[Predictors of chronic aortic events associated with uncomplicated type B aortic dissection].

OBJECTIVE: Stent-graft repair may emerge as a first-line therapy for acute complicated type B dissection(C-TBD), while debate continues over thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (U-TBD). Aggressive medical therapy, which confers a 1-year survival rate of 80-90%, is deemed appropriate for most of these patients. However, it is reported that aortic complications occur in ≤ 50% patients within 5 years after surgery. Subgroups of patients with U-TBD may benefit from early stent-graft placement, but identification of these patients remains difficult. Therefore, we assessed the predictors of chronic aortic events associated with U-TBD. METHODS: Between January 2001 and April 2012, 49 patients diagnosed with communicating U-TBD without aneurysm formation were admitted to our hospital. These patients were divided into 2 groups:group AC (n=25) with chronic aortic complications (aneurysm formation, aortic diameter expansion of 5 mm/0.5 year, re-dissection, and rupture) and group NC (n=24)with no aortic complications. We assessed and compared patient profiles and imaging findings between the 2 groups. RESULTS: Aortic diameter ≥ 40 mm was more often seen in group AC than in group NC (p=0.018). In addition, intimal tear in the distal arch was more often seen in group AC than in group NC ( p=0.002). Initial aortic diameter was significantly larger in group AC than in group NC (p=0.004). There was no significant difference in the length of communicating false lumen between the 2 groups ( p=0.107). CONCLUSIONS: Early endovascular intervention may be appropriate for U-TBD in cases displaying an initial aortic diameter ≥ 40 mm and an initial tear in the distal arch. It is expected that randomized studies, including ADSOAB study (a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta.), will resolve the limitations of our retrospective study.

Clinical benefits of methylprednisolone in off-pump coronary artery bypass surgery.

BACKGROUND: It has not been established whether off-pump coronary artery bypass grafting (OPCABG) is less invasive than conventional CABG. In our experience, OPCABG has several advantages such as shorter operative duration, decreased requirement of blood transfusion and myocardial protection compared with conventional CABG. However, frequency of postoperative paroxysmal atrial fibrillation (PAF) is similar between these techniques and early postoperative C-reactive protein (CRP) levels have been shown to be significantly higher in OPCABG. We hypothesized that preoperative steroid administration, routinely used only in conventional CABG, may alleviate high postoperative PAF and CRP levels. Therefore, a prospective, double-blind, clinical trial was conducted in OPCABG patients to investigate the clinical effects of preoperative steroid administration. METHODS: Thirty OPCABG patients were randomly divided into 2 groups: control (Group C: n = 15) and methylprednisolone (Group M: n = 15) groups. Group M patients were intravenously administered 1000 mg methylprednisolone during anesthesia induction. RESULTS: Hospital death and infectious complication such as mediastinitis were not observed in either group. Postoperative PAF occurred in 47 % (7/15) of patients in group C but in only 1 patient in group M (7 %, P = 0.013). Early postoperative CRP levels were significantly lower in group M than in group C (peak values on postoperative day 2: group M 15 ± 6 mg/dL vs. group C 23 ± 4 mg/dL; P = 0.0002). CONCLUSIONS: Preoperative steroid administration in OPCABG patients significantly suppresses CRP elevation and prevents postoperative PAF without increasing in-hospital mortality or infectious complications.

[Operative invasiveness of off-pump coronary artery bypass grafting].

OBJECTIVE: In our institution, steroid is administrated intravenously during the anesthesia induction for conventional coronary artery bypass grafting( CABG) to prevent the inflammatory response due to cardiopulmonary bypass and reperfusion injury, however, steroid is not used for off-pump CABG (OPCAB) with expectation of less invasiveness of the procedure. We evaluated the early outcomes and postoperative inflammatory response of conventional CABG with preoperative steroid use and OPCAB. METHODS: From May 2004 to April 2010, 120 patients underwent elective CABG requiring the ventricle elevation to expose the target vessels. Twenty eight patients(group C)treated with conventional CABG and 92 patients (group O) with OPCAB. Perioperative course was analyzed and compared between the 2 groups. RESULTS: OPCAB had several advantages such as shorter operative duration, decreased requirement of blood transfusion and myocardial protection compared with conventional CABG. However, frequency of postoperative paroxysmal atrial fibrillation was similar between these techniques and early postoperative C-reactive protein levels were shown to be significantly higher in OPCAB. CONCLUSIONS: OPCAB has advantage over conventional CABG in blood loss during surgery and myocardial protection. However the inflammatory response was significantly severe in OPCAB. OPCAB might become less invasive with the anti-inflammatory medication.

[Distal anastomosis using parachute technique with 4 stay-sutures for Stanford type A acute aortic dissection].

OBJECTIVE: Distal anastomosis in total arch repair for type A acute aortic dissection is difficult because of fragile aortic wall and time-limiting procedure. Until 2008, distal anastomosis was performed with continuous suture technique at 20 ℃, and parachute technique with 4-stay sutures at 26 ℃ was introduced in our institution. This new technique was compared with previous distal anastomosis with continuous suture technique. METHODS: From May 1997 to December 2010, 40 patients underwent emergent arch repair for type A acute aortic dissection. Continuous suture technique was used in 23 patients (group C) and parachute technique with 4 stay-sutures was used in 17 patients( group P). RESULTS: Patient's demographics did not differ between the 2 groups and there was no difference in perioperative or hospital death in the 2 groups. Lower limb ischemic time, cardiac ischemic time, cardiopulmonary bypass time and operation time were significantly shorter in group P. CONCLUSIONS: Distal anastomosis using parachute technique with 4-stay sutures in arch repair for type A acute aortic dissection seems to be useful compared with continuous suture technique.

Effect of type II endoleaks and antiplatelet therapy on abdominal aortic aneurysm shrinkage after endovascular repair.

OBJECTIVE: Endovascular repair of abdominal aortic aneurysm (EVAR) has been shown to be safe, and its use is increasing rapidly, but the long-term results of this procedure remain unclear. A decrease in the diameter of the aneurysm sac is considered to represent successful exclusion of the aneurysm from the circulation, but it has been reported that aneurysm shrinkage occurs in only about 60% of patients who have undergone EVAR. We analyzed several factors to determine whether they were related to aneurysm shrinkage after EVAR. METHODS: From March 2007 to January 2010, EVAR was performed in 65 patients, 58 of whom underwent an enhanced computerized tomographic evaluation 6 months after the procedure. One patient was found to have a type Ia endoleak and was excluded from the study. In the remaining 57 patients, univariate and multiple regression analyses were used to determine whether there was a relationship between aneurysm shrinkage and various patient characteristics, aneurysm dimensions, and procedural outcomes. Aneurysm shrinkage was defined as a decrease in diameter of at least 4 mm. RESULTS: On univariate analysis, a lack of aneurysm shrinkage by 7 days and 6 months after EVAR was significantly associated with hyperlipidemia, ongoing multiagent antiplatelet therapy with clopidogrel, ticlopidine, or cilostazol as well as aspirin, length of the proximal neck of the aneurysm, preprocedure maximum aneurysm diameter, and the presence of a type II endoleak. On multiple regression analysis, only multiagent antiplatelet therapy and type II endoleak were significantly related to a lack of aneurysm shrinkage 6 months after EVAR. Multiagent antiplatelet therapy and type II endoleak 6 months after EVAR were not significantly associated with each other. CONCLUSION: Patients with a persistent type II endoleak and patients undergoing multiagent antiplatelet therapy are at an increased risk of a lack of aneurysm shrinkage 6 months after EVAR.

Endovascular repair and pharmacotherapy of an inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula.

An inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula was successfully treated by stent grafting. Pharmacotherapy with octreotide after endovascular aneurysm repair was also performed with the expectation of spontaneous and rapid closure of the fistula. Gastrointestinal endoscopy performed 10 days after endovascular aneurysm repair showed closure of the large aortoduodenal fistula, and oral intake was started on the operative day 16. To date, 16 months after the initial operation, the patient is doing well without any symptoms or signs of infection and without any antibiotic therapy.

Bronchial and cardiac ruptures due to blunt trauma.

Tracheobronchial and cardiac injuries following blunt thoracic trauma are uncommon but can be life-threatening. We report a case in which the patient with bronchial and right atrial ruptures due to blunt trauma survived after emergent repairs. An 18-year-old female driver was transported to our hospital after a traffic accident and was hemodynamically stable on arrival. Chest computed tomography revealed cervicomediastinal emphysema and hemopericardium, and fiberoptic bronchoscopy showed a tear in the right main bronchus. She was intubated with a double-lumen endotracheal tube guided by bronchoscopy. A median sternotomy was undertaken, and a laceration of the right atrium was oversewn without the use of cardiopulmonary bypass. After that, right-sided thoracotomy was performed. The tear in the membranous portion of the right main bronchus was repaired with interrupted sutures, and the suture lines were wrapped with a pedicled flap of intercostal muscle.

Endovascular management for ruptured Stanford B acute aortic dissection.

Surgery for a complicated Stanford B acute aortic dissection, such as rupture or malperfusion, is still a challenge. We undertook endovascular therapy for ruptured Stanford B acute aortic dissection in two patients. A homemade stent graft was deployed in an 84-year-old woman with a massive mediastinal hematoma; and an aortic extender of Excluder was used for a 76-year-old man with left hemothorax. Both patients recovered without major complications. Careful follow-up is mandatory. Endovascular therapy for a ruptured Stanford B acute aortic dissection seems feasible and efficient.

Forty-year survival with Smeloff-Cutter and Starr-Edwards prostheses.

This case study describes a 40-year follow-up of a man who had a double valve replacement with Smeloff-Cutter aortic (Cutter Laboratories, Berkeley, CA) and Starr-Edwards mitral prostheses (Edwards Laboratories, Santa Ana, CA) when he was 34 years old. Double valve replacement was performed for aortic and mitral valve stenosis and insufficiency. To date, no surgical treatment has been required except a pacemaker implantation. The patient presented with a New York Heart Association functional class of I to II. Echocardiography revealed intact prostheses.

Primary cardiac chondrosarcoma with large cell pulmonary carcinoma.

A 55-year-old man was transferred to our hospital for removal of cardiac and pulmonary tumors. Transesophageal echocardiography demonstrated a large echogenic mass in the left ventricle. The mass was attached to the posterior wall of the left ventricle and the mitral valve. Chest computed tomography showed a solitary, well-defind nodular lesion in the right upper lung. We performed concomitant resection of cardiac and pulmonary tumors through a midline sternotomy. The pathological diagnosis was cardiac chondrosarcoma with pulmonary large cell carcinoma. Postoperatively pelvic computed tomography, bone and gallium scintigrams did not identify any other active lesion, hence the cardiac tumor was considered to be of cardiac origin. He is alive 20 months after the operation and findings from the cardiac and pulmonary examination are unremarkable. Primary cardiac chondrosarcoma is extremely rare, and to our knowledge, only 13 cases have been recorded. We summarize herein these 14 cases.