Optimal stent length and distal positioning of frozen elephant trunks deployed from the aortic zone 0 for type A acute aortic dissection.

OBJECTIVES: To investigate the optimal stent length and distal positioning of frozen elephant trunks (FETs) in patients with type A acute aortic dissection (TAAD). METHODS: Between October 2014 and April 2021, 191 patients (FET-150 group: 37 patients; stent length, 150 mm; 66.3 ± 12.6 years and FET-non-150 group: 154 patients; 60, 90, or 120 mm; 64.1 ± 12.5 years) underwent total arch repair with FETs for TAAD using the "zone 0 arch repair" strategy. In the FET-150 group, the proximal stent end was positioned at the innominate artery origin of the arch. In the FET-non-150 group, the distal stent end was to be positioned just proximal to the aortic valve level using transesophageal echocardiography. The proximal end of the non-stented FET part was sutured to an arch graft together with the aortic wall at 1 to 2 cm proximal to the innominate artery origin. RESULTS: Distal stent ends were positioned at the thoracic vertebrae (Th) 4-5, 6-7, 8-9, and 10 levels in 0 (0%), 12 (32.4%), 25 (67.6%), and 0 (0%) patients, respectively, in the FET-150 group, and in 6 (3.9%), 98 (63.6%), 49 (31.8%), and 1 (0.7%), respectively, in the FET-non-150 group. No between-group difference in postoperative mortality was noted. The incidence of postoperative residual distal malperfusion and new-onset spinal cord ischemia in the FET-150 versus FET-non-150 groups were 2.7% versus 6.5% (P = .62) and 0% versus 1.9% (P = 1.00), respectively. CONCLUSIONS: FET positioning with the distal stent end at around Th 8 can reduce residual distal malperfusion when a FET with a 150-mm stent is deployed from the aortic zone 0 in patients with TAAD undergoing total arch repair.

Aortic remodeling, reintervention, and survival after zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection: Midterm results.

Objectives: To investigate the midterm results after zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection. Methods: Between October 2014 and April 2021, 196 patients underwent zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection. The true lumen area, aortic lumen area, and false lumen status were assessed at four aortic levels, the proximal and distal descending thoracic aorta (level A and level B, respectively), celiac artery branching (level C), and terminal aorta (level D). Aortic remodeling (postoperative area as a percentage of the preoperative area) was classified into 3 groups, positive (true lumen area ≥120% with aortic lumen <120% or true lumen area ≥80% with aortic lumen <80%), minimal (80% ≤ true lumen area and aortic lumen area <120%), and negative remodeling (all other changes). Results: In-hospital mortality was 13 (6.6%) patients. The overall survival rate was 85.1% at 5 years. The freedom from distal aortic reintervention was 89.9% at 5 years. The prevalence of completely thrombosed or obliterated false lumen at 2 years was 96.8% at level A, 88.4% at level B, 47.2% at level C, and 27.6% at level D. The prevalence of positive aortic remodeling at 2 years was 84.7% at level A, 75.0% at level B, 29.2% at level C, and 16.7% at level D. Conclusions: Zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection can avoid invasive aortic arch resection and facilitate aortic remodeling of the descending thoracic aorta. The FET effect on aortic remodeling is limited at the aortic level below the FET stent end.

Enhanced strategy against mediastinitis with thoracic vascular graft infection: A combination of hydro-debridement with pulsed lavage and negative pressure wound therapies.

BACKGROUND: We investigated the effects of hydrodebridement with pulsed lavage (HDPL) and negative pressure (NP) wound therapies, instead of excising the prosthetic graft, in patients with postoperative thoracic vascular graft infection (TVGI). METHODS: Between 2020 and 2021, five TVGI patients aged 49.6 ± 19.4 years old underwent a combined therapy of HDPL and NP. The patients underwent a two-step procedure (first step: re-sternotomy and HDPL; second step: NP) every 3 or 4 days. After negative tissue culture, the patients underwent omentum flap wrapping and skin closure. RESULTS: No hospital death was observed. The time to skin closure was 10.8 ± 3.4 days. The time to the day in which bacteria were not cultured was 3.5 ± 2.4 days. No recurrent infections occurred for 241 ± 186 postoperative days. CONCLUSION: Our strategy for TVGI patients may contribute to (1) sufficient infection control, (2) physical rehabilitation, and (3) less invasiveness for high-risk patients.

Pacemaker Lead-induced Tricuspid Valve Stenosis and Reverse Lutembacher Syndrome.

Reverse Lutembacher syndrome is a rare cause of hypoxia characterized by the triad of tricuspid valve stenosis, elevated right atrial pressure, and an interatrial right-to-left shunt. We report a case of pacemaker lead-induced reverse Lutembacher syndrome in a 45-year-old woman who presented with dyspnea. The patient also developed pacemaker lead-induced superior vena cava obstruction accompanied by a right-to-left shunt through systemic-to-pulmonary venous collaterals, which exacerbated the hypoxia. Tricuspid valve replacement using a bioprosthetic valve and patent foramen ovale closure improved her hypoxia.

Right coronary ostium occlusion by aortic valve tumor during systole.

Here, we present a case of acute myocardial infarction caused by an aortic valve tumor. Electrocardiography (ECG)-gated four-dimensional computed tomography revealed obstruction of the right coronary ostium by a mobile mass during systole. To ensure an accurate diagnosis of angina in patients without significant coronary artery disease, ECG-gated four-dimensional computed tomography is useful because it can simultaneously visualize the coronary ostium and arteries, aortic valve leaflets, and mass.

Endovascular rescue for malpositioned frozen elephant trunk into the false lumen.

We describe a case of frozen elephant trunk deployment unintentionally malpositioned into the false lumen. An 83-year-old man underwent total arch repair with a frozen elephant trunk for type A acute aortic dissection complicated by mesenteric malperfusion. However, intraoperative transesophageal echocardiography showed expansion of the false lumen in the descending aorta, suggesting a malpositioned frozen elephant trunk into the false lumen. Endovascular fenestration of the dissecting flap and subsequent endograft deployment from the inside of the malpositioned frozen elephant trunk graft to the true lumen of the descending aorta was successfully performed under intravascular ultrasound guidance.

Avoiding anticoagulation drugs for postoperative atrial fibrillation enabled successful conservative treatment of left atrial dissection: a case report.

BACKGROUND: Left atrial dissection is a rare complication of cardiac surgery, most commonly associated with mitral valve surgery. Herein, we report on the successful conservative treatment of left atrial dissection while avoiding anticoagulation therapy. CASE PRESENTATION: A 64-year-old man developed left atrial dissection during operation for acute type A aortic dissection, most likely due to retrograde cardioplegia cannulation. As there was no connection between the left atrial dissection cavity and the left atrium on enhanced computed tomography, we did not administer anticoagulants to prevent expansion of the left atrial dissection cavity. However, the patient developed atrial fibrillation, which was successfully managed by beta-blocker and amiodarone administration. Follow-up imaging showed gradual left atrial dissection reduction, and the patient was started on anticoagulation therapy. CONCLUSION: We were able to resolve left atrial dissection by preventing the use of anticoagulation therapy in the acute stage by managing the atrial fibrillation with antiarrhythmic drugs.

[Traction-assisted Negative Pressure Wound Therapy for Pediatric Poststernotomy Mediastinitis:Report of Two Cases].

We herein report two cases of pediatric poststernotomy mediastinitis treated by traction-assisted negative pressure wound therapy (NPWT) with Zip Surgical Skin Closure (Zip), which is a non-invasive skin closure device. We used this device with NPWT in cases of pediatric poststernotomy mediastinitis to stabilize the sternum and reduce the natural retractive forces of the skin. The patients were two boys (two and three months old), with an onset of infection at 13 and eight postoperative days, respectively. The culture examination detected methicillin-susceptible Staphylococcus aureus in both cases. Traction-assisted NPWT with Zip was performed at-75 mmHg for 16 and 33 days, and the wounds healed completely. In conclusion, this modification was successfully applied to treat pediatric poststernotomy mediastinitis and may help reduce the duration of treatment.

Calcified Aortic Wall Removal for Dysphagia Aortica Caused by Chronic Traumatic Aortic Pseudoaneurysm.

In this study, we report a case of a 45-year-old man with dysphagia aortica secondary to chronic traumatic aortic pseudoaneurysm of the aortic isthmus. He had been involved in a motor vehicle accident 27 years earlier. Computed tomography demonstrated a severely calcified aortic pseudoaneurysm of the aortic isthmus that compressed the esophagus extrinsically. An invasive surgical procedure involving a graft replacement and removal of the calcified aortic wall released the esophageal compression and completely improved the patient's symptoms. To the best of our knowledge, a case of dysphagia aortica caused by calcified pseudoaneurysm has never been reported.

Direct Abdominal Aortic Access for Thoracic Endovascular Aortic Repair in a Patient with Severe Aortic and Arterial Calcification.

Aortic and arterial calcification is a complication of advanced atherosclerosis and is a critical intraoperative issue that can reduce the ability to achieve safe and adequate access for stent graft introduction. Different vascular access sites are used to deliver stent grafts when a standard transfemoral or iliac access is not feasible. We report a challenging case of a direct transabdominal aortic thoracic endovascular aortic repair for a thoracic aortic aneurysm complicated with severe aortic and arterial calcification, in which the noncalcified area of the infrarenal abdominal aorta was extremely limited. This may be a reasonable access site, especially for patients with severe aortic and arterial calcification.

[Thoracic Endovascular Repair for Chronic Aortic Dissection with Aberrant Origin of the Left Vertebral Artery;Report of a Case].

We herein report a case of thoracic endovascular aortic repair( TEVAR) for chronic aortic dissection with an aberrant left vertebral artery( LVA) originating from the aortic arch. A 51-year-old man with a medical history of Stanford type B acute aortic dissection 2 years ago was transferred to our institution for the treatment of an aortic expansion. Computed tomography showed a large entry just distal to the takeoff of the left subclavian artery and a dilated dissected thoracic aorta. A left cervical incision over the anterior border of the sternocleidomastoid was made, and the LVA was identified. The proximal LVA was ligated and anastomosed to the left common carotid artery in an end-to-side fashion. After completion of the carotid-subclavian bypass, TEVAR was performed in the usual fashion. The postoperative course was uneventful without stroke or spinal cord injury. At the 1-year follow-up, the false lumen had shrunk and the LVA remained patent.

[Tricuspid Valve Replacement Preserving the Leaflets in a Congenitally Corrected Transposition of the Great Arteries;Report of a Case].

In patients with a congenitally corrected transposition of the great arteries (ccTGA), the regurgitation of the systemic atrioventricular valve (SAVV) increases and anatomical right ventricular (ARV) dysfunction often progressively develops. A low systemic ventricular ejection fraction( SVEF) is a risk factor for mortality. However, in patients with a low ejection fraction of ARV, it is unclear how to best perform valve replacement for patients with regurgitation of SAVV. A 70-year-old female with respirator discomfort was admitted to our hospital and diagnosed to have situs solitus ccTGA, severe SAVV regurgitation, and ARV dysfunction. Her ARV ejection fraction was 25% and she was therefore dependent on inotropic agents. We successfully performed a tricuspid valve replacement while preserving the leaflets, the chorda tendineae's, and papillary muscles, and placing the lead for cardiac resynchronization therapy on the ARV. Her postoperative course was uneventful. Thereafter, she was discharged 6 weeks after surgery.

Multiple graft injury due to migrated nonbroken sternal wires 2 years after cardiac surgery.

The migration of sternal wires into vital structures is a rare but potentially life-threatening complication and associated with infection in some cases. While a few cases have been reported the sternal wires were broken in those cases. To our knowledge, this is the first report of multiple, nonbroken, migrated sternal wires stabbing vascular grafts.

Total arch repair with frozen elephant trunk using the "zone 0 arch repair" strategy for type A acute aortic dissection.

OBJECTIVE: The aim of this study was to investigate the effect of frozen elephant trunk deployment from the zone 0 aorta to the descending aorta on early and midterm postoperative results in patients with acute type A aortic dissection. METHODS: Between October 2014 and April 2018, 108 patients underwent a combined strategy of frozen elephant trunk deployment, ascending aortic replacement, and arch vessel reconstruction ("zone 0 arch repair" strategy) for acute type A aortic dissection (excluding DeBakey type II). Of the 108 patients, 32 (29.6%) had primary tears of the aortic arch or descending aorta. RESULTS: The 30-day mortality rate was 2.8% (3 patients), and in-hospital mortality rate was 6.5% (7 patients). New-onset permanent neurologic dysfunction and spinal cord injury occurred in 3.7% and 0% of patients, respectively. Five of the 101 survivors underwent thoracic endovascular aortic repair during hospitalization (2 for rapid false lumen enlargement; 3 for true lumen stenosis). The overall survival was 89.8%, 88.1%, and 88.1% at 1, 2, and 3 years, respectively. The cumulative incidence of distal aortic reintervention was 5.8%, 9.1%, and 9.1% at 1, 2, and 3 years, respectively. Two patients underwent thoracic endovascular aortic repair for distal aortic enlargement after discharge. CONCLUSIONS: The use of the "zone 0 arch repair" strategy can eliminate the need for invasive aortic arch resection. It also eliminates the false lumen and produces satisfactory early and midterm postoperative results. Therefore, it can be an alternative to hemiarch and total arch replacements, which are based on a conventional "tear-oriented resection" strategy.

Serum Neuron-Specific Enolase Level as Predictor of Neurologic Outcome after Aortic Surgery.

BACKGROUND: This study aimed to evaluate the significance of serum neuron-specific enolase (NSE) level as a predictor of neurologic injury in thoracic aortic surgery. METHODS: We neurologically assessed 60 consecutive patients who underwent thoracic aortic surgery for thoracic aortic aneurysm (n = 26) and aortic dissection (n = 34). Using moderate hypothermic circulatory arrest with antegrade cerebral perfusion, total arch replacement and hemiarch replacement were performed in 37 and 23 patients, respectively. Serum NSE levels in venous blood samples drawn before surgery and at 1 day after surgery were measured. Severity of neurologic injury was categorized as either uncomplicated (n = 48), temporary neurologic dysfunction (TND, n = 5), or permanent neurologic dysfunction (PND, n = 7). The extent of stroke was estimated on computed tomography or magnetic resonance imaging. RESULTS: The NSE level significantly differed among the three groups (PND > TND > uncomplicated) on the first postoperative day. Receiver-operating characteristic curve analysis showed that the cutoff value of NSE level was 34.14 ng/mL for neurologic injury (sensitivity, 0.769; specificity, 0.851) and 43.56 ng/mL for PND (sensitivity, 1.000; specificity, 0.963). The NSE level significantly correlated with the extent of stroke (r = 0.61, p < 0.001). CONCLUSION: Serum NSE level is a significant predictor of adverse neurologic outcomes and extent of stroke after thoracic aortic surgery.

[In situ Replacement with Bovine Pericardial Roll Graft for Infected Aneurysm of the Thoracoabdominal Aorta].

A 63-year-old man presented to a nearby doctor with fever and lumbago. Enhanced computed tomography showed a thoracoabdominal aortic aneurysm and enhancement of soft tissue around the aneurysm. He was diagnosed with an infected thoracoabdominal aortic aneurysm and given antibiotics. After 2 weeks, the infection was controlled and he underwent in situ replacement with a bovine pericardial roll graft. A week after the operation, the inflammatory reaction was increased, but the bovine pericardial roll graft was not infected. This suggests that a bovine pericardial roll graft is a suitable material for use in patients with bacterial infections.

Correction of tetralogy of Fallot in an adult using a stented bioprosthetic valved conduit.

A 55-year-old man with tetralogy of Fallot successfully underwent correction using a valved conduit. He was diagnosed as having congenital heart disease during childhood, but no surgical intervention was performed. Cyanosis and dyspnea on effort had progressed gradually. Catheterization showed a left ventricular end diastolic volume of 126 ml, and the pulmonary arteries had sufficient diameters. To prevent postoperative pulmonary regurgitation, we planned to use a bioprosthetic valved conduit for right ventricular outflow tract reconstruction. At 4.5 years after the operation he is in New York Heart Association functional class I. The catheterization performed 1.5 years after the surgery showed no pressure gradient between the right ventricle and the pulmonary artery. Thus, total correction of tetralogy of Fallot in an adult can be achieved safely, and the use of a bioprosthetic stented valved conduit can be beneficial.