Configuration of the neoaortic root after chimney reconstruction in the Norwood procedure.

OBJECTIVES: After staged reconstruction for hypoplastic left heart syndrome, the neoaortic root tends to dilate, and the incidence of significant neoaortic valve insufficiency increases with time. This study aimed to evaluate the mid-term outcomes of the neoaortic root geometries and valve function after chimney reconstruction in the Norwood procedure. METHODS: Between 2013 and 2021, 20 consecutive patients who underwent chimney reconstruction during the Norwood procedure for hypoplastic left heart syndrome and its variants in our institution were enrolled. The actual diameters of the following points were measured, and Z-scores were calculated based on the normal aortic root geometries using the long axis view of echocardiography at the pre-Norwood stage and the lateral view of angiography at pre-Glenn, pre-Fontan, post-Fontan and follow-up (age 5-6 years) stages: neoaortic valve annulus; sinus of Valsalva; sinotubular junction; and ascending aorta just proximal to the anastomosis to the aortic arch. The degree of neoaortic valve regurgitation was evaluated by echocardiography at each stage. RESULTS: The median follow-up period was 3.9 years. Neoaortic roots after chimney reconstruction were spared from progressive dilation over time. With growth, the conical configuration of the neoaortic roots was preserved without geometrical distortion. The Z-scores of the annulus, sinus of Valsalva, sinotubular junction and ascending aorta ranged roughly from 4 to 6, 4 to 6, 2 to 4 and 0 to 2, respectively. All neoaortic valves at each stage had mild or no regurgitation. CONCLUSIONS: Chimney reconstruction prevented neoaortic root dilation and avoided significant neoaortic valve regurgitation in the mid-term. These neoaortic dimensions with smooth flow profiles in the neoaorta after chimney reconstruction may have contributed to the current results. Further studies are needed to clarify the long-term outcomes.

Successful surgical treatment of brachial aneurysm associated with arteriovenous fistula for hemodialysis.

A 58-year-old female who underwent renal transplantation and closure of arteriovenous fistula (AVF) for hemodialysis at age 24 was presented with left forearm pain and cyanosis. Computed tomography revealed an obstructed true brachial aneurysm at the anterior aspect of the elbow joint. Under a diagnosis of true brachial aneurysm associated with AVF, aneurysm resection and brachial to ulnar artery bypass grafting using a reversed great saphenous vein were performed. To prevent graft occlusion due to elbow flexion, it was routed through the ulnar side of the elbow joint. One year after surgery, the patient was asymptomatic with a patent graft.

Long-term valve performance of St Jude Medical Epic porcine bioprosthesis in aortic position.

The aim of this study was to review long-term clinical outcomes and valve performance after Epic Supra valve implantation in aortic position. From 2011 to 2022, 44 patients (mean age 75 ± 8 years) underwent surgical aortic valve replacement (SAVR) with an Epic Supra valve at our hospital. Survival, incidence of late complications, and echocardiographic date were retrospectively analyzed. During a mean follow-up period of 6.2 ± 3.5 years, the overall survival rate was 91 ± 4% at 2 and 88 ± 5% at 5 years, while rates of freedom from major adverse cardiovascular and cerebrovascular events (MACCE) were 86 ± 5% and 83 ± 6%, respectively. There was one case of reoperation for prosthetic valve endocarditis at 6 years after the initial surgery. Echocardiographic examinations showed 5-year rates of freedom from severe structural valve deterioration (SVD) and moderate SVD of 100 and 92%, respectively. There was no significant increase in mean pressure gradient or decrease in left ventricular ejection fraction from 1 week after surgery to the late follow-up period. Long-term clinical results and durability of the Epic Supra valve in aortic position were satisfactory.

Successful Surgical Treatment for Ruptured Aneurysm of Coronary-Pulmonary Artery Fistula Complicated With Cardiac Tamponade.

A 74-year-old woman with no past medical history showed cardiac tamponade caused by rupture of a coronary-pulmonary artery fistula-related aneurysm. Preoperative pericardial puncture and multidetector computed tomography imaging enabled patient condition optimization and accurate morphologic evaluation of fistula and aneurysm, leading to complete surgical resection of the aneurysm. (Level of Difficulty: Advanced.).

Pulmonary artery augmentation and aortic valve repair using novel tissue-engineered grafts.

Objectives: The objectives of this study were to evaluate the results when tissue-engineered vascular grafts (TEVGs) are used as alternatives to autologous pericardium for surgically augmenting the pulmonary artery (PA) or aortic valve. Methods: TEVG molds were embedded into subcutaneous spaces for more than 4 weeks preoperatively. Since 2014, 6 patients have undergone PA reconstruction, whereas 1 has undergone aortic valve plasty (AVP) with TEVGs. The time from mold implantation to the operation was 8.9 (range, 6.0-26.4) months. The age and body weight at the time of operation were 2.7 (range, 1.8-9.2) and 11.6 (range, 7.9-24.4) kg, respectively. Concomitant procedures comprised the Rastelli, palliative Rastelli, and Fontan operations in 2, 2, and 1 patient, respectively. Results: The median follow-up period was 14.4 (range, 3-39.6) months. There were no early or late mortalities. Moreover, there were no TEVG-related complications, including aneurysmal changes, degeneration, and infection. In 5 patients who underwent PA augmentation, the postoperative PA configuration was satisfactorily dilated. The reconstructed aortic valve function was good in the patient who underwent AVP. Decreased leaflet flexibility due to leaflet thickening was not observed. One patient had postoperative PA re-stenosis; therefore, re-PA augmentation with TEVGs was performed. On histological examination, TEVGs consisted of collagen fibers and few fibroblasts, and elastic fiber formation and/or smooth muscle cells were not observed. Conclusions: The midterm results of PA reconstruction and AVP with TEVGs were satisfactory. TEVGs might be a useful alternative to autologous pericardium in pediatric cardiovascular surgeries that often require multistage operations.

Expanded Polytetrafluoroethylene Conduits With Bulging Sinuses and a Fan-Shaped Valve in Right Ventricular Outflow Tract Reconstruction.

We developed a handmade expanded polytetrafluoroethylene (ePTFE) pulmonary valvular conduit (PVC) with bulging sinuses and a fan-shaped ePTFE valve for right ventricular outflow tract (RVOT) reconstruction. We aimed to investigate the results of this device in this multicenter study. From 2001 to 2020, 1776 patients underwent RVOT reconstruction using ePTFE PVCs at 65 institutions in Japan. The median age and body weight were 4.1 years (range, 3 days to 67.1 years) and 13.3 (range, 1.8-91.3) kg, respectively. The median PVC size was 18 (range, 8-24) mm. The median Z-value of the ePTFE PVC was 1.1 (range, -3.8 to 5.0). The ePTFE PVC conditions were investigated by cardiac echocardiography and catheterization. The median follow-up period was 3.3 years (range, 0 day to 16.2 years). There were only 9 cases (0.5%) with PVC-related unknown deaths. Reintervention was performed in 283 patients (15.9%), and 190 patients (10.7%) required explantation. Freedom from reintervention and explantation at 5/10 years were 86.7/61.5% and 93.0/69.1%, respectively. At the latest echocardiography, PVC regurgitation grade was better than mild in 88.4% patients. The average peak RVOT gradient was 15.7 ± 15.9 mm Hg at the latest cardiac catheterization. ePTFE PVC infection was detected in only 8 patients (0.5%). Relative stenosis due to somatic growth was the most common cause of PVC explantation. The performance of ePTFE in terms of durability, valvular performance, and the resistance against infection is considerable and may replace conventional prosthetic materials. Further improvement of the ePTFE membrane is essential to prevent valvular dysfunction.

A case of redo tricuspid valve repair after neonatal cone operation for Ebstein's anomaly.

Cone reconstruction for Ebstein's anomaly, although effective, is challenging in neonatal cases. Very few reports have discussed recurrent regurgitation. Herein, we report a successful redo tricuspid valve repair for recurrent regurgitation 5 years after cone reconstruction. A 5-year-old boy underwent cone reconstruction for Ebstein's anomaly in the neonatal period. Although tricuspid regurgitation reduced initially, it subsequently worsened. The mechanisms of regurgitation are dilatation of the anteroseptal commissure, indentation in the septal leaflet, and foreshortening of the anterior leaflet. Augmentation of the anterior leaflet using an elliptic autologous pericardium and mending of the gaping commissure and indentation markedly reduced the regurgitation.

Chimney reconstruction provides a wider subaortic space and reduces the risk of pulmonary artery compression in the Norwood-type aortic arch reconstruction without patch supplementation.

OBJECTIVES: Pulmonary artery (PA) compression by the neoaorta is a serious complication after the Norwood-type palliation (NP) for hypoplastic left heart syndrome. Either excess patch tailoring or limited use of autologous tissue may cause narrowing of the subaortic space. The chimney technique could theoretically provide a wide subaortic space. METHODS: Twenty-nine patients with both pre- and post-NP computed tomography data available of the 37 consecutive patients who underwent NP in our institution were reviewed. Arch height, arch width, sinus of Valsalva diameter, area under the neoaortic arch and arch angle were measured. These patients were divided according to the neo-arch reconstruction technique, chimney reconstruction technique (CR) or conventional direct reconstruction technique (DR). RESULTS: Median age and weight at NP were 2.1 months and 3.5 kg, respectively. Twenty-two patients underwent previous bilateral PA banding. During NP, 17 CR and 12 DR were performed. Four patients in the DR group developed PA compression. No neoaortic arch dilatation was found in either group. Post-NP arch width, area under the neo-arch and the arch angle were significantly larger in the CR group. Pre-NP arch height was significantly smaller in DR patients with PA compression than in those without. CONCLUSIONS: The chimney technique decreased the risk of PA compression and provided a wider subaortic space and a less acute arch angle. This technique had no short-term effect on the neoaortic root. Small preoperative arch height is a potential risk factor for PA compression in DR, and the chimney technique could be an effective solution.

Comparison of half-turned truncal switch and conventional operations.

OBJECTIVES: To compare conventional procedures with the half-turned truncal switch operation (HTTSO) for the management of complete transposition of the great arteries with left ventricular outflow tract (LVOT) obstruction using time-resolved 3-dimensional magnetic resonance phase-contrast imaging. METHODS: We identified 2 cases that underwent the Rastelli procedure and one case that underwent the Réparation a l'étage ventriculaire before 2002 [conventional procedures group (group C)], and 16 cases of HTTSO that were performed between 2002 and 2020 [HTTSO group (group H)]. Postoperative haemodynamics were assessed using time-resolved 3-dimensional magnetic resonance phase-contrast imaging in cases in both groups. RESULTS: The median follow-up period was 20.4 years in group C, and 6.1 years in group H. In group C, all 3 patients underwent reoperation because of postoperative right ventricular outflow tract obstruction and/or insufficiency. In addition, permanent pacemaker implantation was needed in 1 patient because of complete atrioventricular block complicated by ventricular septal defect enlargement. In group H, reoperation for LVOT/right ventricular outflow tract obstruction was not needed. A time-resolved 3-dimensional magnetic resonance phase-contrast imaging examination revealed high energy loss and wall shear stress in the winding LVOT in the group C. In contrast, low energy loss and wall shear stress, with straight and smooth LVOT, were identified in group H. CONCLUSIONS: HTTSO was shown to be superior to conventional procedures because a straight and wide LVOT could be obtained. Therefore, HTTSO should be the first choice for complete transposition of the great arteries with LVOT obstruction.

Alternative pulmonary artery reconstruction technique in the arterial switch operation.

OBJECTIVES: Late complications of arterial switch operations (ASO) for transposition of the great arteries, such as neo-pulmonary artery (PA) stenosis and/or neoaortic regurgitation, have been reported. We developed an alternative reconstruction method called the longitudinal extension (LE) method to prevent PA bifurcation stenosis (PABS). METHODS: We identified 48 patients diagnosed with transposition of the great arteries and performed ASO using the Lecompte manoeuvre for neo-PA reconstruction. In 9 consecutive patients (from 2014), the LE method was performed (LE). Before 2014, conventional techniques were performed in 39 patients (C). The median body weight and age in the LE and C groups were 3.0 and 3.1 kg and 12 and 26 days, respectively. In the LE group, 1 patient underwent bilateral PA banding before ASO. In C, PA banding and arch repair were performed in 1 patient each. Patients who received concomitant procedures were included. RESULTS: The median follow-up in LE and C groups was 1.9 and 10.1 years, respectively. Early mortality/late death was not found in group LE and in 1 patient in group C. Only 1 case required ascending aorta sliding plasty in LE, and 8 patients needed PA augmentation for PABS in C. The median velocity of right/left PA was measured as 1.6/1.9 m/s in LE and 2.1/2.3 m/s in C, so it showed a lower value in LE. CONCLUSIONS: Excellent mid-term results were obtained with the LE method. It was considered a useful procedure in preventing PABS, which is a primary late complication of ASO. Further follow-up and investigations are needed.

Midterm results of pulmonary artery plasty with in vivo tissue-engineered vascular grafts.

We evaluated the application of in vivo tissue-engineered vascular graft (in vivo TEVG) in pulmonary artery (PA) reconstruction as a substitute for autologous pericardium. From July 2017 to April 2020, 4 patients (male:female = 2:2) with major aortopulmonary collateral arteries underwent PA reconstruction with in vivo TEVGs. Graft moulds were embedded into the subcutaneous spaces in the first palliative surgery. In the second surgery used in vivo TEVGs were used as patch materials to treat PA stenosis. Preoperative and postoperative PA configurations were evaluated by computed tomography. Patients' median age and body weight were 1.6 (1-4) years and 8.7 (7.3-15.4) kg, respectively. Two patients underwent PA reconstruction during staged repair and 2 underwent reconstruction during definitive repair. One patient had postoperative PA restenosis due to bronchial compression; re-PA reconstruction with in vivo TEVGs was performed. On histological examination, the in vivo TEVG wall mainly comprised collagen fibres and a small number of fibroblasts. The midterm results of this technique are satisfactory. in vivo TEVGs could be a promising alternative to autologous pericardium for paediatric cardiovascular surgeries requiring multi-stage operations. CLINICAL TRIAL REGISTRATION: ERB-C-162.

Long-term results of large-calibre expanded polytetrafluoroethylene-valved conduits with bulging sinuses.

OBJECTIVES: In Japan, homograft and bovine jugular vein are available in very limited institutions for the reconstruction of the right ventricular outflow tract, and handmade expanded polytetrafluoroethylene (ePTFE)-valved conduits have been widely used instead. This study aimed to clarify the long-term outcomes and the durability of the ePTFE-valved conduits purely by narrowing down to those with large sizes to eliminate the influence of the body growth. METHODS: Between January 2002 and December 2015, patients who underwent right ventricular outflow tract reconstruction in 34 Japanese institutions using ePTFE-valved conduits with a diameter of ≥18 mm were included. All the valved conduits were made in the authors' institution and delivered to each participating institution. RESULTS: Overall, 502 patients were included. Early mortality was 1.4% and not related to conduit failure. The overall survival rate was 98.2% at 5 years and 96.6% at 10 years. Freedom from conduit explantation was 99.5% at 5 years and 89.0% at 10 years. Three patients (0.13 per 100 patient-years) developed infective endocarditis of the conduit, and only 1 patient required conduit removal. Pulmonary insufficiency was mild or less in 480 (96%) patients, and conduit stenosis was mild or less in 436 (88%) patients at the latest follow-up. CONCLUSIONS: By narrowing the analyses down to only ePTFE conduits with a large size, satisfactory long-term outcomes of these conduits with a fan-shaped valve and bulging sinuses were shown. These conduits would be among the optimal choices for right ventricular outflow tract reconstruction.

Relationship between postnatal days, serum Cu concentration and plasma diamine oxidase activity in Japanese Black calves.

The aim of study was to investigate the relationships among serum diamine oxidase (DAO) activity, postnatal days and the plasma copper (Cu) concentration, using calves with or without diarrhea. In healthy calves, the serum DAO activity was significantly higher at 2 postnatal days than at ≥7 postnatal days, and no significant changes were observed after 7 postnatal days. In addition, no significant correlation was found between serum DAO activity and plasma Cu concentration at all postnatal days in healthy calves. Although, the serum DAO activity in 14 diarrheic calves (66.78 ± 14.37 IU/ml) was lower than that in 19 healthy calves (170.33 ± 97.83 IU/ml, P<0.01), plasma Cu concentrations in all calves remained within the normal range.

The effect of a valved small conduit on systemic ventricle-pulmonary artery shunt in the Norwood-type palliation.

OBJECTIVES: The aim of this study was to clarify the impact of valved systemic ventricle-pulmonary artery (SV-PA) shunt on outcomes after stage-1 Norwood-type palliation (NP) compared with the modified Blalock-Taussig shunt. METHODS: Consecutive patients who underwent NP between 2003 and 2019 were enrolled. SV-PA shunts using the expanded polytetrafluoroethylene valved conduit were implanted in 18 patients (valved SV-PA group), and another 18 patients underwent modified Blalock-Taussig shunt during NP (modified Blalock-Taussig shunt group). All valved conduits were made in our institution in advance. RESULTS: No differences in baseline characteristics were found between the groups, except for shunt size. During a median 2.9 (interquartile range 0.4-6.4, maximum 14.2) years of follow-up, 8 (22.2%) patients died across both groups. There were no statistically significant differences in early mortality (5.5% vs 11.1%, P = 0.55) and overall survival rates at 5 years (80.8% vs 71.4%, P = 0.48) in the valved SV-PA and modified Blalock-Taussig shunt groups. No statistically significant difference was observed in the frequency of interventions between the groups (31% vs 33%, P = 1.0). At the time of the bidirectional Glenn procedure, the systemic ventricular end-diastolic volume index was significantly lower (84 ± 24 vs 106 ± 31 ml/m2, P = 0.05) and the ejection fraction was significantly greater (62 ± 8% vs 55 ± 9%, P = 0.03) in the valved SV-PA group. There was no statistically significant difference in the pulmonary artery index (228 ± 85 vs 226 ± 60 mm2/m2, P = 0.92). CONCLUSIONS: A valved SV-PA shunt using an expanded polytetrafluoroethylene valved conduit was associated with preserved ventricular function after NP and did not impair pulmonary artery growth by controlling pulmonary regurgitation.

Plasma diamine oxidase activity decline with diarrhea severity in calves indicating systemic dysfunction related to intestinal mucosal damage.

The aim of the present study was to investigate whether abnormalities in plasma diamine oxidase (DAO) activity reflect the degree of intestinal mucosal disorder in calves with diarrhea. A total of 50 Holstein calves were enrolled. Thirty-six of the 50 calves presented diarrhea and were sub-classified by severity based on fecal status (0: firm, 1: pasty, 2: loose, and 3: watery) and blood pH (acidemia: blood pH <7.25) as follows: Seventeen calves exhibiting watery diarrhea and/or fall into acidemia were sub-categorized into the severe group. The other nineteen calves exhibiting pasty or loose diarrhea and not fall into acidemia were sub-categorized into the moderate group. The remaining 14 calves without diarrhea were assigned to the control group. The plasma DAO activity was significantly lower (p < .01) in the calves with severe or moderate diarrhea than in the control group. In addition, the plasma DAO activity was significantly lower (p < .05) in the severe group than in the moderate group. The relationship between plasma DAO activity and fecal score (r = -0.55, p < .01) in calves with diarrhea were found to have significantly and negatively correlated by Spearman's rank test in this study. Our results suggested that plasma DAO activity reflect the degree of intestinal mucosal disorder due to diarrhea.

[Adult Congenital Heart Surgery as a Novel Specialty in Thoracic Surgery; Perioperative Patient Management and Surgical Procedures].

Recently, number of adult congenital heart disease(ACHD) patients are rapidly increasing, but statistical evidences in adult congenital heart surgery are not sufficient because of its short history in addition to the complicated pathophysiology of ACHD. Therefore, a "heart team" including surgeons, pediatricians, and cardiologists are required, and blood flow imaging and 4-dimensional (4D) imaging plays an essential role in perioperative patient management. Enhanced 3-dimensional computed tomography( 3D-CT) scan is useful to determine cardiopulmonary bypass strategies in reoperation, and 4D flow magnetic resonance imaging( MRI) is useful in assessment of complicated hemodynamics. Diastolic function of systemic ventricle is very important in right side heart valve surgery or univentricular heart surgery, echocardiography is essential to examine the valve structure, and electrophysiological mapping is useful in concomitant arrhythmia surgery. This article describes the indications, procedures, and perioperative managements of surgery in the right ventricular outflow tract, tricuspid valve, aortic root, Fontan circulation, and systemic right ventricle.

Effects of substituting kraft pulp with corn silage on dry matter intake, ruminal mat formation, rumen fermentation, and rumination activity in non-lactating cows.

The present study examined the effects of substituting kraft pulp (KP) with corn silage (CS) on dry matter intake (DMI), ruminal mat and rumen fermentation characteristics, and rumination. Four non-lactating, rumen-cannulated Holstein cows were fed a CS diet comprising 36% grass silage (GS) and 64% CS or a KP diet comprising 36% GS, 57% KP, and 7% soybean meal. DMI was significantly lower in cows fed the KP diet than in those fed the CS diet (p < 0.05), whereas rumination time did not significantly differ between the treatments. Dry matter content in the rumen immediately before and 3 h after feeding was significantly higher in cows fed the KP diet than in those fed the CS diet (p < 0.05). The consistency and thickness of the ruminal mat did not significantly differ between the treatments. The ruminal mean retention time of feed particles tended to be longer in cows fed the KP diet than in those fed the CS diet (p < 0.10). The ruminal digestion rate of KP was comparable to that of GS and CS. Because ruminal mat was formed and rumination was stimulated, KP was considered to have the equivalent physical effectiveness as CS.

[Neoadjuvant FOLFIRINOX for Unresectable Adenocarcinoma of the Pancreas - A Case Report].

A 38-year-old male presented to our hospital with complaint of vomiting. A CT demonstrated a mass sized 42mm in the pancreatic head invading to the duodenum and a liver mass sized 15mm in the medial segment. Biopsy revealed adenocarcinoma. Due to liver metastasis, he was deemed surgically unresectable. He was started on FOLFIRINOX therapy after gastrojejunum bypass operation. After 15 courses of the therapy, restaging showed a decrease in pancreatic tumor size and a disappearance of a liver mass along with PET-CT revealing no FDG-avid uptake. A serum value of DUPAN-2 was also normalized. He was offered resection as a potentially curative treatment. He underwent curative pancreaticoduodenectomy(PD), which was difficult to perform because of adhesion and hard fibrous tissues. Operating time and blood loss were 600 minutes and 1,933 mL, respectively. Histologic examination revealed Grade 1a histological chemotherapy effect. His cancer recurred 11 months after PD. He received nab-paclitaxel and gemcitabine regimen at out-patients clinic.

[Long-Term Survival of a Patient with Metastatic Liver and Para-Aortic Lymph Node Cancer from Colon Cancer Treated with Regorafenib].

A 54-year-old man was presented at our hospital with weight loss.He diagnosed with colorectal cancer, multiple liver metastases and para-aortic lymph node metastasis.After undergoing colostomy, he was treated sequentially with mFOLFOX6 plus bevacizumab(Bmab), FOLFIRI plus Bmab or Pmab, according to the guideline.Since these chemotherapy resulted in progressive disease, regorafenib was administered as a salvage-line treatment.PET -CT showed only para-aortic lymph node swelling with high FDG uptake.Severe adverse effects were developed shortly after regorafenib treatment so he requireda reduction in dose.Three years after treatment with regorafenib, the response of the target lesion was stable disease according to the RECIST criteria.Tumor growth had been controlled for a long time.