Venovenous extracorporeal membrane oxygenation for the management of critical airway stenosis.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used not only support gas transfer of patients suffering from respiratory failure, but also to manage hypoxic patients with critical airway obstruction during various procedures. We present a case in which we electively used VV-ECMO to facilitate tube placement and tracheal biopsy in a 67-year-old female with critical tracheal stenosis. The patient was transferred to our hospital for a surgical treatment after emergent tracheostomy for postoperative management of cerebral hemorrhage in right putamen. Her trachea was severely stenotic and just enough for a 5.5 mm tracheostomy tube. Removal of tracheostomy tube, tracheal wall biopsy and intra-tracheal tube placement were successfully performed under VV-ECMO support, drainage from inferior vena cava returned into the right ventricle (RV). RV perfusion was a very useful and effective method in VV-ECMO system, although some careful wire management was needed under fluoroscopic guidance.

[Structural Deterioration of a Bovine Pericardial Valve in a Tricuspid Position 14 Years Postoperatively;Report of a Case].

Although nonstructural dysfunction of a bioprosthesis caused by pannus formation or native valve attachment has been well described, structural valve deterioration( SVD) caused by calcification or tear of a bioprosthesis, especially a bovine pericardial valve, is very rare in the tricuspid position. We report a case of redo tricuspid valve surgery for SVD 14 years after tricuspid valve replacement( TVR) using a Carpentier-Edwards Perimount (CEP) pericardial valve. A 71-year-old woman was referred to our hospital because of exertional dyspnea and pre-syncope. She had undergone mitral valve replacement with a St. Jude Medical mechanical valve and TVR with a CEP pericardial valve 14 years previously. Transthoracic echocardiography revealed tricuspid valve stenosis with a mean trans-tricuspid valve pressure gradient (TVPG) of 7.3 mmHg. Redo TVR using a CEP Magna Mitral Ease valve was performed under cardiac arrest. Severe calcification was observed on the ventricular side of the leaflets of the explanted valve. The mean TVPG decreased to 3.2 mmHg after surgery, and the patient's postoperative course was uneventful.

Enlargement of aortic arch vessels after surgical repair of type A aortic dissection.

BACKGROUND: Information on the growth rate of the diameter of the residual dissected supra-aortic trunk after surgical repair of type A aortic dissection is limited. METHODS: We retrospectively reviewed 95 consecutive postsurgical patients with type A aortic dissection (acute, 91; chronic, 4) between 2005 and 2016 who were followed up with computed tomography. The diameter of the residual dissected supra-aortic trunk was measured by axial images and multiplanar reformatting, and the growth rate was calculated. RESULTS: The mean age was 67.2 ± 12.8 years (range, 34-89 years). Forty-one brachiocephalic arteries (43%), 14 left common carotid arteries (15%), and 7 left subclavian arteries (10%) exhibited residual dissection. The diameter of the residual dissected branch with a patent false lumen (FL) gradually increased over time, whereas that with a thrombosed FL decreased and reached a plateau. The growth rate of brachiocephalic, left common carotid, and left subclavian arteries with a patent FL was 1.3 ± 1.2, 0.8 ± 0.3, and 0.6 ± 0.4 mm/y, respectively. One patient required surgical intervention for dilation of the brachiocephalic artery 8 years postoperatively. Multivariate analysis showed that male sex was an independent risk factor for a patent FL in the brachiocephalic artery (P = .0431; odds ratio, 2.04). CONCLUSIONS: A residual dissected supra-aortic trunk with a thrombosed FL seems to be a benign condition. However, long-term follow-up is necessary for patients with a patent FL of residual dissected supra-aortic trunk, which might occasionally require surgical intervention.

Early outcomes of extra-thoracic debranching thoracic endovascular aortic repair for distal aortic arch disease.

Thoracic endovascular aortic repair (TEVAR) combined with supra-aortic debranching is a promising approach for distal aortic arch disease, especially in high-risk patients. Most debranching TEVAR procedures for distal arch pathologies can now be performed by using extra-thoracic bypass and endovascular repair, without intra-thoracic manipulation needing sternotomy or thoracotomy. To compare the early outcomes of extra-thoracic debranching TEVAR with those of conventional arch replacement, we retrospectively reviewed data from 20 high-risk patients with distal aortic arch disease who underwent extra-thoracic debranching TEVAR and 16 patients who underwent total arch replacement from March 2009 to November 2011. Patient demographics, operative data, and outcomes in each group were evaluated and compared. The mean follow-up period was 22.4 ± 12.7 months. In the extra-thoracic debranching TEVAR group, primary technical success was achieved in all cases. One patient (5 %) died of low cardiac output syndrome within 30 days after surgery. Two patients had perioperative morbidities (10 %); both had a stroke during the procedure. No endoleak or graft migration was observed, and all bypass grafts remained patent. No patient had paraplegia, a new aortic event, or surgical site infection. In conclusion, the early outcomes of extra-thoracic debranching TEVAR in high-risk patients with distal aortic arch disease were satisfactory and encouraging, compared with conventional arch replacement. Extra-thoracic debranching TEVAR has the advantage of less invasiveness and no possibility of sternal infection.

Procedural selection strategy and clinical outcomes in mitral valve surgery with concomitant aortic valve replacement in elderly patients.

Introduction: In the context of double-valve surgery for elderly high-risk patients involving both the aortic and mitral valves, a clinically significant problem has been that no clear criteria or surgical strategies have been reported for the selection of mitral valve plasty (MVP) or mitral valve replacement (MVR) for mitral valve disease management during surgical aortic valve replacement (SAVR) to achieve better clinical outcomes. This study investigated valve durability and survival using our surgical strategy for mitral valve disease with concomitant SAVR in elderly patients. Methods: Eighty-six patients aged > 65 years (mean 75 years) who underwent a double-valve procedure for mitral valve surgery with concomitant SAVR from 2010 to 2022 were reviewed. Our surgical strategy for mitral valve disease with concomitant SAVR for the elderly patients was as follows: MVP was selected for patients in whom mitral valve disease was expected to be controlled with simple surgical procedures (n = 47), otherwise MVR was selected (n = 39). Results: The hospital mortality rate was 8% (n = 7). The mean follow-up was 4.9 (0-12.3) years. And the 10-year survival rate was 62%. The 10-year freedom from aortic valve reoperation rate was 95%. No mitral valve reintervention was performed during follow-up. Echocardiographic follow-up demonstrated freedom from at least moderate mitral regurgitation in 86% of cases at 10 years. Conclusion: In double-valve surgery for elderly high-risk patients, appropriate selection of the mitral valve procedure with concomitant SAVR provided better early and long-term survival and valve durability. This surgical strategy may be beneficial in elderly patients with combined aortic and mitral valve disease.

Terumo-Triplex grafts for total arch replacement: analysis of postoperative graft performance.

We evaluated the performance of Terumo-Triplex (TRP) with a large-diameter vascular graft sealed with non-biodegradable material in 48 patients who underwent total arch replacement under selective cerebral perfusion between 2004 and 2009. TRP grafts were used in 13 patients (T group), Gelseal graft in 15 (G group), Hemashield graft in 10 (H group) and Intergard graft in 10 (I group). The total tube drainage, time to tube removal, graft dilation ratio and inflammation were evaluated postoperatively. Cardiopulmonary bypass and selective cerebral perfusion times did not differ between groups. Two patients died in hospital. The total drain drainage was significantly lower in the T group (956 ± 156 ml) than in the H (2058 ± 403 ml, p = 0.001) or I (5959 ± 1027 ml, p = 0.01) groups. The time to tube removal was significantly lower in T group and G group than H and I group (T: 3.7 ± 0.4, G: 4.1 ± 0.4, H: 8.3 ± 1.6, I: 18.6 ± 3.6 days, T vs. H, I: p = 0.07, 0.0002, G vs. H, I: p = 0.004, <0.0001). The graft dilation ratio was significantly lower in T group than G group (T: 104 ± 4 vs. 130 ± 7 %, p = 0.001). The max C-reactive protein level was significantly lower in T group (16.2 ± 4.5 mg/dl) than in the G group (19.4 ± 3.2 mg/dl, p = 0.047), H (20.4 ± 4.1 mg/dl, p = 0.048), or I (20.5 ± 4.5 mg/dl, p = 0.013) groups. Maximum body temperature was also lower in the T group (38.2 ± 0.5 °C) than in the G (38.7 ± 0.4 °C, p = 0.011), H (38.9 ± 0.6 °C, p = 0.0087), and I (39.3 ± 0.7 °C, p = 0.0005). Thus, TRP graft might attenuate inflammatory response compared to the other sealed grafts for total arch replacement in patients with aortic arch aneurysm or dissection.

Long-term outcome of extensive mitral valve reconstruction with autologous pericardium and artificial chordae for treatment of destructive active infective endocarditis of the mitral valve.

OBJECTIVE: Mitral valve (MV) repair is a well-accepted surgical approach for infective endocarditis (IE). In our hospital, extensive MV reconstruction with fresh autologous pericardium (AP) and artificial chordae (AC) has been performed for patients with profoundly extensive and destructive IE in which valve reconstruction would be extremely challenging, especially in young patients to avoid mechanical valve replacement. Long-term outcome including the future performance of the newly created leaflet has not been established. METHODS: Five patients (54 (38-60) years of age; 3 men, 2 women) underwent this procedure from January 2011 to April 2022. In all patients, preoperative cardiac function was good (left ventricular ejection fraction, 69 (66-75)). After complete debridement of the infective valve tissue, the MV was reconstructed with large, fresh, trimmed AP and AC. RESULTS: The reconstructed leaflets were anterior in three patients and posterior in four, and AC were placed in four patients. All patients showed an uneventful postoperative course and were discharged to home 36 (28-42) days postoperatively after completion of intravenous antibiotic therapy. Pre-discharge echocardiography revealed no or trivial mitral regurgitation (MR) in all patients. The median follow-up period was 9.6 (6.0-10.4) years, and no patients developed recurrence of the IE. The latest echocardiography in four patients showed trivial/mild MR with good leaflet function. One patient developed recurrence of MR, 5 months postoperatively. CONCLUSIONS: The short- and long-term outcomes of this procedure might be acceptable. This procedure might be considered as an effective and valuable option, especially in young patients.

Successful surgical treatment of delayed left ventricular pseudoaneurysm related to Candida albicans infection after repair of ventricular septal rupture complicating acute myocardial infarction.

Left ventricular (LV) pseudoaneurysm is a rare complication after postinfarction repair of ventricular septal rupture (VSR), and surgical treatment of this condition due to mycosis has rarely been reported. We report a rare case of successful surgical treatment of delayed LV pseudoaneurysm related to Candida albicans infection after repair of VSR due to myocardial infarction. A 75-year-old woman was admitted for fever and severe inflammatory reaction. Two and a half years previously, she had undergone postinfarct VSR repair and was treated for mycotic infective endocarditis due to C. albicans. Transthoracic echocardiography and computed tomography revealed a LV pseudoaneurysm (maximum transverse diameter 6.2 cm). The cause of the LV pseudoaneurysm was suspected to be infectious, and broad-spectrum antibiotic treatment was started. Fourteen days after admission, she developed acute abdominal pain and an elevated ß-D-glucan level because the LV pseudoaneurysm ruptured. Emergency surgical treatment was performed with antimycotic drug therapy. The LV wall defect was reconstructed using bovine pericardium under cardiopulmonary support. Her postoperative course was good, and she was discharged to home. Echocardiography revealed no recurrence of the LV pseudoaneurysm at 4 months postoperatively. During 1 year of follow-up, the patient had been doing well without any infection or adverse event. .

Blood flow modification might prevent secondary rupture of multiple pancreaticoduodenal artery arcade aneurysms associated with celiac axis stenosis.

A pancreaticoduodenal artery arcade aneurysm (PDAA) is rare and often associated with celiac axis stenosis by the median arcuate ligament. Although rupture risk of the PDAA is not related to its size, treatment guidelines are absent. Here we describe a 59-year-old woman with multiple ruptured PDAAs associated with celiac axis stenosis who was successfully treated with coil embolization. As follow-up computed tomography revealed rapid expansion of residual PDAAs and new gastric artery dissection, median arcuate ligament resection was followed by aorta-common hepatic artery bypass, which resulted in aneurysmal regression. Blood flow modification might prevent secondary rupture of PDAA associated with celiac axis stenosis.

The Cattell-Braasch maneuver might be a good option for a huge abdominal aortic aneurysm.

Endovascular repair is often difficult in the case of a huge abdominal aortic aneurysm for anatomic reasons. Here, we describe open repair of a huge infrarenal abdominal aortic aneurysm. Open repair was performed through laparotomy with the Cattell-Braasch maneuver, a technique for right-sided medial visceral rotation. Laparotomy with the Cattell-Braasch maneuver is simple and effective in open repair of a huge abdominal aortic aneurysm extending into the right common iliac artery, for which proximal clamping is difficult because of a tortuous proximal neck just below the hepatic region.

Long-term outcomes after entry closure and aneurysmal wall plication for type B aortic dissection.

OBJECTIVE: To examine the long-term outcomes after entry closure and aneurysmal wall plication for type B chronic dissecting aortic aneurysm. This procedure uses no artificial graft and preserves all intercostal arteries. METHODS: We reviewed the records of 40 consecutive patients who underwent this procedure between September 1983 and December 2002. The mean age at operation was 60+/-12 years (range, 38-79 years). The mean follow-up period was 9.8+/-5.1 years (range, 4-23 years). Follow-up was completed in 38 patients (95%). The latest computed tomography scans (n=22) were obtained 9.5+/-5.1 years (range, 3-18 years) after surgery. RESULTS: There were no operative deaths and 14 late deaths, none of which were related to the aneurysm. No paraplegia or paraparesis occurred. The survival rate was 92+/-4% at 5 years and 64+/-9% at 10 years; 24 patients are still alive. Follow-up computed tomography revealed that the mean diameter of the plicated descending aorta was 31+/-5mm (range, 22-39 mm) except in four patients. One of the four patients required reoperation for recurrent aneurysm of the plicated aorta 3 years postoperatively. In the remaining three patients, the plicated aorta has become enlarged; however, these patients have not yet undergone reoperation. Reoperation for residual dissecting aneurysm was performed in another three patients whose plicated aorta was normal. Freedom from reoperation for residual dissecting aneurysm was 78+/-5% at 10 years. CONCLUSIONS: This procedure produces excellent short-term outcomes and low long-term morbidity. It could be the procedure of choice in selected patients to prevent paraplegia, although graft replacement is currently the standard treatment for chronic aortic dissecting aneurysm.

Emergency valve surgery for infective endocarditis complicated by acute intracranial hemorrhage: A case report.

INTRODUCTION: Optimal timing of surgical treatment for infective endocarditis (IE) complicated by intracranial hemorrhage remains controversial. PRESENTATION OF CASE: A 43-year-old man with IE received appropriate antibiotic therapy but had recurrence of cerebral infarction and intracranial hemorrhage (ICH). Emergency valve surgery was performed 2days after ICH onset because of heart failure and recurrence of cerebral complications. Postoperatively, he showed no neurologic symptoms; neuroimaging showed no enlargement of ICH. DISCUSSION: Postoperative risk of neurologic deterioration may be relatively lower than previously thought in patients with IE who undergo surgery within 1 month after ICH onset. CONCLUSIONS: Emergency surgery in patients with ICH is justified in cases of multiple indications for such small ICH. Further evaluation regarding the risk of subsequent hemorrhage in patients with ICH who require emergency valve surgery is warranted.

Unusually high serum levels of lactate dehydrogenase without perivalvular leakage following double valve replacement: predictor of tetany attack after thyroidectomy.

A 57-year-old woman who complained of exertional dyspnea was diagnosed as having severe aortic valve stenosis and mitral valve regurgitation. The patient underwent double valve replacement with a mechanical prosthesis. Postoperative laboratory data showed unusually high serum lactate dehydrogenase (LDH) levels, even though no perivalvular leakage was detected by echocardiography. Tetany occurred suddenly owing to hypoparathyroidism, which seemed to be a late complication after thyroidectomy. After calcium administration, the symptoms dramatically diminished, as did the serum LDH levels. Hypoparathyroidism should be doubted if serum LDH levels increase higher than the normal range following valve replacement without obvious perivalvular leakage.

Ruptured giant aneurysm of the ascending aorta caused by chronic aortic dissection.

A 55-year-old man developed acute chest pain and dyspnea. Computed tomography demonstrated a rupture of a giant aneurysm of the ascending aorta. The lesion was 14 cm in diameter--the largest ever reported-and resulted from chronic aortic dissection. The patient did not have aortic insufficiency or aortic dissection around the coronary ostium. Graft replacement of the ascending aorta was performed successfully under deep hypothermia with right hemisphere perfusion.

Retrograde type A dissection after thoracic endovascular repair due to the barb.

We present a case of retrograde ascending aortic dissection in a 65-year-old man 8 months after emergency thoracic endovascular repair of an atherosclerotic aneurysm. Intraoperative findings identified a retrograde ascending aortic dissection due to the barb of the stent-graft. Retrograde type A dissection is a rare but fatal complication after thoracic endovascular aortic repair. There are some reports of retrograde ascending aortic dissection, but the etiology remains unclear. The subtle back-and-forth motion of the barb during the cardiac cycle may cause aortic injuries that result in retrograde ascending aortic dissection.

Off-pump coronary artery bypass combined with abdominal aortic aneurysm repair in an 88-year-old male.

We present the case of an 88-year-old patient who underwent off-pump coronary artery bypass using an aortic connector followed by repair of an abdominal aortic aneurysm to reduce surgical invasiveness. This approach merits consideration for high-risk patients.

Plasma brain natriuretic peptide reflects left ventricular function during percutaneous cardiopulmonary support.

BACKGROUND: Plasma levels of brain natriuretic peptide (BNP), a cardiac hormone secreted predominantly from the ventricle, are elevated in patients with myocardial infarction, hypertension, and dilated cardiomyopathy. In this study, we assessed the usefulness of measuring BNP to evaluate left ventricular function in patients with severe heart failure receiving mechanical circulatory support. METHODS: Plasma BNP and creatine kinase (CK)-MB levels were measured serially in 8 consecutive patients with cardiogenic shock who received percutaneous cardiopulmonary support (PCPS) at Osaka Police Hospital from August 1999 to March 2000. Coronary artery bypass grafting or percutaneous transluminal coronary angioplasty was also performed in 5 patients during PCPS; in addition, 1 patient underwent insertion of a left ventricular venting catheter and implantation of a left ventricular assist system after PCPS. RESULTS: Five patients were weaned from PCPS, and 3 died. In survivors, plasma BNP and CK-MB levels correlated positively and significantly (r = 0.968, p = 0.03). After PCPS was initiated, plasma BNP levels gradually decreased in survivors, but not in patients who died (p = 0.003). CONCLUSIONS: These results suggest that plasma BNP levels accurately reflect myocardial damage in patients undergoing PCPS. A decrease in BNP might appear to indicate improved left ventricular function and predict successful weaning from mechanical support.

Total arch replacement for thoracic aortic aneurysm via median sternotomy with or without left anterolateral thoracotomy.

BACKGROUND: Thoracic aneurysms involving the ascending aorta, arch, and descending aorta are usually approached in a series of operations. Here, we report our clinical experience with total arch replacement through a median sternotomy with or without left anterolateral thoracotomy, using a technique that preserves the anterior wall of the distal arch to avoid injuring the left recurrent and phrenic nerves. METHODS: Between March 1999 and February 2001, 32 consecutive patients underwent total arch replacement through a median sternotomy alone (median group, n = 23) or in combination with a left anterolateral thoracotomy (LAT group, n = 9). In all cases, antegrade hypothermic selective cerebral perfusion was used in conjunction with mild hypothermic visceral perfusion (cool head-warm body perfusion). RESULTS: There were no in-hospital deaths and two late deaths. One patient in the median group had permanent neurological dysfunction postoperatively. There were no significant differences between the two groups in bypass time, cardiac ischemic time, respiratory assist time, beginning peroral intake, hospital stay, or postoperative respiratory function. The distal anastomosis level was significantly lower in the LAT group (thoracic vertebra level 7.1 +/- 1.5 vs 5.6 +/- 0.5, p = 0.0015). CONCLUSIONS: Preservation of the anterior wall in the distal arch may decrease in-hospital mortality and perioperative neurological dysfunction after total arch replacement. Total arch replacement through a median sternotomy with left anterolateral thoracotomy allowed expeditious and extended replacement of the aorta without increasing postoperative respiratory complications.

Acute thrombotic obstruction of mitral valve prosthesis: low protein C level.

A 51-year-old female underwent redo mitral valve replacement with a pericardial bioprosthesis because of acute thrombotic obstruction of a mechanical valve, in spite of adequate anticoagulation with warfarin. Her protein C level was 24% of the normal value and protein S was reduced to 54% of normal.

Sinus of valsalva aneurysm with congenital aortic stenosis and aortic coarctation.

A 52-year-old female was diagnosed with the extremely rare combination of sinus of Valsalva aneurysm, congenital unicuspid aortic valve stenosis, and coarctation of the aorta. She was successfully treated in a two-stage operation. The first operation consisted of a bypass graft to correct the coarctation. The second, performed 31 days later, included aortic valve replacement, patch closure of the aneurysm, and translocation of the right coronary artery.