Clinical impact of turn-up anastomosis in the treatment of type A acute aortic dissection.

BACKGROUND: The management of anastomosis and hemostasis of the dissected aorta remains challenging. This study aims to establish an optimal surgical strategy for type A acute aortic dissection by reviewing single-center data using the turn-up anastomosis technique. METHODS: Between 2003 and 2015, 264 consecutive patients with type A acute aortic dissection who underwent emergency surgery within 14 days of symptom onset were enrolled. RESULTS: The mean age of the patients was 67.7 ± 13.4 years, and 129 were males. The operative time and surgical bleeding were 390.9 ± 144.5 min and 2983.8 ± 3026.5 mL, respectively. In-hospital mortality was observed in 25 patients (9.4%), and 3 (1.1%) experienced uncontrolled bleeding (from the aortic root in two patients and coagulopathy due to dabigatran in one patient). Immediate reopening for bleeding was performed in 20 patients, and bleeding from the aortic anastomosis was observed at three proximal and two distal sites. Proximal re-dissection was observed in 18 patients; in all of which, glue was used, although two re-ruptures of the aortic root were observed among those without glue use. The rates of freedom from all-cause death, aortic death, and aortic events at postoperative 5 years were 78.5 ± 2.7%, 86.8 ± 2.1%, and 74.4 ± 2.9%, respectively. When these values were stratified according to the operative extent, no significant differences were observed. CONCLUSIONS: Turn-up anastomosis facilitates short circulatory arrest, short operative time, and stable hemostasis, with few anastomotic complications during surgery for type A acute aortic dissection.

Renal cortex thickness and changes in renal function after transcatheter aortic valve implantation.

BACKGROUND: The association between renal morphological findings and changes in renal function in patients undergoing transcatheter aortic valve implantation (TAVI) is unexplored. AIMS: We aimed to investigate the association between renal morphological findings and changes in renal function in patients undergoing TAVI. METHODS: Among 283 consecutive patients undergoing TAVI between 2018 and 2021, the study sample included 224 patients. Renal morphological measurements were performed by preoperative multidetector computed tomography. Estimated glomerular filtration rate (eGFR) improvement and deterioration were defined as positive or negative changes in an eGFR of ≥10% one month after TAVI. The renal cortex thickness index was defined as the ratio of total renal cortex thickness to body surface area. RESULTS: The incidences of eGFR improvement and deterioration were 33.9% and 24.1%, respectively. The renal cortex thickness index had a significant correlation with changes in eGFR (r=0.34, p<0.01). The index of the area under the curve of renal cortex thickness for eGFR improvement and deterioration were 0.73 and 0.68, respectively. The cut-off values were 5.82 mm/m2 for eGFR improvement (odds ratio [OR]: 0.10; 95% confidence interval: 0.05-0.20; p<0.01) and 4.89 mm/m2 for eGFR deterioration (OR: 9.07; 95% confidence interval: 4.55-18.6; p<0.01). CONCLUSIONS: The renal cortex thickness index was associated with changes in renal function in patients who underwent TAVI. Its measurements might be useful for predicting the renal function change in patients undergoing TAVI.

Multiple percutaneous coronary interventions may negatively impact cardiac remodelling after bypass surgery.

OBJECTIVES: Many patients undergo percutaneous coronary intervention (PCI) multiple times before being referred for coronary artery bypass grafting (CABG), in which bypass grafts are often anastomosed to small distal targets with higher risk of graft failure. We aimed to assess whether multiple PCIs adversely affect the long-term outcomes of patients who undergo CABG subsequently. METHODS: A cohort of 368 patients with no history of PCI underwent initial isolated CABG between 2003 and 2013 (no PCI group). Ninety-seven patients who had undergone PCI 2 or more times preoperatively during the same period constituted the multiple PCI group. After propensity score matching, the group outcomes were compared. RESULTS: There were no significant differences in the 10-year all-cause mortality and major adverse cardiac and cerebrovascular event rates in both groups. Although the left ventricular end-diastolic dimension in the multiple PCI group did not change markedly (from 48.0 ± 6.0 to 47.2 ± 7.9 mm; P = 0.25), it decreased significantly in the no PCI group (from 48.3 ± 6.1 to 44.9 ± 9.1 mm; P < 0.001). The left ventricular end-systolic dimension in the no PCI group decreased significantly (from 34.1 ± 8.7 to 31.4 ± 8.6 mm; P = 0.024), while it in the multiple PCI group did not (from 33.6 ± 8.3 to 32.7 ± 8.6 mm; P = 0.21). CONCLUSIONS: For complex coronary artery disease, early surgical intervention could be considered with respect to postoperative left ventricular remodelling during the long-term follow-up.

How far is the left circumflex coronary artery from the mitral annulus?

INTRODUCTION: The relationship between the distance from the mitral annulus to the left circumflex coronary artery (LCX) and iatrogenic LCX injury has been questioned. This study was designed to determine the high-risk sites of LCX injury with an anatomical approach using multiple detector-computed tomography (MDCT) scanning taken before mitral valve annuloplasty (MVA). The purpose of this study is to prevent LCX injury in patients unable to receive MDCT before mitral valve surgery. METHODS: In 2018, we performed MVA on 59 patients, 52 of whom had undergone preoperative MDCT scanning. We retrospectively analyzed the MDCT images of these 52 patients and measured the shortest distance from the mitral annulus to the LCX in three dimensions. Also, we divided the mitral annulus into 12 clockwise areas (A0-A11) to identify the exact location. RESULTS: The site of closest proximity and their numbers of patients were as follows: A6, 1 patient; A8, 2 patients; A9, 32 patients; and A10, 17 patients. Nine (17.3%) of the 52 patients had the shortest distance of less than 2 mm. The shortest distance according to the dominance of coronary artery showed no significant difference (p = 0.81). CONCLUSION: The site of closest proximity from the mitral annulus to the LCX was concentrated on the A8 to A10 areas and it is an interesting result that as many as 17% of patients have their coronary arteries less than 2 mm away from the annulus.

[Surgical Treatment for Primary Pulmonary Artery Sarcoma;Report of a Case].

Primary pulmonary artery sarcoma is a very rare tumor. The prognosis of primary pulmonary artery sarcoma is extremely poor and it is reported as 1.5 months without treatment. Here we report our experience of surgical treatment of primary pulmonary artery sarcoma. A 66-year-old woman with a diagnosis of pulmonary sarcoma by chest computed tomography( CT) scan was referred to our hospital because of a loss of consciousness. An emergecy surgery was planned to eliminate the risk of sudden death. To avoid circulatory collapse, we placed her on extracorporeal bypass before anesthesia induction. The tumor extending from right ventricle outflow tract to bilateral pulmonary artery was removed and resected without leaving residual mass, but the surgical margin was positive, and adjuvant chemoradiotherapy was performed after discharge. In conclusion, surgical resection was succesfully conducted to avoid sudden death.

Comparison of clinical outcomes after coronary artery bypass grafting using stratified SYNTAX scores.

OBJECTIVES: Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are common procedures for managing coronary artery disease (CAD); however, optimal methods of comparing post-procedure outcomes are unclear. We evaluated the reliability of Synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) scores and investigated differences in long-term outcomes after CABG among groups with different SYNTAX scores. METHODS: According to patient selection criteria used in the SYNTAX trial, 368 patients who underwent isolated initial CABG between 2003 and 2014 at Kurashiki Central Hospital were stratified into three SYNTAX score I groups (low: < 23, intermediate: 23 to < 33, and high: ≥ 33) and three SYNTAX score II groups (low: < 30, intermediate: 30 to < 40, and high: ≥ 40). Group outcomes were compared. Overall 4-year mortality data for SYNTAX score II were compared with the cohort data. RESULTS: There were no significant differences in all-cause death, 10-year major adverse cardiac and cerebrovascular events (MACCEs), myocardial infarction, and stroke data in the SYNTAX score I groups. As SYNTAX score II increased, all-cause death and MACCEs rates rose significantly. Four-year mortality at our facility was 11.0 ± 1.7%, whereas that predicted by SYNTAX score II was 12.0 ± 11.1%. The predicted data were close to the clinical data, but not statistically significant, with an area under the curve of 0.769. CONCLUSIONS: SYNTAX score II demonstrated reasonable predictive performance for outcomes after CABG, whereas SYNTAX score I did not. With SYNTAX score systems, treatment options should be discussed with a heart team to achieve better outcomes.

Hypertrophic obstructive cardiomyopathy and mitral regurgitation in Libman-Sacks endocarditis.

Hypertrophic obstructive cardiomyopathy in Libman-Sacks endocarditis is quite rare and the correct etiological relationship between them is unknown. Some changes may cause a secondary disorganization of the ordinary muscle structure, making a disarray pattern with irregular interwoven myocyte fibers. This case report describes one of the first cases of ventricular septal myectomy and mitral valve replacement for hypertrophic obstructive cardiomyopathy and mitral valve regurgitation associated with Libman-Sacks endocarditis.

[Occurrence of New Entry after Thoracic Endovascular Aortic Repair for Retrograde Stanford Type A Aortic Dissection;Report of Two Cases].

We report 2 cases of occurrence of new entry after thoracic endovascular aortic repair(TEVAR) for retrograde Stanford type A aortic dissection. Preoperative chest computed tomography (CT) demonstrated retrograde Stanford type A acute aortic dissection, and TEVAR was performed for entry closure. In the postoperative period, the aortic diameter was not dilated in either case and the false lumen of the ascending aorta disappeared in the case 2. In the chronic phase, however, Stanford type A acute aortic dissection occurred in both cases. TEVAR for acute aortic dissection to close the intimal tear might be a useful procedure, but it could cause a new aortic dissection. We should make a careful decision on surgical procedures in the retrograde Stanford type A aortic dissection.

Is small cusp size a limitation for aortic valve repair?†.

OBJECTIVES: We sought to investigate cusp size limitations for valve repair in patients with aortic regurgitation (AR). METHODS: Preoperative computed tomography was performed in 105 patients. Cusp geometric height (GH) and annulus size were measured. Mean patient age was 60.7 ± 13.7 years. Mean GH of 3 cusps was used in the analysis. Annulus cusp mismatch was graded using predicted coaptation length. Patients were categorized by mean GH into group S (GH <16 mm; n = 35) or L (GH ≥16 mm; n = 70). RESULTS: Preoperative mean GH was 17.1 ± 2.3 mm. GH and body height were significantly correlated (r = 0.61). Intraoperative mean GH (18.8 ± 2.2 mm) was larger than preoperative mean GH (P < 0.0001). However, postoperative (17.1 ± 2.0 mm) and preoperative mean GH did not differ. Moderate AR was not present on predischarge echocardiography. Mild AR was observed in 51% and 17% of patients in groups S and L, respectively (P = 0.006). During follow-up, moderate or severe AR was observed in 14% and 10% of patients in groups S and L, respectively (P = 0.74). Two patients in group S required reoperation for a regurgitant valve. Twenty (83%) and 15 (21%) patients in groups S and L, respectively, had severe annulus cusp mismatch before surgery. Annulus cusp mismatch resolved in most patients in group L postoperatively, whereas more than half the patients in group S still had severe mismatch. CONCLUSIONS: Small cusp size (GH <16 mm) is not necessarily a contraindication in aortic valve repair. However, most patients in this group had annulus cusp mismatch. Root replacement or secure annulus plication is mandatory to correct annulus cusp mismatch.

[Successful Echo-guided Deployment of Stent Graft for Intraoperative Retrograde Aortic Dissection and Rupture;Report of a Case].

We report a case of chronic dissecting thoracoabdominal aneurysm with intraoperative retrograde aortic dissection and rupture at proximal descending aorta, which was successfully treated by echoguided stent-graft insertion. An 82-year old male underwent thoracoabdominal aortic replacement for dilatation of infra-diaphragmatic aorta. Under F-F bypass, his thoracoabdominal aorta was replaced by a Dacron graft with 4-branches. After he weaned from F-F bypass, we found massive bleeding from proximal descending aorta. Trans-esophageal echocardiography (TEE) showed aortic dissection from the clamp site to the distal anastomotic site of the former total arch replacement. We temporary got hemostasis by suture and surgical glue, and anastomosed a 10 mm-graft to the thoracoabdominal main graft as conduit, then inserted and deployed 2 pieces of stent-graft. Direct echo and TEE contributed to the accurate positioning of them. Bleeding was completely controlled. He well recovered without paraplegia. Post-operative computed tomography (CT) showed good positioning and dilatation of the stentgraft and the perfect reverse remodeling of thoracic aorta.

Paralytic ileus as the first presentation in type A acute aortic dissection.

A 78-year-old female was referred to our hospital with a diagnosis of type A acute aortic dissection. There was a history of thrombosed aortic dissection six months prior and conservative management has been performed. Enhanced computed tomography showed type A acute aortic dissection with patent false lumen limited to the ascending aorta and ileus of the small intestine. Emergency hemiarch replacement was performed under mild hypothermic circulatory arrest and selective antegrade cerebral perfusion. Due to preoperative paralytic ileus, oral intake was initiated postoperative day four. Postoperative computed tomography revealed improvement of paralytic ileus. J. Med. Invest. 64: 286-287, August, 2017.

Does Triplex Vascular Prosthesis Contribute to Reducing the Inflammatory Reaction after Surgical Repair of Abdominal Aortic Aneurysms?

Our aim was to evaluate whether a Triplex vascular prosthesis could contribute to reducing postoperative inflammation after surgical abdominal aortic aneurysm (AAA) repair retrospectively. Between July 2011 and December 2013, a Triplex vascular prosthesis was used in 22 patients (group T) and a coated vascular prosthesis in 18 patients (group H) during AAA repair surgery. Body temperature (BT), white blood cell (WBC) count, and C-reactive protein (CRP) level for 5 days were assessed. There was no hospital death in both groups. During the first 2 days after surgery the BT was higher in group T than in group H reaching its maximum on POD 2. On POD 5, it was similar (p = 0.4850). The postoperative WBC count was higher in group H than in group T. It reached its maximum on POD 1 and it was similar in both groups on POD 5 (p = 0.1870). The CRP value increased postoperatively in both groups, peaking during PODs 2 or 3. On POD 5, it was lower in group H than in group T (p = 0.0415). We could not confirm the superiority of Triplex vascular prostheses to other coated vascular prostheses in inflammatory reactions.

Efficient long-term survival of cell grafts after myocardial infarction with thick viable cardiac tissue entirely from pluripotent stem cells.

Poor engraftment of cells after transplantation to the heart is a common and unresolved problem in the cardiac cell therapies. We previously generated cardiovascular cell sheets entirely from pluripotent stem cells with cardiomyocytes, endothelial cells and vascular mural cells. Though sheet transplantation showed a better engraftment and improved cardiac function after myocardial infarction, stacking limitation (up to 3 sheets) by hypoxia hampered larger structure formation and long-term survival of the grafts. Here we report an efficient method to overcome the stacking limitation. Insertion of gelatin hydrogel microspheres (GHMs) between each cardiovascular cell sheet broke the viable limitation via appropriate spacing and fluid impregnation with GHMs. Fifteen sheets with GHMs (15-GHM construct; >1 mm thickness) were stacked within several hours and viable after 1 week in vitro. Transplantation of 5-GHM constructs (≈2 × 10(6) of total cells) to a rat myocardial infarction model showed rapid and sustained functional improvements. The grafts were efficiently engrafted as multiple layered cardiovascular cells accompanied by functional capillary networks. Large engrafted cardiac tissues (0.8 mm thickness with 40 cell layers) successfully survived 3 months after TX. We developed an efficient method to generate thicker viable tissue structures and achieve long-term survival of the cell graft to the heart.

Mitral Valve Stenosis Progression Due to Severe Calcification on Glutaraldehyde-Treated Autologous Pericardium: Word of Caution for an Attractive Repair Technique.

A 42-year-old woman presented with a 6-month history of palpitations and progressive dyspnea on exertion. She had undergone aortic and mitral valve repair using glutaraldehyde-treated autologous pericardium for active infective endocarditis 5 years prior. Transthoracic echocardiography showed mitral valve stenosis with limited movement of the anterior leaflet. At redo surgery, severe calcification of the glutaraldehyde-treated pericardial patch on the anterior mitral leaflet was observed. Double valve replacement was performed with pulmonary vein isolation. Pathologic examination showed calcification of the glutaraldehyde-treated autologous pericardium. The patient was discharged on postoperative day 11 with oral anticoagulant therapy.

Pluripotent stem cell-engineered cell sheets reassembled with defined cardiovascular populations ameliorate reduction in infarct heart function through cardiomyocyte-mediated neovascularization.

Although stem cell therapy is a promising strategy for cardiac restoration, the heterogeneity of transplanted cells has been hampering the precise understanding of the cellular and molecular mechanisms. Previously, we established a cardiovascular cell differentiation system from mouse pluripotent stem cells, in which cardiomyocytes (CMs), endothelial cells (ECs), and mural cells (MCs) can be systematically induced and purified. Combining this with cell sheet technology, we generated cardiac tissue sheets reassembled with defined cardiovascular populations. Here, we show the potentials and mechanisms of cardiac tissue sheet transplantation in cardiac function after myocardial infarction (MI). Transplantation of the cardiac tissue sheet to a rat MI model showed significant and sustained improvement of systolic function accompanied by neovascularization. Reduction of the infarct wall thinning and fibrotic length indicated the attenuation of left ventricular remodeling. Cell tracing with species-specific fluorescent in situ hybridization after transplantation revealed a relatively early loss of transplanted cells and an increase in endogenous neovascularization in the proximity of the graft, suggesting an indirect angiogenic effect of cardiac tissue sheets rather than direct CM contributions. We prospectively dissected the functional mechanisms with cell type-controlled sheet analyses. Sheet CMs were the main source of vascular endothelial growth factor. Transplantation of sheets lacking CMs resulted in the disappearance of neovascularization and subsequent functional improvement, indicating that the beneficial effects of the sheet were achieved by sheet CMs. ECs and MCs enhanced the sheet functions and structural integration. Supplying CMs to ischemic regions with cellular interaction could be a strategic key in future cardiac cell therapy.

Up to 6-year follow-up after pulmonary vein isolation for persistent/permanent atrial fibrillation: importance of sinus node function.

OBJECTIVE: Sinus node dysfunction is commonly associated with atrial fibrillation. There is little information about the long-term results of pulmonary vein isolation in relation to sinus node function. The present study was conducted to investigate whether sinus node dysfunction affects the late outcome of pulmonary vein isolation in patients with persistent/permanent atrial fibrillation. METHODS: Among 76 consecutive patients with persistent/permanent atrial fibrillation who had undergone cut-and-sew pulmonary vein isolation, 66 patients without evidence of intra-atrial thrombus by transesophageal echography, and who were able to tolerate cardioversion, were enrolled. Sinus node recovery time after cardioversion was examined intraoperatively. All of the patients underwent valvular surgery concomitantly (mitral in 62). RESULTS: Sinus node dysfunction was detected in 18 patients. These patients had a significantly lower f wave voltage in V(1) of the electrocardiogram and a larger cardiothoracic ratio than patients with normal sinus node function. Hospital mortality was 3%, and 3 late deaths were observed. Follow-up was conducted for up to 72 months (mean 30 months), with a 100% complete follow-up rate. There were no significant differences in actuarial survival and freedom from cardiac events between patients with normal and abnormal sinus node function. No thromboembolic events occurred. A significantly higher proportion of patients with normal sinus node function (82%) were free of atrial fibrillation at 4 years than patients with sinus node dysfunction (25%; P < .0001). CONCLUSIONS: The atrial fibrillation cure rate after pulmonary vein isolation may be influenced by sinus node function in both the early and late stages. Although further examinations are required, pulmonary vein isolation may be an adequate treatment for persistent/permanent atrial fibrillation in patients with normal sinus node function.

[Pulmonary vein isolation using cut and sew technique].

We reviewed our cut and sew pulmonary vein isolation (PVI) series for chronic or paroxysmal atrial fibrillation (Af). Intraoperative evaluation of sinus nodal function with electrical defibrillation and atrial pacing and the incision to mitral annulus adding to PVI were important factors to restore sinus rhythm. Ninety-two percent of the patients with the good sinus nodal function restored sinus rhythm. These findings will be useful information for surgical ablation of Af with or without new energy sources.

Risk factors for wound infection after off-pump coronary artery bypass grafting: should bilateral internal thoracic arteries be harvested in patients with diabetes?

OBJECTIVE: Wound infection is a rare but life-threatening complication after coronary artery bypass grafting. Risk factors for wound infection after off-pump bypass grafting and the validity of using bilateral internal thoracic arteries harvested in a skeletonized fashion remain unclear, especially in patients with diabetes. METHODS: The data of 1500 consecutive patients having off-pump bypass grafting were prospectively collected from our database based on EuroSCORE. This cohort represents 95% of all patients undergoing coronary bypass during that period and 77% of patients undergoing off-pump bypass grafting who received bilateral internal thoracic artery grafts. Univariate and multivariate analyses were performed for patients with and without wound infection and in the diabetic subgroup. RESULTS: Ninety-eight patients had wound infections: 76, impaired wound healing; 7, superficial sternal wound infection; and 12, deep sternal wound infection. Patients with wound infections had a higher prevalence of female gender, atrial fibrillation, history of congestive heart failure, chronic renal failure, peripheral vascular disease, and diabetes. Patients with a wound infection more frequently had bilateral internal thoracic artery grafting, longer operation time, longer hospital stay, and a higher mortality rate. Blood transfusions were required in 43.9% of patients with wound infections and 28.1% of those without wound infections. On logistic regression analysis, female gender and history of congestive heart failure, chronic renal failure, and diabetes mellitus were independent risk factors for wound infection. In patients with diabetes, female gender, atherosclerosis obliterans, chronic renal failure, and use of bilateral internal thoracic artery grafts were independent risk factors for wound infection. CONCLUSIONS: Risk factors for wound infection after off-pump coronary artery bypass grafting are comparable with those previously reported for conventional bypass grafting. In patients with diabetes, the use of bilateral internal thoracic arteries, even when harvested in a skeletonized fashion, is a risk factor. Thus, appropriate precautions should be taken in patients with diabetes.

Off-pump coronary artery bypass grafting with skeletonized bilateral internal thoracic arteries in insulin-dependent diabetics.

BACKGROUND: We evaluated the effects of coronary artery bypass with off-pump skeletonized bilateral internal thoracic artery grafting in patients with insulin-dependent diabetes. METHODS: One hundred eighty-five consecutive patients with insulin-dependent diabetes who underwent isolated coronary artery bypass grafting with bilateral internal thoracic grafts were retrospectively compared according to surgical technique, ie, off-pump grafting with skeletonized internal thoracic artery (n = 162) or on-pump grafting with pedicled internal thoracic artery (n = 23). RESULTS: The on-pump group was younger (62.3 +/- 9.2 versus 69.9 +/- 8.5 years; p = 0.02) and had fewer distal anastomoses (3.5 +/- 1.0 versus 4.0 +/- 1.1; p = 0.02) than the off-pump group. No 30-day mortality occurred in either group. The incidence of deep sternal infection was significantly lower in the off-pump group than in the on-pump group (0.6% versus 13.0%; p = 0.01). The early angiographic results did not differ between the two groups. The median duration of follow-up was 3.4 years (range, 0.1 to 9.9 years). Rates of survival, freedom from cardiac mortality, and freedom from cardiac-related events (including cardiac-related death, myocardial infarction, percutaneous coronary intervention, repeat coronary artery bypass grafting, and congestive heart failure) did not differ between the two groups. Dialysis, peripheral vascular disease, ejection fraction less than 0.40, and age were independent risk factors of late death. CONCLUSIONS: Overall, our results support the surgical management of coronary artery bypass grafting in insulin-dependent diabetics using off-pump skeletonized bilateral internal thoracic artery grafting.