Effect of Sex on Mortality and Left Ventricular Remodeling After Transcatheter Aortic Valve Implantation.

BACKGROUND: The effect of sex on mortality is controversial; furthermore, sex differences in left ventricular (LV) remodeling after transcatheter aortic valve implantation (TAVI) remain unknown.Methods and Results:This study included 2,588 patients (1,793 [69.3%] female) enrolled in the Optimized CathEter vAlvular iNtervention (OCEAN)-TAVI Japanese multicenter registry between October 2013 and May 2017. We retrospectively analyzed the effect of sex on mortality, and evaluated changes in the LV mass index (LVMI) after TAVI. Female sex was significantly associated with lower all-cause and cardiovascular mortality (log-rank P<0.001 for both). Multivariate analysis showed that female sex was independently associated with lower cumulative long-term mortality (hazard ratio 0.615; 95% confidence interval 0.512-0.738; P<0.001). Regression in the LVMI was observed in both sexes, and there was no significant difference in the percentage LVMI regression from baseline to 1 year after TAVI between women and men. Women had a survival advantage compared with men among patients with LVMI regression at 1 year, but not among patients with no LVMI regression. CONCLUSIONS: We found that female sex is associated with better survival outcomes after TAVI in a large Japanese registry. Although LVMI regression was observed in women and men after TAVI, post-procedural LV mass regression may be related to the sex differences in mortality.

Hemodynamic comparison of CoreValve and SAPIEN-XT TAVI valves in Japanese patients.

Transcatheter aortic valve implantation (TAVI) is a viable treatment option for high-risk patients with severe aortic stenosis. In Japan, TAVI can be performed using first-generation self-expandable Medtronic CoreValve or balloon-expandable Edwards SAPIEN-XT from 2012. Since the durability and hemodynamic outcomes after transcatheter heart valve (THV) implantation in Japanese patients have not been clearly elucidated, we assessed serial changes in post-TAVI THV performances over a-3-year period by transthoracic echocardiography (TTE). From January 2012 to September 2014, among 83 patients with severe aortic stenosis, 26 underwent TAVI with CoreValve and 57 underwent TAVI with SAPIEN-XT. We assessed the serial changes in first post-implant (FPI) and 3-year post procedure THV hemodynamics by TTE. Valve performance was evaluated by serial assessment of aortic valve mean pressure gradient (PG) and aortic valve area (AVA) assessments. Three-year clinical outcomes were compared between the patients with CoreValve and those with SAPIEN-XT. Seventeen patients with CoreValve and 34 patients with SAPIEN-XT had FPI and 3-year TTEs. The AVA decreased significantly from FPI to 3-year follow-up among patients with SAPIEN-XT, but not among patients with CoreValve. The mean aortic PG decreased significantly from FPI to the 3-year follow-up point among patients with CoreValve; however, it was not significantly different from those with SAPIEN-XT. The absolute change in mean PG from FPI to the 3-year follow-up point decreased significantly among those with CoreValve compared to those with SAPIEN-XT. Clinical outcomes after TAVI were similar for both devices at 3-years after TAVI. In this study, long-term clinical outcomes for CoreValve and SAPIEN XT were similar. The 3-year THV performance of both devices was maintained after TAVI. Serial change in mean aortic PGs for CoreValve decreases significantly from FPI to the 3-year follow-up point compared to that for SAPIEN-XT.

Efficacy of Tolvaptan in Patients with Volume Overload after Cardiac Surgery.

BACKGROUND: The vasopressin type 2 receptor antagonist tolvaptan (TLV) has recently become available for treating congestion. However, there is no evidence confirming the efficacy of TLV for patients with volume overload after cardiac surgery. Here, we retrospectively studied the efficacy of TLV in patients with volume overload after cardiac surgery. METHODS: We enrolled a total of 39 patients who had volume overload after cardiac surgery and who were treated with our protocol of body fluid management. The primary endpoint of this study was to evaluate the hospitalization period, while the secondary endpoints were to estimate adverse events such as hypotension, electrolyte abnormality, presence or absence of renal dysfunction and liver damage, and the incidence of atrial fibrillation (AF). RESULTS: The hospitalization period of the T (TLV) and C (furosemide and spironolactone) groups was 12.3 ± 2.6 days and 14.7 ± 4.4 days, respectively (P = .044), the mean urine volume was 2761.5 ± 850.3 mL/day and 2205.2 ± 598.5 mL/day, respectively (P = .024), and the incidence of postoperative AF after diuretics administration was 2/19 (11%) and 9/17 (52%), respectively. CONCLUSION: TLV successfully and rapidly improved organ congestion without causing hemodynamic abnormalities (hypotension, arrhythmia development), electrolyte abnormality, liver damage or renal dysfunction, thus significantly reducing the period of hospitalization.

Surgical outcomes in acute type A aortic dissection based on surgeon experience.

OBJECTIVES: The aim of this study is to evaluate our surgical strategy for acute aortic dissection Stanford A and determine whether it is safe regardless of the experience of the primary surgeon. METHODS: Between April 2015 and September 2020, a total of 160 patients who underwent open surgery for type A aortic dissection at Shonan Kamakura General Hospital were reviewed. Data were collected from reviews of computerized medical records. From this study cohort, we retrospectively reviewed the cases of trainee (group T) and experienced primary surgeons (group E). We evaluated rates of 30 day and in-hospital mortality, stroke, aortic reintervention, and mid-term survival for both groups. RESULTS: The rates of 30 day and in-hospital mortalities in group T were 5.1 and 7.7%, respectively, whereas those in group E were 4.7 and 4.7%, respectively. One and 3 year survival rates in group T were 88.4 and 87.1% and in group E were 95.3 and 95.3%, respectively (log-rank test, p = 0.11). The 1 year and 3 year rates of freedom from reintervention were 90.9 and 72.8% in group T and 96.8 and 92.7% in group E, respectively (log-rank test, p = 0.29). The permanent neurological dysfunction rate was 8.1% overall, 8.5% in group T, and 7.0% in group E, with no significant difference. CONCLUSIONS: Our surgical strategy for acute type A aortic dissection is safe and appropriate regardless of the experience of the primary surgeon.

A Surgical Case of Bronchial Artery Aneurysm Connecting to a Pulmonary Artery and Vein Complicated by Racemose Hemangioma.

We report a surgical case of bronchial artery aneurysm (BAA) that directly connected to a pulmonary artery and a pulmonary vein through an abnormal vessel. It was complicated by racemose hemangioma. This is a rare vascular malformation. An 82-year-old female had a large BAA that was found incidentally. First, we consider treating the BAA with embolization by interventional radiology (IVR). However, because of strong meandering of the bronchial artery, we could not advance a microcatheter into the BAA. Therefore, a surgical operation was performed through a standard posterior lateral thoracotomy. The BAA was located between the upper and lower lobes and directly connected to the pulmonary artery. Some bronchial artery branches that provided inflow to the aneurysm were ligated, and the abnormal vessel that connected the BAA to the upper pulmonary vein was ligated easily. A fistula between the BAA and pulmonary artery was sutured by the cardiovascular surgeon using an artificial cardiopulmonary device, with permissive stenosis of A2b (ascending A2).

Percutaneous transvenous mitral commissurotomy and transcatheter aortic valve replacement for rheumatic mitral and aortic stenosis.

The indications for transfemoral transcatheter aortic valve replacement (TAVR) have been expanding; however, treatment protocol for patients with severe aortic stenosis with other significant valve disease is still controversial. Furthermore, there are few randomized data to guide therapy in multivalvular disease. We describe a successful percutaneous transvenous mitral commissurotomy and TAVR simultaneously. A 3-year follow-up echocardiography showed preserved valve function. Learning objective: A combination of percutaneous transvenous mitral commissurotomy and transcatheter aortic valve replacement for multivalvular disease with severe mitral stenosis and aortic stenosis may be a treatment option. For multivalvular disease, heart team decisions can be valuable for an optimal management strategy.

Acute type A aortic dissection in non-agenarians: to cut or not.

OBJECTIVES: Surgery for acute type A aortic dissection (type AAD) in non-agenarians is usually contraindicated due to advanced age. The aim of this study was to assess and compare outcomes after surgical or conservative treatment for acute type AAD in non-agenarians by evaluating frailty. METHODS: Between October 2012 and September 2018, 273 patients underwent open repair for type AAD at the Shonan Kamakura General Hospital and the Shonan Fujisawa Tokushukai Hospital, and here, we retrospectively reviewed the case reports of 10 surgically treated non-agenarians and 15 conservatively treated non-agenarians. Exclusion criteria for surgery were the patient's refusal of surgery, severe dementia and coma. In patients considered to be at a high risk, our judgements were based on the results of comprehensive evaluation. RESULTS: Both in-hospital mortality and 30-day mortality in the surgical group were zero, while in-hospital mortality in conservatively treated non-agenarians was 73.3%. Importantly, 1-year survival in the surgical group and conservative group was 90% and 25%, respectively. The 5-year survival in the surgical group and conservative group was 49.2% and 25%, respectively (log-rank test, P = 0.0105). Four of 6 patients with preoperative clinical frailty scores not higher than 4 were still alive at 1 year with the same level of preoperative frailty. CONCLUSIONS: Surgery for acute type AAD in non-agenarians can be performed with acceptable outcomes in carefully selected patients, particularly in those with preoperative clinical frailty scores not higher than 4.

Descending aortic banding for re-rupture of retrograde aortic dissection after emergency thoracic endovascular aortic repair.

Conversion to open repair after thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection is rare, but inevitable. We present a case of an 86-year-old man with ruptured type B aortic dissection after TEVAR. He received a successful stent-graft implantation of the descending aorta without any type of endoleak. After the patient was transferred to the intensive care unit, he went into a shock state. Contrast-enhanced CT revealed a re-rupture of acute retrograde type B aortic dissection. The false lumen was patent and perforated to the left thorax. Left thoracotomy and descending aortic banding was performed. Descending aorta was encircled with a woven Dacron graft at the distal part of the rupture site to compress the patent false lumen. The bleeding was stopped, and the follow-up CT showed false lumen thrombosis. Descending aortic banding is one of the quick and effective open conversion techniques.

Novel Mechanism of Delayed Coronary Obstruction after Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis: "Uppercut Phenomenon".

Delayed coronary obstruction is a rare complication after transcatheter aortic valve replacement (TAVR), and leads to a high in-hospital mortality rate. Here, we present a case of unpredictable delayed coronary obstruction in the left main trunk (LMT) after self-expandable device implantation because the left coronary height was enough over 15 mm. LMT obstruction was caused by a heavy calcification that was pushing up from the outside of the LMT, like an "uppercut" phenomenon. Stent-in-stent technique was a useful option for this type of LMT obstruction.

In vivo serial evaluation of superparamagnetic iron-oxide labeled stem cells by off-resonance positive contrast.

MRI is emerging as a diagnostic modality to track iron-oxide-labeled stem cells. This study investigates whether an off-resonance (OR) pulse sequence designed to generate positive contrast at 1.5T can assess the location, quantity, and viability of delivered stem cells in vivo. Using mouse embryonic stem cell transfected with luciferase reporter gene (luc-mESC), multimodality validation of OR signal was conducted to determine whether engraftment parameters of superparamagnetic iron-oxide labeled luc-mESC (SPIO-luc-mESC) could be determined after cell transplantation into the mouse hindlimb. A significant increase in signal- and contrast-to-noise of the SPIO-luc-mESC was achieved with the OR technique when compared to a gradient recalled echo (GRE) sequence. A significant correlation between the quantity of SPIO-luc-mESC and OR signal was observed immediately after transplantation (R(2) = 0.74, P < 0.05). The assessment of transplanted cell viability by bioluminescence imaging (BLI) showed a significant increase of luciferase activities by day 16, while the MRI signal showed no difference. No significant correlation between BLI and MRI signals of cell viability was observed. In conclusion, using an OR sequence the precise localization and quantitation of SPIO-labeled stem cells in both space and time were possible. However, the OR sequence did not allow evaluation of cell viability.

Extracorporeal membrane oxygenation with double venous drainage.

We report on a successful configuration strategy of extracorporeal membrane oxygenation(ECMO) in two consecutive cases of acute lung injury. A 60-year-old woman with Streptococcus pneumoniae infection and a 22-year-old man with hemothorax were admitted to our hospital with failing lungs. Although treatment with a ventilator was started, oxygenation could not be maintained. ECMO with a femoro-femoral circuit was performed, which showed a slight improvement in oxygenation. However, not enough oxygen support was provided. To minimize the venous mixture at the right atrium, we added venous drainage from the right jugular vein which resulted in better oxygenation and patient survival.

Small incision fasciotomy in a patient with compartment syndrome and peripheral arterial occlusive disease.

An 82-year-old-man with a previous history of atrial fibrillation was admitted with acute limb ischemia. Emergent embolectomy was performed, but after the operation, the patient suffered from recurrent ischemic pain. Peripheral angiography revealed thrombosis of the distal popliteal artery due to pre-existing peripheral arterial occlusive disease. Bypass surgery of the popliteal artery and posterior tibial artery was then performed. Although peripheral blood flow was restored after the operation, he suffered from compartment syndrome the next day. The patient was treated with an emergent bed-side fasciotomy using a small incision, achieving full recovery of blood flow to the distal artery. The wound closed secondarily without surgical closure. In a patient with peripheral arterial occlusive disease, fasciotomy should be performed at a lower compartment pressure due to a lack of peripheral perfusion pressure. Emergent small incision fasciotomy was effective in this patient with an acute compartment syndrome and an ischemic limb.

Enlarged coronary artery pseudoaneurysm after drug-eluting stent implantation.

A 73-year-old man with 2-vessel coronary artery disease underwent a staged percutaneous coronary intervention that resulted in rupture of the right coronary artery and pseudoaneurysm formation. Although the pseudoaneurysm regressed over a week, it reexpanded after a year. Resection of the pseudoaneurysm and coronary artery bypass grafting were performed. The drug-eluting stent at the coronary artery injury site may have delayed healing and remodeling of the artery, thus contributing to reexpansion of the pseudoaneurysm.

Successful endovascular treatment of ruptured bronchial artery aneurysm.

Rupture of a bronchial artery aneurysm occurs rarely and may mimic aortic dissection. A 78-year-old-man was admitted with sudden chest pain. Chest radiography showed widening of the mediastinum, suggestive of aortic dissection, but contrast-enhanced computed tomography revealed hemomediastinum and bronchial artery aneurysm. Although open surgery has been the first choice for ruptured bronchial artery aneurysm, this case was successfully treated by an endovascular procedure with the combined use of coils and a gelatin sponge.

Double aortic arch in an adult.

We present the case of a 60-year old man who complained of severe dysphagia caused by a double aortic arch (DAA) with a right-sided descending thoracic aorta. The left-sided aortic arch had a compressive segment located between the left subclavian artery and the descending thoracic aorta. Using left third thoracotomy, the segment, which caused compression of the oesophagus, was ligated and divided. After the operation, the patient was completely relieved of his symptoms. We concluded that the removal of the compressive portion of the left aortic arch and the ligation of the ligamentum arteriosum are the only treatment measures needed in such cases.

Iatrogenic Acute Aortic Dissection during Percutaneous Coronary Intervention for Acute Myocardial Infarction.

Iatrogenic acute aortic dissection during percutaneous coronary intervention is an extremely rare, but critical complication. Localized aortic dissections have been treated by sealing the entry with a coronary stent. Extensive dissections may require a surgical intervention. We present a case of type A extensive aortic dissection occurring during angioplasty of the left circumflex artery for acute myocardial infarction. This iatrogenic aortic dissection required emergent surgical repair with supracoronary replacement of the ascending aorta.

Renal cell carcinoma with tumor-thrombus extension into the right ventricle.

Renal cell carcinoma is a tumor with the distinct feature that it can invade through the renal vein into the inferior vena cava, and can grow intravascularly, sometimes extending into right cardiac chambers. Surgical resection provides the only reasonable chance for a cure, and cardiopulmonary bypass with hypothermic circulatory arrest is used to resect an intracardiac extension of the tumor because the tumor-thrombus adhered strongly to the hepatic vein and to the endocardium of the right atrium (RA). We present 2 patients, with renal cell carcinoma extending into the right ventricle, who have lived for more than five years after the operation.

Cardiac protection with systemic hyperkalemia in reoperations with patent grafts.

A 68-year-old man with a history of coronary artery bypass graft surgery was admitted for ascending aorta replacement. Preoperative coronary computed tomography angiography revealed occlusion of the three coronary arteries. Perfusion of all three coronary vessels was achieved using a T-graft from the right gastroepiploic and radial arteries, which were anastomosed to the right coronary artery and posterolateral artery, respectively. The patient underwent ascending aorta replacement, with hyperkalemia and hypothermia for myocardial protection. Systemic hyperkalemia was useful to maintain cardiac arrest and also to monitor effective perfusion of the myocardium through the bypass grafts.