Benefits and Risks of Delayed Surgery for Ventricular Septal Rupture after Acute Myocardial Infarction.

The timing of surgery for ventricular septal rupture (VSR) after acute myocardial infarction (AMI) remains controversial. This study investigated the benefits and risks of delayed surgery for post-AMI VSR and examined differences in echocardiographic findings between early and delay groups.A total of 38 consecutive patients with post-AMI VSR who underwent surgery at our hospital between May 2003 and November 2020 were retrospectively analyzed. Our strategy was to delay surgery until 2 weeks after AMI. If patients demonstrated organ dysfunction, we considered early surgery. Patients were divided into early (n = 20; 53%) and delay (n = 18; 47%) groups. Risks and benefits were investigated based on echocardiographic findings during the waiting period. The delay group had more preoperative intravenous catheter infections (P = 0.008) but fewer reoperations (P = 0.02) and lower operative mortality (P = 0.04) than the early group. The VSR defect diameter and total pulmonary blood flow to total systemic blood flow (Qp/Qs) increased in both groups while waiting. Nevertheless, the early group had a significantly higher Qp/Qs change rate than the delay group (P = 0.05). The 30 day and hospital mortality rates were 5.3% and 13.2%, respectively.The VSR defect diameter and Qp/Qs in both groups increased with time and can therefore become risk factors. Nonetheless, the benefit of waiting exceeded the risk because our outcomes were better than those previously reported.

Secondary Aortoesophageal Fistula Treated by Covered Esophageal Stent and Muscle Wrapping.

Secondary aortoesophageal fistula is rare but is associated with serious complications and high mortality. We devised a treatment strategy involving a covered esophageal stent, instead of esophageal resection, and placing the latissimus dorsi muscle around the infected aorta without removing the aorta and the stent graft. A 72-year-old man with a history of total arch replacement with a frozen elephant trunk for a thoracic dissecting aneurysm developed aortoesophageal fistula and underwent surgical treatment using our strategy. He recovered well, with no evidence of reinfection 6 months after surgery. This strategy may be a less invasive surgical option.

Surgical Treatment for Primary Mycotic Aneurysms Using Endovascular Therapy, Focusing on Patient Selection: Single-Center Experience.

Background: Mycotic aneurysms (MAs) are relatively rare but life-threatening. Some recent reports have described the use of endovascular therapy for their treatment; however, this still is a controversial treatment, and a definite target population has not been determined. Methods: We performed surgery on 34 patients with MAs from March 2005 to March 2019. Twenty patients who underwent open surgery (OS) first comprised the OS group, and 14 patients who underwent endovascular therapy first comprised the stent-graft (SG) group. We analyzed between-group differences, long-term outcomes, and risk factors for death retrospectively. Patients in the OS group had a higher initial white blood cell count than those in the SG group (p = 0.047). The SG group had more patients with a low albumin concentration (≤2.0 mg/dL) than did the OS group (p = 0.026). Results: There were no significant differences in the operative mortality rates between the groups (p = 0.773). Additional procedures were required more often in the SG than the OS group (p = 0.0013). The overall survival rate as estimated by the Kaplan-Meier method was 88% at 1 month, 67% at 1 year, 57% at 3 years, and 45% at 10 years. In the univariable analysis, chronic obstructive pulmonary disease (COPD) was a risk factor for death (p = 0.003). Conclusions: Endovascular therapy for MAs produced reasonable outcomes when patient selection was based on the activity level, nutritional condition, and degree of inflammation. Endovascular therapy may become an option for patients with a low albumin concentration or COPD despite the fact that additional procedures may be needed.

Influence of Luminal Communication on Aortic Enlargement after Hemiarch Replacement for Acute Type A Aortic Dissection.

BACKGROUND: Aortic enlargement after hemiarch replacement (HAR) for acute type A aortic dissection (AAAD) is a serious problem. We reviewed our experience and analyzed the risk factors for aortic enlargement. METHODS: During April 2005 to December 2017, 364 patients underwent HAR for AAAD. Seventy-three patients fulfilled the inclusion criteria. We analyzed the change in aortic diameter, aortic growth rate, and major adverse aortic events (MAAEs) and their association with luminal communication of the aortic arch. RESULTS: Anastomotic communication, supra-aortic communication (SAC), and distal aortic communication were found in 34 (46.6%), 28 (38.4%), and 20 (27.4%) patients, respectively. The aortic growth rate was high because of the presence of SAC, distal aortic communication, and the number of coexisting aortic communication. Univariate analysis showed that the presence of SAC and an initial aortic diameter > 35 mm at 20 mm distal to the left subclavian artery and at the pulmonary artery bifurcation (PAB) were risk factors for MAAEs. Multivariate analysis showed that SAC and an initial aortic diameter > 35 mm at the PAB were independent risk factors for MAAEs. CONCLUSION: SAC, distal aortic communication, and the number of coexisting aortic communication are significant risk factors for aortic enlargement after HAR for AAAD. SAC and an initial aortic diameter > 35 mm at the PAB are independent risk factors for MAAEs after this procedure.

Successful Surgical Treatment of an Infected Thoracoabdominal Aneurysm Accompanied with Leriche Syndrome.

A 56-year-old man presenting with massive melena and loss of consciousness was diagnosed with an infected thoracoabdominal aneurysm, an aortoduodenal fistula, and Leriche syndrome following an evaluation by computed tomography. Emergency surgery for uncontrolled infection included the reconstruction of the superior mesenteric and bilateral renal arteries using a four-branched graft. The aortoduodenal fistula was resected after omental filling, and an enterostomy was performed for feeding. Intestinal reconstruction was performed in two stages. The patient was discharged on postoperative day 48 and was without evidence of recurrence at 23 months postoperatively.

Renal Stent Migration Following TEVAR for Complicated Type B Aortic Dissection.

We describe renal stent migration following thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. A 68-year-old male presented with type B aortic dissection. His course was complicated by renal and lower extremity malperfusion. Thoracic endovascular aortic repair was performed and completion angiogram showed no flow in the left renal artery. A renal stent was deployed with the proximal margin of the stent 1 mm into the aortic true lumen, providing improved renal perfusion. One week after TEVAR, contrast-enhanced computed tomography (CT) revealed that the renal stent had embolized to the aortic bifurcation. Additional endovascular therapy successfully crushed the renal stent against the iliac artery wall utilizing a larger bare metal stent. At 3 year follow-up, contrast-enhanced CT demonstrated good patency of the left renal artery and right iliac artery. This complication alerts physicians to consider subsequent aortic remodeling during endovascular intervention for acute aortic dissection with malperfusion.

Distal Neo-Neck Formation for Chronic Type B Dissection: False Lumen Closure After TEVAR.

OBJECTIVES:: Patients with chronic aortic dissection often require repeat interventions due to enlargement of the pressurized false lumen or disseminated intravascular coagulation even after additional thoracic endovascular aortic repair (TEVAR) to occlude the entry tear. Residual false lumen flow can persist even after performing the candy-plug technique or branched stent-graft placement in some cases. We have devised a new method for false lumen closure. METHODS:: From December 2010 to May 2017, 5 patients (mean age: 57 [13] years, range: 43-77 years) with chronic dissection at the aortic arch and descending aorta, who underwent initial TEVAR, required additional treatment. Using an open surgical approach, the endograft was fixed with an outer felt under cardiopulmonary bypass after the endograft with stent was expanded by fenestration. The false lumen was closed using this procedure, and the aortotomy was repaired by direct closure in 2 cases and by graft replacement in 3 cases. RESULTS:: No major operative complications occurred, such as respiratory failure or paraplegia. Postoperative enhanced computed tomography (CT) images showed that the false lumen flow disappeared in all cases. All patients were discharged under normal conditions. They were all followed up and their CT did not indicate any complications for a mean of 33.6 (20.3) months. CONCLUSIONS:: Our combined procedure was effective and provided a higher success rate compared with endovascular therapy alone. This staged treatment approach, using a combination of TEVAR and false lumen closure, is less invasive compared with open surgery alone and may represent a valid treatment option for chronic type B dissection.

Graft-Sparing Strategy for Thoracic Prosthetic Graft Infection.

OBJECTIVE: Thoracic prosthetic graft infection is a rare but serious complication with no standard management. We reported our surgical experience on graft-sparing strategy for thoracic prosthetic graft infection. METHODS: This study included patients who underwent graft-sparing surgery for thoracic prosthetic graft infection at Matsubara Tokushukai Hospital in Japan from January 2000 to October 2017. RESULTS: There were 17 patients included in the analyses, with a mean age at surgery of 71.0 ± 10.5 years; 11 were men. In-hospital mortality was observed in five patients (29.4%). CONCLUSIONS: Graft-sparing surgery for thoracic prosthetic graft infection is an alternative option particularly for early graft infection after hemiarch replacement.

Strategy of delayed surgery for ventricular septal perforation after acute myocardial infarction.

BACKGROUND: The timing of surgical repair for ventricular septal perforation (VSP) is important because patients are susceptible to bleeding from fragile myocardial tissue or residual shunt during the acute phase of acute myocardial infarction (AMI). This study aimed to assess the results of delayed surgery for VSP performed 2 weeks after AMI. METHODS: In total, 24 consecutive postinfarction patients with VSP (mean age: 72.6±10.4 years; 13 males) underwent operation between May 2003 and June 2016. We postponed surgery during the acute phase and performed an elective surgery if the patient could wait for 2 weeks with support from intra-aortic balloon pumping (IABP) and respiratory management. If we could not control heart failure and organ function worsened during that period, we performed emergency surgery. Postoperative outcomes included complications, 30-day mortality rate, long-term hospital death, reoperation rate, and risk factors for hospital mortality. We examined whether organ function was maintained by delaying the surgery. RESULTS: Of the 24 patients, 11 (45.8%) required emergency surgery, and 13 (54.2%) could wait 2 weeks for surgery. The average time from AMI onset to diagnosis of VSP was 4.5±1.6 days, and the average time from VSP diagnosis to surgery was 9.0±6.0 days; 5 patients (20.8%) required resurgery for VSP due to residual shunt, recurrent VSP, or pseudoaneurysm of the left ventricle. The 30-day mortality rate was 4.2% (1 patient), and long-term hospital mortality rate was 12.5% (3 patients). Organ function was maintained in 10 patients (76.9%) who underwent elective surgery, and organ dysfunction was not advanced by delaying the surgery. CONCLUSIONS: We could delay surgery for an average of 9 days from VSP onset by means of IABP or respiratory management without the deterioration of organ function. The 30-day mortality and long-term outcome were favorable.

Resternotomy Plus Left Thoracotomy Surgery after Previous Acute Type A Aortic Dissection Repair.

BACKGROUND: As the results of acute type A aortic dissection repair have improved, late reoperation for residual dissection has become increasingly important. We report our experience of graft replacement via extended approaches after a previous acute type A aortic dissection repair. METHODS: From April 2003 to September 2016, 17 patients underwent reoperation via extended (repeat median sternotomy plus left thoracotomy) approaches after a previous repair of an acute type A aortic dissection at the Matsubara Tokushukai Hospital in Japan and were included in the analyses (males, 16; mean age at surgery, 60.0 ± 9.3 years). RESULTS: The postoperative stroke and in-hospital mortality rates were 0 and 5.9%, respectively. CONCLUSION: Extended approach after a previous acute type A aortic dissection repair showed acceptable outcomes.