Impact of Hospital Integration on Emergency Surgery Patients with Stanford Type A Acute Aortic Dissection / 日本心臓血管外科学会雑誌

Objective: Hospitals throughout Japan are being integrated and reorganized under the government's regional medical care plan. However, the effects on cardiovascular surgery practice remain unknown. In the year 2016, our institution employed hospital integration; we report its effects on patients with type A acute aortic dissection who underwent emergency surgery. Methods: This study included 89 patients who underwent emergency surgery for type A acute aortic dissection from May 2012 to December 2020. Evaluation items included preoperative patient factors, number of surgeries, surgical mortality, referral rate, patient transport time, transport distance, number of surgeries performed by young cardiovascular surgeons, and overtime work for surgery. Patients were categorized into pre-(group P: 29 patients) and post-integration (group A: 60 patients) groups, which were retrospectively compared. Results: Preoperative factors were not significantly different between the two groups. Operations accounted for 29 and 60 in groups P and A, respectively; they increased significantly after integration (p=0.005). Surgical mortality was 27.6 and 15% in groups P and A, respectively, with no significant difference (p=0.2). The referral rate was 17 (58.6%) and 21 (35%) patients in groups P and A, respectively; group A displayed a significantly lower referral rate (p=0.04). The interval from the onset of symptoms to arrival at the surgery cite was significantly reduced (p=0.01) in group A (112±140 min) compared to group P (206±201 min). There was no significant difference in the transfer distance between groups P (13.9±14.8 km) and A (13.5±16.2 km). The number of surgeries performed by young surgeons increased in 9 cases (31%) in group P and 34 cases (56.7%) in group A (p=0.02). Overtime work was substantially reduced:446±154 min in group P and 349±112 min in group A. Conclusion: Hospital integration resulted in increased number of acute aortic dissection surgeries and decreased interval time from the onset of symptoms to arrival at the surgery cite. The young surgeons performed more surgeries and reduced their overtime work.

Emergency Total Arch Replacement with J-Graft Open Stent Graft for Acute Type A Aortic Dissection, Requiring TEVAR for Stent Graft Stenosis / 日本心臓血管外科学会雑誌

<p>A 76-year-old man was admitted to our hospital to receive optimal medical therapy for acute type B aortic dissection with a thrombosed false lumen. Eighteen days after admission, computed tomography (CT) was performed because of back pain and showed new retrograde acute type A aortic dissection. Emergency total arch replacement was performed with the aid of a J-graft open stent graft (JOSG). Postoperatively, the blood pressure in the lower extremities decreased to 70% of systemic blood pressure without symptoms. Enhanced CT showed severe stenosis from the non-stent part of the aorta to the proximal part of the JOSG. On postoperative day 2, thoracic endovascular aortic repair (TEVAR) was performed for stent graft stenosis. The blood pressure of the lower extremities promptly recovered after the procedure, and the patient was extubated without any neurologic deficits on the next day. Postoperative CT demonstrated that the stent graft stenosis had been effectively alleviated. The patient's subsequent course was uneventful and he was discharged on postoperative day 24.</p><p>A JOSG should only be deployed after precise evaluation of the anatomy of the target aorta and careful attention should be paid to the length of the non-stent part of the graft in order to prevent unpredictable graft retraction that could cause stent graft stenosis. TEVAR is considered to be a good option to treat complications related to open stent grafts.</p>

A Case of Tricuspid Valve Endocarditis with Systemic Embolization of Vegetation via a Patent Foramen Ovale / 日本心臓血管外科学会雑誌

A 28-year-old woman with patent foramen ovale who developed tricuspid valve infective endocarditis with complications of multiple infarctions and abscesses was treated surgically. The patient was transferred to our institution because of fever and joint pain. Echocardiography revealed a large vegetation (25 mm) on the tricuspid valve and a patent foramen ovale. Computed tomography and magnetic resonance imaging showed cerebral infarctions, multiple lung abscesses, and vertebral osteomyelitis. <i>Staphylococcus epidermidis </i>was identified in blood cultures. After treatment with adequate antibiotics for 5 weeks, the patient underwent surgical resection of the vegetation followed by tricuspid valve repair and direct closure of the patent foramen ovale. Antibiotic therapy was continued postoperatively, and the patient was discharged 7 weeks after the operation. No further endocarditis or embolism has occurred. In cases of right-sided endocarditis with systemic embolism and abscesses, the presence of a patent foramen ovale should be considered, and appropriate timing of the operation should be determined to prevent further systemic embolization of the vegetation.

Ruptured Acute Type A Aortic Dissection with Persistent Left Superior Vena Cava and Absence of a Bridging Innominate Vein / 日本心臓血管外科学会雑誌

Ruptured acute type A aortic dissection in a patient with persistent left superior vena cava (PLSVC) and absence of a bridging innominate vein is rare. A 71-year-old woman presented with a pain in the right side of the neck and nausea. Ruptured acute type A aortic dissection was diagnosed. CT scan revealed a persistent left superior vena cava and absence of a bridging innominate vein. Emergency hemi-arch replacement was performed. After CPB was established with right femoral artery return and right SVC (RSVC), IVC venous drainage was placed. An L-shaped venous cannula was directly placed into the LSVC. After core cooling, the ascending aorta was clamped and the right atrium was incised for retrograde cardioplegia. At a rectal temperature of 28°C, circulatory arrest was started and retrograde cerebral perfusion was performed through right and left SVC. Her postoperative course was uneventful. In cases of ruptured acute type A aortic dissection in a patient with persistent left superior vena cava (PLSVC) and absence of a bridging innominate vein, standard hemiarch replacement can be performed with direct venous cannulation of LSVC for reliable retrograde cardioplagia and retrograde cerebral perfusion.

A Case of Isolated Iliac Aneurysm Associated with Vasculo-Behcet's Disease / 日本心臓血管外科学会雑誌

A 62-year-old man with a complete type of Behçet's disease suffering from lower abdominal pain was admitted to our hospital. Abdominal CT and angiograms demonstrated a right isolated iliac aneurysm. When his general conditions had become stable, we evaluated the activity of Behçet's disease, especially inflammation and the existence of intestinal lesions, and found no abnormalities. He underwent graft replacement for the iliac aneurysm. The postoperative course was uneventful. Angiograms revealed good opacification of the graft and no abnormality of the anastomotic site. Some reports have emphasized anastomotic complications of vascular surgery associated with Behcet's disease. We should periodically check for inflammatory signs, anastomotic aneurysm and other recurrent aneurysms.