Long-Term Outcomes of Coronary Artery Bypass Grafting Using an Internal Thoracic Artery versus a Radial Artery as a Second Arterial Graft.

PURPOSE: To compare the outcomes of left circumflex artery (LCx) revascularization using an internal thoracic artery (ITA) or radial artery (RA) as the second arterial graft. METHODS: Patients who underwent primary isolated coronary artery bypass grafting with left anterior descending artery revascularization using an ITA and LCx revascularization using another bilateral ITA (BITA group) or an RA (ITA-RA group) were included. All-cause mortality (primary endpoint), cardiac death, major adverse cardiac events, in-hospital death, and deep sternal wound infection (secondary endpoints) were evaluated. RESULTS: Among 790 patients (BITA, n = 548 (69%); ITA-RA, n = 242 (31%)), no significant difference in all-cause mortality between the groups was observed (hazard ratio (HR): 0.87; 95% confidence interval (CI): 0.67-1.12; p = 0.27) during follow-up (mean, 10 years). Multivariate analysis revealed that the BITA group exhibited significantly lower rates of long-term all-cause mortality (HR: 0.63; 95% CI: 0.48-0.84; p = 0.01). In the propensity-matched cohort (n = 480, 240 pairs), significantly fewer all-cause deaths occurred in the BITA group (HR: 0.66; 95% CI 0.47-0.93; p = 0.02). There were no significant differences in secondary outcomes. CONCLUSIONS: When used as second grafts for LCx revascularization, ITA grafts may surpass RA grafts in reducing all-cause mortality 10 years postoperatively.

A Case of Floating Aortic Arch Thrombosis in a Patient without Thrombophilia.

Floating aortic arch thrombi-blood clots forming in an aorta without aneurysms or atherosclerosis-in a normal aorta are exceedingly rare. The etiology is unknown, and there are no guidelines for appropriate treatment strategies. We report a case of floating aortic arch thrombosis in a patient without coagulopathy that was treated surgically. As the mass could not be identified preoperatively as a tumor or thrombus, synthetic graft replacement was performed, allowing resection of the lesion site. Histopathological examination revealed erosion and fissures in the tunica intima of the aorta, which suggested vessel damage to the tunica intima as the cause.

Management of cardiovascular surgery in patients with systemic lupus erythematosus including thromboembolism and multiple organ failure prevention: A retrospective observational study.

Systemic lupus erythematosus is a chronic autoimmune disease that affects most tissues. Cardiovascular events are critical, life-threatening, long-term complications of systemic lupus erythematosus (SLE). We report our single-center experience of performing cardiovascular surgery in patients with SLE while avoiding postoperative complications. We also suggest a new approach for cardiopulmonary bypass and perioperative management. We applied the antiphospholipid antibody syndrome (APS) severity classification published by the Japan Intractable Disease Information Center to patients with SLE for perioperative management. Patients with Grade III or higher severity are treated with a slightly relaxed version of catastrophic APS therapy. This treatment modality includes glucocorticoids, anticoagulation, intravenous immunoglobulin, and plasma exchange. Between April 2010 and January 2021, 26 patients (2 males, 24 females) with SLE underwent cardiovascular surgery. The mean age was 74.2 ± 13.0 years (38-84 years). The primary outcomes were in-hospital mortality and long-term results, and the secondary outcomes were related to bleeding/embolization and coagulation function/platelet count. A subset analysis was performed to examine treatment efficacy in the APS Grade III or higher group. Of the 26 patients, 17 underwent valve surgery, 4 underwent isolated coronary artery bypass grafting, and 5 underwent thoracic aortic aneurysm surgery. There were no in-hospital deaths or associated bleeding/embolic complications. Postoperative antithrombin III decreased in patients who underwent valvular and aortic surgery, and platelet counts recovered to preoperative levels within 7 to 10 days. The 5- and 10-year survival rates were 80.5% and 53.7%, respectively. In addition, there were 10 patients with APS Grade III or higher, but there was no significant difference in the frequency of complications other than platelet recovery after treatment. The surgical outcome of open-heart surgery in patients with SLE was good. Surgical treatment of cardiovascular disease in these patients is difficult and complex. We focused on blood coagulation abnormalities and treated each patient by selecting the best individual treatment protocol according to the severity of the disease, taking into account the risk of bleeding and thrombosis. Management of blood coagulation function in these patients is essential, and careful therapeutic management should be considered during open-heart surgery.

Multiple Imaging and Surgical Characteristics in Cardiac Metastasis from Undifferentiated Uterine Sarcoma.

Although cardiac metastasis of malignant tumors has often been reported, undifferentiated uterine sarcoma (UUS) is a rare and aggressive uterine tumor. Thus, little is known of the UUS as a primary site of cardiac metastasis. We report a case of a 66-year-old woman, with a history of uterine myoma for 30 years, who was hospitalized with a large uterine tumor and cardiac masses. Although we investigated cardiac masses using imaging modalities, such as ultrasound, cardiac computer tomography, and magnetic resonance imaging, it was challenging to determine the masses as metastasis or thrombi. Cardiac masses were removed by surgery to assess the tissue characteristics and were later identified as tumors due to their appearance. Then, pathological findings revealed that UUS spreads to the right ventricle. We attempted chemotherapy after surgery; however, the disease progressed very quickly and the patient died on the 49th day of admission. In this report, we described the case of a patient with a difficult diagnosis and rapid disease progression of cardiac metastasis from UUS.

Coronary Artery Bypass Grafting in Patients with Chronic Kidney Disease: Chronic Kidney Disease Has an Independent Adverse Effect on the Long-Term Outcome of Coronary Artery Bypass Grafting.

We examined short- and long-term outcomes of coronary artery bypass grafting (CABG) in patients with ischemic heart disease and the effect of renal function on these outcomes. We included 2783 patients who underwent primary elective CABG at a single institution between 2002 and 2020 (age: 67.6 ± 10.2 years; male: 2281 male). They were stratified based on their preoperative estimated glomerular filtration rate and underwent off-pump CABG (completion rate, 98.1%); 57.6% cases used bilateral internal thoracic arteries (BITA). In-hospital mortality rate was 1.0%. Logistic regression analysis revealed that low left ventricular function (<40%), but not chronic kidney disease (CKD) severity, was an independent predictive risk factor for postoperative hospital mortality. Significant differences existed in respiratory complications, infections, and hospitalization duration according to CKD severity. Deep sternal wound infection rate was 0.5%. The mean follow-up period was 7.1 (0-18.5) years. Estimated 10-year survival rates were negatively correlated with CKD severity; in the Cox hazard model, severe CKD was an independent predictor of long-term survival. We examined the relationship between preoperative and intraoperative factors and their effects on long-term survival using propensity score matching by dividing the renal function severity into G1-2 and G3-5. Renal function severity, age, and operative time were independent risk factors. No prognostic improvement was observed with BITA grafts; graft patency was superior in the right internal thoracic artery (52/52; 100%) than in the great saphenous vein (48/59; 81.4%) in G5. Post-CABG in-hospital mortality was unrelated to renal function, but CKD severity strongly influenced long-term survival. Operation time was an important predictor of long-term prognosis in patients with impaired renal function. Treatment plans, including graft and anastomosis-site selections, should be designed to shorten the operation time. In conclusion, using the right internal thoracic artery in CABG is more beneficial in patients with CKD and cardiovascular comorbidities.

Mycotic Aortic Arch Aneurysm Caused by Clostridium perfringens.

We report a case of a 79-year-old man for a mycotic aortic arch aneurysm caused by Clostridium perfringens. The patient who had been hospitalized for cholangitis two months prior revisited the hospital for fever and left precordial pain. He was suspected of an infected aortic aneurysm in the distal arch due to emphysematous changes observed. After antibiotics treatment, the emphysematous changes disappeared. However, he underwent urgent total arch replacement due to a new ulcer-like projection and enlargement of the aortic aneurysm, which were observed at that time. Clostridium-infected infectious aneurysms require not only treatment for vascular lesions but also scrutiny of complications, such as cancer.

A new technique that prevents paravalvular leakage after aortic valve replacement using a rapid-deployment valve system.

BACKGROUND: We report our 1-year single-center experience of a new technique of aortic valve replacement using a rapid-deployment valve (RD-AVR) to avoid postoperative complications. We also report the unexpected pitfalls and handling techniques that we have seen in past cases. METHODS: We performed aortic valve replacement on 38 patients between May 2019 and April 2020. Their mean age was 74 years. The primary outcomes were in-hospital mortality and short-term results during a 1-year follow-up period, while the secondary outcomes were related to prosthetic valve function, especially paravalvular leakage (PVL). We further analyzed the relationship between the new technique and its outcomes. RESULTS: The mean operative time was 196 min. There were no in-hospital deaths, and the mean duration of postoperative hospital stay was 11.8 days. Valvular measurements using three-dimensional computed tomography were larger and more accurate than those measured using ultrasonic echocardiography. Postoperative RD-AVR prosthetic valve function was excellent. However, PVL occurred in four cases 1 week and 1 year postoperatively and regurgitation did not improve. A gap associated with PVL was identified below the right-noncoronary commissure. To prevent PVL, we additionally stitched this gap in the later 18 cases; there was no case of PVL and no new pacemaker implantation in these cases. CONCLUSIONS: PVL is more likely to occur if there is a gap below the R-N commissure, especially in cases with a large annulus; therefore, applying an additional stitch to the R-N commissure is extremely useful.

Surgical Treatment of Celiacomesenteric Trunk Aneurysm: Report of 2 Cases.

BACKGROUND Celiac artery aneurysm is very rare, and even is more uncommon in patients with celiacomesenteric trunks. With recent developments in diagnostic imaging, the detection of asymptomatic abdominal visceral aneurysms has increased. However, some abdominal visceral aneurysms are still first discovered after a rupture. An abdominal visceral aneurysm rupture can occur suddenly and lead to shock due to intraperitoneal hemorrhage. Two cases of celiac artery aneurysms that involved common celiacomesenteric trunks are presented. CASE REPORT Case 1 was a 63-year-old man who was referred to our facility for further study after a routine abdominal ultrasound identified an aneurysm in the superior mesenteric artery. Contrast-enhanced computed tomography (CT) scan revealed a 39-mm aneurysm in the celiacomesenteric trunk and its branches. Case 2 was a 32-year-old man who was referred to our facility after an abdominal ultrasound performed during a physical examination revealed a celiac artery aneurysm. Contrast-enhanced CT revealed a 31-mm aneurysm in the celiacomesenteric trunk and its branches. In both patients, the aneurysms were proximally located, and the distinctive anatomy of the celiacomesenteric trunk made endovascular treatment difficult. Open replacement and reconstructive surgery was performed to repair the aneurysms with grafts from the great saphenous vein. Both patients had uneventful postoperative courses. CONCLUSIONS The optimal treatment for the patients described was open surgical repair because the lower risk of occlusion of the visceral branch made it safer and more reliable than an endovascular approach.

Free triiodothyronine (fT3) and B-type natriuretic peptide (BNP) predict in-hospital mortality after valve surgery.

BACKGROUND: Increased B-type natriuretic peptide (BNP) and decreased free triiodothyronine (fT3) are associated with increased mortality after cardiac surgery. However, previous studies have addressed mortality primarily in patients undergoing coronary artery bypass graft, and not in those undergoing valve surgery. We assessed abilities of BNP and fT3 to predict mortality after valve surgery. METHODS: This retrospective study included 1050 consecutive patients who underwent valve surgery with normothermic cardiopulmonary bypass (CPB). Predictors of in-hospital mortality were identified with logistic regression analyses. Cutoff values were determined with receiver operating curve analyses. RESULTS: There were 23 deaths (2.2%). By univariate analyses, fT3, log-transformed BNP (log BNP), cholinesterase, estimated glomerular filtration rate, and albumin were profoundly associated with in-hospital mortality (p < 0.0001 for each). By a multivariate analysis, however, only fT3 and log BNP remained significant (p = 0.0053 and p = 0.0449, respectively). fT3 and log BNP remained significant after adjustment for CPB time, and also after adjustment for the EuroSCORE II or JapanSCORE (p < 0.05 for each). Odds ratio and 95% confidence interval from univariate binary analysis for in-hospital mortality were 7.22 (3.12-17.58) for fT3 ≤ 2.21 pg/mL, 6.01 (2.54-15.77) for BNP ≥ 219 pg/mL, and 9.79 (4.21-22.74) for both combined (p < 0.0001 for each). CONCLUSIONS: fT3 and BNP predict in-hospital mortality after valve surgery, independent of each other, independent of CPB time, and independent of established mortality risk SCOREs. Additions of fT3 and BNP may enhance predictive utilities of established mortality risk SCOREs.

Independent Effect of Low Flow on Outcomes in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis.

BACKGROUND: Low flow (LF; i.e., reduced left ventricular stroke volume index <35 mL/m2) can occur with severe aortic stenosis (AS). However, few studies have investigated the effects of LF on early and late outcomes after aortic valve replacement (AVR) for severe AS.Methods and Results:In all, 285 severe AS patients undergoing isolated AVR at Juntendo University Hospital between August 2002 and August 2015 were enrolled in the study. In this cohort, 52 patients (18%) had LF. Compared with patients with normal flow (NF) severe AS, early postoperative mortality (9.6% vs. 1.2%; P=0.006), gastrointestinal complications (5.7% vs. 0.8%; P=0.04), and the duration of the intensive care unit (ICU) stay (81.7 vs. 35.3 h; P=0.02) were increased in LF patients with severe AS. LF was an independent predictor of early mortality (Model A, odds ratio [OR] 6.81, P=0.01; Model B, OR 6.69, P=0.01) and composite complications (Model A, OR 2.44, P=0.02). In propensity score-matched comparisons, early mortality (12.8% vs. 0%; P=0.02), composite complications (28.2% vs. 10.2%; P=0.04), and duration of ICU stay (97.4 vs. 22.1 h; P=0.006) were significantly increased in LF than NF patients. CONCLUSIONS: LF, as an important independent risk factor for postoperative mortality and morbidity, should be included in risk stratification and assessment in severe AS patients.

[Aortic Root Replacement for Patients with Aortic Root Aneurysms;Clinical Outcomes Compared Among Different Types of Abnormality and Operative Procedures].

Aortic root operations are established procedures for patients with aortic root aneurysms, however there is a little insight for comparative long-term outcomes among different types of anatomical abnormalities and procedures. In this study, we sought to compare the results of patients with aortic abnormalities undergoing different procedures. From January 2008 to March 2017, a total of 105 patients without aortic dissection were performed the elective aortic root surgery. Patients with bicuspid aortic valve had enlarged annulus, and those with Marfan syndrome had enlarged Valsalva without enlarged annulus. Bentall operation with mechanical valve or bioprothetic valve was performed for patients with enlarged annulus and/or abnormal aortic cusp, and David operations for patients with normal cusps. This comparative study showed that these different procedures according to our policy were associated with reduced cardiac mortality and valve-related complications. The results suggest David procedure is the treatment of choice for young patients with aortic root aneurysm and normal aortic cusps, however, careful patient selection is paramount.

Push-Up Technique and Anatomical Deployment With the Endurant Stent-Graft System for Severely Angulated Aneurysm Necks.

PURPOSE: To describe a technique suitable for treating severely angulated (>75°) necks during endovascular aneurysm repair using the Endurant stent-graft. TECHNIQUE: In the push-up technique, the suprarenal stent is released early to fix the proximal stent-graft in place so that each stent in the neck can be deployed individually without displacing the device upward. It is important to push the delivery system up after each stent deployment to allow the fabric between the stents to fold up circumferentially. By doing so, there is minimal upward force applied to the suprarenal stent. Because the stents expand along the angulated neck while catching blood flow, this anatomical deployment is feasible, with hardly any change to the proximal neck shape after stent-graft implantation. CONCLUSION: The push-up technique and anatomical deployment with the Endurant stent-graft system are effective and safe methods for treating aneurysms with severely angulated necks.

Comparing mortality between coronary artery bypass grafting and percutaneous coronary intervention with drug-eluting stents in elderly with diabetes and multivessel coronary disease.

Coronary artery disease is a critical issue that requires physicians to consider appropriate treatment strategies, especially for elderly people who tend to have several comorbidities, including diabetes mellitus (DM) and multivessel disease (MVD). Several studies have been conducted comparing clinical outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in patients with DM and MVD. However, elderly people were excluded in those clinical studies. Therefore, there are no comparisons of clinical outcomes between CABG and PCI in elderly patients with DM and MVD. We compared all-cause mortality between PCI with drug-eluting stents (DES) and CABG in elderly patients with DM and MVD. A total of 483 (PCI; n = 256, CABG; n = 227) patients were analyzed. The median follow-up period was 1356 days (interquartile range of 810-1884). The all-cause mortality rate was not significantly different between CABG and PCI with DES groups. The CABG group had more patients with complex coronary lesions such as three-vessel disease or a left main trunk lesion. Older age, hemodialysis, and reduced LVEF were associated with increased long-term all-cause mortality in a multivariable Cox regression analysis. The rate of all-cause mortality was not significantly different between the PCI and CABG groups in elderly patients with DM and MVD in a single-center study.

Early Postoperative Outcome of Off-Pump Coronary Artery Bypass Grafting: A Report from the Highest-Volume Center in Japan.

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) has evolved into a standard technique in coronary artery bypass grafting. However, a detailed investigation in Japanese population undergoing OPCAB has not yet been fully elucidated. METHODS: A total of 1109 consecutive patients undergoing isolated OPCAB between 2006 and 2013 at Juntendo University were reviewed. The data was evaluated in the light of previously published OPCAB-associated reports. RESULTS: There were 904 male (81.5%) and a mean was 67.5 ± 9.8 years. Eight patients (0.5%) died within 30 days postoperatively or before discharge, which was equivalent to or rather better than the previously reported mortality rates, including the European System for Cardiac Operation Risk Evaluation II (2.1 ± 2.1) data. A morbidity analysis revealed that prolonged intubation (>24 h) occurred in 43 patients (3.6%), surgical site infections in 18 (1.9%), neurological complications in 13 (1.3%). A reduced preoperative left ventricular ejection fraction (less than 40%) was found to be a risk factor for early postoperative death (odds ratio 10.58, respectively, p <0.05) in our cohort. CONCLUSIONS: Early postoperative mortality and morbidity rates in Japanese population after OPCAB were rather satisfactory and similar to those reported by other countries.

Early introduction of tolvaptan after cardiac surgery: a renal sparing strategy in the light of the renal resistive index measured by ultrasound.

BACKGROUND: Renal failure is a serious complication after cardiac surgery, which can be caused by long-term intravenous (IV) loop diuretic use. Tolvaptan is an oral selective vasopressin-2 receptor antagonist used in patients irresponsive to loop diuretics. We investigated their renal perfusion changes using the resistive index (RI) postoperatively. METHODS: Serial renal RI, echocardiography, and laboratory examinations from 14 patients requiring continuous postoperative IV loop diuretics were reviewed. Eight patients received tolvaptan (Group T) and six received oral loop diuretics before the discontinuation of IV loop diuretics (Group L). The 1(st) data were obtained between postoperative day 0 and 2, the 2(nd) when patients were still under IV loop diuretic treatment, the 3(rd) after the initiation of tolvaptan or oral loop diuretic, and the 4(th) after the discontinuation of IV diuretics. RESULTS: The 2(nd) RI value was higher in Group T than Group L (0.77 ± 0.09 vs. 0.69 ± 0.01, p = 0.049) but significantly decreased after tolvaptan administration [0.77 ± 0.09 to 0.65 ± 0.05 (2(nd) to 3(rd)), to 0.62 ± 0.04 (to 4(th)), both p = 0.006], while no such changes were seen in Group L. The serum sodium and albumin levels, and echo-derived tricuspid annular plane systolic excursion increased only in Group T (134.1 ± 1.5 to 138.8 ± 3.2 mEq/L, 3.3 ± 0.3 to 3.7 ± 0.5 g/dL, 16.4 ± 3.6 to 19.7 ± 4.2 mm, all p <0.05). The duration of IV loop diuretics tended to be shorter in Group T than Group L (5.6 ± 1.6 vs. 8.7 ± 3.6 days, p = 0.051). CONCLUSIONS: Administration of tolvaptan in patients undergoing cardiac surgery may improve their renal perfusion, as reflected by the renal RI measured using renal Doppler ultrasound.

Coronary artery bypass revascularization using bilateral internal thoracic arteries in diabetic patients: a systematic review and meta-analysis.

This study examined the effect of coronary artery bypass graft surgery with bilateral internal thoracic artery grafting in diabetic patients. Coronary artery bypass graft surgery using skeletonized bilateral internal thoracic artery grafts was not associated with an increased risk of deep sternal wound infection or early death. Moreover, patients who underwent coronary artery bypass graft surgery using bilateral internal thoracic artery grafting had lower remote mortality and cardiac mortality. We conclude that coronary artery bypass surgery using bilateral internal thoracic artery grafts is an excellent strategy, even for diabetic patients.

Mortality risk of triglyceride levels in patients with coronary artery disease.

OBJECTIVE: The association between triglyceride level and the risk of coronary artery disease (CAD) remains controversial. In particular, the prognostic significance of triglyceride levels in established CAD is unclear. We aimed to assess the relationship between triglyceride levels and long-term (>10 years) prognosis in a cohort of patients after complete coronary revascularisation. DESIGN: Observational cohort study. SETTING: Departments of cardiology and cardiovascular surgery in a university hospital. PATIENTS: Consecutive patients who had undergone complete revascularisation between 1984 and 1992. All patients were categorised according to the quintiles of fasting triglyceride levels at baseline. MAIN OUTCOME MEASURES: The risk of fasting triglyceride levels for all-cause and cardiac mortality was assessed by multivariable Cox proportional hazards regression analyses. RESULTS: Data from 1836 eligible patients were assessed. There were 412 (22.4%) all-cause deaths and 131 (7.2%) cardiac deaths during a median follow-up of 10.5 years. Multivariable analyses including total and high-density lipoprotein cholesterol and other covariates revealed no significant differences in linear trends for all-cause mortality according to the quintiles of triglyceride (p for trend=0.711). However, the HR increased with the triglyceride levels in a significant and dose-dependent manner for cardiac mortality (p for trend=0.031). Multivariable analysis therefore showed a significant relationship between triglyceride levels, when treated as a natural logarithm-transformed continuous variable, and increased cardiac mortality (HR 1.51, p=0.044). CONCLUSIONS: Elevated fasting triglyceride level is associated with increased risk of cardiac death after complete coronary revascularisation.