Free-wall perforation of the left ventricle after acute myocardial infarction complicated with pericardial tamponade that mimicked ascending aortic dissection: A case report.

Life-threatening cardiac events may be misdiagnosed as acute aortic dissection because of notable symptom mimicry. We report the case of a 72-year-old male patient with presentations presumed to be of aortic origin. However, surgery revealed posterior free-wall perforation in the left ventricle caused by the occlusion of an obtuse marginal branch.

Ventricular septal rupture after blunt chest trauma: a case report.

Cardiac injury, including myocardial contusion and valvular damage, is a common complication of blunt chest trauma; however, traumatic ventricular septal rupture is a rare complication. We encountered a rare case of ventricular septal rupture following blunt chest trauma that was successfully repaired by emergency surgery. The mechanism underlying rupture may involve acute compression of the heart between the sternum and the vertebral column when the ventricle is filled, thereby causing a sudden increase in intraventricular pressure and leading to septal rupture. Emergency operation should be considered in cases of large defects and hemodynamic instability.

Impact of GERAADA score in patients with acute type A aortic dissection.

BACKGROUND: Despite continuous developments and advances in the perioperative management of patients suffering from acute aortic dissection type A (AADA), the associated postoperative morbidity and mortality remain high and strongly depend on the preoperative clinical status. The associated postoperative mortality is still hard to predict prior to the surgical procedure. The so-called German Registry of Acute Aortic Dissection Type A (GERAADA) score uses very basic and easily retrievable parameters and was specifically designed for predicting the 30-day mortality rate in patients undergoing surgery for AADA. This study evaluated impact of the GERAADA score in the authors' institutional results. METHODS: Among 101 acute type A aortic dissection patients treated at our hospital during August 2015-March 2021, the GERAADA was calculated individually and retrospectively. Predicted and actual mortalities were assessed, and independent predicted factors were searched. The primary endpoint was defined as comparison of GERAADA scores and early mortality, and the secondary endpoints were defined as comparison of GERAADA scores and other postoperative results, and comparison of preoperative factors and postoperative results regardless to GERAADA scores. RESULTS: While the overall 30-day mortality for the entire study cohort calculated by the GERAADA score was 14.3 (8.1-77.6)%, the actual mortality rate was 6%. However, the GERAADA score was significantly high in some postoperative complications and showed significant correlation with some peri- and post-operative factors. In addition, factors not belonging to GERAADA score such as time from onset to arrival at the hospital, time from onset to arrival at the operation room, spouse presence, and hemodialysis were significantly associated with 30-day mortality. CONCLUSIONS: Although the actual mortality was lower than predicted, GERAADA score may impact on the postoperative course. In addition, it would be desirable to add parameters such as the time from onset to arrival, family background, and hemodialysis for further accuracy.

The Simple Technique of Sternal Closure Using An Absorbable Mesh Plate.

BACKGROUND: Several authors have investigated various sternal closure materials and technologies for sternal fixation; nonetheless, the optimal technique for primary sternal closure remains unclear. This study aimed to evaluate the sternal stability of a simple technique using a mesh-type plate (Super Fixorb MX40®; Takiron Co. Ltd., Osaka, Japan), as compared with wire cerclage. METHODS: A total of 70 patients who underwent cardiovascular surgery through median sternotomy between July 2019 and May 2020 were included. Two pieces of mesh-type plates were placed under the sternum in combination with wiring. The technique for sternal closure was randomly applied, which was mainly based on the surgeon's preferences: mesh plate (mesh group: N = 33) or conventional wire cerclage (wire group: N = 37). Sternal displacement was measured using computed tomography at discharge. RESULTS: Pain scale scores and analgesic use on postoperative day 7 were similar between the two groups. However, the displacement in both the anterior-posterior and lateral directions was significantly smaller in the mesh group. CONCLUSIONS: The use of the mesh plate device for sternal closure is simple, safe, easy, and potentially reliable without anterior-posterior sternal displacement.

Impact of Tracheostomy Timing on Outcomes After Cardiovascular Surgery.

OBJECTIVES: This study aimed to investigate whether tracheostomy timing in patients undergoing cardiac surgery had an impact on outcomes. DESIGN: Retrospective, observational study. SETTING: Single-center university hospital. PARTICIPANTS: Patients requiring tracheostomy among a total of 961 patients who underwent cardiovascular surgery via a median sternotomy from January 2014 to March 2021. INTERVENTIONS: Early versus late tracheostomy. MEASUREMENTS AND MAIN RESULTS: During the study period, tracheostomy was performed in 28 patients (2.9%). According to tracheostomy timing, postoperative day seven was chosen as the cutoff to define early (≤seven days) and late (>seven days) tracheostomy. Patients in the early-tracheostomy group had a significantly shorter ventilation time after tracheostomy compared with the late-tracheostomy group (p = 0.039), and early tracheostomy resulted in a reduction in total ventilation time (p = 0.001). The incidence of pressure ulcers was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group. There was a higher tracheal tube removal rate in the early-tracheostomy group compared with the late-tracheostomy group (p = 0.0007). The one-year survival rate in the early- and late-tracheostomy groups was 65% and 31%, respectively. The long-term mortality rate was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group (p = 0.04). CONCLUSIONS: Early tracheostomy (

Impact of the Isolated Cerebral Perfusion Technique for Aortic Arch Aneurysm Repair in Patients with a Shaggy Aorta.

Objective: Total aortic arch replacement (TAR), particularly in individuals with extensive atherosclerotic alterations, especially shaggy aortas, is more crucial and difficult. The objective of this retrospective investigation was to ascertain if patients with shaggy aortas would respond to modified isolated cerebral perfusion (ICP). Materials and Methods: Between 2015 and 2020, nine individuals with shaggy aortas who received treatment for arch aneurysms were examined. Four and five patients, respectively, who had arch replacement with traditional selective cerebral perfusion (SCP) and modified ICP, were evaluated, and their short- and long-term results were compared. Results: There were no appreciable variations in the postoperative results between patients with traditional SCP and those with modified ICP. Following surgery, one patient developed paraparesis, while two individuals with traditional SCP experienced persistent neurological damage. In patients with modified ICP, there were no postoperative neurological or other problems associated to atherosclerosis; nevertheless, one patient experienced stroke 5 months after surgery. Conclusion: Patients with shaggy aorta may not receive enough brain protection from TAR with standard SCP because single axillary artery perfusion can result in nonphysiological flow and atheroma separation. Even in patients with shaggy aortas, TAR with modified ICP is safe, but late-phase severe adverse cerebrovascular events should be taken into account.

The Efficacy and Renal Protective Effect of Tolvaptan in Chronic Kidney Disease Patients after Open-Heart Surgery.

PURPOSE: Unlike loop diuretics, tolvaptan is reported to have a renal protective effect. The purpose of this study was to retrospectively assess the efficacy of tolvaptan administration in chronic kidney disease (CKD) patients following open-heart surgery. METHODS: From February 2017 to August 2020, 75 patients with preoperative CKD stages IIIb-V were enrolled in this study and were divided into two groups: the control group (n = 30) and the tolvaptan group (n = 45). All patients routinely received conventional diuretics starting from postoperative day (POD) 1. Tolvaptan at 7.5-15 mg/day was administered if the patients had persistent fluid retention or poor response to conventional diuretics. RESULTS: Tolvaptan administration was initiated at a mean of POD 2.9 ± 2.2, and the mean dosing period was 4.1 ± 3.0 days. The mean time to return to the preoperative body weight in the control and tolvaptan groups was similar. However, estimated glomerular filtration rate (eGFR) was significantly increased at the time when body weight reached the preoperative level and at discharge in the tolvaptan group than in the control group. CONCLUSION: This study demonstrated the renal protective effect of tolvaptan even in advanced CKD patients after open-heart surgery.

Impact of direct carotid artery perfusion in acute type A aortic dissection involving the common carotid artery.

OBJECTIVES: Acute type A aortic dissection complicated with brain ischemia is associated with significantly higher mortality risks. Even if rescued with central aortic repair, some patients develop permanent postoperative neurological deficiency postoperatively. We recently introduced direct common carotid artery perfusion for acute type A aortic dissection involving the common carotid artery. This study introduced this technique to prevent postoperative neurological deficiency by comparing brain protection strategies. METHODS: Among 91 acute type A aortic dissection patients treated at our hospital during August 2015-October 2020, the common carotid artery was involved in 19 (21%), which had > 90% stenosis in either of the carotid arteries on preoperative contrast-enhanced computed tomography. Twelve patients underwent conventional selective cerebral perfusion during August 2015-December 2018 and seven patients underwent direct carotid artery perfusion during January 2019-October 2020. We assessed patient characteristics, surgical courses, clinical outcomes, and neurological outcomes. RESULTS: The mean age was 69 (range 39-84) years; 17 patients were male (89%). Eight patients (42%) had neurological symptoms. Concomitant procedures, postoperative neurological symptoms, and late mortality were significantly associated with conventional selective cerebral perfusion. Five selective cerebral perfusion patients experienced worsened neurological symptoms and two died of broad cerebral ischemia. No direct carotid artery perfusion patient died during hospitalization or experienced worsened neurological outcomes. CONCLUSIONS: Direct carotid artery perfusion may be useful in aortic dissection with brain ischemia because it does not aggravate neurological symptoms and is not associated with intraoperative cerebral infarction. However, it may be ineffective when cerebral infarction has already developed.

Surgical treatment for brachiocephalic artery aneurysm with Takayasu arteritis using isolated cerebral perfusion: a case study.

BACKGROUND: Takayasu arteritis (TA) is a chronic inflammatory disease that induces stenosis, occlusion, or aneurysmal degeneration of the aorta and its major branches. Though rarely reported, proximal aneurysmal lesions from the aortic root to the arch are more common in Asian populations than in Western populations. In the surgical treatment of TA, anastomotic aneurysm can be problematic. Furthermore, atherosclerotic complications should be considered in surgical treatment for elderly TA patients. CASE PRESENTATION: Here, we report a case of brachiocephalic artery (BCA) aneurysm with TA for which surgical treatment was successful. Though it was solely a lesion of the brachiocephalic artery, after considering the patient's clinical background and the features of TA, we chose a partial arch replacement. Further, for avoidance of anastomotic aneurysm, both distal and proximal anastomosis were reinforced with Teflon felt strips. Preoperative computed tomography detected severe atherosclerotic changes in the arch vessels. The patient underwent partial arch replacement using isolated cerebral perfusion (ICP) for brain protection and recovered without any neurological deficits. CONCLUSIONS: In avoidance with anastomotic aneurysm, reinforcement of the anastomosis was introduced. ICP was effective for brain protection in case with severe atherosclerotic changes.

Prosthetic valve endocarditis caused by silent infection of methicillin-resistant coagulase-negative staphylococci.

Surgery for prosthetic valve endocarditis in the mitral valve position is still challenging for surgeons. Reconstruction of the mitral annulus is useful for patients with a mitral annulus disputed by infection. Here, we report a redo mitral valve replacement using a collar-reinforced tissue valve, which was inserted into a mitral annulus reconstructed with a bovine patch. Though the preoperative blood culture detected Streptococcus anginosus, the intraoperative culture detected methicillin-resistant coagulase-negative staphylococci (MRCNS). MRCNS is rarely detected because of its indolent nature.

Resternotomy and coronary artery bypass grafting after omental flap procedure: A case report.

Few studies have reported resternotomy after an omental flap procedure. We describe the case of a 78-year-old man who received resternotomy after omental flap procedure for deep sternal wound infection and successfully underwent coronary artery bypass grafting. Although preoperative computed tomography showed funnel chest and limited space between the sternum and omentum, resternotomy was performed safely using circular electric sternum saw under partial cardiopulmonary bypass. Because the omentum functioned as cushioning material between the sternum and mediastinal organs, no injuries of the mediastinal organs occurred. An ultrasonic scalpel effectively dissected between the omentum and mediastinal organs, especially above the ascending aorta. The targeted coronary arteries were easily detected. The patient experienced no major cardiac or infectious events for three months. An ultrasonic scalpel is recommended for dissecting between the omentum and mediastinal organs.

Revascularization-first strategy in acute aortic dissection with mesenteric malperfusion.

BACKGROUND AND AIM: Mesenteric malperfusion is a complication with a higher risk of in-hospital mortality because diagnosing mesenteric ischemia before necrotic change is difficult, and when it occurs, the patient's condition has worsened. Although it contradicts the previous consensus on central repair-first strategy, the revascularization-first strategy was found to be significantly associated with lower mortality rates. This study aimed to present our revascularization-first strategy and the postoperative results for acute aortic dissection involving mesenteric malperfusion. METHODS: Among 58 patients with acute type A aortic dissection at our hospital between January 2017 and December 2019, mesenteric malperfusion was noted in six. Four hemodynamically stable patients underwent mesenteric revascularization with endovascular intervention in a hybrid operation room before central repair, and two hemodynamically unstable patients underwent central repair before mesenteric revascularization. RESULTS: No in-hospital mortality was recorded. All four patients with mesenteric revascularization-first strategy recovered with no symptoms related to mesenteric ischemia. Two patients with central repair-first strategy developed paralytic ileus for 1 week; one of them needed exploratory laparotomy, but no patients needed colon resection. CONCLUSION: No in-hospital mortality was recorded. All four patients with mesenteric revascularization-first strategy recovered with no symptoms related to mesenteric ischemia. Two patients with central repair-first strategy developed paralytic ileus for 1 week; one of them needed exploratory laparotomy, but no patients needed colon resection.

Penetration of the ascending aorta and bronchus by a crossbow bolt.

We report the successful repair in a 29-year-old man who experienced penetration of the ascending aorta and bronchus by a crossbow bolt. Imaging studies revealed the arrow penetrating the sternum, right lung, ascending aorta and right bronchus, with mediastinal emphysema. The top of the arrow (8 mm in diameter) was deeply embedded in the body of the thoracic vertebra. The arrow was successfully removed while maintaining a stable respiratory condition by performing differential lung ventilation. There was no need for cardiopulmonary bypass. To our knowledge, this is the first case of a through-and-through penetrating ascending aorta injury.

Potential benefit of non-cardiac arrested thromboembolectomy of acute pulmonary embolism for the impaired right ventricular function.

OBJECTIVES: Acute pulmonary thromboembolism is a fatal condition with high mortality rate in patients with hemodynamic collapse. Early diagnosis and aggressive treatment after circulatory collapse due to pulmonary thromboembolism are important. Although catheter-directed therapy or surgical thromboembolectomy could be considered, the prognosis of such cases is poor. METHODS: We reviewed nine consecutive patients who underwent surgical intervention for acute pulmonary thromboembolism requiring cardiopulmonary resuscitation from March 2010 to May 2017. The patients' demographics, risk factors, operative and postoperative outcomes were retrospectively analyzed. All nine patients who experienced cardiopulmonary arrest or pulseless electrical activity had received cardiopulmonary resuscitation, including endotracheal intubation with cardiac massage. Computed tomography revealed massive pulmonary thromboembolism. Percutaneous cardiopulmonary support was initiated in six cases. Pulmonary thromboembolectomy was performed on a beating heart without aortic cross-clamping in all patients RESULTS: The mean operation time was 251.9 ± 74.7 min. Among the six patients who received preoperative percutaneous cardiopulmonary support, three were able to wean off cardiopulmonary bypass during the surgery. The other three cases were able to wean off within 3 days postoperatively. The mean postoperative intubation time was 56.3 h. No mortality was observed. All patients were discharged with New York Heart Association functional class I without any neurological complications. No patients developed major and residual thrombi in the pulmonary artery upon postoperative computed tomography. CONCLUSIONS: Pulmonary thromboembolectomy on a beating heart for acute pulmonary thromboembolism may be beneficial for minimizing right ventricular damage and improving clinical outcomes.

Unusual rupture of left ventricular pseudo-false aneurysm secondary to subacute anterolateral myocardial infarction: a case report.

BACKGROUND: Left ventricular (LV) pseudo-false aneurysm is a rare complication secondary to myocardial infarction and is caused by intramyocardial dissecting hematoma due to fragile myocardium. Very occasionally, intramyocardial dissecting hematoma appears as a neocavitation entirely contained within the myocardial wall (so called "pseudo-false LV") and is an unusual form of subacute cardiac rupture. CASE PRESENTATION: A 38-year-old male experienced chest discomfort 3 weeks ago, which improved within few days. However, after that episode, he presented at our hospital with rapidly deteriorating severe breathlessness in a preshock state with acute heart failure. Emergency coronary angiography revealed an occluded left anterior descending artery. An intra-aortic balloon catheter was inserted because of unstable hemodynamics. Enhanced computed tomography revealed extensive aneurysm formation in the LV anterior wall and contrast leakage from the inner cavity to the LV myocardium, with a moderately accumulated pericardial effusion. Emergency surgery revealed a large aneurysmal sac on the anterior wall, slightly attached to the pericardium. A 5-mm, slit-like, oozing-type, rupture site was detected in the LV after dissecting the pericardium. CONCLUSIONS: To our knowledge, this is the first report of a pseudo-false aneurysm on the LV anterior wall. Subacute rupture of pseudo-false LV aneurysm is rare.

Surgical repair of massive dilatation of the right atrium with tricuspid regurgitation.

BACKGROUND: Massive dilatation of the right atrium with tricuspid regurgitation is frequently diagnosed by accidental recognition of an enlarged cardiac silhouette during routine chest radiography. Although some patients are asymptomatic, enlargement of the right atrium can cause secondary tricuspid regurgitation due to dilatation of the tricuspid annulus, associated with arrhythmias and thrombus formation leading to pulmonary embolism, stroke, and, rarely, sudden death due to left ventricular compression. CASE PRESENTATION: A 76-year-old woman was followed up due to atrial fibrillation and tricuspid regurgitation for 8 years. A follow-up echocardiogram showed progressive dilatation of the right atrium. Because of the development of shortness of breath, right atrial plication and tricuspid valve repair were performed. Tricuspid annuloplasty was performed on the beating heart with the use of a 28-mm Carpentier-Edwards Physio tricuspid annuloplasty ring. Plication of the enlarged right atrium was performed at the interatrial septum, the free right atrium wall including the appendage, and the space between the inferior vena cava and the tricuspid ring. Closure of the left atrial appendage was performed from outside to prevent left atrial thrombus formation. Postoperative X-ray and computed tomography showed reduced cardiac silhouette and right atrial volume. The patient was discharged uneventfully and returned for follow-up visits with improved symptoms. CONCLUSIONS: An adult case of massive dilatation of the right atrium of unknown etiology is reported. The patient's symptoms were relieved by our operative procedure.

A modified closure technique for postinfarction ventricular septal defect via a right ventricular incision.

Postinfarction ventricular septal defect has been a challenge to cardiac surgeons. Recently, a number of reports have recommended ventricular septal defect closure through the right ventricle. However, when inferior myocardial infarction widely extends to the left ventricle, it is necessary to modify a patch-closure technique due to extensive fragile necrotic myocardium. We describe a simplified surgical technique via a right ventricular incision.

Evaluation of anti-inflammatory drug-conjugated silicon quantum dots: their cytotoxicity and biological effect.

Silicon quantum dots (Si-QDs) have great potential for biomedical applications, including their use as biological fluorescent markers and carriers for drug delivery systems. Biologically inert Si-QDs are less toxic than conventional cadmium-based QDs, and can modify the surface of the Si-QD with covalent bond. We synthesized water-soluble alminoprofen-conjugated Si-QDs (Ap-Si). Alminoprofen is a non-steroid anti-inflammatory drug (NSAID) used as an analgesic for rheumatism. Our results showed that the "silicon drug" is less toxic than the control Si-QD and the original drug. These phenomena indicate that the condensed surface integration of ligand/receptor-type drugs might reduce the adverse interaction between the cells and drug molecules. In addition, the medicinal effect of the Si-QDs (i.e., the inhibition of COX-2 enzyme) was maintained compared to that of the original drug. The same drug effect is related to the integration ratio of original drugs, which might control the binding interaction between COX-2 and the silicon drug. We conclude that drug conjugation with biocompatible Si-QDs is a potential method for functional pharmaceutical drug development.

Amino acid synthesis in a supercritical carbon dioxide - water system.

Mars is a CO(2)-abundant planet, whereas early Earth is thought to be also CO(2)-abundant. In addition, water was also discovered on Mars in 2008. From the facts and theory, we assumed that soda fountains were present on both planets, and this affected amino acid synthesis. Here, using a supercritical CO(2)/liquid H(2)O (10:1) system which mimicked crust soda fountains, we demonstrate production of amino acids from hydroxylamine (nitrogen source) and keto acids (oxylic acid sources). In this research, several amino acids were detected with an amino acid analyzer. Moreover, alanine polymers were detected with LC-MS. Our research lights up a new pathway in the study of life's origin.