Pulmonary vein reconstruction for pulmonary vein stenosis and occlusion after surgical ablation.

Acquired pulmonary vein (PV) stenosis (PVS) is a complication following cardiac catheter intervention. However, very few cases of PVS after surgical ablation have been reported. We herein report a case of stenosis and occlusion at the left atrium to each pulmonary vein after surgical ablation. A 73-year-old woman who had received aortic valve replacement and pulmonary vein isolation 10 months earlier was diagnosed with congestive heart failure accompanied by pulmonary hypertension. Contrast-enhanced computed tomography revealed stenosis and complete occlusion of the left atrium to all four pulmonary veins. Surgical repair was performed via pericardial patch reconstruction of the left atrium to each PV. Treating multiple PV lesions with involvement of the left atrium wall requires tailored methods. However, there have been few reports concerning such methods of reconstruction. We herein report a method of reconstructing the left atrium and pulmonary veins at the same time.

The N-terminal lectin-like domain of thrombomodulin reduces acute lung injury without anticoagulant effects in a rat cardiopulmonary bypass model.

OBJECTIVES: Systemic inflammation evoked by cardiopulmonary bypass (CPB) leads to acute lung injury (ALI) and respiratory failure. Although recombinant human soluble thrombomodulin (rTM) consists of three domains (D1-3), is reported to attenuate systemic inflammation through the N-terminal lectin-like domain (D1), anticoagulant domain (D2) may exacerbate coagulopathy after CPB. We investigated the potential of selective D1 against CPB-mediated ALI free from anticoagulant effects using a rat CPB model. METHODS: Rats were divided into three groups: control (CPB alone, n = 5), D1 (CPB + D1, n = 4), and D123 (CPB + D123, n = 6). D1 or D123 was administrated to the rats of each group before CPB establishment. Blood samples are collected before, during and after CPB. Blood coagulability was assessed by a coagulation analyzer. Lung samples are collected at 1 h after the termination of CPB for histological analyses. RESULTS: D123 group exhibited significantly prolonged glass beads-activated clotting time with heparinase after CPB compared to that in control group, whereas no significant prolongation in control and D1 group (control vs. D1 vs. D123: 65.4 ± 9.2 vs. 65.3 ± 10.9 vs. 83.5 ± 4.6 s, p = 0.036 [control vs. D123], 0.99 [control vs. D1]) indicating the absence of anticoagulant activities of D1. Histological studies revealed less congestion, edema, inflammation, and hemorrhage in both D1 and D123 groups compared to those in control group indicating protective effects of both D1 and D123 against ALI mediated by CPB. CONCLUSIONS: N-terminal lectin-like domain of rTM may reduce the risk of ALI without anticoagulant effects.

A Recovery Cardiopulmonary Bypass Model Without Transfusion or Inotropic Agents in Rats.

Cardiopulmonary bypass (CPB) is indispensable in cardiovascular surgery. Despite the dramatic refinement of CPB technique and devices, multi-organ complications related to prolonged CPB still compromise the outcome of cardiovascular surgeries, and may worsen postoperative morbidity and mortality. Animal models recapitulating the clinical usage of CPB enable the clarification of the pathophysiological processes that occur during CPB, and facilitate pre-clinical studies to develop strategies protecting against these complications. Rat CPB models are advantageous because of their greater cost-effectiveness, convenient experimental processes, abundant testing methods at the genetic or protein levels, and genetic consistency. They can be used for investigating the immune system activation and synthesis of proinflammatory cytokines, compliment activation, and production of oxygen free radicals. The rat models have been refined and have gradually taken the place of large-animal models. Here, we describe a simple CPB model without transfusion and/or inotropic agents in a rat. This recovery model allows the study of the long-term multiple organ sequelae of CPB.

Clinical outcomes of aortic repair in young adult patients with ACTA2 mutations.

OBJECTIVES: Actin, alpha-2, smooth muscle, aorta (ACTA2) mutations are one of the major causes of familial thoracic aortic aneurysms and dissections. The aim of this study was to review our clinical results of young adult patients with aortic disease caused by ACTA2 mutations. METHODS: We reviewed the medical records of 251 patients (<50 years old) who underwent surgery for thoracic aortic diseases between 2004 and 2014. Among them, nine patients (3.5%) had ACTA2 mutations. Their average age was 35 years (range 22-47) and two patients (22.2%) were males. No patients fulfilled the diagnostic criteria for Marfan syndrome. Preoperative diagnoses included annulo-aortic ectasia (n = 2), localized dissection of the sinus of Valsalva (n = 2), acute type B aortic dissection (n = 1), and chronic type B (n = 4). Eight patients (88.9%) had hypertension. RESULTS: A thoracoabdominal aortic replacement was required in three patients who had descending replacement for residual chronic type B aortic dissection. A patient who had thoracic endovascular aortic repair for complicated acute type B aortic dissection showed no aortic dilatation for 7 years after TEVAR. Histological results revealed cystic medial necrosis (CMN) in most cases (7/8; 87.5%). CONCLUSION: Surgical outcomes for patients with ACTA2 mutations were satisfactory. CMN was a major histological finding and family history of aortic event was detected in only half of the patients with ACTA2 mutations. Despite no characteristic physical findings besides hypertension, connective tissue disease including ACTA2 mutations should be considered for aortic dissection in young adult patients.

Surgical Indication for Chronic Aortic Dissection in Descending Thoracic and Thoracoabdominal Aorta.

BACKGROUND: To address the lack of information about the size of ruptures associated with chronic dissection in the descending and thoracoabdominal aorta, we evaluated the natural history of this pathology. METHODS AND RESULTS: We analyzed data from 571 patients (mean age, 69.4±11.6 years) with unrepaired chronic aortic dissection in the descending or thoracoabdominal aorta with a maximal aortic diameter of ≥3.5 cm from 2007 to 2014. This was a cross-sectional study. Data on the timing of computed tomographic scan were as follows: for ruptured cases: at the time of rupture; for nonruptured cases: the initial aortic diameter. Patients with connective tissue disorders were excluded. The primary end point was evidence of aortic rupture on computed tomographic images. The median maximal diameter was 4.3 cm (limits, 3.5-9.0 cm) for all aortas and 5.6 cm (n=31; limits, 3.6-8.0 cm) for ruptured aortas. For aortic diameters of 4.0 to 4.4, 4.5 to 4.9, 5.0 to 5.4, 5.5 to 5.9, and 6.0 to 6.4 cm, the incidence of rupture was 0%, 3.3%, 15.3%, 18.8%, and 28.6%, respectively. The risk factors for rupture were absence of hypertension, chronic heart failure, chronic-phase dissection, and Yale index. CONCLUSIONS: The risk of aortic rupture increased with an aortic diameter of ≥5.0 cm in patients with chronic aortic dissection in the descending or thoracoabdominal aorta. We would recommend 5.0 cm as an acceptable size for elective resection of subacute or chronic aortic dissection in the descending or thoracoabdominal aorta.

Influence of warfarin therapy on the occurrence of postoperative endoleaks and aneurysm sac enlargement after endovascular abdominal aortic aneurysm repair.

Objectives: This study aims to determine whether warfarin therapy influences the occurrence of endoleaks or aneurysm sac enlargement after endovascular aortic repair (EVAR). Methods: A total of 367 patients who underwent EVAR for abdominal aortic aneurysm between 2007 and 2013 were recruited for this study. Satisfactory follow-up data including completed computed tomography scan follow-up for more than 2 years were available for 209 patients, and the mean follow-up time was 37 ± 12 months. Twenty-nine (16%) patients were on warfarin therapy (warfarin group), whereas 180 (84%) patients were not on warfarin therapy (control group). Results: Two- and four-year freedom rates for persistent type II endoleaks were significantly lower in patients of the warfarin group compared with the control group (85 and 49% vs 93 and 91%, respectively; P = 0.0001). Similarly, 2- and 4-year freedom rates for sac enlargement (>5 mm) were significantly lower in patients of the warfarin group compared with the control group (83 and 61% vs 92 and 82%, respectively; P = 0.0036). Using Cox regression analysis, the warfarin therapy was identified to be an independent positive predictor of sac enlargement after EVAR [hazard ratio (HR): 2.4; 95% confidence interval (CI): 1.08-5.40; P = 0.032], together with persistent type II endoleak. Warfarin therapy was also an independent predictor for persistent type II endoleak (HR: 3.7; 95% CI: 1.81-7.41; P < 0.0001) together with the number of patent lumbar arteries. Conclusions: Results suggested that warfarin therapy was significantly associated with an increased risk for persistent II endoleak and sac enlargement after EVAR.

Straight incision for extended descending and thoracoabdominal aortic replacement: novel and simple exposure with rib-cross thoracotomy.

OBJECTIVES: Spiral incision of the thoracic wall towards the tip of a scapula and approach through the sixth intercostal space has been a standard method for the replacement of thoracoabdominal and descending aortic aneurysms. However, the exposure of the proximal lesion of the aorta with the spiral incision is not always sufficient for patients with a lesion extending into the aortic arch. Patients with Marfan syndrome tend to have a flat chest, and exposure using left thoracotomy generally causes difficulty to operate on the aortic arch. METHODS: Since May 2012, 47 patients (mean age 51.2 ± 16.1, range 9-79, 33 males) have received a novel incision for better exposure of the extended descending and thoracoabdominal aneurysm. A straight incision instead of the traditional spiral one was made from the axilla to the umbilical region and the fourth to sixth ribs were transected. The latissimus dorsi muscle and thoracodorsal artery were preserved, which could be a source for collateral circulation to the Adamkiewicz artery. There were two emergent operations for acute aortic dissection. Twenty-four patients (51%) had undergone previous proximal aortic operation, and 2 patients undergone debranched thoracic endovascular aneurysm repair of the aortic arch. Connective tissue disorders were diagnosed in 16 (34.0%) patients (Marfan syndrome 13, Loeys-Dietz syndrome 3). All surgeries were performed under profound hypothermia. RESULTS: Seven patients underwent total descending aortic replacement, and the others had Type II thoracoabdominal aortic replacements. Three had partial aortic arch replacement, 5 had total aortic arch replacement and 3 had Y-grafting for the abdominal aorta concomitantly. Operation time was 567 ± 141 min and cardiopulmonary bypass time was 259 ± 60 min. Three patients had a major stroke (6.4%), and 1 had a minor stroke. There was no spinal cord complication among survivors. Hospital mortality rate was 4.3% (2/47). These 2 patients underwent thoracoabdominal aortic replacement, and had a major stroke. CONCLUSIONS: This new exposure with straight incision with rib-cross thoracotomy provided excellent exposures for the long segment of the thoracoabdominal aorta, and it enabled extended replacement from the ascending aorta to the abdominal aorta.

Surgical outcomes for acute type A aortic dissection with aggressive primary entry resection.

OBJECTIVES: An entry located at aortic arch in acute type A aortic dissection (AAAD) is uncommon. It remains controversial whether or not aggressive primary entry resection should be routinely performed in such patients. We have adopted an aggressive strategy of entry site resection, including total arch replacement (TAR) in patients with arch tears. The purpose of this study was to investigate the efficacy of our surgical management approach, using aggressive primary entry resection. METHODS: Between January 2000 and December 2014, we retrospectively reviewed the records of 334 patients with AAAD who underwent emergent surgery. The mean age was 67 ± 13 years (range, 20-95 years). Ninety-five patients (28%) presented with shock vital status, and 84 patients (25%) manifested malperfusion of branched arteries. Primary entry resection was achieved in 95% of patients under an aggressive surgical strategy [hemiarch replacement for 173 (52%) patients and TAR for 161 (48%) patients] concomitant with 22 coronary artery bypass grafts and 38 root replacements. Ninety-six percent of hospital survivors (298/311) were followed for a median of 39 months (range, 0-179 months). RESULTS: Operation, cardiopulmonary bypass, cardiac arrest, antegrade cerebral perfusion and lower body circulatory arrest times were 447 ± 170, 236 ± 93, 112 ± 74, 115 ± 81 and 54 ± 18 min, respectively. The 30-day mortality rate was 5.4%. The in-hospital mortality rate was 8.4% (6.9% at our hospital). Incidences of postoperative permanent neurological dysfunction, tracheotomy and newly permanent haemodialysis were 6.9, 8 and 2%, respectively, with no spinal cord injuries observed. Complete false lumen thrombosis was achieved in 57% of patients as visualized by postoperative computed tomography angiography. After 3, 5 and 10 years, overall survival rates were 81, 74 and 65%, respectively, and the percentages of patients free from downstream dissection-related reoperation were 89, 86 and 80%, respectively. Multivariable analysis demonstrated that the risk factors for downstream aortic reoperation were patent false lumen, residual primary entry tear and connective tissue disorder. CONCLUSIONS: The surgical outcomes following aggressive treatment of AAAD are satisfactory. False lumen thrombosis can be achieved in a relatively high proportion of patients using this technique, resulting in a low rate of subsequent downstream aortic reoperations.

Utility of Proximal Stepwise Technique for Acute Aortic Dissection Involving the Aortic Root.

Proximal anastomosis is an important operative procedure in type A acute aortic dissection. We report our experience with the proximal stepwise technique, which is widely used during distal anastomosis in total arch replacement, in a series of 53 patients. We treated 53 patients for aortic dissection using this technique in our center. There were no bleeding adverse events during the operations and no early death caused by bleeding. This hemostatic technique was simple to use and demonstrated excellent early and midterm operative results.

A simple and effective method to apply TachoSil® Tissue Sealing sheet using Esmarch's bandage.

We report a novel hemostatic method for using hemostatic patches impregnated with human fibrinogen and thrombin (TachoSil®) together with Esmarch's bandage. The combined use of TachoSil® with Esmarch's bandage is easy and inexpensive. Further, it would ensure sustained and appropriate pressure on the bleeding site, while providing further adhesive strength to TachoSil® at the site.

Adventitial inversion technique for type A aortic dissection distal anastomosis.

OBJECTIVE: Anastomosis in dissected aorta management remains challenging. The patent false lumen of remnant aorta influences the growth of the residual aorta after hemiarch replacement. We evaluated the beneficial effect of adventitial inversion technique for distal anastomotic reinforcement of hemiarch replacement in acute type A aortic dissection. METHODS: From 2006 to 2014, 90 patients with DeBakey type I aortic dissection who underwent hemiarch replacement for acute type A aortic dissection management at the National Cerebral and Cardiovascular Center were retrospectively analyzed. Patients were divided according to the technique used: the adventitial inversion technique in group A and the original Sandwich method with Teflon felt in group S. Surgical variables and aortic morphology from distal aortic anastomosis were evaluated by computed tomography after surgery. RESULTS: The mean follow-up time was 2.2 ± 2.1 years with a follow-up rate of 91.1%. Cardiopulmonary bypass time was 208.2 ± 93.9 minutes in group A and 220.6 ± 93.9 minutes in group S; lower body circulatory arrest time was 51.6 ± 10.2 minutes in group A and 54.5 ± 17.8 minutes in group S. No significant differences were observed between groups. The overall hospital mortality rate was 10.0%. Postoperative false lumen thrombosis rate at proximal descending aorta on enhanced delayed phase computed tomography was significantly higher in group A than in group S. CONCLUSIONS: The adventitial inversion technique may facilitate thrombotic closure of the distal false lumen in acute type A aortic dissection management by hemiarch replacement.

Total Aortic Replacement for a 9-Year-Old Boy With Loeys-Dietz Syndrome.

Loeys-Dietz syndrome (LDS) is a recently identified rare connective tissue disorder caused by mutations of the transforming growth factor-ß receptors and first described in 2005. It is an autosomal dominant syndrome with 2 different phenotypic expressions-LDS I and II. LDS is characterized by the triad of arterial tortuosity and aneurysm, hypertelorism, and a bifid uvula or cleft palate. We present a case of a 9-year-old boy diagnosed with LDS who underwent urgent thoracoabdominal aortic aneurysm repair followed by total arch replacement and aortic valve-sparing root replacement (AVSRR).

Is Conventional Open Repair Still a Good Option for Aortic Arch Aneurysm in Patients of Advanced Age?

BACKGROUND: Although thoracic endovascular aortic repair has advantages in elderly patients, it is not always applicable, and some elderly patients require open surgical repair. METHODS: Between 2008 and 2014, 157 patients (11 men) older then 75 years (mean age, 79.3 ± 3.3 years) underwent conventional total arch replacement, of which 39 were emergency operations. Coexisting diseases included remote stroke in 54 patients, coronary artery disease in 64, chronic obstructive pulmonary disease in 25, and chronic kidney disease in 112. Concomitant procedures were performed in 46 patients. RESULTS: Mean follow-up time was 2.9 ± 1.8 years. Mean cardiopulmonary bypass time was 251.1 ± 68.4 minutes. Mean lowest nasopharyngeal temperature was 23.2° ± 3.4 °C. The hospital mortality rate was 7.6% (12 of 157) overall, 5.1% in elective cases, and 15.4% in emergency cases. Postoperative complications included permanent neurologic dysfunction in 5.7% of patients and prolonged ventilation time exceeding 72 hours in 13.4%. No spinal cord complications occurred. The 1-year and 5-year survival rates were 88.2% and 69.2% in all cases and 91.3% and 77.0% in elective cases, respectively. Univariate analysis demonstrated that risk factors for hospital death in elective cases were chronic kidney disease (odds ratio, 4.00; p = 0.028) and ventilation time exceeding 72 hours (odds ratio, 13.3; p = 0.001). CONCLUSIONS: Even in patients older than 75 years, recent surgical results of conventional open arch repair were acceptable, especially in elective cases. Thus, conventional open surgical aortic arch replacement remains a good option, especially in patients with preserved renal function.

Recent thoraco-abdominal aortic repair outcomes using moderate-to-deep hypothermia combined with targeted reconstruction of the Adamkiewicz artery†.

OBJECTIVES: We retrospectively reviewed the surgical results of thoraco-abdominal aortic repair using moderate-to-deep hypothermia combined with targeted reconstruction of the Adamkiewicz artery (AKA). METHODS: Between 2006 and 2014, 100 patients underwent thoraco-abdominal aortic aneurysm repair using moderate-to-deep hypothermia. Their mean age was 58 ± 15 years and 76 (76%) were men. Their aortic pathologies included acute dissection (5), chronic dissection (74), degeneration (20) and infection (1). Thirty-four had connective tissue disorders and 5 had emergency operations. The degrees of repair were Crawford extent I for 11, II for 76 and III for 13. Seven had concomitant arch repair. Preoperative magnetic resonance angiography or computed tomographic angiography was performed to detect the AKA in 95. We used deep hypothermia (18 °C) for those requiring open proximal aortic anastomosis for cerebral protection and moderate hypothermia (25 °C) for those not requiring open proximal aortic anastomosis. RESULTS: Two patients had spinal cord injuries and 4 had a stroke. For those in whom the AKA was identified (90%), all had targeted artery reconstruction. The mean pairs of reconstructed intercostal arteries were 1.5 ± 0.7. There were 5 in-hospital deaths for which the causes were lung bleeding (2), infection (2) and iliac aneurysm rupture (1). Temporary dialysis for new-onset renal failure was required for 9. The mean postoperative mechanical ventilation period was 1.7 ± 1.9 days. Six required a tracheostomy due to respiratory failure. CONCLUSIONS: Moderate-to-deep hypothermia combined with targeted reconstruction of the AKA provided satisfactory outcomes with thoraco-abdominal aortic repair, particularly for spinal cord protection.

Preoperative Assessment of High-Risk Aortic Plaque by Magnetization-Prepared Rapid Acquisition with Gradient-Echo Imaging in a Patient with Total Arch Replacement.

We present a case of a 70-year-old male who underwent surgical repair of an aortic arch aneurysm. Preoperative assessment of high-risk aortic plaque was performed using magnetization-prepared rapid acquisition with gradient-echo (MPRAGE) imaging. This preoperative image was compared with a histological analysis of plaque specimens from the aortic arch and neck vessels. A high signal intensity on MPRAGE images coincided with intraplaque hemorrhage. MPRAGE, which could detect a fragile plaque in the aorta, could be a powerful modality to prevent intraoperative stroke during cardiovascular surgery.

[Successful endovascular treatment under cardiopulmonary resuscitation for spontaneous rupture of the thoracic aorta].

The patient was a 67-year-old man. He was admitted to a local hospital with severe back pain, and left hydrothorax was noted by a chest X-ray. Then, he went into shock and was transferred to our hospital. Enhanced computed tomography (CT) showed massive liquid retention of the left thorax, but no aortic dissection or aneurysms. He was diagnosed with spontaneous aortic rupture, and endovascular treatment was chosen because of his unstable hemodynamics. He fell into cardiac arrest 10 minutes after the operation started, and we implanted 2 stent-grafts while giving cardiac massage. After 23 minutes cardiac massage, he was resuscitated. He was discharged without any complication. Even if no signs of aortic aneurysms or aortic dissection were detected, the possibility of spontaneous aortic rupture should be suspected. Endovascular treatment is a reliable option in the case of unstable hemodynamics.

Insights of stroke in aortic arch surgery: identification of significant risk factors and surgical implication.

PURPOSE: Although the outcomes of aortic arch surgery have improved, stroke remains one of the most devastating complications. Therefore, identification of true risk factors and understanding the pathogenesis of intraoperative stroke are necessary to decrease its occurrence. METHODS: From January 2002 to December 2010, a total of 251 consecutive patients underwent aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion in our hospital. Hemiarch replacement cases were excluded. Of the remaining patients, 190 elective cases that could be reviewed with full perioperative clinical data were analyzed. Strokes were classified into three subtypes according to their distribution on imaging studies: multiple-embolism type, hypoperfusion type, and solitary-embolism type. RESULTS: Operative death occurred in 1.1% of patients (2/190), and aortic arch surgery-related in-hospital death occurred in 5.3%. Among the 188 survivors, intraoperative strokes occurred in 5.9%. Multiple-embolism, hypoperfusion type, and solitary-embolism stroke occurred in 2.7%, 2.1%, and 1.6%, respectively. Multivariate analysis revealed that the risk factor for multiple-embolism stroke was high-grade atheroma in the ascending aorta [P < 0.001, odds ratio (OR) 118.0], and that for hypoperfusion type stroke was prolonged brain ischemia time over 120 min (P = 0.004, OR 31.5). No significant risk factor was found for solitary-embolism stroke. CONCLUSION: Intraoperative strokes during elective aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion are strongly influenced by the presence of a high-grade atheroma in the ascending aorta and prolonged brain ischemia time. The results suggest that these are key issues to reduce stroke in aortic arch surgery.

Occlusion of left coronary artery ostium by left coronary cusp fusion.

We report two cases of adults who had occlusion of the left coronary artery ostium by the left coronary cusp. Both patients were treated with the Bentall procedure, and both revealed a good, long-term course. We offer proper strategy of perioperative management consisting of precise preoperative diagnosis with a multimodality imaging study and adequate operative technique.

A case report of valve dysfunction associated with abrasion of the Delrin disk used in early Björk-Shiley mitral valves requiring resurgery.

A 39-year-old woman had undergone mitral valve replacement (MVR) (29-mm Björk-Shiley Delrin disk) at 6 years of age. Severe mitral regurgitation, aortic regurgitation, and left ventricular dilatation were detected by echocardiography in October 2006, and MVR (ON-X 25 mm) and aortic valve replacements (St. Jude Medical Regent, 21 mm) were performed in December. The Delrin disk of the previous prosthetic valve, located at the position of the mitral valve, was markedly abraded, broadening the clearance from the valve seat. The postoperative course was smooth without complications, and the patient was discharged, walking by herself, on day 19 after surgery. A Delrin disk was used for the tilting valve in early Björk-Shiley valves, but has been replaced by pyrolytic carbon because of problems with durability of the Delrin material. Follow-ups of patients who have undergone procedures using Delrin disks ares necessary, with consideration of valve replacement.

A case of heparin-induced thrombocytopenia with repeated episodes of acute lower extremity arterial thromboembolism during a short time.

The patient was a 55-year-old female. On the diagnosis of the right acoustic tumor, a subtotal extirpation was performed. Heparinized solution was administered, and on postoperative day 7, an occlusion of the left common femoral artery was confirmed. A continuous administration of heparin was initiated after a thrombectomy. On the following day, the platelet count decreased. Following confirmation of the recurrence of thromboembolism, we again performed a thrombectomy. Considering the possibility of heparin-induced thrombocytopenia (HIT), we terminated the administration of heparin, and treatment with danaparoid and argatroban was initiated. Two days later, she redeveloped thromboembolism. After the administration of danaparoid was terminated, the platelet count improved.