Managing postoperative atrial fibrillation after open-heart surgery using transdermal ß1 blockers.

BACKGROUND: Postoperative atrial fibrillation (POAF) after open-heart surgery is a non-negligible complication. We aimed to describe the efficacy of a transdermal patch of bisoprolol for managing POAF and flutter in thoracic surgical procedures. METHODS: We analyzed the data of 384 patients who underwent open-heart surgery at our hospital and received oral bisoprolol to prevent POAF. Among them, 65 patients (16.9%) also received a 4-mg transdermal patch of bisoprolol to control the heart rate due to POAF. We applied the bisoprolol transdermal patch when the heart rate was > 80 bpm and removed it at ≤ 60 bpm; an additional patch was applied when the heart rate was > 140 bpm. Heparin calcium injections were administered twice daily for anticoagulation between 2 and 6 days postoperatively. RESULTS: The average number of prescriptions for transdermal patches of bisoprolol during hospitalization was 1.8 ± 1.1 (1-5). The median first prescription date was on postoperative day 2 (range: days 0-37). Sinus rhythm recovered within 24 h in 18 patients (27.7%). Eight patients (12.3%) were switched to continuous landiolol infusion because of persistent tachycardia. In three patients, the transdermal patch was removed owing to severe bradycardia. Fifteen patients experienced persistent atrial fibrillation and were treated with electrical cardioversion during hospitalization. We did not observe any serious complications that could be directly attributed to bisoprolol transdermal patch use. CONCLUSIONS: Single-use bisoprolol transdermal patch may help control the heart rate during the initial treatment of POAF after open-heart surgery.

A strategy to enable rapid healing and prevent recurrence of venous ulcers.

INTRODUCTION: Venous ulcers are often intractable. OBJECTIVE: The aim of this study was to retrospectively analyze the effectiveness of endovenous ablation, compression therapy, moist wound healing, and skin care in the management of venous ulcers. MATERIALS AND METHODS: Twenty-eight consecutive patients (10 male, 18 female; mean age, 70.1 years) with Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class C6 venous ulcer underwent endovenous ablation between December 2014 and August 2020. The main treatment strategies were radiofrequency ablation and varicectomy (including stab avulsion of incompetent perforating veins), use of compression therapy until complete healing was achieved, moist wound healing (washing the ulcer site and covering it with dressings twice daily), and skin care, taking into consideration the balance of the microbiome. RESULTS: Active venous leg ulcers (CEAP class C6) were diagnosed in 36 patients at the first visit. In 7 of these patients, compression therapy and use of strategies to promote moist wound healing resulted in ulcer healing by the day of the planned surgery. One patient was unable to quit smoking and, therefore, could not undergo surgery. After excluding these 8 patients, the authors analyzed the data from 28 patients who underwent endovenous ablation. The mean surgical time was 38.9 minutes, and the mean number of stab avulsion incision sites was 9.7. All ulcers healed within a median of 55.5 days (range, 13-365 days). Ulcer healing was achieved by 1 year in all 28 patients (100%). No ulceration recurred as of the final follow-up (median, 24.5 months [range, 3-66 months]). CONCLUSIONS: Endovenous ablation, adequate varicectomy (stab avulsion [maximum number of sites in 1 patient, 43]), compression therapy, moist wound healing, and skin care are effective in treating and preventing recurrence of venous ulcers.

Feasibility of incompetent perforator vein excision using stab avulsion.

OBJECTIVES: Whether incompetent perforator veins (IPVs) require treatment remains controversial. We retrospectively evaluated the feasibility of IPV excision performed using the stab avulsion technique without ligation and sutures in patients undergoing endovenous ablation (EA). METHODS: This was a single-center, retrospective, observational cohort study. EA was performed in 1503 consecutive patients, including 33 patients with ulcers, between December 2014 and May 2021. Varicectomy was performed using the stab avulsion technique; IPV cases were included. RESULTS: Stab avulsion was performed at a mean number of 11.4 ± 7.8 sites. No deep vein thromboses or pulmonary emboli were noted. The incidence of nerve injury was 0.3%. All 33 (100%) patients with ulcers achieved healing by 1 year (median: 55.5 days; range: 13-365 days). CONCLUSIONS: IPV excision via stab avulsion may be a viable option for treating varicose veins and ulcers. This technique offers multiple advantages, including simplicity, safety, and reduced healthcare costs.

[Suspected Takotsubo Cardiomyopathy after Elective Mitral Valve Replacement:Report of a Case].

Reports of takotsubo cardiomyopathy following cardiac surgery are rare. We report a case of postoperative takotsubo cardiomyopathy after mitral valve replacement (MVR). The patient was a 70-yearold woman with mitral stenosis, regurgitation, and a medical history of long-standing persistent atrial fibrillation. Preoperative echocardiogram confirmed severe mitral regurgitation, severe mitral stenosis, severe tricuspid regurgitation, and slight left ventricular dysfunction. Coronary lesions were not observed on preoperative diagnostic coronary angiography. MVR with a bioprosthetic valve, tricuspid annuloplasty, and left atrial maze were performed. Electrocardiogram on postoperative day (POD) 1 revealed a deep negative T wave in V3-V6. Echocardiogram revealed "takotsubo-like" wall motion, and the ejection fraction( EF) was 19%. The EF improved on POD 7. After three months, the electrocardiogram findings and EF appeared normal. We suspected takotsubo cardiomyopathy although postoperative coronary angiography was not performed. Takotsubo cardiomyopathy should be considered as a possible complication of cardiac surgery, especially after MVR.

Strategy to prevent nerve injury and deep vein thrombosis in radiofrequency segmental thermal ablation of the saphenous veins using a new objective pain scale.

OBJECTIVE: We evaluated the benefit of local anesthesia including tumescent anesthesia and active walking soon after surgery in preventing nerve injury and deep vein thrombosis caused during endovenous ablation. METHODS: Endovenous ablation was performed in 1334 consecutive patients. Varicectomy was performed using the stab avulsion technique. After surgery, patients were encouraged to walk 100-200 m inside the ward for 3-5 times/h. The pain was evaluated objectively using the Okamura pain scale and subjectively using the numerical rating scale. RESULTS: Stab avulsion was performed at 11.8 ± 8.0 sites and the mean operative time was 33.9 ± 15.2 min. The mean Okamura pain scale and numerical rating scale scores were 1.6 ± 1.3 and 3.0 ± 2.0, respectively. Deep vein thrombosis and pulmonary embolism were absent. The incidence of nerve injury was 0.3%. CONCLUSIONS: Endovenous ablation should be performed with the patients under local anesthesia to prevent nerve injury and deep vein thrombosis.

Re-expansion of Thrombosed False Lumen after Aortic Dissection Due to Collateral Retrograde Flow from the Aortic Branches.

Re-expansion of thrombosed false lumen after aortic dissection due to collateral retrograde flow from the aortic branches has rarely been reported. Surgical or endovascular local management such as ligation or occlusion of culprit arteries may not be effective in case retrograde blood flow to the false lumen might occur again from another branch after the operation. Here, we report a 68-year-old woman with re-expansion of the thrombosed false lumen after acute type B aortic dissection due to collateral retrograde flow from the aortic branches successfully treated with tranexamic acid therapy and antihypertensive therapy.

Percutaneous Continuous Irrigation and Drainage for Infected Obturator Bypass Graft.

The treatment for obturator bypass graft infection has been rarely reported and is a surgical challenge because it is difficult to debride infected tissue around the graft located in the deep route and to ensure an alternative revascularization route in patients with a history of inguinal infection. Percutaneous continuous irrigation and drainage is an effective and less invasive definitive therapy for obturator bypass graft infection.

Left thoracotomy for coronary artery bypass grafting after sternoturnover for pectus excavatum: a case report.

BACKGROUND: Sternoturnover is a surgical procedure for pectus excavatum. Cardiac surgery in patients with a history of sternoturnover has been rarely reported and is a surgical challenge because it is unknown how median sternotomy or the use of a sternal retractor affects the postoperative stability of the thorax and respiratory function. We report a successful coronary artery bypass grafting through left thoracotomy in a patient treated with sternoturnover for pectus excavatum. CASE PRESENTATION: A 53-year-old man, who underwent sternoturnover in his childhood, was diagnosed with acute myocardial infarction, and percutaneous coronary intervention was performed as the acute treatment of the culprit lesion. Because residual lesions were present, he was referred to our department for coronary artery bypass grafting. Enhanced computed tomography revealed bilateral occlusions of the internal thoracic arteries and a small fragile sternum after fixation. Considering postoperative respiratory dysfunction associated with instability of the thorax following median sternotomy, we selected left thoracotomy for coronary artery bypass grafting. Convalescence was uneventful without any respiratory complications. CONCLUSION: Left thoracotomy is useful for coronary artery bypass grafting in patients previously treated with sternoturnover for pectus excavatum because it can avoid respiratory dysfunction associated with median sternotomy.

[Efficacy of Transdermal Patch of Bisoprolol for Paroxysmal Atrial Fibrillation after Open Heart Surgery].

2014 American Association for Thoracic Surgery (AATS) guidelines recommend beta blocker for prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. In recent years, transdermal patch of bisoprolol (TDPB) has become available in Japan. We examined the efficacy of TDPB for paroxysmal atrial fibrillation (PAF) after open heart surgery. Among 289 patients who had undergone open heart surgery in our hospital from December 2013 to April 2016, 48(16.6%)patients, for whom TDPB was used for PAF, were analyzed retrospectively. The summary of our PAF protocol:HR >80;a sheet of TDPB (4 mg) is pasted, HR≤60;TDPB is removed, HR >140 persisted;another sheet of TDPB is added. Eighteen of the 48 (37.5%) patients recovered sinus rhythm within 24 hours. Six patients( 12.5%), because of persistent tachycardia, shifted to continuous infusion of landiolol. Ten underwent electrical defibrillation during hospitalization. In 3 patients, TDPB was removed due to advanced bradycardia. TDPB could be used safely and feasibly for PAF after open heart surgery.

Hybrid Endovascular Repair of a Right-Sided Thoracoabdominal Aortic Aneurysm.

A right-sided thoracoabdominal aortic aneurysm involving a right-sided aortic arch is extremely rare. Surgical treatment for a right-sided thoracoabdominal aortic aneurysm is challenging due to the anatomical complexity. We report a case of a right-sided thoracoabdominal aortic aneurysm with a right-sided aortic arch successfully treated by hybrid visceral debranching and endovascular repair.

[Incidental diagnosis of giant cell arteritis during a hybrid surgical approach in a patient with annuloaortic ectasia and an extensive thoracic aortic aneurysm].

We report a case of giant cell arteritis that was incidentally diagnosed during a hybrid( open surgical and endovascular) approach to an extensive thoracic aortic disease. A 78-year-old man was admitted for the evaluation and treatment of annuloaortic ectasia and an extensive thoracic aortic aneurysm. We performed aortic root replacement (Bentall procedure) and total aortic arch replacement using the elephant trunk technique under hypothermic circulatory arrest. Pathological examination of the aneurysmal wall revealed giant cell arteritis. He had no specific symptoms such as headache, jaw claudication, or vision loss. Because no findings except for a slightly elevated erythrocyte sediment rate were suggestive of active vasculitis, he was discharged from hospital without steroid therapy 6 weeks after open surgery. However, 4 weeks later he returned in hemorrhagic shock due to rupture of a residual descending thoracic aortic aneurysm. He underwent emergency endovascular repair but died intraoperatively. In conclusion, early second-stage procedure and postoperative steroid therapy may be useful in a patient with aortic aneurysm in giant cell arteritis undergoing a hybrid procedure.

Severe aortic valve regurgitation due to Takayasu's aortoarteritis in a child.

An 8-year-old Japanese boy with severe aortic valve regurgitation was treated by the Ross procedure with use of the full root technique. Takayasu's aortoarteritis was diagnosed 2 months after the operation. At 8 months after the operation, follow-up echocardiography revealed an aortic root pseudoaneurysm, which was surgically repaired. At 24 months after operation, the patient continues to receive prednisolone, azathioprine, and cyclophosphamide and is in good health, with good pulmonary autograft function.