[The Strategy for Aortic Root Pathology Due to Stanford Type A Acute Aortic Dissection].

The surgical outcomes of aortic root replacement for Stanford type A acute aortic dissection( AAAD) remain unacceptable with a 30-day mortality rate of 20%. Additionally, in young patients requiring aortic root replacement for AAAD, the preservation of native valve is desirable, yet challenging to achieve in emergent surgery with poor preoperative status. Ideally, we aim to avoid aortic root replacement whenever possible, opting instead for partial remodeling even in cases necessitating incision into the aortic root. We present our surgical outcomes in the strategy for aortic root pathology due to AAAD. We conducted an analysis of 517 cases of AAAD surgery from 2002 to 2023, wherein 499 cases( 96%) underwent aortic root preservation, 10 cases( 1.9%) underwent partial remodeling, and 8 cases( 1.5%)necessitated emergent aortic root replacement. Of these, 13 cases underwent aortic root replacement after AAAD repair( 8 David procedures and 5 Bentall procedures), all demonstrating favorable surgical outcomes, including long-term results. We believe that this strategy for aortic root pathology holds significant merit, particularly in AAAD in young patients with enlarged aortic root.

[The Long Outcome of the Left Atrial Appendage Preserving Maze Procedure].

We retrospectively study the outcome of left atrial appendage (LAA) preserving maze procedure, focus on thrombus formation in left atrium( LA), postoperative stroke, and LA function. PATIENTS AND METHODS: We studied 131 patients (mean age, 68.2y;77 men and 54 women) who underwent maze procedure for atrial fibrillation( Af) between 2008 and 2020. Full maze was performed for 116 patients with long-standing persistent Af or persistent Af. Pulmonary vein isolation alone was performed for 15 patients with paroxysmal Af. The mean follow-up period was 2.9( 10.1-0.4) years. RESULTS: In perioperative results, there were no death, cerebral infarction, and reoperation in this series. At discharge, 1 year, 3 years, 5 years, and 10 years after the surgery, sinus rhythm was maintained in 92%, 87%, 83%, 77%. Pacemaker was implanted in 8( early 3, late 5) patients. Despite adequate anticoagulant therapy, one patient developed cerebral infarction a month postoperatively. In other patients, there was no cerebral infarction in short-term nor long-term. CONCLUSIONS: The LAA preserving maze procedure was not a risk factor of cerebral infarction under appropriate medication. However, close follow-up is essential.

Impact of introducing endovascular aneurysm repair on treatment strategy for repair of abdominal aortic aneurysm--National Hospital Organization network study in Japan.

BACKGROUND: The objective of the present study was to assess the hypothesis that the introduction of endovascular aneurysm repair (EVAR) into Japan has expanded the indication of abdominal aortic aneurysm (AAA) repair without increasing surgical mortality. METHODS AND RESULTS: From 10 national hospitals, we registered a total of 2,154 consecutive patients (Open surgery [OS]: n=1,577, EVAR: n=577) over 8 years, divided into 4 time periods: Group I (2005-2006: n=522), Group II (2007-2008: n=475), Group III (2009-2010: n=551), Group IV, (2011-2012: n=606). Mean age increased over the 4 time periods (P<0.0001). The incidences of COPD, smoking history, history of abdominal surgery and concomitant malignancy significantly increased as well, while the numbers of patients with preoperative shock or high ASA status reduced over time. The proportion of EVAR in AAA repair increased from: 0% in Group I, 11.6% in Group II, 41.0% in Group III, to 48.8% in Group IV (P<0.0001). Early mortality was 0.8% in the EVAR and 3.4% in the OS (P<0.001) groups. Survival rates among the 4 groups free of all-cause death and aneurysm-related death at 1 year were 92.1-96.3% (P=0.1555) and 95.5-96.8% (P=0.9891), respectively. Multiple logistic regression analysis for surgical death failed to demonstrate survival advantage of EVAR over OS. CONCLUSIONS: Introduction of EVAR expanded the indication of AAA repair without increasing mortality, while high risk for anesthesia and emergency cases reduced over time. UMIN-CTR (UMIN000008345).

[Aortic and mitral valve replacement via right thoracotomy in the case of a patient with severe heart failure following right pneumonectomy].

We report a case of aortic valve replacement (AVR) and mitral valve replacement (MVR) in a patient with severe left ventricular dysfunction who had undergone right pneumonectomy for lung cancer 14 years previously. A 64-year-old man had cathecolamine-dependent heart failure due to bicuspid aortic valve stenosis, functional mitral valve regurgitation and impaired left ventricular function (left ventricular ejection fraction 13%)because of dilated cardiomyopathy. AVR and MVR were performed using St. Jude Medical mechanical valves with right thoracotomy because the heart had shifted to the right side. Poor left ventricular function and postoperative atrial fibrillation made it difficult to control low-output syndrome, but prolonged use of intra-aortic balloon pumping improved it gradually. Intraaortic balloon pumping( IABP) was removed 34 days after the operation, the respirator was removed with tracheotomy 63 days postoperatively, and the patient was discharged on the 177th postoperative day. Careful preoperative assessment and perioperative control of heart failure are important components of successful clinical management.

[Total aortic arch replacement for severe atherosclerotic aortic aneurysms;consecutive 135 cases study].

OBJECTIVE: We study the validity of surgical procedure for total aortic arch replacement according to the atherosclerosis in the aortic arch. METHODS: From 2007 to June 2013, Consecutive 185 patients underwent total aortic arch replacement for thoracic aortic anuerysm. We studied 135 patients[96 males 72.1 year(38~89year)]except emergency operation. We assessed the atherosclerosis in the aortic arch by preoperative enhanced computed tomography (CT)scan and intraoperative epiaortic echocardiography. Based on the degree of atherosclerosis in the aortic arch, we divided into 2 groups:group 1(G1)included 97 patients with mild or moderate atherosclerosis and group 2 (G2) 38 patients with severe atherosclerosis. We used ascending aorta as arterial cannulation site in G1 and axillary artery with 8 mm graft in G2 .We compared with both groups for preoperative comorbidities and outcomes( mortality and stroke). RESULTS: Three patients died in the hospital (2%). In-hospital neurological events occurred in 12 patients, including major stroke in 4 patients, minor stroke in 4 patients and asymptomatic convulsion in 4 patients, although they were transient and clear before discharge except major stroke. There were no statistically significant differences in preoperative characteristics, cardiopulmonary bypass, brain protection, mortality, and neurological events between the 2 groups. There was a statistically difference in operation time( 388.8 minutes vs 448.5 minutes, p<0.01), intensive care unit( ICU) stay( 3.1 day vs 6.5 days, p<0.05) and hospital stay( 19.2 days vs 28.0 days, p<0.05). CONCLUSIONS: We selected surgical procedure for total aortic arch replacement (TAR) according to atherosclerosis in the aortic arch. Although the rate of stroke was largely acceptable, we much need to be improved in prevention of stroke.

Medical Opioid Disposal in Fukuoka and Kumamoto Cities.

Medical expenses are increasing year by year in Japan. However, the quantity of disposed medical opioids is not well known. In this study, we assessed disposed medical opioids in community pharmacies of Fukuoka city and in all of medical organizations of Kumamoto cities for 3 and 2 years, respectively. We collected official opioid disposal reports in Kumamoto city and Fukuoka City Pharmaceutical Association (FCPA) disposal information sheet in Fukuoka city. The total amount of disposed opioids was worth 7.1 million Yen from 2017 to 2019 in Fukuoka city, and 8.9 million Yen in for 2 years (2018 and 2019) in Kumamoto city. In Fukuoka city, the most disposed opioid was 20 mg Oxycontin®, worth approximately 940000 Yen. In Kumamoto city we assessed data in different organizations. The most disposed opioid was 5 mg Oxinorm® at a cost of 600000 Yen at the medical institutions over the 2-year study period. The most disposed opioid was 40 mg Oxycontin®, at a cost of 640000 Yen in community pharmacies. Two hundred micrograms E-fen® buccal tablet was the most disposed of opioid, was amounting to 960000 Yen in wholesalers. On the whole in Kumamoto city, non-dispensing was the most common reason of disposal. These results indicate that the amount of disposed opioids is huge. Small package simulation studies suggest that smaller package units of MS-Contin®, Anpec® suppository, and Abstral® sublingual tablet may be able to reduce the amount of disposed opioids.

Procedure- and age-specific risk stratification of single aortic valve replacement in elderly patients based on Japan Adult Cardiovascular Surgery Database.

BACKGROUND: Successful introduction of trans-catheter aortic valve implantation for selected patients with critical aortic stenosis has raised the question of how to identify appropriate high-risk candidates. METHODS AND RESULTS: To assess the risk profile of patients undergoing single aortic valve replacement (sAVR), multiple logistic regression analysis was applied for open sAVR (n = 7,883) registered in the Japan Cardiovascular Surgery Database to predict surgical mortality. Three subgroup analyses stratified by age, <70 years (young), 70-79 years (middle), and ≥80 years (elderly), were also performed. Preoperative patient characteristics indicated increased prevalence of several variables in the elderly subgroup including New York Heart Association (NYHA) class III/IV, 3-vessel coronary artery disease (3VCAD), respiratory insufficiency, and stroke. The following factors, however, were decreased in the elderly subgroup: dialysis, poor heart function, reoperation, renal dysfunction, and emergency surgery. Mortality was 3.0% in all sAVR patients and 5.2% in the elderly subgroup. Multivariate analysis in all patients produced 16 variables as operative risks (P<0.05) including respiratory insufficiency, dialysis, NYHA class III/IV, and reoperation. The analysis in the elderly subgroup produced 9 variables with more pronounced relative risk (RR), which included dialysis (RR = 5.4), respiratory insufficiency (RR = 3.3), preoperative arrhythmia (RR = 3.0), 3VCAD (RR = 3.6), and emergency surgery (RR = 23.1). CONCLUSIONS: sAVR has produced good surgical results in Japan. Procedure- and age-specific analyses have identified a risk profile that is unique to sAVR patients in the elderly population in Japan.

A case of primary cardiac angiosarcoma with surgical resection and reconstruction.

We report a 52-year-old man with primary cardiac angiosarcoma. He was referred to our hospital with a 3-month history of facial swelling and peripheral edema. Echocardiography and chest computed tomography revealed massive pericardial effusion and a right atrial tumor with a broad base at atrial septum which was extended into superior vena cava. We performed complete resection of the tumor and reconstruction of left atrium, atrial septum, right atrium, and superior vena cava with autologous pericardium and bovine pericardium. Histological examination exhibited angiosarcoma and a sign of radical excision. The patient, who made an uneventful recovery, was given postoperative radiotherapy and chemotherapy for liver metastasis 4 months postoperatively. The patient remains well without any signs of other metastasis for 2 years. We consider that an aggressive approach to resection with extensive reconstruction and multidisciplinary treatment can improve survival. Learning objective: Primary cardiac angiosarcoma is the most common primary malignant heart tumor with poor prognosis. We report a case of a 52-year-old man with primary cardiac angiosarcoma. We performed complete resection of the tumor and reconstruction of left atrium, atrial septum, right atrium, and superior vena cava with autologous pericardium and bovine pericardium. We think aggressive surgical resection with reconstruction is a feasible option.>.

Long-term results of the maze procedure with GP ablation for permanent atrial fibrillation.

OBJECTIVES: We investigated the effect of the maze procedure with intensive pulmonary vein isolation (PVI) guided by ganglionated plexus (GP) mapping (the Maze with GP ablation group) on a long-term postoperative maintenance of sinus rhythm in patients with permanent atrial fibrillation (AF) and compared with that in patients undergoing the maze procedure with the conventional PVI (the Maze group). METHODS AND RESULTS: We investigated 48 patients who underwent the maze procedure with GP ablation for persistent AF and 43 patients who underwent the maze procedure. The Maze procedure was conducted by the endocardial application of bipolar radiofrequency ablation and cryoablation. Conventional PVI was applied three times for the entrance of right and left PVs, respectively. Intensive PVI for GP ablation was repeated six-to-eight times for both sides of PVs to cover the bilateral GP regions identified by GP mapping. The duration of permanent AF, the prevalence of concomitant primary heart diseases, and the postoperative follow-up period were comparable between the two groups. At discharge, 1 year, 5 years after the surgery, sinus rhythm was maintained in 74.4%, 61%, and 40.5% of the Maze group. In contrast, it was maintained in 93.7%, 88.9%, and 75.7% of the Maze with GP ablation group. The cumulative freedom rate from AF at 10 years after surgery was significantly higher in the Maze with GP ablation group. CONCLUSIONS: More intense PV isolation including adjacent GP may improve long-term results of maze procedure in patients with permanent AF.

Cardiac blood cyst with concomitant papillary fibroelastoma.

Cardiac blood cyst in adults is a rare benign tumor. Cardiac blood cyst concomitant with another type of cardiac tumor has never been reported. We report a case of a 77-year-old woman with cardiac blood cyst and papillary fibroelastoma. We performed resection of both tumors. An encapsulated mass (15 mm in diameter) with short stalks was identified in the right atrium, and a soft 1-cm mass was found adhering to a large part of the aortic valve noncoronary cusp without stalks. Postoperative course was uneventful. .

Endovascular stent-graft repair for spontaneous dissection of infra-renal abdominal aorta.

Abdominal aortic dissection (AAD) is a rare pathology and potentially causes rupture or other serious complications. This case report details our experience in endovascular aneurysm repair for AAD in a patient who had a history of coronary bypass surgery. Circumferential dissection of terminal aorta showed stenosis of true lumen as well as blood flow present in the pseudolumen. Using Zenith AAA endovascular device, the entry site was closed and the pseudolumen was thrombosed successfully. In the present report, published data on AAD were reviewed and endovascular aneurysm repair as a treatment option has been discussed as well.

Effect of edaravone, a novel free radical scavenger, supplemented to cardioplegia on myocardial function after cardioplegic arrest: in vitro study of isolated rat heart.

Cardioplegic arrest has been the main mechanism of myocardial protection during open-heart surgery; however, it causes myocardial injury during ischemia-reperfusion. Free radical scavengers are widely known to attenuate ischemia-reperfusion injury in various settings. We investigated the effects of edaravone, a novel free radical scavenger that was originally used for cerebral protection, on myocardial function during ischemia-reperfusion after cardioplegic arrest. Rat hearts were excised and perfused using Langendorff apparatus. The hearts were cardioplegically arrested for 90 min using St. Thomas' Hospital cardioplegic solution (ST solution) at 4 degrees C every 45 min and then reperfused for 20 min. The hearts were divided into 4 groups (n = 13 in each group). In Group ST, the hearts were arrested using the ST solution alone. In Groups L, M, and H, the hearts were arrested using the ST solution supplemented with a low-dose (1 microM), moderate dose (10 microM), and high dose (100 microM) of edaravone, respectively. Left ventricular function (+dp/dt (max)) and the levels of the cardiac enzymes released were measured before and after cardioplegic arrest. At the end of the study, the water content and the tissue oxidative stress (8-hydroxy-2'-deoxyguanosine) of the heart were measured. During reperfusion, the edaravone-treated groups showed a greater functional recovery with regard to the +dp/dt (max) (P < 0.05). The lactate level was the lowest (P < 0.01) in Group M. The water content of the hearts in the edaravone-treated groups was significantly lower (P < 0.05) than that in Group ST. Oxidative stress was significantly lower (P < 0.01) in the edaravone-treated hearts than in Group ST, and it was the lowest in Group M. The addition of edaravone to the cardioplegic solution ameliorates the impairment in myocardial function by reducing the oxidative stress after cardioplegic arrest. In this study, the maximum improvement in the myocardial function was achieved by addition of a moderate dose (10 microM) of edaravone.

Successful repair of thoracoabdominal aortic aneurysm secondary to chronic dissection by hybrid therapy comprising surgical visceral reconstruction and dual Inoue stent graft implantation.

Crawford type II thoracoabdominal aortic aneurysm (TAAA) secondary to chronic dissection was successfully treated with hybrid therapy comprising surgical visceral reconstruction and dual Inoue stent graft implantation. The proximal single-branched Inoue stent graft effectively sealed the entry located near the left subclavian artery and simultaneously excluded the TAAA, while the distal tubular Inoue stent graft sealed the reentry; thus, the artery of Adamkiewicz was left unexcluded and intact between the two Inoue stent grafts. The visceral arteries were reconstructed using a quadrifurcated retrograde bypass with posterior aortic tunneling and end-to-end distal anastomosis to all four vessels to achieve a curved and smooth configuration.

Impact of apex-sparing partial left ventriculectomy on left ventricular geometry, function, and long-term survival of patients with end-stage dilated cardiomyopathy.

BACKGROUND AND AIM: Currently, partial left ventriculectomy (PLV) has not been widely accepted as a treatment option for dilated cardiomyopathy (DCM) because its results thus far have been inconsistent. In an animal study, apex-sparing PLV (AS-PLV) was shown to produce greater improvement in left ventricle (LV) function than conventional PLV in which the apex was removed. The aim of this study is to investigate the effectiveness of AS-PLV in a clinical setting. PATIENTS AND METHODS: From September 1999 to December 2007, 13 patients with DCM underwent AS-PLV. Left ventriculotomy was made in the thinnest portion of the lateral wall without injuring the apex, the papillary muscles, and the circumflex coronary artery, which supplies the neighboring myocardium. RESULTS: All patients were discharged from the hospital, except for one patient who developed refractory ventricular fibrillation on postoperative day 35. After AS-PLV, the LV diastolic dimension decreased from 71 +/- 10 mm to 55 +/- 9 mm; LV ejection fraction (EF) from 28%+/- 8% to 39%+/- 11%; and New York Heart Association (NYHA) class from 3 +/- 1.7 to 1.5 +/- 0.6; the differences were significant (p < 0.01). LV function and geometry remained unchanged 2 years after AS-PLV with LVDD of 60 +/- 7 mm, LVEF of 34%+/- 8%, and NYHA class of 1.7 +/- 0.6, respectively (N.S vs. at discharge). CONCLUSIONS: Regardless of the etiology of LV dilatation, AS-PLV restored the ellipsoidal shape of the LV and improved LV function. AS-PLV is a feasible option for treating diseased LVs with lateral wall lesions.

Adventitial cystic disease of the popliteal artery with intimal tear.

We report the case of a 68-year-old man with right intermittent claudication by adventitial cystic disease. We performed resection of the cyst and affected popliteal artery with interposing an autologous vein graft. Intraoperative findings revealed an intimal tear between the cyst and the compressed artery. His symptoms resolved after surgery, and the postoperative course was uneventful. Although adventitial cystic disease with intimal tear is rare, we consider that conventional surgical intervention remains the favorable treatment option for adventitial cystic disease. .

Chronic chymase inhibition preserves cardiac function after left ventricular repair in rats.

OBJECTIVE: Although left ventricular repair (LVR) has been widely performed, the initial improvement of LV function does not last because of LV remodeling. Recent studies have demonstrated that chymase, a local enzyme in the heart, promotes angiotensin II formation as well as activation of transforming growth factor (TGF)-beta, both of which facilitate myocardial fibrosis. Therefore, chymase blockade may play an important role in the prevention of cardiac remodeling after LVR. In this study, the effects of chronic chymase inhibition (Chy-I) after LVR were evaluated in a rat LV aneurysm model. METHODS: Rats that developed LV aneurysms 4 weeks after coronary artery ligation underwent LVR by plicating the LV aneurysm, and were randomized into two groups, the LVR group and the LVR + Chy-I group that received an oral chymase inhibitor (10 mg/kg/day) for 4 weeks. RESULTS: Echocardiography revealed better LV function in the LVR + Chy-I group than in the LVR group at 4 weeks. Four weeks after LVR, LV end-diastolic pressure and the time constant of LV isovolumic pressure decay, were significantly lower in the LVR+Chy-I group. The end-systolic pressure-volume relationship was higher in the LVR+Chy-I group. In the LVR+Chy-I group, mRNA expressions of TGF-beta1 and BNP significantly decreased in the LV myocardium. Histology showed reduced interstitial fibrosis in the LVR+Chy-I group. CONCLUSIONS: Chronic chymase inhibition prevented myocardial fibrosis and preserved cardiac function after LVR. A chymase inhibition could be an important strategy for management after LV repair surgery.

Is TEVAR with Full Petticoat Technique Effective for Complicated Acute Type B Dissection Cases?

Treatment by thoracic endovascular aortic repair (TEVAR) for type B dissection has improved outcomes. We tried the procedure named "Full Petticoat technique" in which the proximal entry tear was excluded with a covered stent and extended bare metal stents were placed to the aortic bifurcation for three complicated type B dissection cases with dynamic obstruction of the common iliac artery. Follow-up computed tomography revealed favorable aortic remodeling in which the true lumen was expanded. The short-term result of this procedure has shown acceptable aortic remodeling. The significance of this procedure is still unknown in the long term; hence long-term follow-up is necessary to completely understand the usefulness of this technique.

A novel approach to restore atrial function after the maze procedure in patients with an enlarged left atrium.

OBJECTIVE: Left atrial (LA) volume reduction surgery concomitant with the maze procedure has been reported to facilitate sinus rhythm recovery even in patients with refractory atrial fibrillation (AF) with an enlarged LA. However, it is unknown whether the procedures can also restore effective atrial function of the enlarged LA with over-stretched myocardium. METHODS: The maze procedures in association with mitral valve surgery were performed to 57 AF patients with an enlarged LA (LA diameter >or=60mm). Among them, 32 patients had concomitant LA volume reduction surgery (VR group). Another 25 patients did not have the volume reduction (control group). RESULTS: Three months postoperatively LA end-diastolic volume (LAEDV, ml) assessed by magnetic resonance (MR) imaging was larger in the VR group than that in the control group (291+/-117 vs 223+/-81 ml, p<0.05). Postoperatively, sinus rhythm recovery rate was better (84 vs 68%, p<0.05) and LAEDV was drastically smaller (118+/-48 vs 203+/-76 ml, p<0.001) in the VR group than those in the control group. Among the patients with sinus rhythm recovery in both groups, LA contraction ejection fraction (%) improved in the VR group but not in the control group (22.3+/-7.8 vs 10.3+/-4.7%, p<0.001). CONCLUSIONS: The LA volume reduction surgery concomitant with the maze procedure restored contraction of the enlarged LA; however, the maze procedure alone did not restore LA contraction in spite of successful sinus rhythm recovery. LA volume reduction surgery may be desirable to the patients with refractory AF with over-stretched LA.

Quantitative FDG-uptake by positron emission tomography in progressive hypertrophy of rat hearts in vivo.

BACKGROUND: Quantitative myocardial fluorodeoxyglucose positron emission tomography (FDG-PET) for assessing glucose uptake in vivo is reliable in normal rat heart. OBJECTIVE: To assess the applicability of myocardial FDG-PET on multiple occasions in the longitudinal disease process of progressive hypertrophy of rat heart. METHODS: Six salt-sensitive Dahl rats (Dahl-S) developing progressive hypertrophy with subsequent dilated cardiomyopathy were compared with salt-resistant Dahl rats (controls). FDG-PET was applied twice at early stage (ES: 14-18 weeks) and at late stage (LS: 22-26 weeks) of hypertrophy. Standardized uptake value (SUV) was calculated for comparing between different animal weights and different injection dosages of FDG. For validating the quantitative study, radioactivity of a total of 36 tissue samples was compared with the corresponding PET values. RESULTS: The left ventricular mass in Dahl-S increased by 17% at ES and by 25% at LS. The SUV in Dahl-S was 95% of controls at ES and reduced to 62% at LS (P=0.023). The heart function started to deteriorate after LS. Linear regression analysis showed a good correlation between the radioactivity of tissue samples and PET values (Y=1.20X, P<0.0001, R2=0.979). CONCLUSIONS: Small animal PET studies on longitudinal multiple occasions in vivo were feasible and useful for the repeating assessment of glucose uptake. The reduction of glucose uptake in progressive hypertrophy of heart over time may precede its progression to heart failure.

Rare spinal cord infarction in a patient with acute type B aortic dissection.

A 69-year-old man was admitted to our hospital with acute epigastric discomfort and subsequent paraplegia. Computed tomography revealed acute type B aortic dissection with a thrombosed false lumen. Magnetic resonance imaging did not reveal spinal cord infarction. Paraplegia resolved completely within 1 h. However, on the following day, the patient developed motor impairment in the left leg, sensory disorder of the bilateral legs and urinary retention. The symptoms gradually improved with conservative medical therapy. Magnetic resonance imaging on hospitalization Day 20 revealed spinal cord infarction limited to the right posterior area at level T7/T8 and the conus medullaris. The patient was discharged 44 days after admission. The presented case is notable for its atypical presentation of spinal cord infarction resulting from acute aortic dissection. The aetiology of neurological symptoms, especially that of lower extremity monoplegia, remained undiagnosed.