Analysis of anatomical risk factors for persistent type II endoleaks following endovascular abdominal aortic aneurysm repair using CT angiography.

PURPOSE: To predict persistent type II endoleaks (pT2Es) following endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms, we examined factors related to post-EVAR pT2Es. METHODS: Eighty-four cases of EVAR were analyzed. T2Es that persisted for ≥6 months were defined as pT2Es. pT2Es flowing from an inferior mesenteric artery (IMA) and lumbar artery (LA) were termed pIMA-T2Es and pLA-T2Es, respectively. The anatomical factors concerning the aneurysm, IMA and LAs were assessed in the preoperative CT angiography images. A statistical analysis was performed on the factors associated with pT2Es. RESULTS: The incidence of pT2Es was 25 %. pT2Es were associated with postoperative changes in the aneurysm diameter. A univariate analysis showed that a sac thrombus and the number of patent side branches arising from an aneurysm were significant factors associated with pT2Es. The IMA diameters were significantly larger in cases of pIMA-T2Es. The significant factors associated with pLA-T2Es were a circumferential thrombus, the number of patent LAs and the mean LA diameter. Multivariate analyses indicated that a circumferential thrombus was a protective factor for pT2Es, whereas an IMA ≥2.6 mm and each additional LA branch ≥1.9 mm were powerful risk factors for a pT2E. CONCLUSION: Significant anatomical factors associated with pT2E were found in this study. These factors may be useful in selecting patients for perioperative intervention.

Change of luminal diameter of skeletonized and non-skeletonized radial artery graft at early and late postoperative period.

The radial artery is increasingly used as a second arterial conduit for myocardial revascularization. However, the radial artery is susceptible to vasospasm, which is thought to be the principal cause of graft failure. The radial artery is harvested as a skeletonized or a non-skeletonized graft, but the effect of different harvesting technique remains unknown. In this study, we compared the early- and mid-term angiographic findings to elucidate its influence on the graft luminal diameter. We harvested 39 radial arteries either as a skeletonized (n = 18) or a non-skeletonized graft (n = 21) using an ultrasonic scalpel. We constructed a composite straight graft by combining a right internal thoracic artery and a radial artery. All the radial artery grafts were sequentially anastomosed to coronary arteries. We measured the diameters of the radial arteries before the operation, within 1 month and 1 year after the operation. At early postoperative period, graft diameter was significantly larger in skeletonized grafts. Graft diameter at the point before the first and the second anastomosis was similar in skeletonized grafts, although that was significantly smaller before the second anastomosis in non-skeletonized grafts. However, 1 year after the operation, the graft diameter was comparable and equally reduced after the first anastomosis in both groups. Skeletonization with an ultrasonic scalpel increases the luminal diameter of the radial artery graft at early postoperative period, which, however, reduces possibly as adaptation to graft flow 1 year after the operation.

Successful staged operation for acute aortic dissection and chronic thromboembolic pulmonary hypertension.

We describe surgical treatment for a patient with chronic thromboembolic pulmonary hypertension who developed acute type A aortic dissection. Acute aortic dissection is a life-threatening disease and must be operated emergently, and chronic thromboembolic pulmonary hypertension can be treated only by pulmonary endarterectomy. We performed a staged procedure consisting of hemiarch replacement with antegrade cerebral perfusion first and pulmonary endareterectomy with periods of deep hypothermic circulatory arrest a week later. We used extracorporeal membrane oxygenation after aortic surgery as a bridge to pulmonary endarterectomy. Our strategy was useful for patients with chronic thromboembolic pulmonary hypertension who require complicated aortic surgery.

Assessment of functional tricuspid regurgitation using 320-detector-row multislice computed tomography: risk factor analysis for recurrent regurgitation after tricuspid annuloplasty.

OBJECTIVE: Functional tricuspid regurgitation (TR) often develops secondary to left heart disease. Tricuspid annuloplasty (TAP) is usually the treatment of choice for significant TRs, but recurrence of TR after surgery can occur. Previous studies have not clearly demonstrated the cause of the recurrent TR after TAP. By using an electrocardiogram-gated 320-detector-row multislice computed tomography (CT), we sought to delineate the morphologic cause of the incompetent tricuspid valve and identify the risk factors for recurrent TR. METHODS: From August 2010 to September 2011, 35 patients underwent preoperative CT of the tricuspid valve. The distance between each commissure, the tethering angle of each leaflet, and the tethering height were measured. TAP using a rigid annuloplasty ring was performed in 22 patients. Risk factors for recurrent TR were determined by multivariate analyses. RESULTS: End-diastolic and end-systolic tricuspid valve annular diameters (TVAD) correlated significantly with preoperative TR severity (R(2), 0.2734-0.4287; P < .05). However, compared with TVAD, tethering angles and height showed stronger correlation with preoperative TR severity (R(2): tethering angles, 0.5769-0.6810; tethering height, 0.6854). Multivariate analysis revealed that tethering height was an independent risk factor of postoperative recurrent TR (P = .0069). CONCLUSIONS: TVAD, tethering angles, and tethering height correlated significantly with preoperative TR severity. The tethering height of the tricuspid valve showed significant correlation with recurrent TR.

Identification of left atrial ganglionated plexi by dense epicardial mapping as ablation targets for the treatment of concomitant atrial fibrillation.

BACKGROUND: Autonomic ganglionated plexi (GPs) play a significant role in the initiation and maintenance of atrial fibrillation (AF). GPs are key targets for a maze procedure. The purpose of this study was to identify the location of the left atrial GPs based on dense epicardial mapping during a maze procedure in patients with concomitant AF. METHODS: Sixteen patients (age, 68 ± 10 years; 11 males, 69%) with heart failure and concomitant AF (duration 55 ± 86 months) underwent intraoperative epicardial electrophysiological mapping and a GP ablation using the maze procedure at our institution. Twenty-four-site, high-frequency stimulation (1,000/min; output, 18 V; pulse width, 0.75 ms) was performed by placing tweezers directly onto the potential GP sites on the left atrial epicardium. RESULTS: Active GPs were found in 13 (81%) of the 16 patients, and 12 (92%) of 13 patients had active GPs between the right pulmonary veins (PVs) and the interatrial groove. For those patients with active locations, a 7-day event-loop recording demonstrated that 12 (92%) of 13 patients were maintained in sinus rhythm 3 months after the operation. CONCLUSION: Dense epicardial mapping in the potential GP areas identified active GP locations in a high percentage of patients. GPs between the PVs and interatrial groove have a high potential as ablation targets for treatment of concomitant AF.

Acute coronary occlusion by injured aortic valve during percutaneous coronary intervention.

We report a rare case of a 58-year-old male with accidental occlusion of left main trunk (LMT) artery by injured aortic valve during percutaneous coronary intervention (PCI). Although we successfully bailed out this complication by urgent LMT stenting, aortic regurgitation developed immediately after PCI. Echocardiography detected a filamentous structure attached to the aortic valve. An elective aortic valve replacement surgery revealed that his right coronary cusp was torn into two filamentous strips. One strip accidentally plunged into LMT and was fixed by the intracoronary stent. Another strip floated in the aortic root and appeared as though vegetation attached to the aortic valve in case of acute infective endocarditis. Guiding catheters probably injured the aortic valve during PCI. This report reminded us of the importance of meticulous manipulation of a guiding catheter.

Total arch replacement for a subacute type A dissection in a patient with a terminal tracheostoma after total laryngectomy: report of a case.

Standard full median sternotomy for total arch replacement in tracheostomy patients may lead to mediastinitis and graft infection. Several approaches for typical cardiac surgery, including a T-shaped sternotomy, have been used in patients with both terminal and transient tracheostomas; however, these procedures offer inadequate surgical exposure of the arch vessels. We herein report the case of a 67-year-old man with a subacute type A aortic dissection with a terminal tracheostoma after total laryngectomy, who successfully underwent total arch replacement by a fourth intercostal thoracotomy performed using an anterior bilateral approach and the arch-first technique. To our knowledge, this is the first report of a case of total arch replacement in a patient with subacute aortic dissection and a terminal tracheostoma.

Outcomes of single-stage total arch replacement via clamshell incision.

BACKGROUND: Treatment of complex aortic pathologies involving the transverse arch with extensive involvement of the descending aorta remains a surgical challenge. Since clamshell incision provides superior exposure of the entire thoracic aorta, we evaluated the use of this technique for single-stage total arch replacement by arch vessel reconstruction. METHODS: The arch-first technique combined with clamshell incision was used in 38 cases of aneurysm and aortic disease in 2008 and 2009. Extensive total arch replacement was used with clamshell incision for reconstruction of arch vessels under deep hypothermic circulatory arrest. RESULTS: Overall 30-day mortality was 13%. The mean operating time was approximately 8 hours. Deep hypothermia resulted in mean CPB time exceeding 4.5 hours and mean duration of circulatory arrest was 25 minutes. The overall postoperative temporary and permanent neurologic dysfunction rates were 3% and 3% for elective and 3% and 0% for emergency surgery, respectively. All patients except the five who died in hospital were discharged without nursing care after an average post-operative hospital stay of 35 days. CONCLUSIONS: The arch-first technique, combined with clamshell incision, provides expeditious replacement of the thoracic aorta with an acceptable duration of hypothermic circulatory arrest and minimizes the risk of retrograde atheroembolism by using antegrade perfusion.

Successful surgical resection of infected left atrial myxoma in a case complicated with disseminated intravascular coagulation and multiple cerebral infarctions: case report.

Cardiac myxoma is the most common primary cardiac tumour, but infected cardiac myxoma is relatively rare. Infected cardiac myxoma is very fragile, and has a potential to lead to catastrophic disorder with systemic bacteremia, systemic mycotic embolism, and disseminated intravascular coagulation (DIC).We present here the successful surgical treatment of a case of infected left atrial myxoma with septic shock, DIC and cerebral infarction without hemorrahage. Collective review of 58 reported cases with infected cardiac myxoma revealed that surgical treatment for it were still challenging and its result was poor. Until date, only one successful surgical treatment for a case complicated by DIC and cerebral infarctions has been reported, and our report describes second such case of successful resection. Even though this report is limited to a case, only aggressive and prompt surgical intervention could relieve the intractable conditions in such a patient with extremely high risk.

Rapid expansion of another downstream aortic aneurysm with the elephant trunk.

A 75-year-old man developed persistent dysphagia 2 months after successful total arch replacement with a long elephant trunk (ET) for a distal arch aneurysm. Enhanced computed tomography revealed not only complete thrombosis of the distal arch aneurysm, but also rapid expansion of another downstream aortic aneurysm with esophageal compression. Thoracic endovascular aortic repair was undertaken for this symptomatic aortic aneurysm, which was totally thrombo-excluded. ET might produce turbulent or jet-like blood flow from its tip in some situations and have a potential to accelerate the expansion of the downstream aneurysm. Additional endovascular ET completion is simple, effective, and less invasive.

Cuff-preserving technique for aortic mechanical artificial valve replacement performed for perivalvular leakage.

We present a new, less-invasive technique for a re-do for perivalvular leakage after aortic mechanical valve replacement. Only the carbon ring of the previously implanted St. Jude prosthesis was excised, the sewing cuff being preserved. The locations of the perivalvular defects were clearly identified by pulling the sewing cuff inward. They were securely closed by placing pledgeted sutures at the preserved cuff through the full thickness of the aortic wall or through the annulus by a deep bite from the left ventricular side. A new mechanical prosthesis was then sewn onto the preserved sewing cuff.

Unilateral acute lower extremity ischemia with popliteal artery aneurysm as a result of vascular type III entrapment in an elderly patient.

Popliteal artery entrapment syndrome (PAES) is a rare cause of acute limb ischemia in adult patients but commonly demonstrates as claudication in young patients. The most significant, although rare, complication associated with PAES is aneurysm formation. We present the case of an elderly patient with a unilateral popliteal artery aneurysm owing to symptomatic anatomic entrapment. This report presents the oldest patient ever reported with this syndrome and highlights the advantage of multimodal treatment. As multidetector computed tomography highly contributed to the rapid diagnostic confirmation and choice of treatment in the popliteal fossa, limb salvage was achieved in this patient.

Results of definitive repair of complete atrioventricular septal defect in neonates and infants.

BACKGROUND: Early surgical intervention for complete atrioventricular septal defect (AVSD) has contributed to a decline in postoperative mortality. METHODS: We retrospectively evaluated outcomes in 116 complete AVSD patients undergoing definitive repair from February 1997 through October 2002. Patients with an unbalanced AVSD not suitable for biventricular repair, tetralogy of Fallot, or double-outlet right ventricle were excluded. RESULTS: Median age at operation was 4.8 months (range, 9 days to 5.4 years); weight was 4.8 kg (range, 2.1 to 23 kg). Follow-up was 93% complete (mean, 27 months; range, 1 to 73 months). Early definitive repairs were performed in 98% (110 of 112) of patients initially presenting to our institution. Ninety-two patients (79%) underwent repair before 6 months of age, including 25 (22%) before 3 months. Actuarial survival at 1, 3, and 5 years was 98%, 95%, and 95%, respectively. Seventy-five patients (68%) had trivial to mild left AV valve regurgitation at discharge; moderate or severe left AV valve stenosis developed in 3 (3%). Actuarial freedom from reoperation for left AV valve dysfunction at 1, 3, and 5 years was 94%, 89%, and 89%, respectively. Actuarial freedom from reoperation for left ventricular outflow tract obstruction at 1, 3, and 5 years was 100%, 93%, and 90%, respectively. CONCLUSIONS: Definitive repair for complete AVSD can be performed in early infancy with excellent results. The two-patch technique is a safe and reproducible surgical method that can achieve low mortality and good midterm outcomes even in very young infants.

Unroofing aortic intramural left coronary artery arising from right pulmonary artery.

We report an operative case of the anomalous origin of the left coronary artery from the right pulmonary artery with aortic intramural course. This particular anatomy was clearly identified with a preoperative angiogram. The restoration of the two-coronary system was accomplished by unroofing the intramural segment into the left sinus of Valsalva with encouraging midterm results. The details of this anatomical correction are described with a review of the literature.

A case with heterotaxy reaching the Fontan procedure after unifocalizations.

One patient with major aorto-pulmonary collateral arteries and heterotaxy underwent staged unifocalizations, and eventually the staged Fontan completion. Subsequent to the bidirectional Glenn procedure, the left pulmonary artery was once thrombozed, but successfully treated. The progressively regurgitant common atrioventricular valve needed repair twice during the course. Pulmonary arterial pressure was 11 mm Hg 1 year after the Fontan procedure.

Preoperative small pulmonary artery did not affect the midterm results of Fontan operation.

OBJECTIVE: It was well discussed, in the primary Fontan era, that small pulmonary arterial size could affect the results immediately after the Fontan procedure. The objective of the present study is to determine whether this feature remains as a risk factor in the era of the staged Fontan completion and poses functional impediments in the longer terms. METHODS: Between June 1991 and November 2004, the staged Fontan completion was carried out subsequent to the bidirectional Glenn procedure in consecutive 57 patients with a preoperative pulmonary artery index less than 250 mm2/m2 (Group-S; minimum index 104 mm2/m2). Clinical data were reviewed retrospectively. As background and reference information, similar data were collected in another consecutive 64 patients with larger pulmonary arteries who underwent the staged Fontan completion during the same period (Group-L; maximum index 697 mm2/m2). RESULTS: No patients died after the Fontan procedure in Group-S, while six early deaths in Group-L. No takedown of the Fontan circulation was carried out in either group. The latest catheterizations, at 2.8+/-2.7 years postoperatively, showed a pulmonary artery index significantly lower than the preoperative index (Group-S: 198+/-37-176+/-49 mm2/m2; P=0.0082, Group-L: 360+/-94-266+/-89 mm2/m2; P<0.0001). Hemodynamics in Group-S during the intermediate term were identical with those in Group-L in mean pulmonary arterial pressure (10+/-2 in Group-S and 10+/-3 mmHg in Group-L), mean atrial pressure for the systemic chambers (5+/-2 and 6+/-3 mmHg, respectively), mean transpulmonary gradient (5+/-2 and 4+/-2 mmHg, respectively), cardiac index (3.0+/-0.7 and 3.0+/-0.6l/min/m2, respectively), and arterial oxygen saturation (93+/-3% and 94+/-2%, respectively). Similarly, brain natriuretic peptides concentration in the serum (19.4+/-15.6 in Group-S and 28.3+/-37.2 pg/ml in Group-L) and peak oxygen consumption on exercise testing (24.8+/-4.5 and 24.0+/-6.3 ml/kg/min, respectively) were not inferior in Group-S to those in Group-L. CONCLUSIONS: The outcome after the Fontan completion, including functional ones in the intermediate term, was acceptable in patients having a preoperative PA index smaller than 250 mm2/m2. Pulmonary artery index decreased still further postoperatively, but did not obviously militate against functional efficacy of the Fontan circulation.

Optimal timing of the Fontan conversion: change in the P-wave characteristics precedes the onset of atrial tachyarrhythmias in patients with atriopulmonary connection.

OBJECTIVES: Atrial tachyarrhythmia is a common complication late after the atriopulmonary connection Fontan procedure. The P-wave duration and dispersion have been regarded as useful markers for its prediction. The purpose of this study was to analyze change in the P-wave characteristics over time after the atriopulmonary connection Fontan procedure, with a special emphasis on the timing of the Fontan conversion. METHODS: We reviewed clinical and electrocardiographic data in 18 patients with classic tricuspid atresia who underwent the atriopulmonary connection Fontan procedure. Their median age at operation was 4.1 years (range, 1.1-22 years), and the median follow-up period was 18.1 years (range, 10-25 years). We measured the P-wave duration, dispersion, and axis from consecutive 12-lead electrocardiograms in each patient. RESULTS: There was a significant increase in the maximum P-wave duration as well as the P-wave dispersion over time. Transient ectopic atrial rhythm was observed in 16 patients during follow-up. Atrial tachyarrhythmia developed subsequent to transient ectopic atrial rhythm in 8 patients. Ten patients underwent the conversion. Atrial tachyarrhythmia recurred in 2 patients who had sustained arrhythmia (6.0 and 8.0 years) before the conversion. In contrast, the other 8 patients with transient ectopic atrial rhythm alone or nonsustained atrial tachyarrhythmia have been free from arrhythmia after the conversion. CONCLUSIONS: Patients commonly and increasingly had prolonged P-wave duration, larger P-wave dispersion, and ectopic atrial rhythm, along with an atrial tachyarrhythmia propensity, late after the atriopulmonary connection Fontan procedure. These P-wave characteristics were informative when considering the Fontan conversion before a sustained atrial tachyarrhythmia ensued.

Partial anomalous pulmonary venous connection to the superior vena cava.

BACKGROUND: Repair of partial anomalous pulmonary venous connection (PAPVC) to the high portion of the superior vena cava (SVC) may be complicated by atrial arrhythmia and obstruction of the pulmonary veins or SVC. We reviewed our experience with the modified Warden technique, in which the SVC was transected and anastomosed to the right atrial appendage with anterior augmentation of pedicled autologous pericardial flap, and the atrial septum was directly displaced to the SVC orifice. METHODS: Twenty of 51 patients with PAPVC underwent this technique. Mean age was 11.9 years. Follow-up averaged 6.5 years. To quantify the height of insertion of anomalous pulmonary veins, the distance between the highest anomalous pulmonary venous orifice and SVC-right atrial junction was indexed by thoracic vertebral body height (height index). RESULTS: All patients are alive in sinus rhythm. No patients exhibited pulmonary venous obstruction, and mean flow was 0.61 mL. Mean flow of SVC return was 0.79 mL. The SVC occlusion occurred in 2 patients who had persistent left SVC with a good communicating vein. Three patients whose height index exceeded 2.5 successfully underwent catheter intervention at the SVC channel. CONCLUSIONS: Midterm results with the modified Warden technique were satisfactory. Patients with particularly high insertion of anomalous pulmonary veins should be treated and followed with specific caution for preserving an unobstructed caval pathway.

Selective management of the left ventricular outflow tract for repair of interrupted aortic arch with ventricular septal defect: management of left ventricular outflow tract obstruction.

OBJECTIVE: Left ventricular outflow tract obstruction remains an early and late complication after repair of interrupted aortic arch and ventricular septal defect. We reviewed our experience with the selective management of the infundibular septum during primary repair to address left ventricular outflow tract obstruction. METHODS: From 1991 through 2001, all 27 patients presenting with interrupted aortic arch/ventricular septal defect and posterior deviation of the infundibular septum were analyzed. Fifteen patients with the smallest subaortic areas underwent myectomy or myotomy of the infundibular septum concomitant with interrupted aortic arch/ventricular septal defect repair. RESULTS: Patients undergoing myectomy-myotomy (Group I) had significantly smaller subaortic diameter indexes (0.83 +/- 0.16 cm/m2) when compared with those who had only interrupted aortic arch/ventricular septal defect repair (group 2: 0.99 +/- 0.13 cm/m2, P = .012). Two hospital deaths occurred in group 1, and 1 occurred in group 2. No late deaths occurred. No patient in group 2 required reoperation. Six group 1 patients required 9 reoperations for left ventricular outflow tract obstruction. Five patients underwent resection of a new subaortic membrane. Only 1 patient had recurrent muscular left ventricular outflow tract obstruction. Three patients required a second reoperation, primarily related to aortic valve stenosis. CONCLUSIONS: Interrupted aortic arch/ventricular septal defect with posterior malalignment of the infundibular septum can be repaired with low mortality in the neonatal period. Tailored to the degree of subaortic narrowing, resection or incision of the infundibular septum at the time of primary repair was very effective in preventing or prolonging the interval to recurrent left ventricular outflow tract obstruction compared with the published data. However, reoperation for left ventricular outflow tract obstruction, often related to the development of a new and discrete subaortic membrane or valvar stenosis, is still required in a subset of patients.