[Thoracic Endovascular Aortic Repair for Mycotic Thoracic Aortic Aneurysm After BCG Intravesical Therapy].

Bacille Calmette-Guérin( BCG) intravesical therapy is an effective and safe treatment for bladder cancer; however, mycotic aneurysms have been reported as a rare complication. Case 1:A 64-year-old man with a history of BCG intravesical therapy underwent emergent thoracic endovascular aortic repair (TEVAR) for a ruptured thoracic aortic aneurysm (TAA). He was diagnosed with BCG infection by hemosputum specimen culture five months later;then, antituberculous therapy was initiated. However, his follow-up computed tomography scan revealed stent-graft infection and new aneurysm formation. Therefore, we performed a repeated TEVAR with abdominal 4-vessel debranching. There was no recurrence of infection for six years while continuing postoperative antituberculous therapy. Case 2:A 72-year-old man who had undergone BCG intravesical therapy underwent TEVAR for a rapidly enlarging mycotic TAA. He received anti-tuberculous therapy for one year with no recurrent infection for one year. TEVAR may be an effective alternative to the open surgical procedure;however, multidisciplinary treatment including anti-tuberculous therapy and careful long-term follow up are required.

Two-Stage Hybrid Repair in a Patient with Acute Type A Aortic Dissection Associated with Right Aortic Arch with Aberrant Left Subclavian Artery Originating from a Kommerell Diverticulum.

Right aortic arch with aberrant left subclavian artery and Kommerell diverticulum are rare anomalies. A 42-year-old man was referred with sudden-onset chest pain. Enhanced computed tomography (CT) showed a right aortic arch with early thrombosed acute type A aortic dissection and an aberrant left subclavian artery arising from a Kommerell diverticulum. Medical therapy was instituted; however, follow-up CT revealed an ulcer-like projection. The patient was managed with a two-stage hybrid procedure comprising total arch replacement and endovascular repair and experienced no postoperative complications. Two-stage hybrid repair is a safe and effective surgical option for rare complex aortic anomalies.

[Isolated Pulmonary Valve Endocarditis in a Patient with Aortic Regurgitation and Patent Foramen Ovale;Report of a Case].

Isolated pulmonary valve endocarditis is an extremely rare clinical condition. Here, we report a case of pulmonary valve endocarditis caused by methicillin-resistant Staphylococcus aureus (MRSA). An 84-year-old man with a history of aortic regurgitation and patent foramen ovale was admitted to our hospital due to fever of unknown origin for 4 weeks' duration. MRSA was detected in his blood cultures. Transthoracic echocardiography demonstrated a mobile vegetation attached to the pulmonary valve, moderate to severe aortic regurgitation, and patent foramen ovale with left-to-right shunt. After 30-days' treatment with vancomycin, gentamicin and rifampicin, he defervesced and blood cultures became negative. At surgery, a large vegetation was still attached to the pulmonary valve, but the leaflets remained with minimum damage. Aortic valve replacement, direct closure of the patent foramen ovale, and simple resection of the vegetation were performed. The postoperative course was uneventful.

On-Pump Beating Heart Extraanatomical Ascending-Descending Aortic Bypass Using a Beating Heart Positioner in an Adult with Aortic Coarctation.

The prognosis of uncorrected aortic coarctation is poor due to development of heart failure. We performed an on-pump beating heart extraanatomical ascending-descending aortic bypass using a beating heart positioner in an adult with coarctation complicated by severe left ventricular hypertrophy. A 51-year-old woman was referred with severe hypertension. Computed tomography demonstrated severe distal aortic arch narrowing. Coarctation of the aorta was diagnosed. A posterior pericardial beating heart extraanatomical bypass via median sternotomy was performed from the ascending to descending aorta using a heart positioner. Her postoperative course was uneventful and blood pressure was normal on a low-dose beta-blocker.

Primary cardiac malignant lymphoma: survival for 13 years after surgical resection and adjuvant chemotherapy.

We report a patient who has survived for 13 years after surgical resection of a cardiac malignant lymphoma. A 73-year-old woman underwent partial resection of a tumor occluding the tricuspid valve, which arose from the right atrium. The pathologic diagnosis was diffuse large B cell lymphoma. She was treated with adjuvant chemotherapy for 6 months postoperatively. Since then, she has shown no evidence of recurrence, without any further treatment. To our knowledge, this is the longest surviving case of cardiac malignant lymphoma. The therapeutic strategy for this malignant cardiac tumor is discussed briefly.

Ruptured abdominal aortic aneurysm and aortoiliac vein fistula.

A 67-year-old man was admitted with severe abdominal pain and back pain. Computed tomography showed an infrarenal abdominal aortic aneurysm (8.4 × 8.3 cm) and a large retroperitoneal hematoma. Immediately afterwards, the patient suffered circulatory collapse and was rushed to the operating theater. A fistula communicating with the left iliac vein was found. It was repaired with a Dacron patch while balloon-tipped catheters controlled the bleeding. The abdominal aortic aneurysm was replaced with a bifurcated graft. The postoperative course was uneventful. There have been few reports of successful repair of a ruptured abdominal aortic aneurysm associated with aortoiliac arteriovenous fistula.

Surgical repair of large aortocaval fistula with limited shunt: Case report.

A 67-year-old man was admitted with severe back pain and bilateral lower limb swelling. Enhanced computed tomography showed an infrarenal abdominal aortic aneurysm (92 × 75 mm(2)) and a short aortocaval fistula (7 mm). Immediately afterward, circulatory collapse occurred, and the patient was rushed to the operating theater. A much larger aortocaval fistula (22 × 35 mm(2)) than that demonstrated by preoperative computed tomography was found and was repaired with a Dacron patch while using two balloon-tipped catheters to control bleeding. Then, the abdominal aortic aneurysm was replaced with a bifurcated graft. The patient's postoperative course was uneventful. In this case, enhanced computed tomography detected the aortocaval fistula, but could not assess its size accurately. Successful surgical repair of an aortocaval fistula depends on early accurate delineation of the fistula and prompt control of bleeding.

[Current status and prospect of off-pump pulmonary vein isolation for atrial fibrillation].

We reviewed our clinical experience in off-pump pulmonary vein isolation (PVI) using bipolar radiofrequency (RF) device for atrial fibrillation (Af). From August 2004 to July 2007, the combined off-pump PVI and coronary artery bypass grafting (CABG) was performed in 13 of the 22 planned patients. There was no operative mortality or major complication. Sinus rhythmus was established in 69.2% of the patients [paroxysmal Af (PAf), 8/8 patients; chronic Af, 1/5 patients]. Off-pump PVI using bipolar RF may not be indicated to the chronic Af due to the low curability, and bipolar RF is not safe, especially in case with cardiomegaly or low cardiac function. We developed novel technique using RF thermal balloon catheter for off-pump PVI and evaluated the technique in experimental model. Off-pump PVI with RF thermal balloon catheter was considered to be a safe and effective method to ablate the left atrium-pulmonary vein (LA-PV) antrum circumferentially.

Impact of preoperative atrial fibrillation on the late outcome of off-pump coronary artery bypass surgery.

OBJECTIVE: The impact of pre-existing atrial fibrillation on the long-term outcome in patients after off-pump coronary revascularisation is not well known. This study aims to determine the independent effects of preoperative atrial fibrillation on the early and late outcomes of off-pump coronary artery bypass surgery. METHODS: A total of 513 patients undergoing isolated coronary artery bypass surgery using off-pump approach between 2000 and 2005 were studied. Twenty-six of them (5.1%) had preoperative atrial fibrillation (15 had paroxysmal atrial fibrillation and 11 had persistent or permanent atrial fibrillation) and the other 487 patients were in normal sinus rhythm. Early and late outcomes were compared retrospectively between patients with preoperative atrial fibrillation and patients in sinus rhythm. The median follow-up period for the entire study population was 3.3 + or - 2.7 years. RESULTS: The baseline characteristics of the patients with preoperative atrial fibrillation were generally similar to those of patients in sinus rhythm. However, the patients with atrial fibrillation had a significantly lower left ventricular ejection fraction compared with those in sinus rhythm (50 + or - 15 vs 56 + or - 12%, p=0.03). The mean age of the atrial fibrillation group was almost 3 years more than that of the sinus rhythm group. Operative mortality was similar in patients with atrial fibrillation (3.8%) and those in sinus rhythm (1.0%). Ten patients developed cerebral infarction within 7 days after surgery, including one patient (3.8%) from the atrial fibrillation group and nine patients (1.8%) from the sinus rhythm group. Long-term survival was significantly decreased in the atrial fibrillation group (5-year survival: 70 + or - 9.6% vs 87 + or - 1.8%; p=0.0018). Freedom from cerebral complications was also significantly decreased in the atrial fibrillation group (5-year survival: 85 + or - 8.3% vs 95 + or - 1.2%; p=0.0009), but there were no differences in cardiac death and major cardiac adverse events. On Cox proportional hazards regression analysis, preoperative atrial fibrillation was a significant adverse predictor for survival (hazard ratio=3.0, 95% confidence intervals (CIs) 1.3-6.9; p=0.009) and independent predictor of late cerebral infarction (hazard ratio=6.2, 95% CIs 2.0-19.3; p=0.0002). CONCLUSIONS: Uncorrected preoperative atrial fibrillation is strongly associated with poor long-term survival and increased late cerebral complications after off-pump coronary artery bypass surgery. Concomitant atrial fibrillation surgery should be considered to improve the long-term results of surgical revascularisation.

Experimental mitral valve plasty under the beating heart guided by real-time 3-dimensional echocardiography.

BACKGROUND: This study examines whether real-time 3-dimensional echocardiography can provide an image resolution to serve as a substitute for optical visualization in performing mitral valve plasty. METHODS: Three pigs were used in this study. A 3-dimensional echocardiographic system was evaluated on an epicardial surface. Beating heart mitral valve plasty was performed with a surgical stapler inserted from the apex of the left ventricle using only 3-dimensional echocardiographic visualization. RESULTS: The high-quality images of the mitral valve were obtained with the probe at the epicardial position. However, by inserting the surgical instrument into the left ventricle, an acoustic shadow developed on the images. The images became indistinct because of the acoustic shadow, and operation became difficult. For the mitral valve plasty, an edge-to-edge mitral valve repair was carried out using a stapler (10 mm) under the beating heart. The stapler was confirmed to seize both leaflets evenly in only 1 of the 3 pigs. CONCLUSIONS: Real-time 3-dimensional echocardiography provided clear 3-dimensional images of the mitral valve; however, when a surgical instrument was inserted into the left ventricle, an acoustic shadow appeared on the image and made detailed confirmation difficult. Lessening or eliminating the acoustic shadow would be a key point to improve this procedure.

Predictors of early postoperative cerebral infarction after isolated off-pump coronary artery bypass grafting.

BACKGROUND: Risk factors associated with cerebral infarction within 7 days after off-pump coronary artery bypass grafting require further statistical elucidation. METHODS: From January 1997 to July 2006, off-pump coronary artery bypass grafting was performed in 576 patients at Toyama University Hospital. Factors including previous cerebral infarction, lesions in head and neck vessels, preoperative cerebral ischemic symptoms, intraaortic balloon pump use, number of coronary lesions, number of coronary bypasses, sites of coronary bypasses, number of proximal anastomoses in the ascending aorta, use of aortic no-touch procedure, partial aortic clamping, automatic proximal anastomosis devices, and a proximal seal system were compared retrospectively between patients with and without early cerebral infarction. Factors differing between groups were analyzed further by multivariate logistic regression. RESULTS: Ten patients (1.7%) had cerebral infarction within 7 days after surgery. The subjects were divided into two groups, those who had cerebral infarction after surgery (n = 10) and those who did not (n = 566). Factors showing significant intergroup differences were a previous history of cerebral infarction (p < 0.001), preoperative presence of cerebral ischemic symptoms (p < 0.001), vascular lesions in head and neck vessels (p < 0.001), use of partial aortic clamping (p = 0.002), and postoperative atrial fibrillation within 7 days after surgery (p = 0.011). Multiple logistic regression analysis indicated close relationships between previous history of cerebral infarction (odds ratio, 26.6; 95% confidence interval, 2.8 to 251.1; p = 0.004), preoperative presence of cerebral ischemic symptoms plus lesions in head and neck vessels (odds ratio, 22.8; 95% confidence interval 1.8 to 285.7; p = 0.015), and use of partial aortic clamping (odds ratio, 11.1; 95% confidence interval, 1.4 to 85.7; p = 0.021). Postoperative atrial fibrillation within 7 days after surgery (odds ratio, 3.4; 95% confidence interval, 0.7 to 16.5; p = 0.121) was suspected as a risk factor for postoperative cerebral infarction. CONCLUSIONS: Multivariate analysis identified independent factors strongly associated with cerebral infarction after off-pump coronary artery bypass grafting, such as partial aortic clamping, presence of cerebral ischemic symptoms plus head and neck vascular lesions, and previous cerebral infarction.

Ischemic changes in evoked spinal cord potentials during profound hypothermic circulatory arrest in thoracic aortic surgery.

PURPOSE: We examined the changes in evoked spinal cord potentials (ESCP) during profound hypothermic circulatory arrest to estimate the safe ischemic time. METHODS: We monitored ESCPs during surgery for descending thoracic or thoracoabdominal aneurysms in five patients. Evoked spinal cord potential recordings were obtained before cooling (baseline), then every few minutes during circulatory arrest, and at the end of the operation. RESULTS: After circulatory arrest, the amplitude of ESCPs decreased with time. We calculated the simple linear regression between the amplitude of ESCPs and the circulatory arrest time by the least-squares method, and found a highly linear relationship between amplitude and arrest time in all five patients. The time until disappearance of ESCPs was estimated as 50.7 +/- 20.4 min (95% level of confidence). CONCLUSION: When an ESCP disappeared, ischemic spinal cord injury had occurred. This demonstrates the potential value of estimating the time of disappearance of ESCPs to prevent ischemic spinal cord injury during descending thoracic aortic surgery.

Abdominal surgery following coronary artery bypass grafting using an in situ right gastroepiploic artery graft.

OBJECTIVE: The usefulness of the gastroepiploic artery (GEA) as arterial grafts in coronary artery bypass grafting (CABG) has been studied extensively. We report our experience performing abdominal surgery after CABG using in-situ GEA. METHODS: The subjects were eight patients who underwent abdominal surgery after CABG with an in situ GEA graft. The surgical indications were malignant tumors in five patients, an infrarenal abdominal aortic aneurysm in two patients and a diaphragmatic hernia in one patient. The interval from the CABG to the abdominal surgery ranged from 3 to 19 months. RESULTS: Operations included distal gastrectomy in two cases, total gastrectomy in one case, local excision of the stomach in one case, and excision of the transverse colon in one case. Aorto-biiliac artery bypass was performed in two cases, and the diaphragmatic hernia was reconstructed using standard techniques. When the skeletonization method has been used to harvest the GEA, GEA grafts were easily identified during a laparotomy, and the abdominal procedure was performed using routine methods. One patient died of cancer, and the other patients are alive 1 year 2 months to 4 years 5 months after surgery. No patient reported recurrence of angina. CONCLUSION: The risk of abdominal reoperations should be considered when using the in situ right GEA for CABG. We recommend the skeletonization method for GEA harvest to decrease the difficulty during second abdominal operations.

Evaluation of regional aortic distensibility using color kinesis.

Regional aortic stiffness cannot be evaluated by conventional methods. Regional aortic wall velocity during systole in the descending aorta was evaluated by using transesophageal echocardiography with color kinesis. The authors defined regional aortic distensibility (RAD) by considering pulse pressure, with RAD (microm/s/mm Hg) = (regional aortic wall velocity)/(pulse pressure). RAD was evaluated in 38 patients who had coronary artery disease (CAD) and 10 who did not. RAD decreased depending on aging (partial regression coefficient was -5.39 x 10(-1), p<0.001), and RAD was lower in the CAD group than that in the no-CAD group (p<0.05). In the CAD group, 19 patients had a single fixed plaque (4 calcified and 15 noncalcified plaques). RAD in the calcified plaque was lower than that in the noncalcified plaque (p<0.01), and RAD was lower in the noncalcified plaque than that in the no-plaque region (p<0.05). In noncalcified plaques, the relation between RAD and maximum intimal thickness had a significant correlation, r=0.7, p<0.001. The residual of RAD from the regression line was significantly larger in the calcified plaque than that in the noncalcified plaque (p<0.001). In conclusion, RAD can express increasing regional aortic wall stiffness brought about by arteriosclerosis quantitatively. Color kinesis provides information on characteristic difference between calcified and noncalcified plaque.

Myocardial ischemic preconditioning during minimally invasive direct coronary artery bypass grafting attenuates ischemia-induced electrophysiological changes in human ventricle.

OBJECTIVE: Ischemic preconditioning (IPC) has been found to protect the myocardium in animal studies. However, clinical studies have been limited and the clinical effects of IPC are still uncertain. The purpose of this study was to assess whether IPC has any protective effect on the human myocardium during minimally invasive CABG (MIDCAB), by means of epicardial electrophysiological testing. METHOD: Forty-five patients with left anterior descending artery disease who underwent a MIDCAB procedure were evaluated. In the present study, the electrical potentials which were not affected by cardio-pulmonary bypass or cardioplegia were measured. The ratio of longitudinal to transverse conduction velocity (phiL /phiT), and QT, JT dispersions were measured using plaque electrodes in the preischemic state, during a 5-minute coronary occlusion, during the subsequent 5-minute reperfusion, during 5- and 10-minute anastomosis periods, and after anastomosis. RESULT: The phiL/phiT was 2.2 +/- 0.2 at baseline. Anisotropy was exaggerated during the 5-minute coronary occlusion (2.6 +/- 0.3). During anastomosis, conduction velocities were decreased, but showed no further deterioration (2.4 +/- 0.3, and 2.4 +/- 0.3, respectively). QT and JT dispersions were improved by reperfusion. CONCLUSION: The effectiveness of IPC during the MIDCAB procedure was confirmed electrophysiologically. Anisotropy and dispersions were minimized after IPC, therefore IPC demonstrated antiarrhythmic protective effects on the human myocardium.

Long-term usefulness of percutaneous intrapericardial fibrin-glue fixation therapy for oozing type of left ventricular free wall rupture: a case report.

This report describes a long-term survival case of left ventricular free wall rupture treated with percutaneous intrapericardial fibrin-glue fixation therapy. A 82-year-old woman was admitted to the emergency room because of vomiting and syncope diagnosed as acute posterolateral myocardial infarction complicated by cardiac tamponade. After her hemodynamic condition was stabilized by drawing off the bloody pericardial effusion, fibrin-glue was injected into pericardial space with the expectation that the glue would cover the oozing site of the left ventricular epicardium. After this therapy, the patient recovered and did not have any no recurrent cardiac events for 1 year. Serial echocardiographic studies revealed a preserved left ventricular function and no development of left ventricular restriction. This case suggests that percutaneous intrapericardial fibrin-glue fixation therapy is an effective treatment for the oozing type of left ventricular free wall rupture and that there is no risk of left ventricular restriction during long-term follow-up.