Impact of Residual Entry Tears in the Descending Aorta After Type A Dissection.

BACKGROUND: Aggressive resection/exclusion of the primary entry in the descending aorta remains controversial in older patients with acute type A aortic dissection (ATAAD). We investigated the effect of residual primary entry in the descending aorta in younger and older groups. METHODS: Patients with ATAAD who underwent emergency operation (n = 1103) were divided into younger (<70 years; n = 681) and older (≥70 years; n = 422) cohorts. Each cohort was further divided into groups with or without residual primary entry in the descending aorta. After propensity score matching, 179 and 71 matched pairs were obtained in the younger and older cohorts, respectively. Surgical outcomes were compared between the residual and nonresidual groups in each age cohort. RESULTS: In the younger cohort, the cumulative incidence rate of distal aortic events was significantly higher in the residual than in the nonresidual group at 10 years (35% [95% CI, 27%-44%] vs 22% [95% CI, 15%-31%], P = .001). However, in the older group, residual or nonresidual primary entry did not affect the rates at 10 years (11% [95% CI, 5%-20%] vs 9% [95% CI, 4%-17%], P = .75). Multivariate analysis identified age <70 years (hazard ratio, 2.188; 95% CI, 1.493-3.205; P < .001) and residual primary entry at the descending aorta (hazard ratio, 2.142; 95% CI, 1.559-2.943; P < .001) as significant predictors for distal aortic events. CONCLUSIONS: Aggressive resection/exclusion of the primary entry in the descending aorta should be considered for patients aged <70 years to avoid distal aortic events; however, it might not always be appropriate for the older patients ≥70 years.

[Coagulation Management During Open Heart Surgery Based on a Heparin Dose Sensitivity Test for Antiphospholipid Antibody Syndrome].

A 63-year-old woman with severe aortic regurgitation was admitted to our hospital due to congestive heart failure. She also had antiphospholipid syndrome (APS), necessitating strict coagulation management. Given her history of cerebellar infarction, deep vein thrombosis, and recurrent miscarriages, her thrombosis risk was higher, with all three types of antiphospholipid antibodies testing positive. Before the surgery, we created a heparin-activated clotting time (ACT) titration curve using the patient's blood, and the calculated ACT corresponding to the target heparin concentration of 3 U/ml was 650 seconds. We planned to administer heparin according to this target during cardiopulmonary bypass. The patient underwent an aortic valve replacement (AVR) using a bioprosthesis and was discharged without complications.

Appropriate sizing of the frozen elephant trunk: How to predict proximal descending aortic diameter prior to dissection?

OBJECTIVE: The predissection aortic diameter is the best reference for determining the size of the frozen elephant trunk in aortic dissection. We aimed to develop a new prediction method to estimate the predissection diameter of proximal descending aorta. Furthermore, we evaluated the accuracy of the estimated predissection proximal descending aortic diameters calculated using 3 prediction methods. METHODS: A total of 39 patients with acute type A aortic dissection who underwent predissection computed tomography were included in derivation sets. We measured the aortic dimensions at 3 levels of the proximal descending aorta: 5, 10, and 15 cm from zone 2. We developed a new prediction method-postdissection aortic diameter divided by 1.13 (AoDNew factor)-and estimated the predissection aortic diameter using the new and previously proposed methods by Rylski (AoDRylski) and Yamauchi (EquationYamauchi). Furthermore, we validated the new prediction method using a validation dataset with 24 patients. RESULTS: The rate of bias ≤2 mm was significantly greater with EquationYamauchi and AoDNew factor than with AoDRylski in the derivation group at each level of the proximal descending aorta (P < .001). In the validation group, the rate of bias ≤2 mm was significantly greater with EquationYamauchi and AoDNew factor than with AoDRylski at 10 cm and 15 cm from zone 2 (10 cm: P = .014, 15 cm: P < .001). CONCLUSIONS: These results suggest that the new prediction method can be used as a simple and accurate estimation method for the predissection aortic diameter at the proximal descending aorta.

[Primary Cardiac Undifferentiated Pleomorphic Sarcoma in the Left Atrium:Report of a Case].

A rare case of primary cardiac undifferentiated pleomorphic sarcoma (UPS) is reported. A 77-yearold female was admitted to the authors' hospital with complaints of palpitation and dyspnea on effort. Echocardiography revealed a mobile tumor arising from the atrial septum of the left atrium. The tumor obstructed the mitral valve and the patient experienced acute heart failure. Emergent open-heart surgery was performed to resect the tumor. Although she was discharged from hospital on postoperative day 14 in a satisfactory condition, local recurrence in the left atrium was observed 16 months after surgery. Repeated tumor resection was performed, and histological examination confirmed UPS. The patient did not agree to undergo chemotherapy or radiation therapy and died of local recurrence 27 months after the first surgery.

[Incidentally Detected Right Atrial Blood Cyst].

A 48-year-old man underwent computed tomography for the examination of lower back pain, which incidentally detected a cardiac tumor in the right atrium. On echocardiography, the tumor was identified as a 30 mm round mass with a thin wall and iso- and hyper-echogenic contents that originated from the atrial septum. The tumor was successfully removed under cardiopulmonary bypass, and the patient was discharged in good health. The cyst was filled with old blood, and focal calcification was observed. Pathological examination revealed that the cystic wall was composed of thin-layered fibrous tissue lined with endothelial cells. Regarding a treatment, it is reported that early surgical removal is preferable to avoid embolic complications, however it is controversial. Furthermore, it needs to discuss about the difference between fetal/neonatal and adult cases.

Morphological Changes in Endothelial Cell Organelles in a No-Touch Saphenous Vein Graft.

INTRODUCTION: Improved long-term patency of the no-touch (NT) saphenous vein graft has been reported to result from the preservation of a healthy vascular microstructure, especially endothelial cells. However, the precise morphology of endothelial cells and their organelles in NT saphenous vein graft has not been fully investigated. In this study, we assessed the ultrastructure of preserved endothelial cells in saphenous vein graft using transmission electron microscopy. METHODS: Intact control (IC) vein, NT saphenous vein graft, and conventional (CT) saphenous vein graft were harvested from a patient. After observation by light microscopy, the nuclei and mitochondria in the preserved endothelial cells were compared among IC, NT, and CT using transmission electron microscopy, and the endothelial organelles were assessed quantitatively. RESULTS: Light microscopy showed that the preservation of endothelial cells was comparable in IC, NT, and CT. Subsequent transmission electron microscopy observation showed that the nuclei in preserved endothelial cells appeared more swollen in CT than that in NT. Quantitative analysis revealed that nuclear size and circularity of preserved endothelial cells in NT and IC were similar, but those in CT were larger and higher, respectively, than those in IC and NT. In addition, the mitochondrial size in preserved endothelial cells in CT was larger than that in IC and NT. CONCLUSION: Necrotic changes in endothelial organelles characterized by swelling of nuclei and mitochondria were prominent in CT saphenous vein graft. The normally maintained ultrastructure of preserved endothelial cells in NT saphenous vein graft could contribute to long-term patency.

Bicuspidalization of the Native Tricuspid Aortic Valve: A Porcine in Vivo Model of Bicuspid Aortopathy.

Objective: To examine early histologic changes in the aorta exposed to bicuspid flow. Material and Methods: A porcine bicuspid aortopathy model was developed by suturing aortic cusps. Of nine pigs, eight underwent sham surgery (n=3) or bicuspidalization (n=5); one was used as an intact control. Wall shear stress (WSS) was assessed by computational fluid dynamics (CFD). Animals were exposed to normal or bicuspid flow for 48 h and were then euthanized for histologic examinations. Results: No animal died intraoperatively. One animal subjected to bicuspidalization died of respiratory failure during postoperative imaging studies. Echocardiography showed the aortic valve area decreased from 2.52±1.15 to 1.21±0.48 cm2 after bicuspidalization, CFD revealed increased maximum WSS (10.0±5.2 vs. 54.0±25.7 Pa; P=0.036) and percentage area of increased WSS (>5 Pa) in the ascending aorta (30.3%±24.1% vs. 81.3%±13.4%; P=0.015) after bicuspidalization. Hematoxylin-eosin staining and transmission electron microscopy showed subintimal edema and detached or degenerated endothelial cells following both sham surgery and bicuspidalization, regardless of WSS distribution. Conclusion: A bicuspid aortic valve appears to increase aortic WSS. The endothelial damage observed might have been related to non-pulsatile flow (cardiopulmonary bypass). Chronic experiments are needed to clarify the relationship between hemodynamic stress and development of bicuspid aortopathy.

A Compressed Collagen Construct for Studying Endothelial-Smooth Muscle Cell Interaction Under High Shear Stress.

The coculture of vascular endothelial cells (ECs) on collagen gels containing smooth muscle cells (SMCs) has been carried out to investigate cellular interactions associated with blood vessel pathophysiology under wall shear stress (WSS) conditions. However, due to a lack of gel stiffness, the previous collagen gel coculture constructs are difficult to use for pathologic higher WSS conditions. Here, we newly constructed a coculture model with centrifugally compressed cell-collagen combined construct (C6), which withstands higher WSS conditions. The elastic modulus of C6 was approximately 6 times higher than that of the uncompressed collagen construct. The level of α-smooth muscle actin, a contractile SMC phenotype marker observed in healthy arteries, was elevated in C6 compared with that of the uncompressed construct, and further increased by exposure to a physiological level WSS of 2 Pa, but not by a pathological level of 20 Pa. WSS conditions of 2 and 20 Pa also induced different expression ratios of matrix metalloproteinases and their inhibitors in the C6 coculture model but did not in monocultured ECs and SMCs. The C6 coculture model will be a powerful tool to investigate interactions between ECs and SMCs under pathologically high WSS conditions.

[Stanford Type A Acute Aortic Dissection Complicated by Takotsubo Cardiomyopathy:Report of a Case].

No case report about takotsubo cardiomyopathy with Stanford type A acute dissection is present in the literature. Here we report a case of takotsubo cardiomyopathy that was diagnosed following Stanford type A acute aortic dissection. A 65-year-old man was admitted with dyspnea. He had experienced acute chest pain 10 days prior. Computed tomography (CT) confirmed Stanford type A aortic dissection and primary entry tear in the proximal aortic arch with a thrombosed false lumen in the ascending aorta. Echocardiography revealed takotsubo-like wall motion, with an ejection fraction (EF) of 20%. Electrocardiography (ECG) showed ST-segment elevation in V2-V3. Subsequently, coronary artery disease was excluded by coronary CT. After 1 month, ECG findings and EF appeared normal. Thirty-five days after admission, aortic arch replacement was performed with the frozen elephant trunk technique. The patient's postoperative course was uneventful. Takotsubo cardiomyopathy should be considered as a possible complication of acute aortic dissection with ST-segment elevation.

Influence of residual primary entry following the tear-oriented strategy for acute type A aortic dissection.

OBJECTIVES: Although a tear-oriented strategy has contributed to improving short-term surgical outcomes of acute type A aortic dissection (ATAAD), long-term clinical influences of residual entry tear in the downstream aorta have not been fully investigated. The goal of this study was to assess the long-term surgical outcomes of ATAAD with or without a residual entry tear in the downstream aorta. METHODS: Medical records of 1107 patients with ATAAD who underwent emergency surgery between 1990 and 2018 were retrospectively reviewed. A tear-oriented paradigm was adopted for the baseline strategy. The 837 patients in whom the entry tears were resected comprised the resected group, and the 270 patients with a residual entry tear comprised the residual group. Of these patients, 252 in each group were analysed using propensity score matching, and long-term outcomes were compared with or without residual entry. RESULTS: Hospital deaths were lower in the resected group (3.2% vs 8.3%; P = 0.020). The survival rate was not significantly different between the groups: It was 83.8% and 68.5% in the resected group and 80.2% and 66.5% in the residual group at 5 and 10 years, respectively (P = 0.600). However, residual entry in the downstream aorta affected the distal aortic event-free survival rate (90.4% and 80.6% in the resected group and 82.3% and 67.4% in the residual group at 5 and 10 years, respectively; P = 0.003). Furthermore, multivariable risk analysis of 1107 patients confirmed that a residual entry in the downstream aorta was a risk factor for distal aortic events. CONCLUSIONS: The tear-oriented strategy remains the gold standard for high-risk patients; however, the extensive operation might be considered for stable patients to reduce long-term aortic events.

Morphological Changes in Endothelial Cell Organelles in a No-Touch Saphenous Vein Graft

ABSTRACT Introduction: Improved long-term patency of the no-touch (NT) saphenous vein graft has been reported to result from the preservation of a healthy vascular microstructure, especially endothelial cells. However, the precise morphology of endothelial cells and their organelles in NT saphenous vein graft has not been fully investigated. In this study, we assessed the ultrastructure of preserved endothelial cells in saphenous vein graft using transmission electron microscopy. Methods: Intact control (IC) vein, NT saphenous vein graft, and conventional (CT) saphenous vein graft were harvested from a patient. After observation by light microscopy, the nuclei and mitochondria in the preserved endothelial cells were compared among IC, NT, and CT using transmission electron microscopy, and the endothelial organelles were assessed quantitatively. Results: Light microscopy showed that the preservation of endothelial cells was comparable in IC, NT, and CT. Subsequent transmission electron microscopy observation showed that the nuclei in preserved endothelial cells appeared more swollen in CT than that in NT. Quantitative analysis revealed that nuclear size and circularity of preserved endothelial cells in NT and IC were similar, but those in CT were larger and higher, respectively, than those in IC and NT. In addition, the mitochondrial size in preserved endothelial cells in CT was larger than that in IC and NT. Conclusion: Necrotic changes in endothelial organelles characterized by swelling of nuclei and mitochondria were prominent in CT saphenous vein graft. The normally maintained ultrastructure of preserved endothelial cells in NT saphenous vein graft could contribute to long-term patency.

Right ventricular outflow obstruction with squamous cell carcinoma of unknown origin.

A 60-year-old man was referred to our hospital because of chest tightness. CT scans showed no specific findings except a right ventricular (RV) mass. Echocardiogram revealed that the large cardiac mass was compressing the right ventricular outflow tract, and the patient thus underwent an emergency operation. As the tumour on the inlet side of the right ventricle was tightly adhered to the entire tricuspid chordae, a complete resection was impossible. Pathological findings revealed that the tumour was metastatic squamous cell carcinoma. Four cycles of chemotherapy were administered. Further investigations were conducted to identify the primary cancer focus, but there were no specific findings. Eight months after the operation, the patient returned to the hospital. Echocardiogram showed a severely occupying mass once again, and the patient died as a result. Autopsy revealed no findings relating to the primary origin of the cardiac metastases.

Artificial endocrine pancreas with a closed-loop system effectively suppresses the accelerated hyperglycemic status after reperfusion during aortic surgery.

OBJECTIVES: To control intraoperative hyperglycemia in patients who underwent aortic surgery using STG-55® artificial endocrine pancreas and clarify the effectiveness of this device. METHODS: Blood glucose control using the STG-55® was performed in 18 patients (15 men and 3 women; age, 66 ± 10 years) who required hypothermic circulatory arrest (STG-55® group). Seventeen patients (10 men and 7 women; age, 71 ± 8 years) whose blood glucose was controlled using the conventional method were included in the control group. Glucose concentration was controlled with the aim of maintaining it at 150 mg/dl. RESULTS: In both groups, the blood glucose concentrations did not significantly change during the interruption of systemic perfusion; however, a sharp increase was noted immediately after reperfusion. Although the hyperglycemic status persisted after reperfusion in the control group, it was effectively suppressed in the STG-55® group (STG® vs. control group at 50 min after reperfusion: 180 ± 35 vs. 212 ± 47 mg/dl, p = 0.026) and blood glucose concentration reached the target value of 150 mg/dl at 100 min after reperfusion (STG® vs. control group: 153 ± 29 vs. 215 ± 43 mg/dl, p = 0.0008). The total administered insulin dose was 175 ± 81 U and 5 ± 3 U in the STG® and control groups, respectively (p < 0.0001). CONCLUSIONS: To treat the accelerated hyperglycemic status in aortic surgery requiring circulatory arrest, strict glycemic control using an artificial endocrine pancreas might be beneficial.

Successful treatment of Aspergillus mural endocarditis in malignant lymphoma using a combined antifungal and surgical approach: a case report.

BACKGROUND: Aspergillus endocarditis (AE) is a rare and lethal cardiac infection with a high rate of mortality. AE most commonly presents in immunocompromised patients and is associated with various co-morbidities. Herein, we present a case of AE associated with lung, brain, and cervical abscesses after chemotherapy for malignant lymphoma that was successfully treated by a combination of antifungal and surgical therapy. CASE PRESENTATION: A 29-year-old man was admitted to our hospital with an unidentified fever. He was diagnosed with malignant lymphoma (extra-nodal NK/T cell lymphoma nasal type), and chemotherapy was administered. After chemotherapy, nodular lung shadows along with new brain, cervical, and myocardial abscesses appeared, despite anti-bacterial/fungal therapy. Gene analysis of the cervical abscess biopsy revealed the presence of Aspergillus fumigatus species, and the transesophageal echocardiogram showed a mobile mural vegetation in the left ventricle (22 × 8 mm). He underwent surgical resection of this mural vegetation. His postoperative course was uneventful. He remains healthy at 28 months after surgery with continued oral antifungal therapy. CONCLUSION: Although AE associated with immunosuppression is a fatal clinical presentation, combined treatment with surgical resection and antifungal therapy was effective.

[Surgical Pulmonary Embolectomy for Acute Massive Pulmonary Embolism Using a Surgical Endoscope;Report of a Case].

Despite advances in medical and surgical therapeutic techniques, acute massive pulmonary embolism has a high mortality rate. Complete clot extraction without arterial wall injury is essential to save critically ill patients. Herein, we present a case of a 72-year-old woman who was treated by surgical pulmonary embolectomy using a surgical fiberscope. The patient was admitted to our hospital with a complaint of dyspnea. Computed tomography demonstrated a massive pulmonary embolism, and echocardiography revealed a floating thrombus in the right atrium and severe right heart failure. As she suffered from circulatory collapse, percutaneous cardiopulmonary support was immediately introduced and emergency surgical embolectomy was performed. Surgery was performed under circulatory arrest, and complete clot extraction was achieved using a surgical endoscope. The patient recovered well and was discharged from the hospital on day 48, with good health.

Effects of Obesity on Outcomes of Acute Type A Aortic Dissection Repair in Japan.

Background: The prevalence of obesity among Japanese acute type A aortic dissection (ATAAD) patients and its effect on repair outcomes remain to be elucidated. Methods and Results: The prevalence of obesity (body mass index [BMI] ≥30.0 kg/m2) among 1,059 patients (mean [±SD] age 64.3±12.7 years) who underwent ATAAD repair between 1990 and 2018 was compared with that among the general Japanese population (National Health and Nutrition Survey data). The prevalence of obesity among male patients (17.1% [6/35], 20.0% [18/90], and 14.4% [20/139] for those aged 20-39, 40-49, and 50-59 years, respectively) was significantly higher than that among the age- and sex-matched general population. The 1,059 patients were divided into groups according to weight (normal [BMI <25.0 kg/m2; n=742], overweight [BMI 25.0-29.9 kg/m2; n=248], or obese [BMI ≥30.0 kg/m2; n=69]). Comparing the normal weight, overweight, and obese groups revealed significant differences among the 3 groups in median cardiopulmonary bypass time (143, 167, and 183 min, respectively), ventilation >48 h (44.5%, 60.1%, and 78.3%, respectively), and in-hospital mortality (7.0%, 7.3%, and 17.4%, respectively), but not in 30-day survival. Shock, visceral malperfusion, operation time >360 min, obesity, and coronary malperfusion were identified as predictors of in-hospital mortality. Conclusions: The prevalence of obesity is increased among Japanese male patients with ATAAD aged ≤59 years. Obesity may increase these patients' operative risk; overweight does not.

[Right Atrium Thrombus Due to Cardiac Amyloidosis;Report of a Case].

A 51-year-old man complaining of exertional dyspnea and syncope was admitted to our hospital. Computed tomography(CT) and transesophageal echocardiography demonstrated a mobile tumor-like lesion in the right atrium. Surgical resection was performed under cardioplegic arrest, which revealed an organized thrombus. Pathological examination revealed amyloid deposition in the myocardium, and bone marrow biopsy revealed CD138 (+) stem cells. Therefore, the patient was diagnosed with amyloid light-chain (AL) amyloidosis associated with multiple myeloma. Although he required percutaneous cardiopulmonary support for postoperative right heart failure for 3 days, he recovered well and was discharged from the hospital on day 44, in a good condition. He was treated with bortezomib for multiple myeloma after surgery. Thus, despite the maintenance of sinus rhythm, intra-cardiac thrombus could be formed with amyloidosis.