A prospective randomized controlled study to assess the effectiveness of super FIXSORB WAVE® for sternal stabilization after sternotomy.

BACKGROUND: We developed a new sternal fixation device, Super FIXSORB WAVE®, a corrugated plate made of u-HA/PLLA, to improve sternal stability after sternotomy. This present study aimed to evaluate the new device clinically. METHODS: This prospective, single-blinded, multicenter trial randomized 69 patients to either wire cerclage only (group C, n = 30) or wire cerclage plus Super FIXSORB WAVE® (group W, n = 39). The primary endpoint was a degree of sternal displacement at six months. Displacement of the sternal halves in the anteroposterior and lateral directions was measured using computed tomography horizontal section images at the third costal and fourth intercostal levels. The secondary endpoints were sternal pain and quality-of-life over 6 months. RESULTS: Group W showed significantly reduced sternal anteroposterior displacement at both the third costal (0 [0-1.9] mm vs. 1.1 [0-2.1] mm; P = 0.014) and fourth intercostal (0 [0-1.0] mm) vs. 1.0 [0-1.8] mm; P = 0.015) levels than group C. In group W, lateral displacement was suppressed without a significant increase from 2 weeks to 6 months, while it increased in group C. There was no significant difference in postoperative sternal pain and quality-of-life between the two groups. No adverse events, such as infection, inflammation, or foreign body reaction, were observed with this device. CONCLUSIONS: Using Super FIXSORB WAVE®, sternal displacement was significantly suppressed in both the anteroposterior and lateral directions. The use of this device results in safe and easy sternal reinforcement without any adverse events, and sternal healing can be accelerated. CLINICAL TRIAL REGISTRY NUMBER: This study was registered in the Japan Registry of Clinical Trials (February 21, 2019; jRCTs032180146).

Short-Term Evaluation of a Novel No-Touch Technique for Harvesting Saphenous Veins With Long-Shafted Ultrasonic Scalpel.

OBJECTIVE: Saphenous vein grafts (SVGs) are widely used as bypass conduits in coronary artery bypass grafting. Compared with the conventional technique, the "no-touch" technique, wherein the saphenous veins are harvested with the surrounding tissue, may improve SVG patency; however, there are concerns regarding wound complications. To address this issue, we describe our novel no-touch technique with separate skin incisions using a long-shafted ultrasonic scalpel and report the clinical outcomes. METHODS: We enrolled 66 male patients who underwent isolated coronary artery bypass grafting between April 2016 and April 2021. There were 30 and 36 patients treated using our no-touch technique and the conventional technique, respectively. The participants underwent coronary angiography before discharge and were followed clinically. SVG samples were taken for pathological examination. RESULTS: SVGs harvested using our no-touch technique displayed preservation of the vessel wall structure and surrounding tissues. Our no-touch technique demonstrated no inferiority in patency compared with the conventional technique, and there was no SVG occlusion in the no-touch group. The frequency of leg wound complications was higher in the no-touch group than the conventional group, but no surgical site infections and severe complications occurred in the no-touch group. CONCLUSIONS: SVGs harvested using our novel no-touch technique had similar pathological characteristics to those harvested using the original no-touch technique reported previously. Our no-touch technique maintained SVG patency and caused no severe wound complications. However, a large-scale, longitudinal study is required to accurately assess the clinical outcomes of our no-touch technique.

Surgical strategy for inflammatory thoracic aortic aneurysms in the endovascular surgery era.

OBJECTIVE: Inflammatory thoracic aortic aneurysms (TAAs) are very rare aortic conditions. Resection and replacement of the inflammatory aorta is the first-line treatment, and thoracic endovascular aortic repair (TEVAR) has recently been reported as a less invasive alternative even for this aortic cohort. In the present study, we reviewed our experience with inflammatory TAAs and assessed the preoperative management, surgical procedures, and outcomes. METHODS: From 2006 to 2019, 21 surgeries were performed for inflammatory TAAs in 17 of 2583 patients (0.7%) who had undergone cardiovascular surgery at our institution. The etiologies were Takayasu's arteritis in 13 patients, giant cell arteritis in 2, antineutrophil cytoplasmic antibody-associated vasculitis in 1, and unknown in 1. The mean follow-up period was 66.2 ± 50.2 months (range, 19-186 months). RESULTS: Three patients had undergone multiple surgeries. The aorta was replaced in 14 patients (ascending aorta in 9, aortic arch in 4, and thoracoabdominal aorta in 1). Three isolated TEVARs were performed in two patients and single-stage hybrid aortic repair (ascending aorta and partial arch replacement combined with zone 0 TEVAR) in four patients for extended arch and descending thoracic aortic aneurysms. Stent grafts were deployed on the native aorta in five of the seven TEVARs. The perioperative inflammation was well-controlled with prednisolone (mean dose, 7.4 ± 9.4 mg) in all patients except for one who had required two surgeries under inflammation-uncontrolled situations. No aorta-related complications, including anastomotic aneurysms and TEVAR-related aortic dissection, developed during the follow-up period, and the 5-year freedom from all-cause death was 92.9%. CONCLUSIONS: The mid-term outcomes of surgery for inflammatory TAAs were acceptable. Although replacement remains the standard procedure for inflammatory TAAs, TEVAR is a less invasive acceptable alternative when the inflammation is properly managed.

Corrugated Sheet of Unsintered Hydroxyapatite Poly-L-Lactide for Sternal Fixation: A Preclinical Study.

PURPOSE: To stabilize the sternum after median sternotomy, unsintered hydroxyapatite poly-L-lactide (u-HA/PLLA) sternal pins are frequently used in Japan. However, sternal pins are ineffective in the fragile bone marrow. Thus, a corrugated sheet made of u-HA/PLLA was developed as a new sternal fixation device. METHODS: To examine the effects of the device, we measured the shear force using a sternal model and cadaver. The shear force of the corrugated sheet, sternal pin, and simple wire was compared. The device size was determined after reviewing the sternal computed tomography (CT) of 128 patients. RESULTS: The shear force of the model with the corrugated sheet (286 [256-295] N) was higher than that with sternal pins (135 [134-139] N, p = 0.03) and simple wire (94 [90-104] N, p = 0.03) at 2-mm displacement. In the cadaver test, the shear force of the sternal halves with the device was about two times higher than that without the device. Retrospective CT showed that 18-mm wide device applies to 99% male and 87% female patients at the fourth intercostal level. CONCLUSION: The corrugated sheet might provide a stronger fixation effect in the fragile bone marrow. The device width was modified to 18 mm to be applicable for most Japanese patients.

Safe and Effective Ultrasound-guided Myectomy and Mitral Valve Repair for HCM.

Surgery for obstructive hypertrophic cardiomyopathy with mitral abnormality requires a combined procedure of myectomy and mitral leaflet plication for relieving mitral systolic anterior motion and left ventricular outflow tract obstruction. We report a combined procedure of myectomy using intracardiac high-resolution ultrasonography and mitral bileaflet shortening in obstructive hypertrophic cardiomyopathy. Stepwise real-time verification of residual ventricular mass using high-resolution ultrasonic probe would be a potent addition to our armamentarium. This modality provides safe and effective myectomy, which has been a most technically challenging surgical procedure especially for inexperienced surgeons.

Surgical Repair of an Arch and Descending Aortic Aneurysm in a Child.

Pediatric thoracic aortic aneurysms are very rare, and almost all patients with such aneurysms have inflammatory or connective tissue diseases. This report describes a case involving 10-year-old girl who had an aortic arch and descending thoracic aortic aneurysm. Preoperative fluorine-18-fluorodeoxyglucose positron emission tomography combined with computed tomography showed an inflammatory lesion corresponding to the aneurysm's location. The ascending aorta, aortic arch, and descending thoracic aorta were replaced through median sternotomy and left thoracotomy with safe systemic and brain perfusion to avoid placing the anastomoses within the inflammatory lesion. The patient was discharged without complications, and an SMAD3 mutation was detected by postoperative mutational screening.

[Salvage from Extracorporeal Membrane Oxygenation due to Acute Deteriorated Heart Failure;Treatment Decision-tree Based on the Risk Factors].

BACKGROUND: Salvage rates for patients requiring extracorporeal membrane oxygenation (ECMO)due to acute cardiogenic shock remain poor due to difficulties in decision making on optical timing of ECMO removal or conversion to ventricular assist devices( VAD). METHOD: From 2005 to 2018, 37 patients supported with ECMO due to acute circulatory deterioration were referred to our department for implantation of VAD. Their outcomes were analyzed using multi-variate analysis to assess the risk factors of VAD implantation, and we adopted a new decision-tree to improve the outcomes. RESULTS: Four patients had severe cerebral complications and 2 patients suffered severe infection. Those 6 patients were withdrawn from VAD implantation. ECMO could be removed in 6 patients, but one of them underwent VAD implantation due to the intraaortic balloon pumping (IABP) -dependent circulatory condition. In total, 25 patients underwent VAD implantation. Four patients reached to heart transplantation. Six patients remain on VAD. VAD was explanted due to recovery in 2 patients. Statistically significant risk factors by multi-variate analysis on 2-year mortality were preoperative necessity of renal replacement (p=0.006) and T-Bil (p=0.051, >4.0 mg/dl). Two-year survival of patients without end-organ dysfunction was 83.3%.However, 2-year survival of patients with end-organ dysfunction was miserable (23.1%). Based on these findings, we applied to a new decision-tree with 4 steps from 2016;(1) rule out strokes and sepsis, (2) End-organ dysfunction should be treated before VAD implantation with proper management of mechanical circulatory support to recover end-organ dysfunction, (3) urgent conversion to VAD if there is no aortic valve opening, (4) conversion to VAD if cardiac functional recovery cannot be observed within 5 to 7 days. According to this decision-tree, 3 patients underwent VAD implantation after recovery from end-organ failure and survived in 2016. CONCLUSIONS: Our experiences of salvage from ECMO in patients with severely impaired cardiac function suggest that end-organ dysfunction( necessity of renal replacement and T-Bil>4.0 mg/dl) was a strong risk factor for mid-term mortality. Those patients should undergo VAD implantation after recovery from end-organ dysfunction.

Management of Right Gastroepiploic Arterial Coronary Grafts in Subsequent Abdominal Surgeries.

BACKGROUND: The right gastroepiploic artery (GEA) is utilized as an excellent in situ arterial graft conduit to right coronary artery territory for coronary artery bypass grafting (CABG). However, there remain great concerns regarding the management of patients with a patent in situ GEA during abdominal surgery following CABG. METHODS: From 1995 to 2016, GEA was used for CABG in 278 patients at our institution. Of the patients, 14 abdominal surgeries were performed for subsequent abdominal diseases in 11 patients with a patent in situ GEA for CABG. We investigated the results of the surgeries and how to manage the GEAs in abdominal surgery. RESULTS: Laparotomy was required for gastric cancer in 3 patients, pancreatic cancer in 3, hepatic cancer in 2, cholangiocarcinoma in 1, duodenal papillary head cancer in 1, and cholecystitis in 1; multiple abdominal surgeries were needed in 2 patients for cancer recurrence and ileus. The intraabdominal adhesions around the GEAs were minimal in all patients. No graft injury occurred at the time of opening of the abdomen, and the planned procedures were completed without any circulatory problems. In 3 patients undergoing pancreaticoduodenectomy, intraabdominal off-pump rerouting of the GEA with a short saphenous vein was necessary for en bloc resection of the cancers and lymph nodes. There was neither operative mortality nor graft-related cardiac event except for 1 due to multiple organ failure. CONCLUSIONS: Although intraabdominal rerouting of GEA is necessary for pancreaticoduodenectomy, abdominal surgery can be safely performed in patients with a patent in situ GEA coronary graft.

Antineutrophil Cytoplasmic Antibody-Associated Multiple Giant Saccular Aortic Aneurysms.

We describe a very rare case of a 67-year-old man with multiple saccular aortic aneurysms throughout the entire aorta due to antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The patient underwent staged aortic surgical procedures, including stent-graft insertion for a left iliac artery aneurysm, thoracic endovascular aortic repair for a descending aortic aneurysm, and total replacement of the ascending aorta and aortic arch with the use of high-dose steroids to control inflammation. The histologic findings demonstrated that the damage to the vasa vasorum of the adventitia resulting from AAV caused ischemia of the media, resulting in the formation of saccular aneurysmal changes.

Easy and Safe Total Debranching of Arch Aneurysms Using Axilloaxillary Arterial Bypass.

Techniques used in hybrid repair of proximal aortic arch diseases are associated with perioperative complications such as cerebrovascular emboli. We present an easy and safe technique of total debranching thoracic endovascular aortic repair for arch diseases using axilloaxillary arterial bypass. The placement of the axilloaxillary arterial bypass enables perfusion of the brachiocephalic artery even when the artery is clamped. After reconstruction of the brachiocephalic artery and the left common carotid artery, the left subclavian artery is proximally ligated, and it is perfused through the bypass. This procedure is simple, safe, and useful for the prevention of neurologic complications.

Influence of procedural differences on mitral valve configuration after surgical repair for functional mitral regurgitation: in which direction should the papillary muscle be relocated?

BACKGROUND: After restrictive mitral annuloplasty (RMAP) for functional mitral regurgitation (MR), the MR frequently recurs. Papillary muscle relocation (PMR) should reduce the recurrence rate. We assessed the influence of procedural differences in PMR on the postoperative mitral valve configuration. METHODS: Thirty-nine patients who underwent mitral valve repair for functional MR were enrolled. In limited tethering cases, RMAP alone was performed (RMAP group; n = 23). In severe tethering cases, in addition to RMAP, bilateral papillary muscles were relocated in the direction of the posterior annulus (posterior PMR group; n = 10) or anterior annulus (anterior PMR group; n = 6). We performed pre- and postoperative transthoracic echocardiographic studies, introducing a new index, mitral inflow angle (MIA), to assess the diastolic mitral leaflet excursion. MIA was measured as the angle between the mitral annular plane and the bisector of the anterior and posterior leaflets. RESULTS: Postoperative MR grade was significantly reduced in each group (P < 0.001). Follow-up echocardiography showed recurrent MR in 13% of the patients in RMAP group. In contrast, no recurrent MR was observed in either the anterior PMR or the posterior PMR group. After surgery, MIA was significantly reduced in both the RMAP group (P < 0.01) and the posterior PMR group (P < 0.001), but was preserved in the anterior PMR group (NS). None of the postoperative variables showed any significant difference between the early and late postoperative phases. CONCLUSIONS: In the surgical treatment of functional MR, a PMR procedure in addition to RMAP was effective in reducing systolic MR. However, mitral valve opening assessed by MIA was restricted even after RMAP alone. The restriction was severely augmented after additional posterior PMR, but was attenuated after additional anterior PMR. The papillary muscle should be relocated in the direction of the anterior annulus to preserve the diastolic opening of the mitral valve.

[Successful treatment of aortoesophageal fistula due to a thoracic aortic aneurysm].

A 78-year-old female presented at a nearby hospital with hemorrhage and loss of consciousness. After examination by computed tomography (CT) scan, she was referred to our hospital on suspicion of an impending rupture of the descending thoracic aorta aneurysm. She underwent a 2 stage operation. At the 1st operation, graft replacement of the descending aorta and closing of the aneurysmal wall over the aortoesophageal fistula were performed. On the 2nd postoperative day, intrathoracic esophagogastrostomy was performed by the gastric tube interposition technique. On the 54th postoperative day, she was discharged to a rehabilitation hospital.