A surgical case of infected cardiac myxoma.

A 60-year-old woman presented with a fever of unknown origin. Echocardiography revealed a large left atrial tumor protruding into the left ventricle during diastole. Laboratory investigation showed an elevated white blood cell count, C-reactive protein concentration, and interleukin-6 concentration. Magnetic resonance imaging showed hyperacute microinfarcts and multiple old lacunar infarcts. Surgery was performed under suspicion of cardiac myxoma. A dark red jelly-like tumor with an irregular surface was removed. Histopathological examination revealed cardiac myxoma, the surface of which was covered with fibrin and bacterial masses. Preoperative blood culture was positive for Streptococcus vestibularis. These findings were compatible with a diagnosis of infected cardiac myxoma. We used an antibiotic therapeutic regimen for infective endocarditis, and the patient was discharged home on postoperative day 31. Prompt diagnosis and treatment, including effective and efficient antibiotic therapy and complete tumor resection, increased the chance of a better outcome in patients with infected cardiac myxoma.

Midterm Performance of the Autologous Adventitial Overlay Method in Aortic Surgery.

BACKGROUND: We developed an adventitial overlay method for reinforcing aortic anastomoses. This study evaluated the midterm morphological and clinical outcomes of this method. METHODS: We harvested and prepared adventitia from a resected aneurysm or dissected aortic wall and performed aortic repair using the adventitial overlay method. At the midterm follow-up, we examined the differences among overlay, inversion, and felt-sandwich (FS) methods by evaluating the morphology of the anastomosis using computed tomography (CT) scans. Moreover, we performed macroscopic evaluation of one patient who required a second operation. RESULTS: Between May 2009 and April 2020, 160 consecutive patients (104 males, 56 females; mean age, 68.6 ± 11; range, 39-88 years) underwent thoracic aortic surgery. The overlay technique was successfully performed in 84 cases. The anastomosis sites of the overlay method maintained their morphology without any clinical complications. The inner diameter ratio of anastomosis/graft was measured using CT, which revealed that the overlay method was not significantly different from inversion and was significantly larger than the FS method. There was no anastomotic stenosis in the proximal or distal overlay anastomosis. Only one patient required a second operation for an enlarged aneurysm of the distal false lumen. We observed that the proximal overlaid adventitia was smoothly attached to the native lumen and was macroscopically indistinguishable from the original intima. CONCLUSIONS: This study showed the midterm stability of the overlay technique. The midterm outcome was clinically acceptable. No anastomotic stenosis or pseudoaneurysm formation in either the true aortic aneurysm or dissection cases was observed.

Comprehensive Pain Control Strategy in Minimally Invasive Mitral Valve Repair.

PURPOSE: The effect of our comprehensive strategy to reduce pain after minimally invasive mitral valve repair through a right mini-thoracotomy was assessed retrospectively. METHODS: Our comprehensive strategy constituted the following: planned rib cutting to avoid rib injury, sufficient intercostal muscle division to mobilize the cut rib, limiting the number of intercostal ports, avoiding nerve entrapment, continuous extra-pleural intercostal nerve block, and regular use of oral non-steroidal anti-inflammatory drugs. We compared patients treated with this comprehensive strategy (Group S, n = 13) and patients before this strategy was implemented (Group C, n = 13). We used a numerical rating scale (NRS) as a pain scale during the first 3 days postoperatively. RESULTS: The average NRS was significantly lower in Group S (0.82 ± 0.49) than in Group C (2.40 ± 1.46) (P <0.01). The maximum NRS was also significantly lower in Group S (3.23 ± 1.17) than in Group C (5.69 ± 2.43) (P <0.01). The number of patients using additional single-dose analgesic were significantly less in Group S (23.1%) than in Group C (84.6%) (P <0.01). CONCLUSION: Our comprehensive pain control strategy effectively reduced postoperative pain in minimally invasive mitral valve repair.

Utility of Ultrasonographic Assessment of Distal Femoral Arterial Flow during Minimally Invasive Valve Surgery.

PURPOSE: To evaluate the utility of ultrasonographic assessment of blood flow to the lower limb below the cannulation site in minimally invasive cardiac surgery (MICS). METHODS: Twenty-two patients who underwent ultrasonographic assessment in MICS were reviewed retrospectively. In all patients, the right femoral artery was used for arterial cannulation. Ultrasonographic assessment was performed using a 15-MHz ultrasonography small probe, and regional oxygen saturation was monitored by near-infrared spectroscopy (NIRS). RESULTS: The mean flow velocity at the distal side of the cannulation site was 46.2 ± 25.4 cm/s. In six patients, a >40% decreased from baseline regional oxygen saturation was observed. In five of the six patients, the flow velocity was very slow, and spontaneous echo contrast was also observed in three cases. Their regional oxygen saturation was improved rapidly after distal leg perfusion. In the remaining case, the flow velocity was not decreased. In another one case, the stenosis at the cannulation site was detected after decannulation and repaired immediately. No limb ischemic complications were observed in this series. CONCLUSION: Ultrasonographic assessment combined with the NIRS monitoring is useful to prevent lower limb ischemic complications after femoral arterial cannulation in MICS.

Trunk Muscle Cross-Sectional Area as a Predictive Factor for Length of Postoperative Hospitalization after Surgical Aortic Valve Replacement.

PURPOSE: We investigated the utility of trunk muscle cross-sectional area to predict length of hospitalization after surgical aortic valve replacement (AVR) for aortic stenosis (AS). METHODS: Adult AS patients who underwent isolated AVR at a single institution were studied. The cross-sectional area of the erector spinae muscles (ESM) at the first and second lumbar vertebrae and that of the psoas muscle (PM) at the third and fourth lumbar vertebrae were measured on preoperative computed tomography (CT). Each was indexed to body surface area. Risk factors for prolonged postoperative hospitalization (>3 weeks) were assessed using multivariate regression analyses. RESULTS: Of 56 patients (mean age 76 ± 9 years; 25 men), 20 (35.7%) patients required prolonged hospitalization. A smaller indexed ESM cross-sectional area at the first lumbar vertebra (per 1 cm/m2, odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.57-0.88, P <0.01) and lower preoperative serum albumin level (per 0.1 g/dL, OR = 0.83, 95% CI = 0.70-0.99, P <0.05) were shown as independent predictors. Indexed PM cross-sectional area was not statistically significant. CONCLUSION: The cross-sectional area of the trunk muscles can be used to identify patients at risk for prolonged hospitalization after AVR for adult AS.

Commissure enhancement technique in aortic valve repair.

Sinotubular junction enlargement is one of possible causes of aortic valve regurgitation. However, there is no appropriate technique for sinotubular junction diameter reduction in aortic valve repair in a patient without disease of the ascending aorta or sinus of Valsalva. Herein, we report a simple commissure enhancement technique comprising the placement a horizontal mattress suture buttressed with felt at the sinotubular junction level in the commissure area. This technique results in the relocation of the commissure to the inner side, and a reduction in the diameter of the sinotubular junction.

The Risk Factor Analysis for the Late Graft Failure of Radial Artery Graft in Coronary Artery Bypass Grafting.

OBJECTIVE: The aim of this retrospective study was to investigate the early operative results and detect the factors influencing the fate of radial artery grafts (RAGs) by evaluating the mid-term patency. METHODS: We retrospectively reviewed 410 patients who underwent isolated coronary artery bypass grafting using RAG. RAGs were anastomosed to 526 coronary arteries. Mid-term angiography was performed in 214 patients at an average 4.9 years after the operation. RESULTS: The early patency of RAGs was 97.6%. Cumulative 5-year patency was 86.5% for RAG, 94.1% for LITA graft, and 81.0% for saphenous vein graft (SVG). RAG was significantly superior to SVG in mid-term patency. Individual grafting (not sequential grafting) (hazard ratio [HR]: 2.535; 95% confidence interval [CI]: 1.293-5.281; p = 0.006) and grafting to the target coronary artery with ≤75% proximal stenosis (HR: 1.947; 95% CI: 1.090-3.484; p = 0.025) were found to be independent risk factors influencing late RAG patency. CONCLUSIONS: The patency of RAGs was superior to that of SVGs in the studied population. When using RAGs, grafting to the target vessel with severe proximal stenosis is favorable. The RAG is suitable for sequential grafting.

Posterior leaflet reconstruction using autologous pericardium in mitral repair.

A 75-year-old woman experienced recurrent mitral regurgitation caused mainly by a shrunken and tethered posterior mitral leaflet with a dilated left ventricle. Posterior leaflet motion was severely restricted. We successfully resolved the tethering and restored valve coaptation and competence using posterior leaflet reconstruction, which is a modified method of posterior leaflet augmentation using autologous pericardium. This technique can recover the posterior leaflet function by improving tissue volume and tethering.

Transapical Endovascular Repair of Thoracic Aortic Pathology.

BACKGROUND: Alternative access for thoracic endovascular aortic repair (TEVAR) has been explored for patients with unsuitable femoral and iliac access, but few cases of transapical access have been described. We report our experience with transapical access for various aortic pathologies. METHODS: We reviewed 6 cases undergoing transapical access for endovascular repair of thoracic aortic pathology between December 2013 and August 2015. Five patients had an aortic arch aneurysm and 1 patient presented with Stanford type A subacute aortic dissection. Transapical access was indicated to avoid approach through the severely atherosclerotic thoracic descending aorta in 4 patients and severely kinked aorta in 1 patient and to treat an ascending aortic dissection lesion in 1 patient. RESULTS: Transapical endografting was completed in all patients. Significant aortic valve regurgitation occurred in 3 patients when a large bore sheath was placed across the aortic valve. There was 1 death attributed to global cerebral ischemia due to carotid dissection after carotid bypass and chimney stent-graft insertion. There were no access-related complications. Computed tomography revealed complete exclusion of the aortic aneurysm in 4 patients, and shrinkage of the false lumen in 1 patient with aortic dissection. CONCLUSIONS: Transapical access for TEVAR would be a potential alternative when the anatomy is unfit for routine retrograde approach. This method might have potential benefit of reducing the risk of embolism in patients with severe atherosclerotic thoracic descending aorta. However, certain safety concerns must be addressed, including maintenance of hemodynamics, wire exteriorization for navigation of the device tip, and rapid pacing during deployment.

Preoperative simulation of minimally invasive aortic valve replacement using patient-specific replica.

Exposure of surgeons to minimally invasive cardiac surgery is typically limited. We developed a patient-specific aortic root silicon replica for simulating minimally invasive aortic valve replacement (MIAVR). From this 3D model, important anatomical information was obtained. To understand the best procedural option, different techniques were attempted without time limitation, leading to the complete planning of the operation. The patient-specific replica and simulated surgery were useful for preoperative training and planning for the MIAVR procedure.

Surgical treatment for thoracoabdominal intra-aortic thrombus with multiple infarctions: a case report.

BACKGROUND: Mobile intra-aortic thrombus without atherosclerosis, aneurysm, or congenital coagulopathy is very rare, and there are few reports especially in young or middle-aged patients. Furthermore, there are presently no established guidelines or common strategies for the treatment of mobile intra-aortic thrombus. In this case report, we describe the first case of intra-aortic thrombus caused by secondary erythrocytosis and describe the recommended treatment strategy for intra-aortic thrombus. CASE PRESENTATION: We report a case of an independent 40-year-old Asian man with a current history of heavy cigarette smoking who had sudden onset of abdominal and lumbar pain. Contrast-enhanced computed tomography revealed partial renal and splenic infarction, and he was transferred to our hospital. He also had a large mural thrombus in his thoracoabdominal aorta. Blood analysis on admission showed a hemoglobin level of 19.4 g/dL and hematocrit of 54.3 %; his international normalized ratio of prothrombin time, fibrin degradation products, and activated partial thromboplastin time levels were 1.02, 2.8 µg/ml, and 26.9 seconds respectively. We could find no abnormalities in protein C and protein S activity levels. Lupus anticoagulant and anti-cardiolipin antibody were both negative. He had no past medical history of arrhythmia and we found no signs of an arrhythmic event during admission. We promptly started anticoagulant therapy, but as the thrombus seemed at high risk of causing further critical infarction, we performed emergency aortic thrombectomy using partial extracorporeal circulation. To prevent dissemination of the thrombus during extracorporeal circulation, we first clamped his proximal and distal aorta on either side of the thrombus just before initiating extracorporeal circulation. After the aortotomy we removed a 14-cm length of intra-aortic thrombus without residual lesion. He was discharged from our hospital 20 days after surgery. From the results of his blood analysis, we considered the only cause of this thrombus was secondary erythrocytosis, which was probably induced by his current heavy cigarette smoking. CONCLUSION: We are the first to report such a thrombosis caused by secondary erythrocytosis and conclude that once the diagnosis of intra-aortic thrombus with systemic embolism is clear, emergency surgical removal of such a thrombus must be considered to prevent further embolic complications.

Externalized Transapical Guidewire for Aortic Arch Aneurysm Repair.

A 77-year-old woman with previous coronary artery bypass grafting and total arch replacement with the elephant-trunk technique was now planned for thoracic endovascular repair of residual distal aortic arch aneurysm. Because of her unfavorable aortic anatomy (severely angulated arch, previous graft, and short distance from aortic valve to proximal landing zone), we elected to use an externalized transapical guidewire technique with a through-and-through wire. By placing tension on the wire to transmit torque and force, we could advance the endograft tip safely through the angulated aorta and deploy the endograft sections accurately along the greater curvature of the aortic arch.

Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis.

OBJECTIVES: Deep sternal wound infection (DSWI) after cardiovascular surgery via median sternotomy remains a severe complication associated with a drastic decrease in the quality of life. We assessed the risk factors for in-hospital death caused by DSWI and the available treatments for DSWI. METHODS: Between January 1991 and August 2015, we retrospectively reviewed 73 patients (51 males and 22 females, mean age 67.5 ± 10.3 years) who developed DSWI after cardiovascular surgery via median sternotomy. Pathogenic bacteria mainly comprised methicillin-resistant Staphylococcus aureus (MRSA) (49.3%). Fifteen patients (20.5%) died in hospital with DSWI. Treatment of DSWI consisted of open daily irrigation (up to 2006) or negative pressure wound therapy (NPWT) (2007 onwards), followed by primary closure or reconstruction of tissue flaps. We assessed the risk factors for in-hospital mortality from DSWI by comparing data from the 15 patients who died and the 58 survivors using propensity score matching analysis of the treatments used for DSWI. RESULTS: Univariate analysis identified age, use of intra-aortic balloon pumping, prolonged mechanical ventilation, tracheotomy, prolonged intensive care unit stay, postoperative low output syndrome, postoperative myocardial infarction, postoperative renal failure, postoperative use of haemodialysis, postoperative pneumonia, postoperative cerebral disorder, MRSA infection, NPWT and tissue flaps as being associated with in-hospital mortality (P < 0.05). Multivariate analysis identified NPWT (odds ratio, 0.062; 95% confidence interval, 0.004-0.897; P = 0.041) and tissue flaps (odds ratio, 0.022; 95% confidence interval, 0.000-0.960; P = 0.048) as independently associated with reduced in-hospital mortality after DSWI. On comparing 22 patients receiving NPWT with 22 not on NPWT using propensity score matching, patients on NPWT had significantly lower in-hospital mortality than those without NPWT (NPWT vs non-NPWT, 5 vs 36%, P = 0.021). In DSWI infected by MRSA, NPWT significantly reduced the in-hospital mortality caused by DSWI (NPWT vs non-NPWT, 0 vs 52%, P = 0.003). CONCLUSIONS: NPWT and tissue flaps may be favourable factors associated with reduced in-hospital mortality attributable to DSWI. NPWT as a bridge therapy to tissue flaps may play a major role in treating DSWI and improve the prognosis for patients with MRSA-infected DSWI.

Right Axillary Artery Cannulation in Aortic Valve Replacement.

OBJECTIVE: This retrospective study aimed to evaluate the results of our experience with axillary artery cannulation via a side graft in aortic valve replacement in patients with ascending aortic atherosclerotic disease. METHODS: From January 2002 to 2012, we operated on 76 patients for aortic valve disease with the use of the axillary artery for arterial inflow in our institute. The indications for cannulation of the axillary artery were aortic aneurysm in 37 patients, severe aortic atherosclerosis in 28 patients, and re do surgery in 11 patients. RESULTS: Right axillary artery cannulation via a side graft provides sufficient antegrade aortic flow of 2.6 ± 0.1 L/m(2) during cardiopulmonary bypass. No additional arterial cannulation was necessary to obtain sufficient perfusion during cardiopulmonary bypass. Although permanent perioperative stroke was observed in two patients, this did not occur during the operation. There were no problems with cannulation or wound and graft infections. During the follow-up period, there were no thrombotic events due to an axillary graft stump in the right upper extremities. CONCLUSIONS: Axillary artery cannulation via a side graft is a useful and safe option for cardiopulmonary bypass in patients with atherosclerotic disease of the ascending aorta undergoing aortic valve replacement.

Efficacy and Safety Evaluation of Tolvaptan on Management of Fluid Balance after Cardiovascular Surgery Using Cardiopulmonary Bypass.

Background: Tolvaptan is an orally administered selective vasopressin 2 receptor antagonist that promotes aquaresis. This study aimed to evaluate the efficacy and safety of tolvaptan on management of systemic fluid balance after cardiovascular surgery using cardiopulmonary bypass. . Methods: Sixty-four patients who underwent cardiovascular surgery using cardiopulmonary bypass in our hospital were enrolled for this prospective, randomized study. These patients were divided into three groups: tolvaptan 15 mg+furosemide 20 mg (TH group), tolvaptan 7.5 mg+furosemide 20 mg (TI group), and furosemide 40 mg+spironolactone 50 mg (C group). The endpoint was safety management of systemic fluid balance using tolvaptan without renal dysfunction and electrolyte imbalance. Results: The mean daily urine output in the TH and TL groups (2656±767 and 2505 ±684 mL) was significantly higher than that in the C group (1956±494 mL, TH vs C: p<0.01 and TL vs C: p=0.03). The lowest serum sodium level during medication in the TH group (139.3 ±2.3 mEq/L) was significantly higher than that in the C group (137.1±2.9 mEq/L, p=0.03) The lowest serum osmolality during medication in the TH group was significantly higher than that in the C group (284.8 ±4.3 vs 279.5± 6.3 mOsm/kg, p<0.01). None had critical hypernatremia, hyperosm6lality, or renal dysfunction in any. of the groups. Conclusions: Tolvaptan exerts, a strong diuretic effect compared with conventional diuretics (furosemide and spironolactone) during the postoperative period after an operation using cardiopulmonary bypass without adverse effects on electrolyte balance and renal function.

[Risk Factors in Surgical Intervention for Prosthetic Valve Endocarditis].

The aim of this retrospective study was to detect the risk factors for in-hospital mortality after surgery for active prosthetic valve endocarditis ( PVE). We reviewed 35 operations for active PVE, including 6 cases of early PVE. Seven patients were New York Heart Association (NYHA) functional class IV. Preoperative mechanical ventilation was necessary in 3 patients, 1 patient required intra-aortic balloon pumping, and another needed percutaneous cardiopulmonary support. Preoperatively, cerebrovascular events were observed in 13 patients, annular abscess in 12, and perivalvular leakage in 14. Valve replacement was performed in 24 patients and aortic root replacement in 11. Annular reconstruction was required in 18 patients. There were 6 hospital deaths (17.1%). The results of risk factor analysis showed that early PVE, NYHA functional class IV, and preoperative mechanical ventilation were independent risk factors for in-hospital death after surgery. In conclusion, surgical treatment of PVE should be performed before hemodynamic deterioration.

[Surgical treatment for pseudoaneurysm of the sinus of valsalva ruptured into the right atrium after mycotic right coronary artery aneurysm repair;report of a case].

A 67-year-old man was admitted to our hospital by ambulance after syncope due to complete A-V block. He had received surgical treatment for mycotic aneurysm of the right coronary artery 3 months before, with patch plasty of the right sinus of Valsalva and bypass grafting to the right coronary artery (RCA) as well as the left anterior descending branch. Computed tomography revealed pseudoaneurysm of the right Valsalva sinus of about 8 cm in diameter and a shunt flow to the right atrium. The previous bypass graft to RCA had been occluded due to compression by the aneurysm. As he was in a shock state, emergency operation was performed. Cardiopulmonary bypass was first established, and after the rectal temperature reached to 26 degrees centigrade, the chest was opened. The pseudoaneurysm burst out when the sternum was re-opened. Under circulatory arrest, the ascending aorta was clamped, and then the circulation was resumed. The previous bovine pericardium patch repairing the Valsalva sinus was detached due to infection, and mural thrombus and pus were observed in the aneurysm. At the bottom of the aneurysm, a fistula connected to the right atrium was found. Debridement around the aneurysm was performed as much as possible. The defect of the Valsalva sinus was repaired with a Dacron patch immersed in gentian violet. The postoperative course was uneventful without any recurrence of infection.