Bicuspidalization of the Native Tricuspid Aortic Valve: A Porcine in Vivo Model of Bicuspid Aortopathy.

Objective: To examine early histologic changes in the aorta exposed to bicuspid flow. Material and Methods: A porcine bicuspid aortopathy model was developed by suturing aortic cusps. Of nine pigs, eight underwent sham surgery (n=3) or bicuspidalization (n=5); one was used as an intact control. Wall shear stress (WSS) was assessed by computational fluid dynamics (CFD). Animals were exposed to normal or bicuspid flow for 48 h and were then euthanized for histologic examinations. Results: No animal died intraoperatively. One animal subjected to bicuspidalization died of respiratory failure during postoperative imaging studies. Echocardiography showed the aortic valve area decreased from 2.52±1.15 to 1.21±0.48 cm2 after bicuspidalization, CFD revealed increased maximum WSS (10.0±5.2 vs. 54.0±25.7 Pa; P=0.036) and percentage area of increased WSS (>5 Pa) in the ascending aorta (30.3%±24.1% vs. 81.3%±13.4%; P=0.015) after bicuspidalization. Hematoxylin-eosin staining and transmission electron microscopy showed subintimal edema and detached or degenerated endothelial cells following both sham surgery and bicuspidalization, regardless of WSS distribution. Conclusion: A bicuspid aortic valve appears to increase aortic WSS. The endothelial damage observed might have been related to non-pulsatile flow (cardiopulmonary bypass). Chronic experiments are needed to clarify the relationship between hemodynamic stress and development of bicuspid aortopathy.

Risk of Out-of-Hospital Cardiac Arrest in Aged Individuals in Relation to Cold Ambient Temperature　- A Report From North Tochigi Experience.

BACKGROUND: The impact of cold ambient temperature on out-of-hospital cardiac arrest (OHCA) in aged individuals caused by cardiovascular events in indoor environments has not been investigated sufficiently.Methods and Results:We conducted a case-crossover study. The relationship between OHCA caused by cardiovascular events and exposure to minimum temperature <0℃ was analyzed. Conditional logistic regression analysis was performed to estimate the odds ratios for the relationship between exposure to minimum temperature <0℃ and the risk of OHCA. Between January 1, 2011, and December 31, 2015, a total of 1,452 cases of OHCA were documented, and patients were screened for enrollment. A total of 458 individuals were enrolled in this analysis, and were divided into 2 groups of 110 (elderly group: 65-74 years old) and 348 (aged group: ≥75 years old). The aged individuals had a significant increased risk of OHCA after exposure to minimum temperature <0℃ (odds ratio [OR]: 1.528, 95% confidence interval [CI] 1.009-2.315, P=0.045). Cold ambient temperature was an especially significant increased risk for OHCA occurrence for males (OR: 1.997, 95% CI 1.036-3.773, P=0.039) and during winter (OR: 2.391, 95% CI 1.312-4.360, P=0.004) in the aged group. CONCLUSIONS: Cold ambient temperature significantly affected aged individuals (≥75 years old) experiencing an OHCA caused by cardiovascular events in indoor environments.

[Hip Fracture Repair with Concomitant Transcatheter Aortic Valve Implantation;Report of a Case].

The incidences of hip fracture and aortic valve stenosis are increasing in the aging population. Operative repair for hip fracture contributes to excellent clinical results. Transcatheter aortic valve implantation, which does not require cardiopulmonary bypass, represents a new era for the treatment of aortic valve stenosis. We herein describe a patient with both hip fracture and severe aortic valve stenosis. A 93-year-old woman underwent transcatheter aortic valve implantation for the valve stenosis immediately followed by open repair surgery for the fracture. She fully recovered without heart failure during the postoperative rehabilitation period. The performance of concomitant surgeries for hip fracture and aortic valve stenosis might increase in the future.

Outcomes of Early-Onset Acute Type A Aortic Dissection　- Influence of Etiologic Factors.

BACKGROUND: Outcomes of early-onset acute type A aortic dissection (ATAAD) associated with Marfan syndrome (MFS) are known, but not with other etiologies. Methods and Results: ATAAD patients from 2 centers (n=1,001) were divided into 2 groups: age ≤45 years (n=93) and age >45 years (n=908). Although in-hospital death and 10-year survival were similar (12% vs. 7% and 62.6% vs. 67.3%), the 10-year aortic event-free survival differed (50.0% vs. 80.2%; P<0.01). ATAAD patients from 3 centers (n=132), all aged ≤45 years, were divided into 5 groups: lone hypertension (HTN, n=71), MFS (n=23), non-syndromic familial thoracic aortic aneurysm and dissection (NS-FTAAD, n=16), bicuspid aortic valve (BAV, n=11), and no known etiologic factor (n=11). The incidence of severe aortic insufficiency varied between groups (HTN: 11%, MFS: 39%, NS-FTAAD: 38%, BAV: 55%, no known factor: 46%; P<0.01), whereas in-hospital death did not (14%, 22%, 0%, 0%, and 9%; P=0.061). The 10-year survival was 52.2%, 64.7%, 83.6%, 100%, and 90.9%, respectively, and 10-year aortic event-free survival was 55.6%, 36.3%, 77.5%, 90.0%, and 30.0%. Median descending aorta growth (mm/year) was 1.1 (0.1-3.4), 2.3 (0.3-5.3), 1.9 (1.3-2.7), 0.9 (-0.1-2.0), and 1.0 (-0.2-2.9) (P=0.15), respectively. CONCLUSIONS: Late aortic events are common in young ATAAD patients. Known etiologic factors, though not BAV, negatively influence late outcomes in these patients.

Open Surgical Decompression Is Useful for the Prevention and Treatment of Abdominal Compartment Syndrome after the Repair of Ruptured Abdominal Aortic and Iliac Artery Aneurysm.

Objective: This study was performed to determine whether open surgical decompression (OSD) decreased the mortality associated with abdominal compartment syndrome (ACS) following open repair (OR) of ruptured abdominal aortic aneurysm and iliac aneurysm (rAAA), and to investigate the risk factors associated with OSD. Material and Methods: Total 113 consecutive patients with rAAA underwent OR in our institution. Ninety patients underwent primary abdominal closure; however, three of them developed ACS and required OSD. Prophylactic OSD was performed at the initial OR in 23 patients. Results: The in-hospital mortality rate was higher in those who underwent OSD than in those who did not undergo OSD [27.0% (7/26) vs. 6.9% (6/87), respectively; p=0.01]. However, no ACS-related death occurred in the OSD group. Multivariate analyses revealed that a preoperative/intraoperative base excess (BE)<-11 [p=0.045; odds ratio (OR), 3.33; 95% confidence interval (CI), 1.021-10.850], performance of left thoracotomy (p=0.038; OR, 5.17; 95%CI, 1.098-24.357), and intraoperative blood transfusion >1,800 mL (p=0.012; OR, 4.30; 95%CI, 1.386-13.322) were associated with OSD. Conclusion: The prevalence and mortality rates of ACS were low at our institution. OSD is considered to be useful for the prevention and treatment of ACS after repair of rAAA. OSD should be considered in patients with the above-mentioned factors.

[Two-stage Surgery for Uterine Intravenous Leiomyomatosis with Right Ventricular Extension;Report of a Case].

Intravenous leiomyomatosis is a rare neoplastic condition characterized by the benign intravascular proliferation of smooth muscle cells originating from either the uterine venous wall or a uterine leiomyoma. In the present report, we describe the case of a 36-year-old woman, who was referred to our institution due to abdominal pain. Computed tomography indicated the presence of a giant intravenous leiomyoma originating from the uterus and extending to the right ventricle with complex pathways. The patient was successfully treated by tumor resection under circulatory arrest in two-stage operations in conjunction with gonadotrophin-releasing hormone agonists therapy. She continued to recover and did not exhibit any recurrence at the 8-month follow-up.

A case of immunoglobulin G4-related aortic diseases.

A 65-year-old man had histories of retroperitoneal fibrosis, membranous nephropathy, and acute coronary syndrome. Chest computed tomography showed an enlarged ascending aorta and type B aortic dissection, and he underwent ascending aorta and arch replacement. A pathological examination of the resected aorta showed immunoglobulin G4-positive plasma cell infiltration.

Chronic aortic dissection with tricuspid regurgitation: report of a case.

Dilatation of aortic root may distort the tricuspid annulus. We experienced a case of chronic aortic dissection presented with tricuspid regurgitation. Chest computed tomography revealed an enlarged ascending aorta displacing the right heart. The patient successfully underwent replacement of the aorta and tricuspid annuloplasty with a prosthetic annulus.

A Case of Left Atrial Myxoma Whose Initial Symptom Was Finger Ischemic Symptom.

We experienced a 45-year-old Japanese man who was transferred to our hospital complaining of acute onset of pain and pallor in the right lower limb. Two years earlier, he had complained of repetitive pain at rest and pallor in the left third and fourth fingers. The physical exam and angiography demonstrated occlusion of finger arteries, however we could not reach final diagnosis. Acute arterial occlusive disease in the right lower limb was suspected. Transthoracic echocardiography demonstrated a gross tumor in the left atrium, which suggested left atrial myxoma. An emergency tumorectomy was successfully conducted. Pathologically, the fragile tumor and resultant thrombosis could have caused the patient's peripheral circulatory failure at least two years prior to this episode. A rigorous systemic survey is important even when the ischemic symptom is localized in peripheral circulation.

Early and Late Surgical Outcomes of Acute Type A Aortic Dissection in Octogenarians.

BACKGROUND: Although surgical outcomes of acute type A aortic dissection (ATAAD) have improved, it is still a high-risk procedure for octogenarians. This study analyzed early and late outcomes of surgical repair of ATAAD among octogenarians. METHODS: From 1990 through 2016, 1,260 consecutive patients with ATAAD were emergently admitted to Jichi Medical University Hospitals. Of them, 1,026 patients who underwent emergency surgery for ATAAD within 48 hours of symptom onset were included in this retrospective study. Of these, 112 were aged 80 years or more (mean, 83.1 ± 2.7) and formed the octogenarian group; and 914 were aged less than 80 years (mean, 62.0 ± 11.4) and formed the control group. Early and late outcomes were compared. RESULTS: The inhospital mortality rate was 6.3% for the octogenarian group and 7.4% for the control group (p = 0.85). No significant difference was observed in the causes of hospital death. Although the overall postoperative complication rate was not different (24.1% versus 23.0%), pneumonia was more frequent among octogenarians (p = 0.03). Multivariate analysis of hospital mortality did not indicate age 80 years or more as a risk factor. Overall postoperative survival for the octogenarian group was 84.6%, 70.5%, and 57.1% at 1, 3, and 5 years, respectively. For the control group, the rates were 89.1%, 85.6%, and 82.1%, respectively. Pneumonia and decrepitude were the major causes of remote death for the octogenarian group. CONCLUSIONS: No significant difference in the hospital mortality rate or the complication rate was observed between the groups. Emergency surgery for ATAAD in octogenarians could be performed with the same low risk observed for younger patients.

Spike in glucose levels after reperfusion during aortic surgery: assessment by continuous blood glucose monitoring using artificial endocrine pancreas.

OBJECTIVES: Although strict blood glucose control during cardiovascular surgery is essential to avoid postoperative complications, the various changes in glucose levels that occur during surgery have not been investigated in detail. In this study, we continuously monitored blood glucose changes during aortic surgery using the STG-55Ⓡ artificial endocrine pancreas (Nikkiso Inc., Tokyo). METHODS: Between December 2015 and 2016, we performed continuous blood glucose monitoring in 22 patients (14 men and 8 women, 72 ± 11 years old), who required hypothermic circulatory arrest during an ascending/aortic arch surgery, at the Jichi Medical University Hospital. Ascending aorta replacements were performed in two patients and partial/total arch replacement, in 20. All the patients required selective cerebral perfusion and hypothermic circulatory arrest (bladder temperature at 25-26 °C) during distal anastomosis. Closed-loop continuous blood glucose monitoring was performed during cardiopulmonary bypass using the STG-55Ⓡ artificial endocrine pancreas (Nikkiso Co., LTD, Tokyo). RESULTS: Blood glucose concentrations did not increase significantly from the time of the commencement of cardiopulmonary bypass to lower body ischemia. However, they dramatically increased immediately after reperfusion following lower body ischemia, and this hyperglycemia was sustained until the end of cardiopulmonary bypass. CONCLUSION: The current study clarified the peak glucose concentration during aortic surgery. These data may contribute to the management of blood glucose levels during aortic surgery.

[Coronary Artery Perforation Secondary to Primary Percutaneous Coronary Intervention;Report of a Case].

Stent perforation of a coronary artery during percutaneous coronary intervention (PCI) is a rare but life-threatening complication. A 70-year-old man was admitted to our hospital for management of acute coronary syndrome. PCI was attempted for the left circumflex artery(LCX);however, catheterization was complicated by perforation of the LCX by the stent. He developed cardiac tamponade and was resuscitated using percutaneous cardiopulmonary support. Emergency surgery( ligation of the LCX and aorto-coronary bypass grafting for the distal LCX) was performed. His postoperative course was uneventful, and the patient was discharged on the 20th postoperative day. Collaboration between cardiologists and surgeons is essential to salvage such a critical patient.

Left ventricular blood cyst in an adult case.

We present a 57-year-old man with a 1.5-cm-diameter blood cyst in the left ventricle, which was incidentally detected by conventional diagnostic echocardiography before colon surgery. The cyst originated from the papillary muscle, and the pathological findings were compatible with a cardiac blood cyst.

[Prophylactic Effectiveness of Vacuum-assisted Closure for High-risk Patients Undergoing Cardiovascular Surgery through Median Sternotomy].

Vacuum-assisted closure(VAC) therapy is mainly used for tissue defects. VAC therapy can remove exudate that could impair the healing process. We applied VAC therapy in patients considered at high risk of surgical site infection who underwent cardiovascular surgery via standard median sternotomy. Risk factors included advanced heart failure, obesity, diabetes mellitus, steroid administration, immunosuppressant administration, and chronic renal failure, etc. VAC therapy was used in 134 patients. Only 3 of these patients (2.2%) developed surgical site infection caused by Staphylococcus epidermidis;2 patients fully recovered after prolonged VAC therapy for 2 weeks, and the other required an additional sternal fixation after the sternal wires were removed for wound infection control. No patient developed infective mediastinitis. Prophylactic VAC therapy can reduce postoperative wound infection in high risk patients undergoing open heart surgery via full sternotomy.

[Intravascular Hemolysis Caused by Stenosis of an Elephant Trunk;Report of a Case].

Symptomatic intravascular hemolysis after prosthetic aortic graft replacement is rare. It is primarily attributed to mechanical injury of red blood cells caused by stenosis of the vascular graft. A 50-year-old man presented with hemolytic anemia, 5 years after total arch replacement with an elephant trunk for type A aortic dissection. The hemolysis was caused by graft stenosis of the elephant trunk. Endovascular treatment for the stenotic elephant trunk was successfully performed. The postoperative course was uneventful, and the hemolysis was resolved immediately after operation.

[Aortic Valve Replacement Via a Partial Sternotomy in an Ankylosing Skeletal Hyperostosis Patient after Prophylactic Tracheostomy;Report of a Case].

A 77-year-old man presented with exertional dyspnea. The patient had a history of ankylosing skeletal hyperostosis and sleep apnea syndrome. Echocardiographic examination revealed severe aortic valve regurgitation. The patient underwent a prophylactic tracheostomy 2 weeks before cardiac surgery to decrease his risk of perioperative respiratory failure. He successfully underwent aortic valve replacement through a lower partial sternotomy. His postoperative course was uneventful, and the tracheostoma was closed 6 months after the cardiac surgery.