One-stage surgery for type A aortic dissection and iliac artery aneurysm rupture.

We present a patient with Stanford type A aortic dissection with malperfusion of the left kidney and lower extremity, and rupture of a common iliac artery aneurysm. After establishing lower extremity reperfusion using a percutaneous femorofemoral shunt in the emergency room, simultaneous open aortic arch repair and open abdominal aorta repair were performed. Our approach allowed concomitant repair of proximal dissection, limb ischemia, and iliac artery aneurysm rupture, all of which are critical predictors of mortality.

Primary Percutaneous Coronary Intervention Followed by Valve Surgery for Acute Coronary Syndrome at Left Main Trunk Complicated With Severe Aortic Stenosis.

An 89-year-old woman appeared to have acute coronary syndrome at the left main trunk (LMT) complicated with severe aortic stenosis, moderate-severe mitral regurgitation, depressed left ventricular (LV) function, and multivessel disease. Because of sustained hypotension even under intra-aortic balloon pumping support during emergency coronary angiograhy, we performed primary percutaneous coronary intervention solely for the LMT lesion using a bare metal stent, leading to recovery from the shock state. On the second hospital day, based on our heart-team consensus, we performed aortic valve replacement and coronary artery bypass grafting surgery, and added edge-to-edge repair (Alfieri stitch) of the mitral valve, resulting in complete revascularization and dramatically improved LV function.

Safety and Efficacy of Sequential Left Internal Thoracic Artery Grafting to Left Circumflex Area.

BACKGROUND: This study investigated short-term and long-term results of coronary artery bypass grafting (CABG) with in situ sequential left internal thoracic artery (LITA) grafting to the left circumflex area. METHODS: The study divided 452 patients who underwent CABG with bilateral ITA grafting to the left coronary artery into two groups: 191 in the sequential group and 261 in the individual group. The 147 pairs were matched by the propensity score. RESULTS: In the matched pairs, the rates of off-pump, complete revascularization, and hospital death were comparable between the two groups. Early graft evaluation was performed in 78.6%. There was no occlusion of the sequential LITA graft itself, but 5 complications occurred involving the distal segment of the LITA graft (occlusion, 2; string, 2; and competition, 1), and 3 complications (occlusion, 2; and string, 1) developed in the individual group. Event-free anastomosis rates were 97.8% in the sequential group and 97.4% in the individual group (p = 0.847). Diamond anastomosis of proximal sequential grafting showed a better patency of the distal part of sequential anastomosis compared with a parallel anastomosis of proximal sequential grafting (98.4% vs 90.7%, respectively). The freedom from target lesion revascularization and overall survival at 8 years was 94.6% and 96.3% in the sequential and individual groups, respectively (log-rank p = 0.645) and 80.7% and 77.4% (p = 0.300), respectively. CONCLUSIONS: In situ sequential LITA grafting provides acceptable early graft patency and freedom from repeat revascularization, resulting in excellent survival. This technique is a useful strategy for multivessel revascularization including the left circumflex area.

Commissural detachment and Valsalva sinus dilatation after implantation of Prima Plus stentless valve with full root technique.

The stentless aortic bioprosthesis has been used because of its excellent hemodynamics and few valve-related complications. We report a case of redo aortic root replacement for severe aortic regurgitation and dilatation of the Valsalva sinus 7 years after the implantation of a Prima Plus aortic root bioprosthesis (Edwards LifeScience, Irvine, CA, USA) using a full root technique. Intraoperative findings showed the complete detachment of the commissure between the left and non-coronary cusps, and Valsalva sinus dilatation of the porcine aortic root bioprosthesis. Redo aortic root replacement with a 23-mm porcine bioprosthesis and 28-mm straight graft was performed. There were no findings of intimal tear, suture dehiscence, degeneration, and perforation of the bioprosthesis. Such complications associated with the Edwards Prima Plus aortic root bioprosthesis were rarely reported. Commissural detachment of a porcine stentless aortic bioprosthesis can occur; thus, careful follow-up involving echocardiography and computed tomography is necessary.

The off-pump technique in redo coronary artery bypass grafting reduces mortality and major morbidities: propensity score analysis of data from the Japan Cardiovascular Surgery Database†.

OBJECTIVES: The benefits of off-pump coronary artery grafting (OPCAB) have been demonstrated. Especially in patients with a high number of comorbidities, redo coronary artery bypass grafting (CABG) remains a difficult entity of CABG, because patients are likely to have multiple risk factors and often have diseased patent grafts with adhesions. The aim of the present study was to evaluate the effects of the OPCAB technique in redo CABG on mortality and morbidity using data from the Japan Cardiovascular Surgery Database (JCVSD). METHODS: We analysed 34 980 patients who underwent isolated CABG between 2008 and 2011, as reported in the JCVSD. Of these, 1.8% of patients (n = 617/34980) had undergone redo CABG, including those who underwent OPCAB (n = 364; 69%) and on-pump CABG (n = 253; 41%). We used propensity score (PS) matching with 13 preoperative risk factors to adjust for differences in baseline characteristics between the redo OPCAB and on-pump redo CABG groups. By one-to-one PS matching, we selected 200 pairs from each group. RESULTS: There were no significant differences in patient background between the redo OPCAB and on-pump redo CABG groups after PS matching. There was no significant difference in the mean number of distal anastomoses after matching (2.41 ± 1.00 vs 2.21 ± 1.04, P = 0.074); nevertheless, the mean operation time was significantly shorter in the redo OPCAB than the on-pump redo CABG group (353.7 vs 441.3 min, P < 0.00010). Patients in the redo OPCAB group had a lower 30-day mortality rate (3.5 vs 7.0%, P = 0.18), a significantly lower rate of composite mortality or major morbidities (11.0 vs 21.5%, P = 0.0060), a significantly lower rate of prolonged ventilation (>24 h) (7.0 vs 15.0%, P = 0.016), a significantly shorter duration of intensive care unit (ICU) stay (ICU stay ≥ 8 days) (7.0 vs 14.5%, P = 0.023) and a significantly decreased need for blood transfusions (71.5 vs 94.0%, P < 0.00010) than patients in the on-pump redo CABG group. CONCLUSION: The off-pump technique reduced early operative mortality and the incidences of major complications in redo CABG.

A novel technique of aortic root reconstruction for extensive endocarditis: the pericardial skirt technique.

Extensive aortic valve endocarditis requires thorough debridement of the paravalvular tissue, and reconstruction of the destroyed aortic root can be technically difficult. In the present report, we describe a simple technique for aortic root reconstruction. In this technique, a doughnut-shaped bovine pericardial sheet (skirt) is attached to the proximal end of a valved conduit and then sewn onto the destroyed aortic annulus. Because skirt flexibility facilitated excellent adaptation to the irregular annular plane, we did not encounter any severe bleeding from the proximal anastomosis of the valved conduit in any of the cases. We believe that our procedure may be beneficial for aortic root reconstruction in patients with extensive endocarditis.

Upgrading redo coronary artery bypass graft by recycling in situ arterial graft.

We present a case of redo coronary artery bypass grafting (CABG) in which a single internal thoracic artery (ITA) graft was upgraded to a bilateral ITA graft by recycling a left ITA graft, anastomosed to the left anterior descending artery in primary CABG performed 17 years previously. During redo CABG, we dissected the left ITA, reused it in situ for the circumflex artery, and used the right ITA to the left anterior descending artery for a bilateral ITA graft. All grafts remained patent 2 years after redo CABG. Recycling ITA grafts may enable upgrading to bilateral ITA grafting during redo CABG.

Prediction of early postoperative cerebral hemorrhage in infective endocarditis patients using magnetic resonance imaging.

OBJECTIVE: To evaluate the relationship between preoperative magnetic resonance imaging (MRI) findings and the occurrence of postoperative intracranial hemorrhage (ICH) in infective endocarditis (IE) patients. METHODS: Between 2002 and 2012, 30 IE patients required surgical intervention. Four patients developed and 26 patients did not develop postoperative ICH. All patients underwent preoperative brain MRI. The presence of acute brain infarction was detected by diffusion-weighted imaging (DWI), and cerebral microbleeds were detected by T2*-weighted imaging. RESULTS: Two ICH(+) patients died of stroke. Preoperative patient characteristics and operative results were not significantly different. Regarding MRI findings, the presence of cerebral microbleeds or acute brain infarction alone was not significantly different between the two groups (100 vs. 29.6 %, p = 0.07; 75.0 vs. 38.5 %, p = 0.37, respectively). The concurrent presence of cerebral microbleeds and acute brain infarction was significantly correlated with the development of major ICH (75 vs. 14.8 %, p = 0.04). In multiple logistic regression analyses, the concurrent presence of cerebral microbleeds and acute brain infarction on MRI was an independent predictor of major postoperative ICH (p = 0.03, odds ratio 16.5, 95 % confidence interval 1.35-201.3). CONCLUSION: The combination of T2*-weighted MRI and DWI may be useful to evaluate the risk of IE patients developing major postoperative cerebral bleeding.

Surgical removal of extensive left pulmonary vein stump thrombus after pulmonary lobectomy: a rare cause of acute cerebral embolism.

A 46-year-old woman presented with loss of consciousness and was diagnosed with acute cerebral embolism. She had undergone left upper lobectomy for primary lung cancer 6 months before this event. Transesophageal echocardiography and computed tomography showed a large mobile thrombus in the left upper pulmonary vein (LSPV). An emergent operation was performed through a median sternotomy. Cardiopulmonary bypass was performed and the heart was arrested, and the LSPV was incised. A fresh thrombus had formed in the stump of the LSPV and was removed successfully. The postoperative course was uneventful. During a 1 year of follow-up, there was no recurrence of the thrombus.

Delayed-onset systolic anterior motion of the mitral valve after aortic valve replacement for severe aortic stenosis.

Systolic anterior motion (SAM) of the mitral valve after aortic valve replacement (AVR) for severe aortic stenosis (AS) is one of the causes of perioperative left ventricular outflow tract (LVOT) obstruction in older patients. A 90-year-old woman underwent AVR with a 19-mm bioprosthesis for symptomatic aortic valve stenosis. Preoperative transthoracic echocardiography (TTE) showed left ventricular hypertrophy, with LVOT obstruction and mild mitral regurgitation (MR). Intraoperative transesophageal echocardiography and postoperative TTE showed that the degree of MR was unchanged after surgery. The patient's postoperative course was uneventful. However, she developed shortness of breath 6 months after discharge. A subsequent TTE showed significant LVOT obstruction and SAM, which resulted in moderate to severe MR. Because of the patient's advanced age, cibenzoline was administered to decrease the left ventricular pressure gradient (LVPG) and improve the left ventricular diastolic function. Two months after administration of cibenzoline, a TTE showed decreased LVPG, trivial MR, and the absence of SAM. This case clearly demonstrated that cibenzoline improved the SAM of the mitral valve that arose after AVR for AS in a remote postoperative period.

Surgical management of ischemic mitral regurgitation: indications, procedures, and future prospects.

Ischemic mitral regurgitation (IMR) is one of the most important risk factors affecting prognosis of patients who suffer from myocardial infarction. The mechanisms of IMR, the indications for surgical intervention, the operative procedures, and the limitations of surgical procedures are discussed in this review article.

Off-pump coronary artery bypass grafting revisited: experience and evidence from Japan.

Off-pump coronary artery bypass grafting (OPCAB) is performed in about 65% of patients who require surgical coronary revascularization, and has become the standard procedure in coronary artery bypass grafting (CABG) in Japan. As a background of the high rate of OPCAB, many clinical and experimental studies have been performed and reported in Japan. In this review, several factors associated with OPCAB are discussed based on relevant and important clinical studies published in Japan in the English language.

[Surgical ventricular restoration for ischemic cardiomyopathy; to further improve surgical outcomes].

One of the problems of the surgical treatment for ischemic heart failure (STICH) trial was that they did not clearly show how they assessed preoperative myocardial viability. We have been stressing on the importance of accurate preoperative evaluation of myocardial viability to determine the indication of surgical ventricular restoration (SVR), and the location of the exclusion area, if indicated. To this end, we have been using late enhancement of magnetic resonance imaging (MRI), and the surgical strategy for patients with left ventricular ejection fraction (LVEF) less than 35% was constructed based on the findings of MRI. When the ventricle had the extent of hyperenhancement of less than 50% of its wall thickness in any region, complete revascularization with coronary artery bypass grafting (CABG) was performed without SVR. When the ventricle had extensive area of hyperenhancement of 50% or more of its wall thickness, the area was surgically excluded. The early and mid-term surgical outcomes were satisfactory in both the CABG only group and the CABG + SVR group. However, the patients who had residual myocardium with low viability were likely to show higher incidences of cardiac death and readmission for heart failure after SVR in the mid-term. Regeneration therapy of myocardium need to be developed to improve myocardial contractility of residual myocardium after SVR to obtain further better long-term surgical outcomes.

Surgical ventricular restoration based on evaluation of myocardial viability with delayed-enhanced magnetic resonance imaging.

OBJECTIVE: We examined whether the determination of myocardial viability by preoperative delayed-enhanced magnetic resonance imaging (DE-MRI) would be useful for planning surgical ventricular restoration (SVR). METHODS: Eight consecutive patients with poor cardiac function (ejection fraction < 30%) due to ischemic cardiomyopathy underwent surgical treatment based on findings of preoperative cine-MRI and DE-MRI. Our surgical strategy consisted of (1) complete revascularization on viable segments; (2) SVR in a patient with extensive nonviable segments; and (3) mitral valve plasty in a patient with a more than moderate degree of mitral regurgitation. Based on the MRI assessments, four of the patients (group A) underwent isolated coronary bypass surgery, and the other four (group B) underwent SVR and mitral valve plasty concomitantly with coronary bypass surgery. Perioperative changes in ventricular function were quantitatively assessed in each group. RESULTS: The mean end-diastolic volume index was reduced from 115 +/- 29 ml/m2 to 95 +/- 14ml/m2 in group A and from 163 +/- 35ml/m2 to 125 +/- 28ml/m2 in group B. The mean end-systolic volume index was reduced from 91 +/- 25ml/m2 to 68 +/- 16ml/m2 in group A and from 135 +/- 36ml/m2 to 98 +/- 28 ml/m2 in group B. The mean ejection fraction increased from 20% +/- 6% to 28% +/- 9% in group A and from 17% +/- 6% to 22% +/- 5% in group B. The mean New York Heart Association (NYHA) functional class was reduced from 3.0 +/- 0.8 to 1.8 +/- 0.6 in group A and from 3.5 +/- 0.5 to 2.2 +/- 0.2 in group B. CONCLUSION: DE-MRI was highly effective in helping to select which patients and which areas of the left ventricle are indicated for SVR, which contributed to excellent early clinical outcomes.

Renal outcome in off-pump coronary artery bypass grafting: predictors for renal impairment with multivariate analysis.

OBJECTIVE: : Recent studies on the efficacy of off-pump coronary artery bypass grafting (OPCABG) have reported encouraging results on postoperative renal function, but improvements can still be made. METHODS: : A total of 368 patients, none needing chronic dialysis, underwent isolated OPCABG at our institution between January 1999 and March 2005. They were divided into 3 groups according to renal function as indicated by the serum creatinine levels: group N (n = 332) with normal function, group M (n = 30) with mild to moderate renal dysfunction, and group S (n = 6), with severe renal dysfunction. Creatinine ratio and early outcomes were compared among the groups. Predictors for renal impairment were determined by multiple regression analysis. RESULTS: : In-hospital mortality rate was similar (group N, 0.6%; group M, 0%; group S, 0%). The percentage of patients with a creatinine ratio greater than 1.6 was significantly larger in group S (group N, 13%; group M, 13%; group S, 50%; P < 0.05). Postoperative hemodialysis, which was temporary, was required more frequently in group S (group N, 0.3%; group M, 3%; group S, 67%; P < 0.05). In group N, 38 patients (11%) had new renal impairment after OPCABG. Preoperative serum creatinine levels ≥2.5 mg/dL, ejection fraction <0.4, amount of blood transfusion, and more than 4 bypasses were potent predictors for postoperative renal impairment. CONCLUSIONS: : Clinical results of OPCABG on renal function were satisfactory regardless of preoperative renal function. However, perioperative renal function should be closely monitored in patients with known risk factors, even when OPCABG is performed.