Open, endovascular, or hybrid repair of aortic arch disease: narrative review of diverse strategies with diverse options.

OBJECTIVES AND METHODS: The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices. In New York, we have developed a collaborative group named the New York Aortic Consortium (NYAC) as a means of crosslinking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature, as well as the integration of endovascular technology into disease management. In this review article, we summarize the current state of aortic arch surgery. RESULTS: Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve hemostasis, simplify future operations, or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Amongst our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and management strategies of patients with aortic arch disease. CONCLUSIONS: It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair, and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.

[Repair of Traumatic Brachiocephalic Artery Pseudoaneurysm by Open Surgery:Report of a Case].

The patient is a 56-year-old man. He fell while playing golf and sustained a contusion on his right chest. He fell into hemorrhagic shock during surgery for a right clavicle fracture at a nearby hospital and required cardiac resuscitation. Computed tomography( CT) scan revealed left pneumothorax and right hemothorax, and a contrast-enhanced CT scan revealed a pseudoaneurysm at the brachiocephalic artery origin. He underwent surgery three weeks later. Surgery was performed through a median sternotomy and partial arch replacement (zone 2) with antegrade cerebral perfusion under moderate hypothermia. He was discharged on postoperative day 10 without significant complications.

Long-term Results of Valve-Sparing Aortic Root Replacement and Aortic Cusp Repair.

BACKGROUND: Long-term results of valve-sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation are unclear. METHODS: VSRR by reimplantation was performed in 363 patients. Tricuspid aortic valve (TAV) and bicuspid aortic valve were found in 285 and 71 patients, respectively. RESULTS: Aortic cusp repair was performed in 268 patients. Of patients with TAV 129 had central plication of the Arantius node, 36 had free margin resuspension, and 71 had reinforcement. Mean follow-up was 71.4 months. Among TAV patients freedom from aortic valve reoperation at 10 and 15 years was 85.1% and 78.3%, respectively. Freedom from aortic valve reoperation at 10 years was lower in patients with cusp prolapse than without (77.4% vs 93.2%, P = .007). The overall freedom from more than mild aortic regurgitation at 10 and 15 years was 72.4% and 64.0%, respectively. It was also significantly greater in patients without cusp prolapse (78.4% vs 67.7%, P = .02). As for the cusp repair technique the freedom from aortic valve reoperation at 10 years was significantly better in patients who underwent only resuspension or reinforcement techniques compared with patients who underwent only central plication technique (100% vs 72.8%, P = .008). CONCLUSIONS: Long-term results of VSRR with aortic cusp repair were satisfactory. The resuspension technique appears to be useful for repairing aortic cusp prolapse in patients with TAV.

Mid-term outcomes of surgical aortic valve replacement using a mosaic porcine bioprosthesis with concomitant mitral valve repair.

This study retrospectively evaluated the mid-term outcomes of surgical aortic valve replacement (SAVR) using a stented porcine aortic valve bioprosthesis (Mosaic; Medtronic Inc., Minneapolis, MN, USA) with concomitant mitral valve (MV) repair. From 1999 to 2014, 157 patients (median [interquartile range] age, 75 [70-79] years; 47% women) underwent SAVR with concomitant MV repair (SAVR + MV repair), and 1045 patients (median [interquartile range] age, 76 [70-80] years; 54% women) underwent SAVR only at 10 centers in Japan as part of the long-term multicenter Japan Mosaic valve (J-MOVE) study. The 5-year overall survival rate was 81.5% ± 4.1% in the SAVR + MV repair group and 85.1% ± 1.4% in the SAVR only group, and the 8-year overall survival rates were 75.2% ± 5.7% and 78.1% ± 2.1%, respectively. Cox proportional hazards analysis showed no significant difference in the survival rates between the two groups (hazard ratio, 0.87; 95% confidence interval, 0.54-1.40; P = 0.576). Among women with mild or moderate mitral regurgitation who were not receiving dialysis, those who underwent SAVR + MV repair, were aged > 75 years, and had a preoperative left ventricular ejection fraction of 30-75% tended to have a lower mortality risk. In conclusion, this subgroup analysis of the J-MOVE cohort showed relevant mid-term outcomes after SAVR + MV repair.

Current status of surgical treatment for acute aortic dissection in Japan: Nationwide database analysis.

OBJECTIVE: To clarify the current status of surgical treatment of acute aortic dissection (AAD) in Japan through the Japan Cardiovascular Database analysis. METHODS: In total, 7194 patients who underwent surgical treatment for AAD in 2021, including type A (TAAAD) (n = 6416) and type B (TBAAD) (n = 778), were investigated. RESULTS: The median age was 70 years, with patients older than age 80 years constituting 21.7% and 23.4% of TAAAD and TBAAD cases. Emergency admission was 88.5% and 78.5%. Shock was found in 11.8% and 6.0%. Rupture/impending rupture occurred in 10.7%/6.0% and 24.0%/11.1%, respectively. Branch malperfusion was complicated in 10.4% and 25.2%. Open repairs were performed in 97.7% and 20.3%, whereas endovascular repairs were performed in 2.3% and 79.7%, respectively. In the increased prevalence of endografting procedures, neurological complications and renal failure occurred frequently after open repair with frozen elephant trunk for 29.9% and 50.3%. The operative mortality rate was 9.8% and 11.5% for open repair and 8.1% and 10.0% for endovascular repair. In patients with TAAAD, age older than 80 years, preoperative critical comorbidities, classical dissection, and coexisting chronic vital organ diseases were independent risk factors for mortality. In frozen elephant trunk procedures, neurologic complications and renal failure were frequent. The operative mortality was higher during the superacute phase within 1 or 2 hours from onset to arrival and between arrival and surgery. CONCLUSIONS: The current status of surgical treatments for AAD including the increased prevalence of endografting of thoracic endovascular aortic repair and frozen elephant trunk were demonstrated with favorable outcomes in the Japan Cardiovascular Database analyses.

Cardiac rupture during the course of treatment for acute purulent pericarditis caused by Staphylococcus aureus: a case report.

Background: Purulent pericarditis is rare in the modern era of antibiotics. However, it is a rapidly progressive, life-threatening disease with complications, including cardiac tamponade and left ventricular pseudoaneurysm. Case summary: A 44-year-old female was admitted with a pontine haemorrhage. On the 25th day of admission, she developed a fever along with chest pain and dyspnoea. Transthoracic echocardiography and computed tomography revealed a large pericardial effusion, leading to the diagnosis of cardiac tamponade. Pericardiocentesis was performed, resulting in the drainage of 750 mL of blood-stained fluid. Blood and pericardial fluid cultures were positive for Staphylococcus aureus; therefore, ceftriaxone was administered. On the 49th day, she became febrile again, and computed tomography showed increased pericardial effusion. Transthoracic echocardiography confirmed the large pericardial effusion and revealed a pseudoaneurysm on the inferior of the left ventricular wall, with blood flowing from the pseudoaneurysm into the pericardial space. Urgent surgical intervention was performed to repair a myocardial defect as a left ventricular pseudoaneurysm had ruptured in the pericardium. The patient recovered and was transferred to another hospital for rehabilitation after 108 days of hospitalization. Discussion: Purulent pericarditis can be a lethal complication; therefore, careful follow-up and strict adherence to therapeutic strategies, including the use of imaging technologies such as echocardiography, are important.

Recommendations for the management of the vascular involvement in Behçet's disease by the Japanese National Research Committee for Behçet's disease-secondary publication.

OBJECTIVES: This study aimed to develop clinical guidelines for the management of vascular Behçet's disease (BD) by the Behçet's Disease Research Committee of the Ministry of Health, Labour and Welfare of the Japanese Government. METHODS: A task force proposed clinical questions (CQs) concerning vascular BD based on a literature search. After screening, draft recommendations were developed for each CQ and brushed up in three blinded Delphi rounds, leading to the final recommendations. RESULTS: This study provides recommendations for 17 CQs concerning diagnosis and differential diagnoses, assessment of disease activity, and treatment. The guidelines recommend immunosuppressive treatments, for both arterial and venous involvement with active inflammation. Anticoagulation is also recommended for deep vein thrombosis except in high-risk patients. Surgical and endovascular therapies can be optional, particularly in patients with urgent arterial lesions undergoing immunosuppression. In addition, two sets of algorithms for diagnosis and treatment are shown for arterial and venous involvement. CONCLUSIONS: These recommendations are expected to serve as useful tools in the daily clinical practice of BD. This content has already been published in Japanese in the Guideline for the Management of Behçet's Disease 2020 and is submitted with permission from both the primary and secondary publishers.

The Asian Cardiovascular and Thoracic Annals turns 30.

The Asian Cardiovascular and Thoracic Annals turns 30 in 2023. A historical review since it was first published in March 1993 is presented.

Virtual Reality Computed Tomography Evaluation　- Anatomy and Clinical Implications for Valve-Sparing Aortic Root Replacement.

BACKGROUND: Three-dimensional aortic root evaluation using virtual reality (VR) techniques for valve-sparing aortic root replacement (VSARR) preparation has not yet been implemented, so we demonstrated VR computed tomography (VR-CT) and assessed its utility for VSARR.Methods and Results: We enrolled 72 patients who underwent multidetector CT before elective VSARR for annuloaortic ectasia with tricuspid aortic valve. The geometries of their aortic roots were measured with a VR-CT workstation. The mean values of geometric height (GH), free margin length (FML), and commissural height (CH) were 17.2±2.4 mm, 36.0±5.2 mm, and 24.0±4.3 mm, respectively. The right coronary/noncoronary CH was significantly greater than the left coronary/right coronary and left coronary/noncoronary CH. The left coronary cusp had the shortest FML, intercommissural distances (ICD), and smallest central angle. Although the right coronary cusp had the largest values for FML, ICD, and central angle, the right coronary cusp had the lowest GH and EH. The VR-CT measurements strongly correlated with intraoperative alternatives, especially with mean GH (R2=0.75) and left coronary/noncoronary CH (R2=0.79). Furthermore, mean GH was observed to be significantly different among the selected graft size groups; therefore, the preoperative mean GH could play a significant role in graft sizing. CONCLUSIONS: VR-CT evaluation allows a thorough understanding of aortic root anatomy, which could facilitate VSAAR.

The fate of the downstream aorta after total arch replacement.

OBJECTIVES: The goal of this study was to evaluate the fate of the downstream aorta following total arch replacement. METHODS: Between October 1999 and March 2018, a total of 740 patients underwent total arch replacement. After excluding connective tissue disease, previous descending or thoracoabdominal aortic surgery, patients without adequate preoperative images or operative mortality, late outcomes consisting of additional surgery for distal dilation and distal aortic events were evaluated in 623 survivors (240 aortic dissections, including 139 patients with acute dissection and 383 with a non-dissection aneurysm). The mean follow-up was 5.0 ± 4.0 years. RESULTS: The mean preoperative maximum diameter of the descending aorta was 36.9 ± 8.0 mm. An elephant trunk was inserted in 232 patients, including 183 patients with aortic dissection. Freedom from additional surgery for distal dilation was 88.5% at 5 years and 80.2% at 10 years. Freedom from distal aortic events was 81.9% at 5 years and 70.5% at 10 years. Multivariable regression analysis demonstrated that the preoperative diameter of the descending aorta was a significant risk factor for unfavourable distal aortic events. Computed tomography evaluation demonstrated a significant increase in the descending aortic diameter over time (P < 0.001). Positive aortic remodelling was observed in the proximal descending (P < 0.001) to mid-descending (P < 0.001) aorta exclusively in patients with acute aortic dissection. CONCLUSIONS: The diameter of the descending aorta increased significantly after total arch replacement, particularly in the distal descending aorta. The preoperative descending aortic diameter portended a significant risk for unfavourable distal aortic events.

Recent trends of open surgery for acute type A aortic dissection in Japan.

OBJECTIVE: Reporting clinical outcomes of acute type A aortic dissection. METHODS: Data derived from the survey of the Japanese Association for Thoracic Surgery, the Japan Cardiovascular Database, and the Japanese Registry of All Cardiac and Vascular Diseases were analyzed. RESULTS: Between 2012 and 2015, the Japanese Registry of All Cardiac and Vascular Diseases study collected 13,131 patients and the hospital mortality was 24.3%. The surgical mortality was significantly lower than medical one (11.8% vs 49.7%; p < 0.001). The Japanese Association for Thoracic Surgery survey disclosed the number of surgeries has been increased to 6157 in 2018 and the hospital death has decreased to 10.5%. The Japan Cardiovascular Database, collected 29,486 patients from 2013 to 2018. Age at surgery was 59.8 ± 14.2 years and patients younger than 65 years in 61% and 21% were older than 75 years. Ninety-four percent had surgery within 24 h after diagnosis. Antegrade cerebral perfusion was used in 74% and deep hypothermic circulatory arrest with/without retrograde cerebral perfusion in 26%. Replacement of the ascending aorta was performed in 62% and total arch replacement in 28%. The aortic valve was replaced in 7.9% and repaired in 4.4%. The hospital mortality was 11%. New stroke occurred in 12%, hemodialysis in 7.3%, paraplegia in 3.9%, and prolonged ventilation in 15%. CONCLUSION: The number of operations for type A aortic dissection has increased, and hospital mortality has improved. Although the early results after surgery for type A aortic dissection are acceptable, new strategies to improve early outcomes in patients with preoperative comorbidities are required.

Kinking of frozen elephant trunk: reality versus myth-a case report and literature reported.

Background: Kinking or iatrogenic stenosis in the frozen elephant trunk (FET) is a possible complication, however, there have been few cases reported. Case Description: A 43-year-old male with acute type A aortic dissection (ATAAD) underwent total arch replacement and FET installation. After weaning from the cardiopulmonary bypass, both femoral pulses were absent. A right axillo-bifemoral bypass using 8 mm graft was performed. Postoperative aortography showed a 100 mmHg-stenosis at the FET and 28 mm stent-graft was inserted to relieve stenosis. Eleven cases of postoperative FET stenosis have been reported from 2007 to 2019. The ages ranged from 30 to 72 years and 6 patients had ATAAD, 4 had chronic type A dissection, and 1 had non-dissection. They all underwent total arch replacement. To correct the iatrogenic stenosis of the FET, additional TEVAR was done in 8 patients, 2 had axillo-femoral bypass, 1 had a bare stent graft, and one required re-anastomosis. Conclusions: To prevent the FET kinking, surgeons should place the stented portion of the FET in the aortic arch angle. Also, we should make the non-stented portion as short as possible at the distal anastomosis. The DANE (distal anastomosis new entry) should be avoided by the secure anastomosis. Over-sizing or under-sizing of the FET should be minimized.

The combination approach with Rhokinase inhibition and mechanical circulatory support in myocardial ischemia-reperfusion injury: Rho-kinase inhibition and ventricular unloading.

BACKGROUND: It remains unclear whether the Rho-kinase (ROCK) inhibition in combination with mechanical circulatory support (MCS) had a synergic protective effect on myocardial ischemia (MI)/reperfusion injury in therapeutic strategies for acute myocardial infarction (AMI). We report the results of an approach using a rat model consisting of a miniaturized cardiopulmonary bypass (CPB) and AMI. METHODS: A total of 25 male Wistar rats were randomized into 5 groups: (1) Sham: a suture was passed under the left anterior descending artery (LAD) creating no MI. A vehicle solution (0.9% saline) was injected intraperitoneally. (2) Myocardial ischemia (MI) + vehicle (MI + V): LAD was ligated for 30 min and reperfused for 120 min, followed by administration of vehicle solution. (3) MI + fasudil (MI + F): the work sequence of group 2, but the selective ROCK inhibitor fasudil (10 mg/kg) was administered instead. (4) MI + V + CPB: CPB was initiated 15 min after the ligation of the LAD to the end of the reperfusion, in addition to the work sequence in group 2. (5) In the MI + F + CPB group, the work sequence of group 4, but with fasudil administration (10 mg/kg). RESULTS: Measurements of cardiac function through conductance catheter indicated that the drop of + dP/dt after reperfusion was moderately limited in MI + F + CPB (vs. MI + V, dP/dt p = 0.22). The preload recruitable stroke work was moderately improved in the MI + F + CPB (p = 0.23) compared with the corresponding control animals (MI + V). Phosphorylated protein kinase B expression in the MI + V + CPB and MI + F + CPB was higher than that in MI + V (p = 0.33). CONCLUSION: Therefore, fasudil administration with MCS resulted in a moderately better left ventricular performance.

Impact of High-Resolution Epiaortic Ultrasonographic Imaging on Evaluating Aortic Wall Pathology.

There has been no definitive method, other than pathological findings, to identify the degeneration of the tunica media in the aortic wall (TM). We describe how high-resolution intraoperative epiaortic ultrasonographic imaging identifies changes in the TM of patients with aortic dissection. This method shows great promise in facilitating presymptomatic diagnoses of various aortic wall pathologies.