (5.6-11.0) vs. 14.2 mmHg (11.2-18.8) (P=0.001); and peak velocity, 1.8 (1.6-2.4) vs. 2.7 m/s (2.3-3.1) (P=0.001). Although new left bundle branch block was higher with SE-THV (24% and 62%, P=0.02), patient-prosthesis mismatch (PPM) ≥ moderate (indexed EOA <0.85 cm2/m2) was significantly less with SE-THV than with BE-THV (8% vs. 55%; P=0.04). Hemodynamic findings were consistent up to 1 year. CONCLUSIONS: Small annuli are often seen in Asian patients, for whom SE-THV implantation results in favorable hemodynamics with less PPM.

Candy-Plug Technique Using an Excluder Aortic Extender for Distal Occlusion of a Large False Lumen Aneurysm in Chronic Aortic Dissection.

PURPOSE: To describe the candy-plug technique using an Excluder aortic extender for distal occlusion of a large false lumen aneurysm in chronic aortic dissection. TECHNIQUE: A 60-year-old female patient with a history of chronic type B aortic dissection and high-dose steroid use for Churg-Strauss syndrome developed a large 6.2 cm maximum diameter false lumen aneurysm. She underwent thoracic endovascular aortic repair from the left common carotid artery to the descending aorta to cover the proximal entry at the level of distal arch, with coil embolization of the left subclavian artery. To occlude the large false lumen from the reentry just below the level of the left renal artery ostium, a modified 32×45-mm Excluder aortic extender was deployed in the false lumen through the reentry, and a 16-mm Amplatzer Vascular Plug I was deployed in the waist of the modified Excluder aortic extender for complete occlusion. No obvious technical complication was seen. Contrast-enhanced computed tomography at 1 and 14 months revealed no endoleaks and showed complete false lumen thrombosis. CONCLUSION: The candy-plug technique using the Excluder aortic extender is feasible for occlusion of a large false lumen aneurysm in chronic aortic dissection.

Aberrant Glycosylation of Lumican in Aortic Valve Stenosis Revealed by Proteomic Analysis.

To identify proteins related to the pathophysiology of aortic valve stenosis (AS), we investigated the protein profiles of AS aortic valves. Specifically, proteins were extracted from a thickened and calcified area (AS-C) and an apparently non-thickened and non-calcified area (AS-N) in an identical aortic valve leaflet in each of 6 AS patients. The proteins were then separated by 2-dimensional gel electrophoresis (2DE). Protein spots detected by 2DE were compared between the AS-C and AS-N samples. Protein spots of interest were subjected to protein identification by mass spectrometry.In total, 670 protein spots were detected by 2DE, 28 of which showed more than 1.5-fold different intensity (P < 0.05) between the AS-C and AS-N samples. Proteins were identified in 17 out of the 28 spots. Fibrinogen and lumican were identified in 9 and 3 spots, respectively. Intensity of these 12 spots was lower in the AS-C samples than in the AS-N samples. In the 1D-Western blot analysis, 4 lumican bands (80 kDa, 75 kDa, 65 kDa, and 53 kDa) were detected, of which 2 bands with 80 kDa and 75 kDa showed lower intensity in the AS-C samples than in the AS-N samples. When de-glycosylated protein samples were used in the 1D-Western blot, only a single lumican band with ~40 kDa was detected, indicating that lumican was variously glycosylated and that highly glycosylated lumican molecules were decreased in AS-C.Collectively, insufficient glycosylation of lumican in the thickened and calcified areas of AS aortic valves may be involved in the pathophysiology of AS.

Dialysis Amyloid Deposition in the Aortic Valve and Its Association with Aortic Stenosis.

BACKGROUND: The relationship between dialysis amyloid (DA) deposition in the aortic valve (AV) and aortic stenosis (AS) is unknown. METHODS: This was a cross-sectional study. AV specimens of dialysis patients (median vintage: 8.8 years) consecutively collected from cardiac surgeries (n = 56) or autopsies (n = 13) were examined by a board-certified pathologist blinded to clinical data. DAs were considered to be present if deposits were stained both by Congo red with apple-green birefringence under polarized light and by anti-ß2-microblobulin antibody. Degree of deposition was graded as follows: Amyloid (-), no deposit; Amyloid (1+), occasional small deposits; Amyloid (2+), multiple small to large deposits or a single large deposit. Calcification was defined as a calcified deposit with a diameter >1 mm in the specimen. Severe AS (sAS) was defined as a mean gradient >50 mm Hg by echocardiogram. We examined the proportion of DAs and the association between DAs and the sAS. RESULTS: DAs were present in 71% (n = 49) of specimens and primarily co-localized with calcification. Non-dialysis related amyloid was found in one specimen. After excluding this specimen, sAS was associated with 'Amyloid (1+) and Calcification >1 mm' and 'Amyloid (2+) and Calcification >1 mm' (vs. 'Amyloid (-) and Calcification ≤1 mm', odds ratios (ORs): 13.5 and 34.2, respectively). Furthermore, after adjustment for covariates, sAS was found to be associated with 'Amyloid (2+) and Calcification >1 mm' (OR: 24.3). CONCLUSIONS: DA deposition in the AV was prevalent among dialysis patients. DA deposition with accompanying calcification might contribute to the severity of AS.

Coronary artery spasm following off-pump coronary artery bypass surgery.

Coronary artery spasm after coronary artery bypass surgery may result in life-threatening arrhythmias, circulatory collapse, or death. We report two cases of coronary artery spasm after coronary artery bypass surgery, one of which developed ventricular fibrillation requiring extracorporeal membrane oxygenation support. Both patients were discharged in good condition and are currently followed as outpatients. Unexpected sudden hemodynamic compromise could be due to coronary vasospasm, and this should be considered as one of the possible differential diagnoses. We were able to prevent the lethal consequences seen with coronary artery spasm by early diagnosis and management.

[Right ventricular rupture due to blunt trauma diagnosed by MDCT; report of a case].

The survival rate of cardiac rupture due to blunt trauma is generally low. We experienced a case with right ventricular rupture due to blunt trauma. The patient was a 49-year-old man who was crushed in a traffic accident and transported to a local hospital in a shock state. He was diagnosed with cardiac tamponade due to cardiac rupture, and for pericardial drainage was immediately performed. He was then transferred to our hospital for emergency surgery. His hemodynamics was stable, and he was diagnosed with right ventricular rupture by multi-detector row computed tomography (MDCT). The operation was performed successfully without cardiopulmonary bypass, and his postoperative course was uneventful. MDCT is useful for detecting the rupture site of the heart.

Intraoperative assessment for mitral valve competency in a beating heart under retrograde coronary perfusion.

Intraoperative assessment of a repaired mitral valve is of paramount importance for reparative mitral surgery. From September 2010 through November 2012, 20 consecutive patients underwent mitral valve plasty for mitral regurgitation. The patients who underwent surgery after June 2012 received assessment of the repair with the heart beating (HB group, n = 10), and the patients who underwent the operation before May 2012 were assessed for the repair only under cardioplegic heart arrest (non-HB group, n = 10). Intermittent cold retrograde blood cardioplegia was used in all patients. In the HB-group, after completion of the procedures, pump blood without a crystalloid additive was delivered into the coronary sinus. The function of the mitral valve was assessed under beating conditions. There were no differences between the two groups in aortic cross clamp time and operation time, although operative and concomitant procedures were slightly more complicated in the HB group than in the non-HB group. Postoperative echocardiography revealed none or mild mitral regurgitation in all the patients in both groups. Reopening of the closed left atrium for additional repair was necessary only in one patient in the HB group and 3 patients in the non-HB group. In conclusion, the method of perfusing the myocardium retrogradely via the coronary sinus with warm blood is safe and effective for assessing the competency of the mitral valve in a beating heart.

Risk model of cardiovascular surgery in 845 Marfan patients using the Japan adult cardiovascular surgery database.

The aim of this study was to evaluate the short-term operative results of patients with Marfan syndrome who underwent thoracic or abdominal aortic surgery in a 4-year period in Japan. Data were collected from the Japan Cardiovascular Surgery Database (JCVSD). We retrospectively analyzed the data of 845 patients with Marfan syndrome who underwent cardiovascular surgery between January 2008 and January 2011. Logistic regression was used to generate risk models. The early mortality rate was 4.4% (37/845). Odds ratios (OR), 95% confidence intervals (CI), and P values for structures and processes in the mortality prediction model were as follows: renal insufficiency (OR, 11.37; CI, 3.7234.66; P < 0.001); respiratory disorder (OR, 11.12; CI, 3.20-38.67; P < 0.001); aortic dissection (OR, 13.02; CI, 2.8060.60; P = 0.001); pseudoaneurysm (OR, 11.23; CI, 1.38-91.66; P = 0.024); thoracoabdominal aneurysm (OR, 2.67; CI, 1.22-5.84; P = 0.014); and aorticrupure (OR, 4.23; CI, 1.26-14.23; P = 0.002). The mortality prediction model had a Cindex of 0.82 and a Hosmer-Lemeshow P value of 0.56. In conclusion, this study demonstrated that renal insufficiency and respiratory disorder had great impact on the operative mortality of Marfan patients undergoing cardiovascular surgery. Because patients with aortic dissection or aortic rupture showed high operative mortality, close follow-up to avoid emergency operation is mandatory to improve the operative results. Achieving good results from surgery of the thoracoabdominal aorta was quite challenging, also in Marfan patients.

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.

Coil Embolization of Recurrent Internal Iliac Artery Aneurysm via the Superior Gluteal Artery.

We report a case of recurrent internal iliac artery aneurysm previously treated with a combination of stent graft placement and coil embolization in an 85 year-old male patient. The patient was scheduled for the direct puncture embolization of the superior gluteal artery. The patient was placed in a prone position under general anesthesia. An 18G-PTC needle was inserted into the superior gluteal artery under ultrasonographic guidance. A 2.2F microcatheter was inserted through an outer needle and advanced to the aneurysmal sac. Coil embolization was successfully performed without endoleaks. This approach is technically feasible when other treatment options fail or are deemed unsuitable.

Iliac neck dilatation causes rupture of abdominal aortic aneurysm previously treated with endovascular aortic aneurysm repair.

A 78-year-old male had undergone endovascular aortic aneurysm repair (EVAR) 7 years prior to presentation. Although the sac was stable 6 months ago, the patient presented with shock at arrival, and CT showed aortic rupture with rapid expansion due to type Ib endoleak caused by iliac neck dilatation (IND). The aneurysm sac was excluded using an endovascular strategy. Bell-bottom iliac limbs can cause IND associated with type Ib endoleak. Additionally, the risk of rupture is high when re-expansion of an aneurysm occurs after sac regression after EVAR. Therefore, close follow-up is mandatory for patients with IND after EVAR.

Feasibility of Transcatheter Aortic Valve Implantation in Patients With Very Severe Aortic Stenosis.

Background: Very severe aortic stenosis (AS) has a poor prognosis even in asymptomatic patients, and asymptomatic very severe AS is a Class IIa indication for aortic valve replacement, although the safety and effectiveness of transcatheter aortic valve implantation (TAVI) for very severe AS is not well-established. Methods and Results: This study included 366 patients undergoing TAVI at a single center, with 85 and 281 patients in the very severe AS (peak velocity ≥5 m/s or mean pressure gradient (PG) ≥60 mmHg) and severe AS groups, respectively. Procedural and clinical outcomes at 1-year follow-up were compared between groups. The calcium scores were significantly higher in the very severe AS group (2,864.5 vs. 1,405.8 arbitrary units [AU] (P<0.001). Although the patient-prosthesis mismatch rate was higher in the very severe AS group (38.3% vs. 25.7%; P=0.029), there was no significant difference in the early safety and clinical efficacy between the groups (16.5% vs. 17.1% and 12.0% vs. 18.9%, respectively). Similarly, there was no significant difference in all-cause mortality at 1 year (4.8% vs. 9.8%). Conclusions: Despite a higher incidence of prosthesis-patient mismatch in those with very severe AS, the procedural and clinical outcomes were comparable to those in patients with severe AS. TAVI may be a reasonable treatment option for very severe AS.

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.

Longterm Followup of a Pediatric Patient with Congenital Abdominal Aortic Aneurysm with Coarctation.

Congenital abdominal aortic aneurysm (AAA) with coarctation has been considered an extremely rare condition. In this study, we present a 3-year-old boy, who was diagnosed by chance with congenital AAA at first operation. We replaced the AAA+coarctation with a 6-mm polytetrafluoroethylene (PTFE) graft. Histological examination of the aortic wall revealed no particular abnormalities. Collateral vessels were noted to develop over 14 years of followup. Good blood flow to both lower limbs and no intermittent claudication were observed. After growth, at the age 17, he underwent extra-anatomical bypass using a 12-mm PTFE graft. This is the first report of successful treatment of congenital AAA+coarctation with longterm followup.

Long term results with the Cabrol aortic root replacement.

Cabrol aortic root replacement is rarely performed in recent years because of potential coronary complications. The purpose of this study was to investigate its early and late results, including coronary complications, by evaluating our experience thus far. A retrospective lookup of patients who underwent Cabrol aortic root replacement between 1988 and 2001 found a total of 36 patients (24 men and 12 women) with a mean age of 45 years. Annuloaortic ectasia was the most frequent cause (n = 22), followed by chronic dissection (n = 5), acute dissection (n = 5), and aneurysm with prior aortic operation (n = 4). Early mortality occurred in one patient (2.8%). The mean follow-up period was 104 months. There were 7 late deaths, 4 of which were disease-related. The actuarial survival was 83.3% at 5 years and 72.9% at 10 years, and the freedom from reoperation was 87.9% at 5 years and 76.6% at 10 years. There were no reoperations on the ascending aorta. Coronary ostia were examined by angiography or 64-row multidetector computed tomography in 18 patients 43 to 189 months after the operation. Two patients developed stenosis or occlusion of the right coronary ostium. The early and late results of the Cabrol operation were favorable with the exception of coronary complications. The importance of careful follow-up for late coronary complications cannot be overemphasized.

[Thoracic aortic stent-grafting at general hospital].

Now stent-grafting is regarded as 1st-line treatment for thoracic aortic aneurysm in the setting of favorable anatomic situation. Therefore all the hospitals that have the department of cardiovascular surgery should be capable of performing stent-grafting. Japanese committee of stent-graft management set criteria for the equipment and the license for stent-grafting. We made exertions to fulfill the severe criteria and established a hybrid operating room and a specialized treatment team for stent-grafting.

[Acute forearm compartment syndrome after total arch replacement].

A 61-year-old female presented with shortness of breath and was found to have moderate aortic regurgitation with annulo-aortic ectasia and an aneurysm involving the aortic arch. She underwent Bentall operation and total arch replacement with a branched prosthesis. The patient developed hypesthesia and paresis of the left forearm one day after the surgery. Computed tomography revealed complete occlusion of the left subclavian artery (LSA). An emergency operation was performed 15 hours after the initial operation. A new bypass graft to the axillary artery was placed since the LSA was occluded by the wide arterial dissection. However, her left forearm showed rapid swelling within a few hours. Under the diagnosis of acute compartment syndrome (ACS) of the forearm, emergency decompression fasciotomy was performed. She was discharged with a mild dysfunction of her forearm and hand 40 days after the operation. The rapid progression of ACS was thought to have been associated with not only the severe and prolonged ischemia but also the venous obstruction caused by the ligation of left brachiocephalic vein during the initial operation. Immediate and complete decompression, including the deep compartment of the forearm, was essential to achieve a full functional recovery from ACS.

[Hybrid vascular intervention].

Hybrid vascular intervention denotes the intentional combination of surgical intervention with endovascular repair. For coronary artery disease, minimally invasive bypass grafting of the left thoracic artery to the left descending artery is combined with stenting of non-LAD stenoses using drug eluting stents. This hybrid therapy is expected to confer the merits of both intervention, that is the less invasiveness of percutaneous coronary intervention and the beneficial effect for long-term survival rate of coronary artery bypass grafting. For aortic aneurysms, extended endovascular aortic repair using stent grafts is performed after bypasses to the aortic branches. This hybrid approach is expected to yield low mortality and morbidity rate by omitting the cardiopulmonary bypass and laborious procedural details of the conventional surgical intervention.

Clinical Utility of the Candy-Plug Technique Using an Excluder Aortic Extender.

Objective: To describe the clinical utility and technical aspects of the candy-plug technique using an Excluder aortic extender (Ex-cuff) for false lumen (FL) occlusion in chronic aortic dissection. Materials and Methods: This is a retrospective study analyzing seven consecutive patients (mean age, 63 years; range, 44-78 years; 6 men) with aneurysmal dilatation or rupture in chronic aortic dissection. All patients had undergone thoracic endovascular aortic repair with FL occlusion using this technique. We assessed technical (deployment accuracy) and clinical (no FL backflow on the latest contrast-enhanced computed tomography) success. Results: Technical success was obtained in six patients (86%). Technical failure was caused by the malposition of the candy-plug. The mean follow-up period was 593 days (range, 222-1225 days). Clinical success was obtained in four (57%), and incomplete Amplatzer Vascular Plug (AVP) embolization was seen in two. There was no enlarged FL after the procedure, and all patients are alive during the follow-up periods. Conclusion: The candy-plug technique using an Ex-cuff may be a feasible option; however, it takes time to achieve complete AVP embolization. Therefore, using additional embolic materials should be considered when we use it for the rupture case. (This is a translation of Jpn J Endovasc Interv 2018; 19: 29-35.).