Right anterolateral thoracotomy with partial sternotomy for chronic type B aortic dissection with right aortic arch and Kommerell's diverticulum.

Chronic type B aortic dissection with the right aortic arch was rare. We present the case of a 59-year-old man with a right aortic arch and chronic type B aortic dissection, with a maximum size of 80 mm. Graft replacement was successfully performed through right anterolateral thoracotomy with partial sternotomy through the fourth intercostal space. The patient's postoperative course was uneventful. He had no paralysis and was extubated on postoperative day 2 and discharged from the hospital on postoperative day 15. Anterolateral thoracotomy with partial sternotomy could be a suitable approach for right-sided aortic aneurysms.

Reimplantation approach for an anomalous aortic origin of the right coronary artery with an aberrant right subclavian artery.

Anomalous aortic origin of the right coronary artery is a rare disease. Although there are various reports on its treatment, the method of the surgical approach is still controversial. Here, we present a rare case of a 17 year-old man who had an anomalous aortic origin of the right coronary artery with an aberrant right subclavian artery. As a treatment, he underwent reimplantation of the right coronary artery. The surgical approach for the anomalous aortic origin of the right coronary artery should be selected by considering the age of the patient and size of the right coronary artery.

Hybrid single staged treatment of coronary arteries and aorto-iliac obstruction disease: a case report.

BACKGROUND: If the internal thoracic artery is a collateral circulation to the lower extremities, careful consideration should be given to its use when coronary artery bypass grafting is required. We report a case of CABG with bilateral common iliac artery lesions and collateral circulation from the bilateral ITAs on the peripheral side. CASE PRESENTATION: A 58-year-old man was admitted to our department with claudication and dyspnea upon exertion. He was diagnosed with right common iliac artery obstruction and 90% stenosis of the left common iliac artery. Coronary angiography revealed three-vessel disease with 50% stenosis of the left main trunk. The bilateral ITA showed a rich collateral flow to the lower extremities. Hybrid single staged repair with percutaneous transluminal angioplasty for the left iliac lesion was performed, followed by off-pump coronary artery bypass grafting (CABG) and femoro-femoral crossover bypass. Postoperative angiography revealed that all grafts were patent. The postoperative course was uneventful, except that the patient's creatinine kinase level increased to 7177 U/L on postoperative day 1. CONCLUSION: To treat coronary artery disease with peripheral artery disease, especially those with iliac artery occlusion lesions with collateral circulation from the ITA, not only graft selection but also the treatment strategies for peripheral lesions are considered extremely important. Hybrid single staged coronary and lower limb artery revascularization could be safely achieved by multidisciplinary team strategies.

Proposal of a new classification: "sealed type" postinfarction left ventricular free wall rupture.

OBJECTIVE: Postinfarction left ventricular free wall rupture (FWR) has been classified into blow-out type and oozing type. However, considering past papers, oozing type included the cases in which the bleeding had spontaneously stopped or sealed, and the distinction between blow-out type and oozing type was not always clear. We classified FWR into the BO type (combination of blow-out type and oozing type) with continuous bleeding and sealed type and clarified the pathophysiology of the sealed type. METHODS: Thirty-five patients who underwent surgical treatment for FWR during the past 21 years were retrospectively evaluated. RESULTS: Twenty-one patients (60%) were sealed. Comparing the sealed type with the BO type, the incidence of sudden collapse with acute onset was significantly lower (sealed type; 62%, BO type; 100%, P = 0.0118), and there were more cases of transport from outside the hospital (76%, 43%, P = 0.0453). Significantly few cases had electro-mechanical dissociation immediately before surgery (10%, 71%, P = 0.0001). In the sealed type, median sternotomy was performed in 9 patients (43%), and subxiphoid drainage was performed in 12 (57%). Fifteen patients (71%) were supported by IABP postoperatively, and re-rupture occurred in 3 patients without IABP. Long-term outcomes were significantly better in the sealed type than in the BO type. CONCLUSION: Sixty percent of postinfarction ventricular free wall rupture was the sealed type. Median sternotomy and sutureless repair with postoperative IABP support were reliable treatments. Subxiphoid drainage and strict blood pressure control with IABP may be acceptable surgical strategies in elderly, frail patients.

Brachiocephalic artery dissection is a marker of stroke after acute type A aortic dissection repair.

OBJECTIVE: Postoperative stroke is a serious unsolved complication after acute type A aortic dissection (ATAAD) repair. We investigated the incidence and risk factors of stroke, and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity. METHODS: Between 2012 and 2019, 202 (56% men, median age 68 years) patients with ATAAD underwent surgical repair. Clinical data, image findings, method of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke. RESULTS: Of the 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n = 25). Brachiocephalic artery (BCA) dissection was associated with a higher risk of stroke (odds ratio, 3.89; 95% confidence interval, 1.104-13.780; p = .035) having no relation to the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection. CONCLUSION: BCA dissection was an independent risk factor of stroke after ATAAD repair.

Results of ascending aortic and arch replacement for type A aortic dissection.

OBJECTIVE: The outcomes of emergency surgery for type A acute aortic dissection have improved. However, ascending aortic replacement sometimes leads to dilatation of the distal aorta. The present study reviewed our outcomes of ascending aortic replacement and total arch replacement in patients with type A acute aortic dissection. METHODS: A total of 253 patients with type A acute aortic dissection underwent a central repair operation. Our standard technique was ascending aortic replacement. Total arch replacement was performed only when entry existed in the major curvature of the aortic arch and the proximal descending aorta. A total of 169 patients (67%) underwent ascending aortic replacement, and 84 patients (33%) underwent total arch replacement. Hospital death due to initial surgery, dilatation of the distal aorta greater than 5 cm, new occurrence of aortic dissection, any distal aortic surgery, and aortic-related deaths were defined as distal aortic events. RESULTS: The mortality was 7.1% in the ascending aortic replacement group and 6.0% in the total arch replacement group. Postoperative computed tomography was performed in 162 patients in the ascending aortic replacement group. The false lumen of the residual aortic arch had thrombosed and healed in 94 patients (58%) and remained present in 68 patients (42%). The distal aortic event-free rate in the ascending aortic replacement group decreased from 74% at 5 years to 51% at 9 years, and the rate in the total arch replacement group was 83% at 5 to 9 years (P < .01). For the ascending aortic replacement group, more patients with a dissected arch had a distal aortic event compared with patients with a healed arch (P < .01). CONCLUSIONS: Total arch replacement was associated with fewer distal aortic events. We may expand the indications for total arch replacement in stable patients.

Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation in descending aortic surgery.

Hypoxia during one-lung ventilation is a significant problem in descending aortic surgery via left thoracotomy. Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation (VAPa-ECMO), which consists of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and an additional arterial branch to perfuse a pulmonary artery (Pa), is useful.

Tracheo-innominate artery fistula with continuous bleeding successfully treated through the suprasternal approach: a case report.

BACKGROUND: Tracheo-innominate artery fistula (TIF) is a rare but fatal complication occurring after tracheotomy. Brachiocephalic trunk transection, one of the surgical treatments for TIF, is mostly associated with a full or partial median sternotomy. We describe a case of TIF with continuous bleeding, which was successfully treated with brachiocephalic trunk transection through a collar incision without the need for median sternotomy. CASE PRESENTATION: Case 1. An 18-year-old man was referred to our hospital with bleeding from a tracheal stoma, which had ceased prior to admission. TIF was suspected after examination. Innominate artery transection was performed through a collar incision. TIF was not revealed when we cut the innominate artery anterior wall open; therefore, we opted for preventive surgical intervention. The post-operative course was uneventful, and the patient was asymptomatic at the 3-year follow-up. Case 2. A 14-year-old male patient was admitted to our hospital with bleeding from a tracheal stoma, and TIF was suspected after examination. There was persistent bleeding when the cuff of the tracheotomy tube was deflated. Brachiocephalic trunk transection was performed through a collar incision using balloon occlusion. The post-operative course was uneventful, and rebleeding has not occurred 2 years later. CONCLUSIONS: Brachiocephalic trunk transection without any median sternotomy may offer the benefits of post-operative infection prevention. In patients with suspected continuous bleeding, using a balloon catheter may be a safe and effective method of treatment.

Aortic and Internal Carotid Atherosclerosis in Patients with Carotid Stenosis: Semiautomatic Volumetric Analysis of Low-Attenuation Plaque on Curved Planar Reformations Using MDCT Angiographic Data.

This retrospective study included 65 patients who underwent multidetector computed tomography (MDCT) carotid angiography; 28 patients were <70 years old (group 1), and 37 were ≥70 years old (group 2). Each low-attenuation (<30 Hounsfield units [HU]) plaque volume (LPV) and total uncalcified plaque volume ([TUPV] ≤150 HU) were semiautomatically measured on each aortic arch and internal carotid artery (ICA) curved planar reformations (CPR), using MDCT angiographic data. Correlation coefficients were employed to assess the impact of each plaque volume on various factors including ICA stenosis. The correlations (r > 0.5) were observed between aortic LPV and each ICA stenosis ratio and >30% stenosis in group 1, between aortic TUPV and male gender in group 1, and between ICA-TUPV and each aortic TUPV or the largest plaque thickness in group 2. Marginal correlations were observed between hyperlipidemia and aortic LPV and ICA-TUPV in group 1. There was no association between cerebral infarction and the aortic and ICA plaques. Both the aortic arch and ICA plaque volumes can be measured clinically. The increasing aortic LPV may be a significant factor associated with the development of ICA stenosis in patients younger than 70 years old.

Impact of Isolated Cerebral Perfusion Technique for Aortic Arch Aneurysm Repair in Elderly Patients.

BACKGROUND: In aortic surgery, a severely atherosclerotic aorta is a known risk factor for perioperative stroke. The authors adopted a novel procedure of selective cerebral perfusion, named isolated cerebral perfusion (ICP), for the prevention of stroke during aortic arch operations. METHODS: Between January 2010 and June 2016, 48 patients (mean age, 80 ± 3 years) at Yokohama City University Medical Center, Yokohama, Japan underwent total aortic arch replacement, which included nine emergency cases with rupture. ICP was routinely performed for extracorporeal circulation during total arch replacement. The ICP procedure included the following steps: First, 9-mm Dacron grafts were anastomosed to the bilateral axillary arteries for systemic perfusion. Next, the left common carotid artery (LCCA) was clamped just before starting systemic perfusion. Dissection of the LCCA and insertion of a balloon-tipped cannula into the LCCA were performed. Extracorporeal circulation through the bilateral axillary arteries and selective cerebral perfusion to the LCCA were simultaneously started. Finally, at a bladder temperature of 25°C, clamping of the brachiocephalic and left subclavian arteries was performed. RESULTS: Preoperative evaluation by enhanced computed tomography confirmed that 62.2% of patients had severely atherosclerotic aortas and 37.8% had shaggy aortas. The overall 30-day mortality rate was 2.1%, whereas that for elective cases was 0%. Neurologic deficits developed in 3 patients (6.3%), 1 patient (2.6%) after an elective procedure. The 1-year and 3-year survival rates were 85.3% and 69.5% overall and 87.0% and 70.4% in elective cases, respectively. CONCLUSIONS: ICP during total aortic arch replacement presents an acceptable procedure for elderly patients with severely atherosclerotic aortas.

Semiautomatic Volumetry of Low Attenuation of Thoracic Aortic Plaques on Curved Planar Reformations Using MDCT Angiographic Data with 0.5 mm Collimation.

To evaluate the relationship of aortic low attenuation plaque volume (LAPV) on multidetector computed tomography (MDCT) with the abdominal aortic aneurysm (AAA), the coronary arterial disease (CAD, ≥50% stenosis), severe (≥90% stenosis) CAD, hypertension, and long-term (≥10 years) hypertension. Curved planar reformations (CPR) of three segments (the ascending, the arch, and the upper descending aorta) of the thoracic aorta were generated with attenuation-dependent color codes to measure LAPV with 0~29 HU and total noncalcified plaque volume (TNPV) with 0~150 HU in 95 patients. Correlation coefficients were employed to assess the impact of each LAPV and TNPV on AAA, CAD, severe CAD, hypertension, and long-term hypertension. Each Mean LAPV/cm and TNPV/cm was statistically greater in the aortic arch than the ascending (p < 0.001 on each) or the proximal descending segment (p < 0.001 on each). LAPV in the aortic arch has moderate correlations with AAA, severe CAD, and long-term hypertension (r = 0.643, 0.639, 0.662, resp.). Plaque volumes in each aortic segment can be measured clinically and the increasing LAPV in the arch may be a significant factor associated with the development of severe atherosclerosis underlying AAA, severe CAD, and long-term hypertension.

Early reperfusion strategy improves the outcomes of surgery for type A acute aortic dissection with malperfusion.

OBJECTIVE: The control of malperfusion is the key to improving the outcomes of surgery for type A acute aortic dissection. We revised our treatment strategy to reperfuse each ischemic organ before central repair. METHODS: Our current early reperfusion strategy consists of percutaneous coronary artery intervention for coronary malperfusion, direct surgical fenestration for carotid artery occlusion, active perfusion of the superior mesenteric artery for visceral malperfusion, and external shunting from the brachial artery to the femoral artery for lower limb ischemia. Central repair is performed without delay after reperfusion therapy, but if irreversible organ damage is recognized, further aggressive treatment is discontinued. RESULTS: Among 438 patients who underwent initial treatment for type A acute aortic dissection, malperfusion in one or more organs was diagnosed in 108 patients (24%). We applied an early reperfusion strategy in 33 patients, (coronary, 14 patients; carotid, 4; visceral, 7; lower extremity, 8). Central repair was then performed in 28 patients. One patient (3.6%) died of pneumonia; 27 patients overcame the ischemic organ damage and survived. Among the 108 patients with malperfusion, 10 patients (9.3%) were treated medically without early reperfusion and central repair. During the same period, mortality from central repair procedures in patients with malperfusion who had not received early reperfusion therapy was 12 of 65 (18%), and the mortality of patients without malperfusion was 9 of 262 (3.4%). Malperfusion was a serious risk factor for hospital death, but the mortality rate of the patients with an early reperfusion strategy was significantly (P < .01) lower than the patients without early reperfusion. CONCLUSIONS: Our strategy might improve the outcomes of surgery for type A acute aortic dissection with malperfusion. This strategy enables us to avoid unproductive central repair procedures in irreversibly damaged patients.

Systolic and diastolic unloading by mechanical support of the acute vs the chronic pressure overloaded right ventricle.

BACKGROUND: Right ventricular (RV) mechanical support is well described in cases of sudden increase in RV afterload. In cases of chronic RV pressure overload (e.g., pulmonary arterial hypertension), it has rarely been described. METHODS: The pulmonary artery was banded in 18 sheep. In the acute group (n = 9), we immediately implanted a Synergy Pocket Micro-Pump. Blood was withdrawn from the right atrium to the pulmonary artery. In the chronic group (n = 9), this pump was implanted 8 weeks after banding. Hemodynamics and pressure-volume loops were recorded before and 15 minutes after pump activation. RESULTS: Low-flow RV mechanical support significantly improved arterial blood pressure in both groups, but cardiac output only in the acute group. Intrinsic RV contractility was not affected. The RV contribution to the total right-sided cardiac output was 54% ± 8 in the acute group vs 10% ± 13 in the chronic group (p < 1.10-5), indicating a more profound unloading in the latter. Diastolic unloading (reflected by decreases in central venous pressure, end-diastolic pressure and volume, and ventricular capacitance) was successful in both groups. Decreases in pressure-volume area and RV peak pressure reflected successful systolic unloading only in the chronic group. CONCLUSIONS: Low-flow RV mechanical support improved arterial blood pressure in both conditions but caused a more profound unloading in the chronic group. Diastolic unloading was successful in both groups, but systolic unloading was successful only in the chronic group. The potential use of low-flow mechanical support for a chronic pressure overloaded right ventricle warrants further research to assess its long-term effects.

Pitfalls for the "Sandwich technique" via a right ventricular incision to repair post-infarction ventricular septal defects.

BACKGROUND: We have reported "sandwich technique," via a right ventricular incision, to treat a post-infarction ventricular septal defect (VSD). This technique involves the placement of patches on both the left and right sides of the septum, pinching the VSD sealed with surgical adhesive between the two patches. In this study, we analyzed factors influencing 1-year mortality to determine the pitfalls in our procedure. METHODS: We evaluated 24 consecutive patients with post-infarction VSD who underwent the "sandwich technique" via a right ventricular incision. One-year survival and major residual leak were used as the criteria for the analysis of survival and technical success, respectively. In protocol 1, clinical variables were evaluated as predictors of one-year mortality. In protocol 2, surgical techniques were evaluated as predictors of major residual leak, which was found to be related to one-year mortality in protocol 1. RESULTS: In protocol 1, the one-year mortality was higher in patients with major residual leak (75 %, 3/4) than in those without (15 %, 3/20) (p = 0.035). In protocol 2, the patients with major residual leak had smaller patches than those without (41.9 ± 3.8 vs. 47.8 ± 4.8 mm, p = 0.031) and a smaller size difference between the patches and the VSD (22.5 ± 6.5 vs. 30.0 ± 5.7 mm, p = 0.028). CONCLUSION: For the "sandwich technique" via a right ventricular approach to treat post-infarction VSD, the choice of patch size according to VSD size is an important variable for reducing major residual leak.

Immediate outcome after sutureless versus transcatheter aortic valve replacement.

The aim of this study was to compare the immediate outcome of patients undergoing transcatheter (TAVI) versus surgical aortic valve replacement with the sutureless Perceval bioprosthesis (SU-AVR). This is a retrospective multicenter analysis of 773 patients who underwent either TAVI (394 patients, mean age, 80.8 ± 5.5 years, mean EuroSCORE II 5.6 ± 4.9 %) or SU-AVR (379 patients, 77.4 ± 5.4 years, mean EuroSCORE II 4.0 ± 3.9 %) with or without concomitant myocardial revascularization. Data on SU-AVRs were provided by six European institutions (Belgium, Finland, Germany, Italy and Sweden) and data on TAVIs were provided by a single institution (Catania, Italy). In-hospital mortality was 2.6 % after SU-AVR and 5.3 % after TAVI (p = 0.057). TAVI was associated with a significantly high rate of mild (44.0 vs. 2.1 %) and moderate-severe paravalvular regurgitation (14.1 vs. 0.3 %, p < 0.0001) as well as the need for permanent pacemaker implantation (17.3 vs. 9.8 %, p = 0.003) compared with SU-AVR. The analysis of patients within the 25th and 75th percentiles interval of EuroSCORE II, i.e., 2.1-5.8 %, confirmed the findings of the overall series. One-to-one propensity score-matched analysis resulted in 144 pairs with similar baseline characteristics and operative risk. Among these matched pairs, in-hospital mortality (6.9 vs. 1.4 %, p = 0.035) was significantly higher after TAVI. SU-AVR with the Perceval prosthesis in intermediate-risk patients is associated with excellent immediate survival and is a valid alternative to TAVI in these patients.

Aortic valve replacement through full sternotomy with a stented bioprosthesis versus minimally invasive sternotomy with a sutureless bioprosthesis.

OBJECTIVES: The aim of this study was to analyse early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) through a ministernotomy with a sutureless bioprosthesis implantation compared with a full sternotomy with implantation of a stented bioprosthesis. METHODS: Patients who underwent primary isolated non-emergent AVR at six European centres were included in the study. Of these, 182 (32%) underwent a ministernotomy with a sutureless bioprosthesis (ministernotomy sutureless group) and 383 (68%) a full sternotomy with a stented bioprosthesis (full sternotomy stented group). Propensity score matching was used to reduce selection bias. RESULTS: In the overall cohort, 30-day mortality was 1.6 and 2.1%, and 2-year survival was 92 and 92% in the ministernotomy sutureless group and in the full sternotomy stented group, respectively. Propensity score matching resulted in 171 pairs with similar characteristics and operative risk. Aortic cross-clamp (40 vs 65 min, P < 0.001) and cardiopulmonary bypass time (69 vs 87 min, P < 0.001) were shorter in the ministernotomy sutureless group. Patients undergoing ministernotomy received less packed red blood cells but the risk for postoperative permanent pacemaker implantation was higher. There were no differences regarding 30-day mortality or 2-year survival between the two groups. CONCLUSIONS: AVR through a ministernotomy with implantation of a sutureless bioprosthesis was associated with shorter aortic cross-clamp and cardiopulmonary bypass time and less transfusion of packed red blood cells, but a higher risk for postoperative permanent pacemaker implantation compared with a full sternotomy with a stented bioprosthesis.

Late cardiac metastasis from colorectal carcinoma 15 years after surgery.

Late recurrence of malignant tumors in the heart more than 10 years after surgery is quite rare, especially for colorectal carcinoma. Here, we report a case of late cardiac metastasis from a primary colorectal carcinoma, which occurred more than 15 years after the initial surgery. To our knowledge, this is the first such reported case.

Two-stage approach for mixed total anomalous pulmonary venous connection.

A 4-day-old boy underwent an urgent operation for mixed total anomalous pulmonary venous connection with the left upper pulmonary vein draining into the innominate vein and the other pulmonary veins draining into the coronary sinus. The left upper pulmonary vein was left uncorrected at that time. After periodical follow-up for 5 years, repair of the uncorrected anomalous pulmonary vein was performed. This two-stage operation is a viable option in cases of mixed type total anomalous pulmonary venous connection, leaving the isolated left upper vein uncorrected in the neonatal period, instead of an aggressive full repair.

Ministernotomy versus full sternotomy aortic valve replacement with a sutureless bioprosthesis: a multicenter study.

BACKGROUND: The aim of this study was to analyze early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) with the sutureless Perceval bioprosthesis (Sorin Biomedica Cardio Srl, Salluggia, Italy) performed through ministernotomy compared with full sternotomy. METHODS: This was a study of 267 consecutive patients who underwent isolated AVR with the sutureless Perceval bioprosthesis between 2007 and 2014 at 6 European centers. Of these, 189 (70.8%) were performed through ministernotomy and 78 through a full sternotomy. Propensity score matching was used to reduce selection bias. RESULTS: In the overall cohort of ministernotomy and full sternotomy patients, in-hospital mortality was 1.1% and 2.6% and 2-year survival was 92% and 91%, respectively. Propensity score matching resulted in 56 pairs with similar characteristics and operative risk. Aortic cross-clamp (44 minutes in both groups, p = 0.931) and cardiopulmonary bypass time (69 vs 74 minutes, p = 0.363) did not differ between the groups. Apart from higher values in the ministernotomy group for postoperative peak gradients (28.1 vs 23.3 mm Hg, p = 0.026) and mean aortic valve gradients (15.2 vs 11.7 mm Hg, p = 0.011), early postoperative outcomes did not differ in the propensity-matched cohort. There were no differences in the in-hospital mortality rate or 2-year survival between the groups. CONCLUSIONS: AVR with the sutureless Perceval bioprosthesis through a ministernotomy was a safe and reproducible procedure that was not associated with prolonged aortic cross-clamp or cardiopulmonary bypass time compared with a full sternotomy. Early postoperative outcomes and 2-year survival were comparable between patients undergoing ministernotomy and full sternotomy.

Total arch replacement for coarctation of the aorta in an adolescent.

A 16-year-old boy suffered a subarachnoid hemorrhage and underwent open head surgery. He was subsequently diagnosed with coarctation of the aorta and referred to our hospital. The coarctation was at the distal transverse arch, just at the site of branching of the subclavian artery. Total arch replacement with selective cerebral perfusion was selected because of the short hypoplastic arch. The patient had an uneventful postoperative course, and was doing well 3 years after the surgery.