ABSTRACT
Purpose : The current status of treatment for thoracic/thoracoabdominal aortic diseases in Japan was analyzed. Methods : Using the Japan Cardiovascular Surgery Database (JCVSD), the number of cases, operative mortality and major morbidities (stroke, renal failure, pneumonia, paraplegia) of thoracic and thoracoabdominal aortic surgery in 2017 and 2018 were analyzed by surgical site (root-ascending, arch, descending, thoracoabdominal aorta), surgical procedure and age group. Results : The total number of cases was approximately 40,000 and aortic dissection and non-dissection were almost the same. The number of cases was highest in the 70s, and in the elderly, the rates of root replacement (particularly valve-sparing operation) in the root-ascending aorta and open-chest surgery (prosthetic graft replacement, OAR ; open stent graft, Open SG) in the arch, descending and thoracoabdominal aorta were lower. The outcome by procedure showed the lowest mortality and morbidity rate of valve-sparing in the root-ascending region, and lower mortality and morbidity (cerebral infarction, renal failure, and pneumonia) in non-open-chest procedures (TEVAR with/without branch reconstruction) than those in open-chest procedures in the arch, descending and thoracoabdominal regions. Unlike other complications, the incidence of paraplegia in the arch was lower in OAR than in non-open-chest procedures. With regards to age, the operative mortality in patients aged 80 or older was significantly higher than those under 80 for all surgical procedures in the root-ascending, arch and descending regions. Conclusions : Thoracic and thoracoabdominal aortic surgery in Japan was most often performed in elderly patients in their 70s with an overall good mortality rate of 5.3%. Mortality and postoperative morbidity in patients aged 80 or older were still high. Further improvement of surgical results is required.
ABSTRACT
Background : Thoracic and thoracoabdominal aortic diseases are treated using operative procedures like open aortic repair (OAR), thoracic endovascular aortic repair (TEVAR) or even hybrid aortic repair (HAR), a combination of OAR and TEVAR. The surgical approach to aortic repair is evolving over the decades. The purpose of this study was to examine the current trends in treatment. Methods : We extracted the nationwide data of aortic repair procedures performed between 2015 and 2016 from the Japan Cardiovascular Surgery Database (JCVSD). In addition to estimating the number of cases, we also classified the cases based on various criteria such as operative mortality, associated major morbidities (e.g. stroke, spinal cord insufficiency, renal failure), disease pathology (e.g. acute dissection, chronic dissection, ruptured aneurysm, unruptured aneurysm), site of operative repair (e.g. aortic root, ascending aorta, aortic root to arch, aortic arch, descending aorta, thoracoabdominal aorta) and the preferred surgical approach (i.e. OAR, HAR or TEVAR). Results : The total number of cases studied was 35,427, with an overall operative mortality rate of 7.3%. Among the 3 procedures, 64% of patients were treated with OAR. In comparison to the data in our previous report (also derived from the JCVSD in 2013 and 2014), the total number of cases and numbers of OAR, HAR, and TEVAR have increased by 17.0%, 2.4%, 126.1% and 34.9%, respectively. While the overall stroke rates following aortic arch surgical repair with HAR, OAR, and TEVAR were 10.1%, 8.4%, and 7.3% respectively. OAR was found to have the lowest stroke rate when limited to cases presenting with a non-dissected/unruptured aorta. The incidence rates of paraplegia following descending/thoracoabdominal aortic surgical repair using HAR, OAR, and TEVAR were 6.3%/10.4%, 4.3%/8.9% and 3.4%/4.6%, respectively. TEVAR was found to be associated with the lowest incidence of postoperative renal failure. Conclusions The number of operated thoracic and thoracoabdominal aortic diseases has increased, though the rate of operations using an OAR approach has decreased. While TEVAR showed the lowest mortality and morbidity rates, OAR demonstrated the lowest postoperative stroke rate for non-dissecting aortic arch aneurysms.
ABSTRACT
<p><b>Background</b> : Although open aortic repair (OAR) is still considered to be a standard treatment for thoracic aortic diseases, recently the indication of thoracic endovascular treatment (TEVAR) /hybrid aortic repair (HAR) is expanding. The purpose of this study is to review the current status of treatment of thoracic aortic diseases. <b>Methods</b> : The data concerning surgery for diseases in thoracic/thoracoabdominal aorta in 2013 and 2014 are extracted from the Japan Cardiovascular Surgery Database (JCVSD). The number of cases and operative mortality are evaluated for pathology (acute dissection, chronic dissection, ruptured aneurysm, un-ruptured aneurysm), treatment modality (OAR, HAR, TEVAR), JapanSCORE (＜5%, 5 to 10%, 10 to 15%, 15%≦) and their combination. <b>Results</b> : The total number of cases included in this study was 30,271 and the overall operative mortality was 5.9%. Among 3 types of treatment, 73.2% of patients underwent OAR (root, 98.3% ; ascending, 97.4% ; root to arch, 95.5% ; arch, 81.7% ; descending, 34.2% ; thoracoabdominal, 64.4%). Although the rate of OAR was in negative correlation with JapanSCORE (JS) in treatment for thoracoabdominal region (JS＜5%, 80.4% ; 5%≦JS＜10%, 67.6% ; 10%≦JS＜15%, 58.8% ; 15%≦JS, 55.7%), such relation was not observed in other regions. The operative mortality of OAR was well reflected by JS (JS＜5%, 2.1% ; 5%≦JS＜10%, 5.5% ; 10%≦JS＜15%, 10.2% ; 15%≦JS, 20.3%), however, those of TEVAR/HAR was less than the range of JS. <b>Conclusions</b> : The distribution of treatment differs depending on site of diseases and is not much influenced by JS. It has become clear that JapanSCORE is a reliable tool for estimating operative mortality in OAR. However, the observed operative mortality was lower than JS in TEVAR/HAR and a new risk score for TEVAR/HAR should be established.</p>
ABSTRACT
Among 232 patients undergoing repair for abdominal aortic aneurysms (AAA) during a 10-year period, 5 (2.2%) patients had evidence of inflammatory abdominal aortic aneurysms (IAAA). We examined their clinical course, laboratory, operative and histopathological findings, and considered possible correlations between their diagnosis and surgical treatment. Among these cases of IAAA, 2 patients complained of severe abdominal or back pain. The differential diagnosis from rupture of AAA was difficult in these cases. They also showed inflammatory signs in laboratory, operative and histopathological findings. Ultrasonography, computed tomography and magnetic resonance imaging appear to offer reliable means for diagnosing IAAA; In particular we could recognize the“Inflammatory mantle”in 3 cases, which indicated IAAA. In the surgical treatment, the presence of IAAA necessitates certain modifications in the surgical approach, in order to avoid injuring the retroperitoneal and abdominal structures. We could observe post-operative change in the thickness of the aortic wall, which decreases with time without anti-inflammatory agents.
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Marfan's syndrome associated with multiple arterial aneurysms of the abodominal aortic branches in a pair of identical twins is described. The first case, a 21-year-old male, visited our affiliated hospital because of severe upper abdominal pain. Computed tomography (CT) and aortography (AOG) demonstrated multiple abdominal aneurysms, i.e., celiac artery, bilateral renal arteries and superior mesenteric artery, but there were no findings of dissecting aneurysm of the aorta. The aneurysm of the superior mesenteric artery, which had ruptured, was replaced with a greater saphenous vein graft. The postoperative course was uneventful until sudden cardiac arrest occurred on the 5th POD. An autopsy revealed a dissecting aortic aneurysm (DeBakey type I), massive intrathoracic hemorrhage, and subarachnoidal hemorrhage. Two years later, the second case, the 23-year-old twin brother of the prior case, visited our hospital because of upper abdominal pain similar to that of his brother. The clinical course bore a close resemblance to his brother's. CT and AOG revealed the intact aorta and aneurysms of the celiac artery and right renal artery. The ruptured aneurysm of the celiac artery was ligated. Immediately after his returning to the ICU, he developed sudden massive intrathoracic bleeding and cardiac arrest. This is the fourth report of identical twins with Marfan's syndrome in Japan. It is also noteworthy that in both cases rupture of the extra-aortic aneurysm occurred prior to the aortic dissection or aneurysmal formation.
ABSTRACT
A case of tricuspid regurgitation due to nonpenetrating chest trauma was presented. A 58-year-old man who had an episcde of a traffic accident 18 years ago was admitted because of the edema of the lower extremities and easy fatigability. On physical examination, engorgement of the jugular vein, enlagement of the liver and the slight edema of the lower extremities were observed. Systolic regurgitant murmur with Rivero-Carvallo sign was audible. Chest X-ray film revealed marked cardiomegaly and electrocardiogram presented atial fibrillation and complete right bundle branch block. Two-dimentional echocardiography revealed marked dilatation of the right atrium and ventricle, and systolic exertion of anterior and posterior leaflets of tricuspid valve. On cardiac catheterization, right atrial <i>v</i> wave was 23mm Hg. At operation, the pericardium was adheded to the epicardium, and the chorda tendae of the anterior and posterior leaflet were ruptured. Tricuspid valve replacement with 33mm Carpentier-Edwards pericardial prosthetic valve was performed without any complications. To the best of our knowledge, this is the 19th operated case of traumatic tricuspid regurgitation in Japan.
ABSTRACT
The patient is a 47-year-old male who presented with abnormal shadows in his chest X-ray. On the third intercostal space, diastolic regurgitant murmur and systolic ejection murmur were heard. X-ray of the chest showed a projection of the right second costal arch in addition to the right atrium shadow. Cardiac catheterization showed no abnormalities except for a rise in the left ventricular end diastolic pressure which was 18mmHg. The patient was found to have Grade II aortic regurgitation. All there findings diagnosis of the case as extra-cardiac right Valsalva sinus aneurysm with aortic regurgitation. Incision of the aneurysm, showed a Valsalva sinus aneurysm having an opening of approximately 3cm just above the right aortic valve ring with the orifice of the right coronary artery occluded. Complete patch closure was performed with elevation of the aortic valve ring. No reconstruction for the right coronary artery was made.
ABSTRACT
From the surgical stand point of view we have classified 129 patients with aortic dissections, of which anatomic variations were clearly identified. In addition to the DeBakey's nomenclature, we newly employed two groups, aortic arch type and abdominal aortic type. Futhermore, each type was divided into subgroups. This report provides practical and suitable operative approaches according to anatomic variations of the aortic dissecting aneurysms. 1. Twenty-one patients had type I dissections. Thirteen of 21 (62%) were combined with aortic valve regurgitations. 2. Ten patients had type II dissections. Eight of 10 (80%) showed aortic valve regurgitation. This type was further divided into three subgroups. 3. Eighty patients had type III dissections, consisting of 18 type III a and 62 type III b dissections. The type III a dissection included all the cases in which dissections did not involve major branches of the abdominal aorta. Retrograde dissections to the proximal ascending aorta were found in eight patients out of 80 (10%). 4. Twelve patients had aortic arch type dissections. This group was divided into two subgroups, according to the extent of the aortic dissection. 5. Six patients had abdominal aortic type dissections. This group was also subdivided into two. 6. On the basis of the types of dissections outlined above, the most suitable radical operative procedure was selectively proposed in each case.