Impact of frailty and prefrailty on the mid-term outcomes and rehabilitation course after cardiac surgery.

PURPOSE: This study examined the impact of frailty and prefrailty on mid-term outcomes and rehabilitation courses after cardiac surgery. METHODS: A total of 261 patients (median age: 73 years; 30% female) who underwent elective cardiac surgery were enrolled in this study. The Japanese version of the Cardiovascular Health Study Frailty Index classified 86, 131, and 44 patients into frailty, prefrailty, and robust groups, respectively. We examined the recovery of walking ability, outcomes at discharge, mid-term all-cause mortality, and rehospitalization related to major adverse cardiovascular and cerebrovascular events (MACCE) across the three cohorts. RESULTS: The 3-year survival rates in the frailty, prefrailty, and robust groups were 87%, 97%, and 100%, respectively (p = 0.003). The free event rates of all-cause mortality and re-hospitalization related to MACCE were 59%, 79%, and 95%, respectively (p < 0.001), with a graded elevation in adjusted morbidity among patients in the prefrailty (hazard ratio [HR], 4.57; 95% confidence interval [CI], 1.08-19.4) and frailty (HR, 9.29; 95% CI 2.21-39.1) groups. Patients with frailty also experienced a delayed recovery of walking ability and a reduced number of patients with frailty were discharged home. CONCLUSION: Frailty and prefrailty adversely affect the mid-term prognosis and rehabilitation course after cardiac surgery.

Rapid Synthesis of Chiral Figure-Eight Macrocycles Using a Preorganized Natural Product-Based Scaffold.

Chiral D2 -symmetric figure-eight shaped macrocycles are promising scaffolds for amplifying the chiroptical properties of π-conjugated systems. By harnessing the inherent and adaptable conformational dynamics of a chiral C2 -symmetric bispyrrolidinoindoline (BPI) manifold, we developed an enantio-divergent modular synthetic platform to rapidly generate a diverse range of chiral macrocycles, spanning from 14- to 66-membered rings, eliminating the need for optical resolution. Notably, a 32-membered figure-eight macrocycle showed excellent circularly polarized luminescence (CPL: |glum |=1.1×10-2 ) complemented by a robust emission quantum yield (Φfl =0.74), to achieve outstanding CPL brightness (BCPL : ϵ×Φfl ×|glum |/2=480). Using quadruple Sonogashira couplings, this versatile synthetic platform enables precise adjustments of the angle, distance, and length among intersecting π-conjugated chromophores. Our synthetic strategy offers a streamlined and systematic approach to significantly enhance BCPL values for a variety of chiral D2 -symmetric figure-eight macrocycles.

[Disruption of Matsui-Kitamura Stent-graft Six Years after Treatment for Rupture of Thoracic Aortic Aneurysm].

Matsui-Kitamura stent-graft (MKSG) is a home-made device for thoracic endovascular aortic repair (TEVAR) developed in Japan. A 76-year-old man who had been treated by TEVAR (zone 3) with a MKSG for ruptured thoracic aortic aneurysm was diagnosed as having type Ia endoleak caused by suture disruption and aneurysmal sac expansion 6 years later. He underwent TEVAR (zone 1) with debranching and type Ia endoleak disappeared. MKSG had been the effective device especially for acute aortic emergencies in the descending thoracic aorta until the stent-grafts became commercially available, but careful observation and appropriate re-intervention is mandatory for the continued life-saving contribution.

[Early and Long Term Outcomes of Surgery for Acute Type A Aortic Dissection Complicated with Organ Malperfusion].

OBJECTIVE: The purpose of this study was to evaluate early and long term outcomes of surgery for acute type A aortic dissection complicated with organ malperfusion. METHOD: From January 2001 to October 2015, 336 consecutive patients (mean age 68.6±12.2, male 172) underwent surgery for acute type A aortic dissection at out center. Early and late outcomes were compared between patients accompanied with and without organ malperfusion. RESULTS: Preoperative organ malperfusion was observed in 76 patients( 22.6%). That consisted of 38 neurological systems, 13 coronary, 8 visceral, and 26 extremities. Nine patients had 2 organ malperfusion. In-hospital mortality was 22.4% and 6.5% in patients with and without organ malperfusion, respectively. Multivariate logistic analysis showed preoperative organ malperfusion was a significant risk factor for in-hospital mortality (Odds ratio 3.59, 95% confidence interval 1.56~8.28, p<0.01). Five year survival rate of hospital survivors were 84.5±5.5% and 80.9±3.3% with and without organ malperfusion (p=0.51). CONCLUSIONS: Although organ malperfusion is still associated with high mortality, however, acceptable long term outcomes could be obtained if organ malperfusion is treated appropriately. Ischemic organ oriented approach might be very important to improve surgical outcomes of these critically ill conditions.

False aneurysm with an aorto-superior vena cava fistula after replacement of the ascending aorta: report of a case.

A 58-year-old female presenting with congestive heart failure due to a fistula between an aortic false aneurysm and the superior vena cava (SVC) is described. She had a history of Takayasu's arteritis (TA) and she had undergone aortic valve and ascending aorta replacement and coronary artery bypass grafting 6 years before. The false aneurysm had occurred 1 year after the surgery, and she had been conservatively managed. The operation revealed that the cause of the false aneurysm was the detachment of the two proximal saphenous vein anastomoses to the ascending aortic graft. After the surgery, the patient made an uneventful recovery. A false aneurysm of the ascending aorta is one of the most serious complications after replacement of the ascending aorta for patients with TA (Miyata et al. in J Vasc Surg 27:438-445, 1998). We herein present the exceptional case of a fistula between an aortic false aneurysm and the SVC that occurred after ascending aorta graft replacement.

Recurrent Pulmonary Embolism Caused by Superficial Femoral Vein Aneurysm.

Venous aneurysms (VA), particularly superficial femoral VAs (SFVAs), are rare vascular lesions. A 65-year-old woman with a history of pulmonary embolism (PE), treated with tissue plasminogen activator and oral anticoagulation, was admitted to hospital for dyspnea. Enhanced computed tomography showed recurrent PE and right SFVA with a mural thrombus. The SFVA was not identified during the first PE. The PE was not massive and was treated with direct oral anticoagulants. The thrombus in the SFVA caused the PE, and surgical repair was performed to prevent further embolic events. Under general anesthesia, the SFVA was excised, and direct anastomosis was performed. PE recurrence, venous aneurysmal changes, and thrombosis were not noted at the 1-year follow-up.

Distal Stent Graft-Induced New Entry after Total Arch Replacement with Frozen Elephant Trunk for Aortic Dissection.

Objectives: Distal stent graft-induced new entry (dSINE), defined as a new tear caused by a stent graft, has been increasingly observed following total arch replacement using frozen elephant trunk (FET) for aortic dissection. We aimed to investigate the incidence and treatment of dSINE after the use of FET. Methods: This retrospective study evaluated 70 patients who underwent total arch replacement using FET for aortic dissection between August 2014 and March 2020. They were followed up for at least 6 months postoperatively. Between-group comparisons were performed between those who did and did not develop dSINE. The risk factors for the development of dSINE and the treatment of dSINE were analyzed. Results: dSINE occurred postoperatively in nine patients (12.9%) with a median time frame of 17.7±11.7 months. The incidence of dSINE did not differ significantly according to classification, phase of dissection, or oversizing. All patients in the dSINE group developed enlargement of the false lumen. dSINE closure was successfully achieved without complications via thoracic endovascular aortic repair (TEVAR) in all patients. Conclusion: No independent factors predicting the development of dSINE were noted in this study. Additional TEVAR for dSINE provides good results and achieves false lumen thrombosis in the thoracic aorta, with no complications.

Fatal Complications of New-Onset Complicated Type B Aortic Dissection After Endovascular Abdominal Aortic Aneurysm Repair: Report of 2 Cases and Literature Review.

New-onset antegrade Stanford type B aortic dissection (TBAD) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is rare. The extension of aortic dissection leads to various symptoms and affects the stent graft. Moreover, various symptoms may arise owing to a stent graft being present. We describe 2 cases of complicated acute TBAD occurring after EVAR, which were ultimately fatal. The case in which rupture occurred could not be treated and the patient died. In another case with bilateral lower extremity malperfusion caused by collapse and occlusion of the endograft, extra-anatomical bypass was performed. Although the collapsed endograft gradually re-expanded, the patient ultimately died because of multiorgan failure. We have reviewed the literature and analyzed the treatment of complicated TBAD after EVAR.

Outcomes of Late Open Conversion after Endovascular Abdominal Aneurysm Repair.

Objective: To review our experience with a late open conversion as a final option for an endograft infection and aneurysm expansion after endovascular aneurysm repair (EVAR), especially in endoleaks for which radiological intervention is impossible. Materials and Methods: In this retrospective study, 13 late open conversions out of 513 consecutive patients treated by EVAR were analyzed. Indications for an open conversion were aneurysm enlargement, including all endoleaks, endograft migration, and endograft infection. The patients' data on demographics, operative details, and outcomes were reviewed. Results: Indications for a late open conversion included endoleaks, infection, and migration in 61.5%, 30.8%, and 7.7% of patients, respectively. The median interval from the initial EVAR was 32.4 months. Complete endograft explantation was performed in four patients with an endograft infection. In endoleak cases, the endograft was partially preserved and a neo-neck was used. Sacotomy and branch ligation were performed in one case. One major operative complication was an aortic injury during infrarenal aortic cross-clamping in an endograft migration case. There was no operative mortality. Conclusion: A late open conversion after EVAR is valuable as a final option. The aortic cross-clamp site, especially in endograft migration cases, should be carefully considered. To avoid aneurysm-related events, graft replacement is recommended, if possible.

Preventing brain embolism by using a modified isolation technique in transcatheter aortic valve implantation for a patient with shaggy and porcelain aorta.

Transcatheter aortic valve implantation (TAVI) has become a useful and effective treatment for surgical high-risk patients with severe aortic valve stenosis (AS). Stroke is one of the most frequent complications associated with TAVI. Shaggy and porcelain aortas are a risk factor for procedure-related strokes. Preventing brain embolism is one of the most important goals in patients with diseased aortas. We present a case where we performed TAVI in an 89-year-old man with severe AS, a shaggy aorta, a porcelain aorta, and congestive heart failure. TAVI via a transfemoral approach was performed using a modified isolation technique with cannulation from bilateral axillary arteries and cardiopulmonary bypass to prevent brain embolism. The catheter-delivered embolic protection device is necessary to pass the diseased aorta, but the modified isolation technique can be used without any contact with the shaggy aorta. Embolism did not occur, and his heart failure improved immediately. .

Long-term results of bioprosthetic tricuspid valve replacement: an analysis of 25 years of experience.

BACKGROUND: Current knowledge in long-term results of tricuspid valve replacement is limited. Present study reviews our experience from a consecutive series. METHODS: We retrospectively studied the early and late results of 32 consecutive patients (7 male and 25 female; mean age 60.2 ± 18.1 years) undergoing bioprosthetic tricuspid valve replacement between 1985 and 2010. The etiology is rheumatic in 38 %, congenital in 3 %, endocarditis in 9 %, and functional in 50 %. Patients underwent isolated valve replacement. The remaining underwent combined aortic and tricuspid (n = 5, 16 %), mitral tricuspid (n = 15, 47 %), and aortic, mitral, and tricuspid (n = 1, 3 %) valve replacement. Preoperative liver dysfunction was evaluated using Model for End-stage Liver Disease (MELD) score. Mean follow-up was 5.6 ± 6.8 years (ranging from 0 to 25.0 years). RESULTS: Hospital mortality was 19 %. On univariate logistic regression analysis, NYHA class IV (p = 0.039, odds ratio 11.3, 95 % confidence interval 1.2-112.5), MELD score (>10) (p = 0.011, odds ratio 21.0, 95 % confidence interval 12.0-222.0) and congestive liver (p = 0.05, odds ratio 9.4, 95 % confidence interval 1.0-93.5) were incremental risk factors for hospital death. The 15- and 25-year actuarial survival were 56.5 ± 10.3 % and 45 ± 13.0 %, respectively. Multivariate analysis using Cox proportional hazard model showed MELD score (p = 0.024, hazard ratio 7.0, 95 % confidence interval 2.1-23.9) and postoperative pulmonary hypertension (p = 0.012, hazard ratio 4.4, 95 % confidence interval 1.4-14.1) were significantly associated with decreased survival. At 15 years, freedom rates from tricuspid valve reoperation, anticoagulation-related bleeding, and valve related events were 85.7 ± 13.2 %,95.7 ± 4.3 % and 81.8 ± 13.2 %, respectively. The linearized incidence of structural valve deterioration was 0.50 %/patient-year, anticoagulation-related bleeding was 0.94 %/patient-year, and valve-related events were 1.52 %/patient-year. CONCLUSION: Preoperative hepatic congestion and liver dysfunction which were indicated by the MELD score >10 were associated with poor outcome for patients undergoing tricuspid valve replacement. The MELD score is useful to predict the morality among these patients.

Inflammatory aneurysm of the ascending aorta: report of a case.

Inflammatory aortic aneurysms are found most commonly in the infrarenal abdominal aorta. We report the case of a 78-year-old man with an inflammatory aortic aneurysm of the ascending aorta, which is extremely unusual. Surgery revealed that the ascending aorta was adherent to the superior vena cava and pulmonary artery, but a dissection membrane was not found. The wall of the ascending aorta was up to 20 mm thick with perianeurysmal fibrosis. Pathologic examination revealed an inflammatory aneurysm with adventitia remarkably thickened by fibrotic tissue and infiltrated by lymphocytes and plasma cells. Our search of the literature found only seven other cases of an inflammatory ascending aortic aneurysm. Preoperative diagnosis was very difficult in most of these cases; however, improved scanning techniques using multidetector row computed tomography may allow the differential diagnosis of this clinical entity.