Safe and promising outcomes of in-hospital preoperative rehabilitation for coronary artery bypass grafting after an acute coronary syndrome.

OBJECTIVE: In patients with stable hemodynamic status after an acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) after preoperative investigations can provide outcomes comparable to those of emergency surgery. However, no established guidelines exist regarding the preparation period before surgery. We report the results of the use of an inpatient cardiac rehabilitation program followed by CABG after an ACS to improve post-operative outcomes and prognosis after discharge. METHODS: From 2005 to 2017, 471 patients underwent either isolated or combined CABG at our institution, and of those, the 393 who received isolated CABG were included in the analysis. Twenty-seven patients (6.9%) were admitted with ACS and underwent preoperative rehabilitation before undergoing CABG, with a subsequent review of surgical morbidity and mortality rates. Propensity score matching yielded a cohort of 26 patients who underwent preoperative rehabilitation (group A) and 26 controls (group B). Preoperative characteristics were similar between groups. RESULTS: The completion rate of the rehabilitation program was 96.3%. All programs were conducted with inpatients, with an average length of stay of 23 ± 12 days. All patients completed in-bed exercises, and 85% completed out-of-bed exercises. The 30-day postoperative mortality was 0% in both groups A and B, and the rate of postoperative major adverse cardiac or cerebrovascular events at 12 months did not differ significantly between groups (7.7% vs 3.9%, respectively; p = 1.0). The duration of mechanical ventilation (1.3 ± 0.3 vs 1.5 ± 0.3 days, respectively; p = 0.633), length of intensive care unit stay (4.4 ± 2.1 vs 4.8 ± 2.3 days, respectively; p = 0.584) and length of hospital stay (25 ± 13 vs 22 ± 9 days, respectively; p = 0.378) did not differ significantly between groups. CONCLUSIONS: No complications of preoperative rehabilitation were observed, suggesting that it is an acceptable option for patients who experience ACS and undergo CABG. These results are promising in offering more robust designs of future trials.

Iatrogenic aortic dissection during aortic root replacement in an older Loeys-Dietz syndrome type III patient with no family history of aortic disease: a case report.

BACKGROUND: Iatrogenic aortic dissection during cardiac surgery is a rare but critical complication. At present, no strategies have been developed to prevent it. We herein report a case of intraoperative aortic dissection during aortic root replacement in an older patient with Loeys-Dietz syndrome type III who had no family history of aortic disease. CASE PRESENTATION: A 60-year-old man was admitted to the hospital for Stanford type B acute aortic dissection and given conservative treatment. He was found to have aortic root dilatation and severe aortic regurgitation. Thus, elective Bentall procedure was performed. Postoperative computed tomography showed new Stanford type A aortic dissection that may have developed due to aortic cannulation during surgery. The patient was given conservative treatment and successfully discharged to home at postoperative day 34. Although he had no family history of aortic disease, a genetic test revealed an unreported SMAD3 frameshift mutation (c.742_749dup, p. Gln252ThrfsTer7), and the patient was diagnosed with Loeys-Dietz syndrome type III. CONCLUSION: In patients with connective tissue disorder, aortic manipulations may become the cause of critical complications. Avoiding the use of invasive techniques, such as cannulation and cross-clamping, and implementing treatment strategies, such as perfusion from other sites than the aorta and open distal anastomosis, can prevent these complications, and may be useful treatment modalities. The possibility of connective tissue disease should be considered even if the patient is older and has no family history of aortic disease.

[Repeated Myocardial Infarction due to Intraluminal Thrombus in a Coronary Aneurysm Suspected to be Caused by Vasculitis in a Young Male:Report of a Case].

Coronary artery aneurysms are rare and are often associated with atherosclerosis in adults and Kawasaki disease in children. Thromboembolism and rupture of the aneurysm are common complications associated with this condition. We report a case of coronary aneurysm resection and coronary artery bypass grafting (CABG) in a 36-year-old man with a history of recurrent acute myocardial infarction. There was no coronary aneurysms in first acute myocardial infarction. Histopathological examination of the resected coronary artery aneurysm wall revealed features of vasculitis, although the patient showed no episodes and physical findings of vasculitis. Coronary vasculitis can cause vascular endothelial cell injury and therefore requires careful follow-up.

Spinal cord ischemia following open surgery of a ruptured isolated internal iliac artery aneurysm: A case report.

INTRODUCTION: Isolated internal iliac artery (IIA) aneurysms (IIIAAs) rarely occur. However, they may enlarge asymptomatically and rupture, causing fatality. Even after successful surgery of ruptured IIIAAs, there might be a potential risk of postoperative spinal cord ischemia (SCI)-related paraplegia, which is extremely rare. However, this paraplegia significantly impacts patients' activities of daily living. PATIENT CONCERNS: A 71-year-old man who had no remarkable medical history was referred to our hospital with sudden lower abdominal pain. DIAGNOSIS: Computed tomography (CT) revealed right IIIAA with small volumes of contrast medium extravasation and hematoma. He presented with cyanosis in the bilateral lower limbs. Moreover, blood gas analysis showed lactic acidosis. Therefore, he was diagnosed with ruptured IIIAA complicated by peripheral circulatory failure. INTERVENTIONS: Considering his pre-shock status, an emergency operation comprising ligation of the proximal neck and suture closure of the distal IIA orifice was successfully performed. OUTCOMES: Immediately after surgery, motor and sensory dysfunction in the bilateral lower limbs occurred. Magnetic resonance imaging confirmed the presence of SCI. The patient could not stand independently and had neurogenic bladder and rectal disorder. CONCLUSION: Postoperative SCI is a serious complication with no definitive predictors, preventive methods, or highly efficacious treatments. Therefore, vascular surgeons should preempt its occurrence and focus on preventing hemodynamic instability and maintain collateral extra-segmental arterial blood flow, especially in ruptured cases.

Hybrid operation for infectious thoracic and abdominal aortic aneurysms complicated with Bacillus Calmette-Guérin therapy for bladder cancer: A case report.

RATIONAL: Bacillus Calmette-Guérin (BCG) intravesical instillation therapy is a widely used treatment for bladder cancer; however, an infectious aneurysm has been reported as a rare complication. PATIENT CONCERNS: A 76-year-old man who underwent BCG intravesical instillation therapy for bladder cancer presented with prolonged dull back pain for 3 months. DIAGNOSIS: Computed tomography (CT) revealed both thoracic and abdominal aortic aneurysms (AAAs). Follow-up CT at 4 weeks after the initial examination showed rapid enlargement of both aneurysms and typical findings of inflammation. Therefore, he was diagnosed with an impending rupture of infectious aneurysms. INTERVENTIONS: Although open surgical resection of both aneurysms and vascular reconstruction were ideal, these operations were considered highly invasive for the patient. Therefore, a hybrid operation consisting of simultaneous endovascular repair of the thoracic aneurysm and open surgery of the abdominal lesion was performed. OUTCOMES: BCG "Tokyo-172" strain was identified in the resected sample from the aneurysmal wall, and he continued to receive oral antituberculosis drugs for 6 months. No sign of recurrent infection was observed 1 year after the operation. LESSONS: A hybrid operation might be justified as an alternative to the conventional open surgical procedure, especially for patients with infectious aneurysms caused by weak pathogenic bacteria such as, the BCG mycobacteria.

[Open Heart Surgery to Remove an Ablation Catheter Entrapped in the Left Ventricle;Report of a Case].

A 66-year-old man underwent catheter ablation for Wolff-Parkinson-White syndrome. When we advanced the ablation catheter clockwise in the left ventricle, it was entrapped and became unable to control. Thus, the patient underwent open heart surgery for catheter removal. During the surgery, the last few millimeters of the catheter were observed entrapped by multiple basal chordae of the posterior mitral valve. We released the catheter safely, and visual inspection of the left ventricle showed no abnormalities. His postoperative course was uneventful. Ablation catheter entrapment in the heart is a rare but severe complication that requires open heart surgery.

[Valve Re-replacement Combined with Patch Enlargement of the Aortic Annulus for Bioprosthetic Valve Deterioration;Report of a Case].

A 42-year-old woman had undergone aortic valve replacement with a 19 mm bioprosthetic valve for aortic stenosis due to a bicuspid valve 8 years before. She was admitted to our hospital for valve re-replacement owing to the prosthetic valve dysfunction. As the patient's valve annulus was markedly thickened owing to pannus formation, we were unable to pass a 19 mm valve sizer through the annulus even after removal of the prosthetic valve and the tissue surrounding the annulus. Valve re-replacement combined with patch enlargement of the aortic annulus was performed to obtain maximally effective orifice area. Her postoperative course was uneventful, and echocardiography revealed no perivalvular leak. In valve re-replacement, it is important to remove the prosthetic valve and the tissue surrounding the annulus to the greatest extent possible and consider patch enlargement of the aortic annulus to avoid patient-prosthesis mismatch in a patient with a small aortic annulus.

[Right Atrial Thrombus which was Difficult to Differentiate from Tumor;Report of a Case].

We report a case of a 79-year-old woman with a right atrial mass. She had a history of hypertension, idiopathic thrombocytopenic purpura, and chronic atrial fibrillation. Computed tomography and transthoracic echocardiography showed a 31×31 mm mass in the right atrium. Though it was considered to be a thrombus at first, it did not become smaller despite anticoagulation, and tumor was suspected. To prevent onset of pulmonary embolism, she underwent surgery and the mass was removed. Pathological examination confirmed that it was a thrombus. Her postoperative course was uneventful.

Surgical treatment for saphenous vein graft aneurysm without redo sternotomy.

BACKGROUND: Saphenous vein graft aneurysm (SVGA) is a rare complication after coronary artery bypass grafting; however, it may lead to fatal conditions. A redo sternotomy poses a high risk of injury to the patent graft. CASE REPORT: A 59-year-old man with chest pain was diagnosed with a giant SVGA (67 mm) anastomosed to the right coronary artery (RCA) and compressing the right atrium. Considering the high risk of injury to a patent graft through the sternum, a surgical procedure was planned without redo sternotomy. Through an upper midline abdominal incision, redo bypass grafting was performed to the distal RCA using the right gastroepiploic artery, followed by resection of the aneurysm using the right anterior lateral thoracotomy approach. The postoperative course was uneventful. CONCLUSION: In patients with an SVGA anastomosed to the right coronary system, our surgical strategy may be a useful alternative to redo sternotomy to avoid injury to the patent graft.

The use of prophylactic intra-aortic balloon pump in high-risk patients undergoing coronary artery bypass grafting.

OBJECTIVE: Intra-aortic balloon pump (IABP) is one of the most commonly used mechanical circulatory assist devices for high-risk patients undergoing cardiac surgery. In an effort to validate previously reported clinical outcomes, we describe the preoperative characteristics and outcomes of patients who underwent prophylactic IABP in high-risk patients undergoing coronary artery bypass grafting (CABG). DESIGN: A prospective observational study. METHODS: From 2005 to 2017, 471 patients underwent either isolated or combined CABG at our institution. Of those, 393 patients underwent isolated CABG and were included for the analysis. Eighty-five patients (22%) were considered high-risk and underwent prophylactic IABP, with subsequent review of surgical morbidity and mortality rates. RESULTS: The 30-day postoperative mortality (prophylactic IABP group vs non prophylactic IABP group: 0% vs 1.6%, p = 0.589) and major adverse cardiac or cerebrovascular events (5.9% vs 3.3%, p = 0.333) were not significantly different between the two groups. Prolonged mechanical ventilation (>72 hours) (12.5% vs 4.2%, p = 0.014) occurred more frequently in the prophylactic IABP group. CONCLUSIONS: No IABP-related complications were noted, emphasizing that the use of prophylactic IABP in high-risk patients undergoing CABG is an acceptable option.

[Simultaneous Repair for Aorto-iliac Occlusive Disease and Transcatheter Aortic Valve Implantation;Report of a Case].

A 79-year-old womam presented with severe aortic stenosis (AS) and aorto-iliac occlusive disease (AIOD). The distal end of her abdominal aorta was occluded with severe calcification. Simultaneous Y-grafting of the terminal abdominal aorta and transcatheter aortic valve implantation (TAVI) using the left limb of a Y-shaped artificial graft as an access route were planned. After proximal and distal anastomoses of the abdominal aorta and the right common iliac artery(CIA) using the Y-shaped artificial graft, TAVI was performed through the left limb of the artificial graft. The technique was similar to that used for transfemoral TAVI. Subsequently, the left limb of the graft was anastomosed to the left CIA. The patient's postoperative course was unremarkable, without heart failure or lower limb ischemia. This option serves as an effective access route for TAVI in patients with AIOD.

[Two Cases of Quadricuspid Aortic Valve].

We report 2 cases (a 59-year-old man and a 61-year-old man) of quadricuspid aortic valve that had aortic regurgitation. Preoperative transthoracic or transesophageal echocardiography was useful for diagnosing definitely and deciding treatment plan. Their aortic valves were type F in each according to the Hurwitz-Roberts classification. They underwent aortic valve replacement and had good postoperative courses.

[Omental turnover technique; an alternative of omental transfer for sternal wound infection after cardiac surgery].

Mediastinitis is a devastating complication after cardiac surgery. An omental flap transposition is frequently used for the treatment of poststernotomy mediastinitis. Here we describe a new technique of omental transfer into not only the mediastinum but also the subcutaneous dead space. After an irrigation and débridement of inflammatory tissues, the greater omentum was dissected along with the right gastroepiploic artery and transferred into the pericardial cavity. The omentum was turned over the sternal edge and the anterior aspect of the sternum was covered in order to eliminate the dead space. The patient survived with this technique and postoperative computed tomography (CT) showed developed omental tissue around the sternum. We consider that greater omentum is the ideal reconstruction tissue for deep sternal wound infections. This modification is thought to contribute to the improvement of surgical mortality of this lethal complication.

[Left ventricular outflow tract pseudoaneurysm complicated with prosthetic valve endocarditis after aortic valve replacement].

A rare case of left ventricular outflow tract (LVOT) pseudoaneurysm complicated with prosthetic valve endocarditis was reported herein. A 78-year-old male previously underwent aortic valve replacement (AVR) with a bioprosthesis. Four years after the initial operation, he presented with prolonged high fever and bloody sputum. Multi-detector row computed tomography (MDCT) clearly showed LVOT pseudoaneurysm originating from a subvalvular fibrous region. The patient underwent re-AVR and repair of pseudoaneurysm. The postoperative course was uneventful, and the patient recovered good condition.

Quadricuspid aortic valve illustrated by 64-slice multidetector computed tomography: Surgical treatment of a rare cause of severe aortic regurgitation.

The quadricuspid aortic valve (QAV) is a rare congenital malformation that usually presents with aortic regurgitation (AR). The first case was reported in 1862. Most cases were diagnosed at the time of surgery or postmortem examination. With advances in imaging techniques, more cases have been diagnosed before surgery. We describe a 59-year-old man whose QAV had not been noted until the current admission. Transthoracic echocardiography revealed dilation of the left ventricle, severe AR, and suspected QAV. The QAV was confirmed by transesophageal echocardiography and 64-slice multidetector computed tomography. This case was a QAV with three equal cusps and one smaller cusp (type B in Hurwitz and Roberts classification). Because the cardiac catheterization and aortography showed severe AR and a QAV, the patient underwent elective surgery. The surgery consisted of replacing the QAV by a mechanical prosthesis. There were no post-operative complications. The patient revealed no symptoms in the post-operative 7 months.