Is systolic blood pressure high in patients with acute aortic dissection on first medical contact before hospital transfer?

Acute aortic dissection (AAD) cases are thought to have high blood pressure (BP) on admission; however, little data are available on BP prior to admission. The purpose of this study was to investigate systolic blood pressure (SBP) very early after symptom onset and before hospital transfer in patients with AAD to determine whether SBPs were high, and also whether SBPs were higher or lower compared with SBPs at hospital admission. We obtained results using three-year data derived from the Tokyo Acute Aortic Super Network Database. First, we selected 830 patients with AAD for which the "duration from symptom onset to first medical contact by ambulance crews" (SO-FMC) was within 60 min. We examined the SBPs of such patients. Next, we selected 222 patients with AAD whose SBPs were measured both at FMC, within 15 min after symptom onset, and at hospital admission, and compared SBPs at FMC with those at hospital admission. Among types A (n = 190) and B (n = 117), in patients with an SO-FMC ≤ 15 min, the median SBP was 100 mmHg and 178 mmHg (p < 0.001), respectively; 9% and 50% (p < 0.001) of such patients, respectively, exhibited an SBP ≥ 180 mmHg; and 43% and 10% (p < 0.001) of such patients, respectively, had an SBP < 90 mmHg. Of patients with types A (n = 124) and B (n = 98) AAD whose SBPs were measured both at FMC, within 15 min after symptom onset, and at hospital admission, SBPs at FMC were higher than those at hospital admission for the SBP ≥ 180 mmHg subgroups of both type A (194 mmHg vs. 159 mmHg, p < 0.001) and type B (199 mmHg vs. 186 mmHg, p < 0.001). Approximately 10 min after symptom onset and before hospital transfer, the measured SBPs of many patients with type A AAD were not necessarily high. However, the SBPs of cases with type B AAD were high as previously reported for SBP on admission. In addition, for the subgroup of SBP ≥ 180 mmHg at FMC within 15 min after symptom onset, SBPs at FMC were significantly higher than those at hospital admission for both types A and B; the higher SBP at symptom onset may have been partially associated with being a trigger of AD.

A persistent sciatic artery aneurysm containing a free-floating thrombus: report of a case.

A persistent sciatic artery is a rare vascular anomaly in which the sciatic artery, which involutes in the embryonic stage, persists as the blood supply to the lower limb. This vascular anomaly is often associated with aneurysm formation. A persistent sciatic artery aneurysm is a rare cause of peripheral arterial embolic disease. We herein describe the case of a 72-year-old female with a free-floating thrombus in a persistent sciatic artery aneurysm. She underwent iliac-popliteal artery bypass and exclusion of the aneurysm to prevent an embolic event.

Clinical Features of Cardiac Calcified Amorphous Tumor: A Narrative Review.

A cardiac calcified amorphous tumor (CAT) is a non-neoplastic cardiac mass composed of calcified nodules surrounded by amorphous fibrous tissue in a context of degeneration and chronic inflammation. Although CAT cases are increasingly reported, its clinical manifestation remains unclear. We aimed to conduct a narrative review of CAT and identify its clinical characteristics. We conducted a comprehensive literature search using PubMed, with the keyword "Cardiac Calcified Amorphous Tumor" to identify relevant articles. A total of 113 articles published between 1997 and 2022 were retrieved. The clinical features allowing for assess patient background, differences with and without end-stage renal disease (ESRD), symptom-related factors, risk factors for embolism caused by CAT, and features of CAT, such as shape, location, mobility, pathology, and treatment, were statistically analyzed in 106 criteria-matched cases. The mean patient age was 60.2 ± 18.6 years, with 45 men and 61 women. Of the data collected from 21 countries, 52 patients were from Japan. Mobile CAT was more common in the chronic renal failure group. Linear, club-shaped, and spindle-shaped CAT tended to be mobile and more common in the ESRD group as well as located in the mitral valve region. The shape, mobility, location, and underlying mechanism of CAT depended on the presence or absence of ESRD. The risk of embolism was considered high because mobile CAT was more common in the ESRD group, and CAT originated in the mitral valve region. Hence, early diagnosis based on periodic examination in patients with ESRD and aggressive surgical treatment are necessary.

[Modified infarct exclusion technique of postinfarction ventricular septal perforation].

Ventricular septal perforation is one of the most serious complications of acute myocardial infarction, and is often fatal unless treated surgically. Despite the development of various surgical techniques for repair of postinfarction ventricular septal perforation, the operative mortality remains high. We report 3 consecutive cases in which a modified infarct exclusion technique was used to repair ventricular septal rupture after anterior myocardial infraction. The septal rupture was closed by the 1st pericardial patch with buttressed mattress sutures. Then buttressed mattress sutures were passed sequentially through the septal portion of the 2nd patch, the ventricular septum, and the free wall of the right ventricle to exclude the infarcted myocardium and septal perforation. The pericardial patch was sutured to the free wall of the left ventricle with a continuous suture for reconstruction of the left ventricular cavity. The ventriculotomy was closed with buttressed mattress sutures and a continuous suture. All 3 patients had an acceptable postoperative course and were discharged in satisfactory conditions. This technique seems to achieve satisfactory early results when used in the acute phase of myocardial infarction.

Ruptured abdominal aortic aneurysm with left-sided inferior vena cava.

We present a case of ruptured abdominal aortic aneurysm with left-sided inferior vena cava. An 82-year-old man was admitted to our hospital with a sudden onset of severe abdominal pain and loss of consciousness. Computed tomography revealed rupture of an infrarenal abdominal aortic aneurysm and a left-sided inferior vena cava. At surgery, the inferior vena cava was found to cross anteriorly over the abdominal aorta at the usual level of the renal vein. Graft replacement was successfully performed, with careful mobilization and retraction of the inferior vena cava. The patient had an uneventful postoperative course without any deterioration of renal function.

Total arch replacement and open stent graft implantation using a newly developed stent graft: report of a case.

We experienced a case in which a total arch replacement and an open stent implantation were performed for a distal aortic arch aneurysm using a newly developed stent graft (Ube CL-0201; Ube Medical, Tokyo, Japan). This novel stent graft is composed of a woven polyester graft and a nickel-titanium alloy stent, and has been under evaluation in clinical trials at four institutions in Japan, including our hospital, since 2008. The patient was weaned from the respirator on the day after surgery, and 9 months have passed since the surgery with no complications. A follow-up computed tomography scan showed that the stent part was sufficiently open, and no complications, such as an endoleak, have been observed.

Cardiac angiosarcoma with cardiac tamponade diagnosed as a ruptured aneurysm of the sinus valsalva.

Primary cardiac angiosarcoma is a rare, diagnostically elusive disease with a poor prognosis. In this report, we describe the case of a 56-year-old woman with a right atrial angiosarcoma. The patient presented with impending cardiac tamponade caused by right atrial perforation, but was misdiagnosed as a ruptured aneurysm of the sinus valsalva based on findings of a continuous murmur and an aorta to right atrium shunt by echocardiography. In the emergent operation that ensued, we found a right atrial perforation and a right coronary artery fistula to the right atrium. Coronary artery fistula is a rare complication of primary cardiac angiosarcoma, and a continuous murmur is also extremely rare as a clinical finding of angiosarcoma. We report the case and review the literature.

First clinical application of the DuraHeart centrifugal ventricular assist device for a Japanese patient.

The DuraHeart ventricular assist device (VAD) is a third-generation implantable centrifugal pump with a magnetically levitated impeller. Since February 2007, the device has been clinically applied with excellent results as a bridge to heart transplantation in Europe. As of this writing, however, the device has yet to be approved by the Ministry of Health, Labour and Welfare for clinical use in Japan. We herein report the first clinical application of this device for a Japanese patient. A 31-year-old man with dilated cardiomyopathy was transferred to the Heart and Diabetes Center NRW (HDZ-NRW) in Bad Oeynhausen, Germany, where he was to await heart transplantation. The transfer was safely completed under management with low-dose dopamine. His condition gradually deteriorated at HDZ-NRW, and the DuraHeart left ventricular assist device was implanted for the left ventricle at 7 weeks after admission. Shortly thereafter, however, on POD 7, a Thoratec VAD had to be inserted on the right side due to refractory right heart failure. The right ventricular assist device could be explanted after a 3-month assist, and the patient is now waiting for heart transplantation at home in Germany.

Less invasive quick replacement of the proximal arch with aggressive rapid rewarming for type A acute aortic dissection.

We describe a newly modified technique, which we term "less invasive quick replacement" (LIQR) for type A acute aortic dissection (AAD). After cooling to a rectal temperature of 28 degrees C without any cerebral perfusion, circulating blood in the cardiopulmonary bypass (CPB) circuit was warmed up to 40 degrees C during open distal anastomosis. As soon as the distal anastomosis was completed, rapid rewarming was initiated by perfusing blood at 40 degrees C. The average CPB and total operative times were 71.8 +/- 9.6 and 130.6 +/- 7.7 min, respectively. The shortest operative time was 101 min from skin incision to skin closure. All patients were weaned off the ventilator within 12 h of surgery. The postoperative hospital stay was 9.3 +/- 1.2 days. There was no incidence of cerebral damage or hospital mortality. Our initial results showed LIQR to be safe and effective.

A transesophageal echocardiographic and cine-fluoroscopic evaluation of an ATS prosthetic valve opening.

PURPOSE: The effectiveness of the ATS valves includes their durability and the quietness of the valve sound. However, a cine-fluoroscopic study revealed an incomplete opening of the valve leaflet. An overall evaluation of the ATS valve was conducted by transesophageal echocardiography. METHODS: The patients were divided into two groups based on the opening angle (OA): Group A, with a maximum OA of 80 degrees or greater and Group B, with a maximum OA of under 80 degrees. RESULTS: In Group A, the peak pressure gradient (PPG) sites of the anterior, central and posterior mitral commissure were 8.17, 8.05, and 8.09 mmHg, respectively, with no significant differences among the three sites. Similar results were obtained for Group B; the PPG at the three respective measurement sites were 8.59, 8.43, and 8.51 mmHg, and the differences were not statistically significant. No statistically significant differences were observed in the mean pressure gradient or pressure half time among the three measurement sites or between the two patient groups. CONCLUSION: Although, in many cases, the ATS valves did not open completely, the incomplete valve opening did not pose any problems in the valve function itself or in the cardiac functions of the patients.

Successful treatment of fulminant myocarditis with mechanical circulatory support.

A 66-year-old man with acute fulminant myocarditis was supported by a left ventricular assist device (LVAD) for 22 days, and successfully recovered from severe heart failure. Prior to this, he was treated using percutaneous cardiopulmonary support (PCPS) for five days. However, cardiac function was not recovered, so we conducted implantation of the LVAD. It is essential to make an immediate decision regarding LVAD implantation to save patients with fulminant myocarditis.

Vascular protecting effect of angiotensin receptor blocker (ARB) on the radial artery graft.

PURPOSE: We hypothesized that the vascular protecting effect of an angiotensin receptor blocker (ARB) reduced endothelial damage of the radial artery (RA) after coronary bypass and conducted a comparative study. PATIENTS AND METHODS: One hundred and sixty four patients were divided into the following two groups, Group C: 92 subjects who were orally administered Candesartan 8 mg/day, Group I: 72 subjects who were administered Imidapril at 5 mg/day. Graft angiography was performed one year after surgery and the RA intima was evaluated using an angioscope. RESULTS: Total cholesterol of Group C was 151.4+/-66.9 mg/dL, which was significantly lower than in Group I (182.2+/-27.8 mg/dL), and LDL cholesterol of the ARB-treated group, i.e., Group C was 96.1+/-32.5 mg/dL and significantly lower than in Group I (139.1+/-48.7 mg/dL). In angioscopy, yellow plaque was detected in the proximal RA in 7 (8.0%) and 8 (11.6%) patients of the Groups C and I, respectively, showing a lower tendency in the ARB-treated group. CONCLUSIONS: The results of evaluation one year after surgery revealed no significant difference in effects on the RA endothelium between ARB and ACE inhibitor. ARB reduced cholesterol and its effect was confirmed with blood examination data and endoscopic findings.

A surgical case of left ventricular pseudoaneurysm complicating myocardial infarction in a diabetic patient on dialysis.

A 57-year-old man was hospitalized with dyspnea and heart failure. We performed an electrocardiogram, coronary angiogram, echocardiogram, and magnetic resonance imaging. He was diagnosed with a left ventricular pseudoaneurysm (i.e., heart tumor) at the posterolateral wall. Minimal contrast medium was utilized when making the diagnosis as the patient was on dialysis. We subsequently repaired the ventricular unruptured pseudoaneurysm and performed a coronary artery bypass grafting. This case presented difficulty in ascertaining the difference between a cardiac tumor and a ventricular pseudoaneurysm.

Prophylactic reoperation after mitral valve replacement with the Starr-Edwards ball valve: a report of four cases.

PURPOSE: The Starr-Edwards ball valve was first applied clinically in 1960. In our hospital, this valve has been used since 1963, and some patients have been followed up for 30 years or more. Based on our experience, therapeutic strategies included revalve replacement as a preventive procedure in the absence of valve-related complications. In this study, we investigated whether prophylactic reoperation after valve replacement with the Starr-Edwards ball valve is appropriate. PATIENTS AND METHODS: Of 58 patients in our institute who underwent mitral valve replacement with the Starr-Edwards ball valve, 12 underwent revalve replacement. Of these 12, the subjects of the present study were 4 patients who underwent prophylactic revalve replacement. RESULTS: The mean postoperative follow-up of the 4 patients was 31.0+/-3.7 years. There were no operative deaths or postoperative complications. On examination of the extirpated Starr-Edwards valves, cloth wear was observed in all 4 patients. Although there was no influence on the range of ball motion, they showed the entity of "thrombus/pannus." CONCLUSION: In this study, all of the patients showed cloth wear in the absence of complications. Therefore we consider that prophylactic reoperation after valve replacement with the Starr-Edwards valve should be performed to prevent complications.

New Treatment for Percutaneous Sites in Patients with a Ventricular Assist Device: Nihon University Crystal Violet Method.

BACKGROUND: Infection of the percutaneous site of a ventricular assist device (VAD) is a challenging complication. We report our experience with crystal violet Solbase (Nihon University crystal violet method) for prevention of driveline or cannula infections in VAD patients. PATIENTS AND METHODS: The crystal violet method was used in 10 patients (prophylaxis in nine and treatment in one). Eight patients had an extracorporeal VAD (Nipro) and two had an implantable VAD (Heart Mate II). RESULTS: The infection-free period was 4-623 days (mean: 144.2 ± 222.9 days). All eight patients with an extracorporeal VAD died, while the two patients with an implantable VAD (Heart Mate II) survived. Infection was improved in a patient with MRSA, and the results of bacteriological examination were always negative in the patients receiving prophylaxis. The two patients with an implantable VAD had no infection for 2 and 20 months after implantation. CONCLUSION: These findings suggest that the Nihon University crystal violet method is effective for prevention and treatment of driveline or cannula infections in patients with a VAD.

New Treatment for Infection of the NIPRO LVAD Cannula Site: Nihon University Crystal Violet Method.

Driveline and cannula site infections are still a frequent adverse event in patients with a ventricular assist device (VAD), and it is important to treat and prevent them because the spread of local infection may cause sepsis in some cases. We report our experience with a patient in whom infection of the NIPRO LVAD cannula site after implantation of an extracorporeal VAD was controlled by treatment with crystal violet Solbase (Nihon University crystal violet method).

Surgical treatment for innominate artery aneurysm with a coronary pulmonary artery fistula: a case report.

A 50-year-old woman complained of hoarseness and chest X-ray demonstrated a widening of the superior mediastinum. Computed tomography scanning and aortography demonstrated aneurysmal dilatation at the innominate artery. Coronary arteriography showed a coronary pulmonary artery fistula originating from the left anterior descending artery. The surgical procedure was prosthetic bifurcated bypass grafting from the ascending aorta to the right common carotid artery and right subclavian artery. During the period of innominate artery occlusion, the patient was cooled to 25 degrees C with selective cerebroperfusion and circulatory arrest. Pathologic diagnosis of the specimen was that of a true aneurysm with atherosclerotic plaque and calcification. The coronary pulmonary artery fistula was closed inside the pulmonary artery. There were no signs of neurologic deficit noted. Innominate artery aneurysm is uncommon and the surgical approach varies in each case. A coronary artery fistula is also an uncommon congenital malformation but has been recognized more often with the improvement in diagnostic techniques such as selective coronary arteriography. We performed successful surgical treatment for a rare case of innominate artery aneurysm with a coronary pulmonary artery fistula.

Long-term results of pediatric heart transplantation.

OBJECTIVE: We retrospectively reviewed 104 consecutive patients who underwent orthotopic heart transplantation between November 1989 and February 2004. PATIENTS AND METHODS: From November 1989 to February 2004, the total number of heart transplantations were 1,340 cases at our institute. One hundred four (7.8%) of these 1,340 patients were pediatrics. Average age was 6.2 years, ranging from 4 months to 16 years. The cause of heart disease before transplantation was: idiopathic dilated cardiomyopathy (DCM) in 74 patients (71%), and congenital heart disease (CHD) in 30 (29%). RESULTS: Hospital mortality rate was 14.4% (15 patients). Late complications were rejection in 23 (22.1%), infection in 11 (10.6%), gingival hyperplasia in 28 (26.9%), hypertention in 22 (21.1%), coronary artery disease (CAD) in 12 (12.5%), graft failure in 11(10.5%), and malignancy in 2 (1.9%). Late mortality occurred in 11 (10.6%) patients. Causes of death were sudden death in 2 (1.9%), CAD in 3 (2.8%), graft failure in 1 (1.0%), acute rejection in 4 (4.6%), and infection in 1 (1.0%). Actuarial survival rates in pediatrics at 1, 5, 10 years were 82%, 80%, and 78%, respectively. On the other hand, actuarial survival rates in adults at 1, 5, 10 years were 78%, 75%, 59%, respectively. CONCLUSION: Heart transplantation for pediatrics is an effective therapy with acceptable morbidity and mortality. The long-term survival results in pediatrics are comparable to those of adult heart transplantations. However, the actuarial survival rate in pediatrics after 10 years is significantly better than in adults' cases. Renal function in pediatric heart transplantation recipients treated with cyclosporine remains stable during long-term follow-up.

Surgical Extirpation of Apical Left Ventricular Thrombus in Takotsubo Cardiomyopathy.

We report a patient with takotsubo cardiomyopathy who underwent surgical resection of apical left ventricular thrombus. A 59-year-old woman was transferred to our hospital in shock with hypothermia and diabetic ketoacidosis. The electrocardiogram showed ST segment elevation, while echocardiography revealed a reduced ejection fraction with apical and midventricular akinesis. Emergency coronary angiography showed normal coronary arteries, so takotsubo cardiomyopathy was diagnosed. Follow-up echocardiography revealed improvement of the ejection fraction. A mobile apical thrombus was also detected. Thrombectomy was performed via a left apical incision and postoperative recovery was uneventful.

An Infected Abdominal Aortic Aneurysm Caused by Helicobacter cinaedi.

We present a rare case of an infected abdominal aortic aneurysm due to Helicobacter cinaedi that was detected by blood culture. A 79-year-old man with lumbago and left lower quadrant pain was admitted for the treatment of an infected abdominal aortic aneurysm. H. cinaedi was isolated from a blood culture, which was obtained on admission. The aneurysm was successfully treated with antibiotic therapy, aneurysmectomy, debridement, replacement of a bifurcated Dacron prosthesis, and omental wrapping. Our present case suggests that H. cinaedi should be considered as the causative agent of an infected aortic aneurysm.