Impact of quantitative flow ratio on graft function in patients undergoing coronary artery bypass grafting.

Recent studies showed that preoperative functional assessment with fractional flow reserve (FFR) could predict a long-term patency of arterial bypass grafts in patients with coronary artery bypass grafting (CABG). Quantitative flow ratio (QFR) is a novel angiography-based approach to estimate FFR. This study aimed to investigate whether preoperative QFR could discriminate arterial bypass function at 1 year after surgery. The PRIDE-METAL registry was a prospective, multicenter observational study that enrolled 54 patients with multivessel coronary artery disease. By protocol, left coronary stenoses were revascularized by CABG with arterial grafts, whereas right coronary stenoses were treated with coronary stenting. Follow-up angiography at 1 year after surgery was scheduled to assess arterial graft patency. QFR was performed using index angiography by certified analysts, blinded to bypass graft function. The primary end point of this sub-study was the discriminative ability of QFR for arterial graft function, as assessed by receiver-operating characteristic curve. Among 54 patients enrolled in the PRIDE-METAL registry, index and follow-up angiography was available in 41 patients with 97 anastomoses. QFR were analyzed in 35 patients (71 anastomoses) with an analyzability of 85.5% (71/83). Five bypass grafts were found to be non-functional at 1 year. The diagnostic performance of QFR was substantial (area under the curve: 0.89; 95% confidence interval: 0.83 to 0.96) with an optimal cutoff of 0.76 to predict functionality of bypass grafts. Preoperative QFR is highly discriminative for predicting postoperative arterial graft function.Trial registration: Clinical.gov reference: NCT02894255.

Giant Coronary Aneurysm with Coronary-Pulmonary Artery Fistula in a Jehovah's Witness.

With an incidence of 3 in 100 million, giant coronary artery aneurysm (CAA) with coronary artery fistula (CAF) is a very rare condition. To prevent rupture, giant CAA with CAF should be swiftly treated. We present a Jehovah's Witness patient with giant CAA and coronary-pulmonary artery fistula. We resected the giant CAA in one piece, while ligating the CAF, without allogeneic blood transfusion. Due to rarity of these conditions, many thoracic surgeons lack direct experience in its surgical procedures. Herein, we share footage of this surgery as an example of how to safely resect CAA with minimal bleeding.

Transcatheter aortic valve implantation with a balloon-expandable prosthesis in a patient with single coronary artery: a case report.

Background: Single coronary artery is a rare coronary artery anomaly with an incidence of <0.03%. The coexistence of coronary artery anomalies with severe aortic stenosis is extremely rare. Due to the singularity of the coronary artery orifice, the most concerning risk of transcatheter aortic valve implantation (TAVI) in such patients is coronary occlusion, which may very well be life-threatening. Case summary: An 83-year-old female complaining of chest pain was referred to our hospital for severe aortic stenosis. The multi-slice computed tomography showed a congenital single coronary artery originating from the right sinus of Valsalva. The left coronary artery branched off of the right coronary artery, and passed between the aorta and main pulmonary artery. The heart team of the hospital decided to perform TAVI via femoral artery with a balloon-expandable prosthesis, with coronary angioplasty devices on standby in case of coronary occlusion. The TAVI procedure was performed successfully without coronary occlusion. Discussion: Although there have been some case reports of TAVI in patients with single coronary artery, little is known about the safety of TAVI in such cases, and which device (such as the balloon-expandable or the self-expandable prosthesis) is preferable. From this particular case, and accumulation of past and various TAVI experience, the balloon-expandable prosthesis can be a safe device choice in carefully selected patients with coronary artery anomalies.

Prospective multicenter registry of hybrid coronary artery revascularization combined with non-saphenous vein graft surgical bypass and percutaneous coronary intervention using everolimus eluting metallic stents (PRIDE-METAL study).

The concept of hybrid coronary revascularization (HCR) combines the advantages of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) to improve the treatment of patients with complex multivessel disease. This study aimed to investigate a 1-year clinical follow-up of a prospective multicenter registry of HCR combined with non-saphenous vein graft surgical bypass and PCI using everolimus-eluting metallic stents (the PRIDE-METAL study). From June 2016 to June 2018, a total of 54 patients with multivessel coronary disease from six Japanese institutes were enrolled in this study. The primary endpoint of the study was the occurrence of major adverse cardiovascular event (MACE; all-cause death, myocardial infarction, stroke, and repeat revascularization) at 1 year. Three patients declined before complete HCR, and two patients were lost by the 1-year follow-up. All-cause mortality at 30 days and at 1 year was 0% and 4.1%, respectively. The rates of myocardial infarction, repeat revascularization, stroke, and MACE were 0% at 30 days, and 0%, 2.0%, 2.0%, and 8.2% at 1-year follow-up, respectively. No occlusion of arterial bypass graft at the 30-day follow-up was observed, and was observed in 1.7% at the 1-year follow-up. HCR was safe and feasible and associated with a low risk of MACE at the 1-year follow-up. Further validation in multicenter and randomized studies is needed.

A case of a giant pulmonary artery aneurysm due to an atrial septal defect with left main coronary artery occlusion.

Cases of coronary artery occlusion due to the exclusion of pulmonary artery aneurysm are extremely rare, and there are few reports of surgical treatment. A 60-year-old woman with pulmonary hypertension due to an atrial septal defect and obstruction of the left main coronary trunk due to the exclusion of a giant pulmonary artery aneurysm underwent surgery. The surgery included atrial septal defect closure, tricuspid annulus plasty, pulmonary artery aneurysmorrhaphy, and coronary artery bypass grafting. One and a half years after the surgery, no re-expansion of the pulmonary artery was observed, and the symptoms of heart failure had improved. There are no reports of improvement in pulmonary valve regurgitation by aneurysmorrhaphy in pulmonary artery aneurysm. Surgery for pulmonary artery aneurysm with the exclusion of other organs was effective, and aneurysmorrhaphy for pulmonary artery aneurysm was acceptable.

Effectiveness of Conservative Treatment without Early Colonoscopy in Patients with Colonic Diverticular Hemorrhage.

Aim: This study was aimed to clarify the effectiveness of conservative treatment without performing early colonoscopy and the indications for early colonoscopy in patients with colonic diverticular hemorrhage. Methods: This retrospective study included 142 participants who were urgently hospitalized due to bloody stools and were diagnosed with colonic diverticular hemorrhage between April 2012 and December 2016. At the time of hospital visit, only when both shock based on vital signs and intestinal extravasation on abdominal contrast-enhanced computed tomography were observed, early colonoscopy was performed within 24 hours after hospitalization. However, in other cases, patients were conservatively treated without undergoing early colonoscopy. In cases of initial treatment failure in patients with shock, interventional radiology (IVR) was performed without undergoing early colonoscopy. Results: Conservative treatment was performed in 137 (96.5%) patients, and spontaneous hemostasis was achieved in all patients. By contrast, urgent hemostasis was performed in five (3.5%) patients; three and two attained successful hemostasis via early colonoscopy and IVR, respectively. There were no significant differences between two groups in terms of early rebleeding (7.3% vs. 0%,P=0.690) and recurrent bleeding (22.7% vs. 20.0%, P=0.685). The factors associated with the cumulative recurrent bleeding rates were a previous history of colonic diverticular hemorrhage (hazard ratio 5.63, 95% confidence interval 2.68-12.0, P < 0.0001) and oral administration of thienopyridine derivative (hazard ratio 3.05, 95% confidence interval 1.23-7.53, P=0.016). Conclusions: In this series, conservative treatment without early colonoscopy was successful in patients with colonic diverticular hemorrhage.

Obstruction of 2 Coronary Arteries from Different Causes Immediately after Transapical Transcatheter Aortic Valve Replacement.

Coronary obstruction, a rare complication of transcatheter aortic valve replacement, can be fatal. Few data exist on this phenomenon, and, to date, authors have reported only single coronary lesions. We present a case in which 2 coronary arteries obstructed immediately after transapical transcatheter aortic valve replacement. The patient was an 81-year-old woman with symptomatic severe aortic stenosis who underwent transapical transcatheter aortic valve replacement. Immediately after an Edwards Sapien XT valve was deployed, she experienced sudden cardiogenic shock resulting from obstruction of the left main coronary artery ostium and the distal left anterior descending coronary artery. The left main obstruction was caused by direct compression from a large calcified mass and the valve frame. The left anterior descending coronary artery obstruction was caused by ambient myocardial tightening and external compression around the apical sutures. Revascularization was achieved through coronary stent placement and suture removal, respectively. Our patient's case highlights the risk for coronary obstructions after transapical transcatheter aortic valve replacement, and we discuss how they can be managed.

Total surgical repair for secondary aortoesophageal fistula: two case reports.

We present two consecutive patients with secondary aortoesophageal fistula (AEF) who successfully underwent total repair including partial esophagectomy, removal of infected vascular prosthesis, graft replacement, and esophageal reconstruction using gastric tube concomitant to omental wrapping for staged operation in short phase. One 81-year-old male who had undergone thoracic endovascular aortic repair and another 69-year-old male who had undergone graft replacement of the descending thoracic aorta were referred to our hospital for treatment of AEF. In the first operation, partial esophagectomy, removal of infected vascular prosthesis, and graft replacement were performed via left rib-cross thoracotomy. About half a day after the operation when the patients became hemodynamically stable, esophageal reconstruction was started. The gastric tube was prepared via median laparotomy and introduced to the left thoracic cavity with the omentum through the enlarged hiatus. Thereafter, the gastric tube was anastomosed to the oral side of the esophageal stump via left thoracotomy with the same wound similar to the first operation. Finally, the graft positioned parallel to the gastric tube was completely wrapped by the omentum. Both patients could ingest orally 4 weeks after surgery and maintained no recurrence of infection.

Surgical Therapy for Angiosarcoma of the Aorta: A Case Report.

We describe the case of a 71-year-old woman presenting with abdominal angina with an intra-aortic mass at the thoracoabdominal aorta that restricted blood supply to the organs. Initially, the intra-aortic mass was suspected to be a mural thrombus; thus, endarterectomy was performed. However, postoperative histopathological examination revealed an intimal sarcoma, which relapsed locally within a few months. Additional en bloc resection of the aorta with graft interposition was performed. Despite surgical therapy, splenic metastasis was detected a few months after the second surgery; therefore, palliative care was selected for the patient.

Utility and safety of tocilizumab in Takayasu arteritis with severe heart failure and muscle wasting.

Takayasu arteritis (TA) is a large vessel vasculitis of unknown aetiology characterized by chronic inflammatory changes of the aorta and its major branches. We report the active TA case who had severe heart failure due to acute myocardial infarction and aortic regurgitation. Bentall procedure was successfully performed, but he had severely depressed left ventricular function and muscle wasting together with vascular inflammation. The treatment with tocilizumab, an interleukin-6 receptor monoclonal antibody, in addition to prednisolone and standard heart failure therapy led to prompt remission of TA activity and improvement of left ventricular function and muscle wasting. Taken together with possible involvement of interleukin-6 in the pathogenesis of heart failure and muscle wasting, inhibition of interleukin-6 receptor signalling by tocilizumab may be a safe and reasonable approach in the treatment of active TA with heart failure and muscle wasting.

Surgical resection of the giant right coronary artery aneurysm.

A 74-year-old man had undergone two-vessel coronary artery bypass grafting (CABG), 19 years ago, with the left internal mammary artery (LITA) to the left anterior descending artery and the saphenous vein graft (SVG) to the posterior descending artery. In outpatient care, a thoracic aortic aneurysm was suspected by the chest X-ray. In the computed tomography, appeared the distal arch aortic aneurysm, abdominal aortic aneurysm (AAA), and giant right coronary artery aneurysm (rCAA). The diameter of rCAA was 70 mm and it oppressed the right atrium and ventricle of the heart. The patient was referred to our hospital. After the initial treatment of distal arch aneurysm and AAA, surgical treatment for the rCAA was performed. The rCAA was resected completely and CABG with new SVG was performed without cardiopulmonary bypass. The histopathology of rCAA wall revealed that the etiology was an atherosclerotic change. The postoperative course was good, the oppressed right heart system was released and the hemodynamics of the tricuspid valve showed improvement.

Differential Phenotypes in Perivascular Adipose Tissue Surrounding the Internal Thoracic Artery and Diseased Coronary Artery.

Background Perivascular adipose tissue ( PVAT ) is causally associated with vascular function and the pathogenesis of vascular disease in association with metabolically driven chronic inflammation called metaflammation. However, the difference in PVAT surrounding the coronary artery ( CA - PVAT ) and that surrounding the internal thoracic artery (ITA-PVAT), a vessel resistant to atherosclerosis, remains unclear. Herein, we investigated whether CA - PVAT , ITA - PVAT , and subcutaneous adipose tissue ( SCAT ) have distinct phenotypes. Methods and Results Fat pads were sampled from 44 patients (men/women, 36:8; age, 67±13 years) with CA disease who underwent elective CA bypass grafting. Adipocyte size in ITA - PVAT and that in CA - PVAT were significantly smaller than that in SCAT . A greater extent of fibrosis and increased gene expression levels of fibrosis-related molecules were observed in CA - PVAT than those in SCAT and those in ITA - PVAT . CA - PVAT exhibited more pronounced metaflammation, as indicated by a significantly larger extent of CD 68-positive and CD 11c-positive M1 macrophages, a lower ratio of CD 206-positive M2 to CD 11c-positive M1 macrophages, a lower gene expression level of adiponectin, and higher gene expression levels of inflammatory cytokines and inflammasome- and endoplasmic reticulum stress-related molecules, than did ITA - PVAT and SCAT . Expression patterns of adipocyte developmental and pattern-forming genes were totally different among SCAT , ITA - PVAT, and CA - PVAT . Conclusions The phenotype of ITA - PVAT is closer to that of SCAT than that of CA - PVAT , which may result from inherent differences in adipocytes. ITA - PVAT appears to be protected from metaflammation and consecutive adipose tissue remodeling, which may contribute to the decreased atherosclerotic plaque burden in the ITA.

Infundibular pulmonary stenosis after radiotherapy for breast cancer.

Postoperative radiotherapy for breast cancer may be associated with cardiotoxicity. We present a case of acquired infundibular pulmonary stenosis that developed 43 years after radiotherapy for left breast cancer, which necessitated a right ventricular outflow tract myectomy.

Partial root remodelling for treatment of a giant isolated right sinus of Valsalva aneurysm.

Sinus of Valsalva aneurysms are rare cardiac abnormalities that may be congenital or acquired. Patch closure or direct closure of the aneurysm orifice is a frequently performed surgical repair strategy. In this report, we present a rare case of an isolated giant right sinus of Valsalva aneurysm with aortic insufficiency and right coronary artery obstruction. We treated this patient by a valve-sparing aortic root remodelling procedure with partial preservation of the intact Valsalva sinuses and coronary artery bypass grafting with a favourable outcome.

[Discrete Subaortic Stenosis in an Adult; Report of a Case].

Discrete subaortic stenosis (DSS) is a well-described cause of isolated left ventricular outflow tract obstruction( LVOTO) in children. But prevalence, rate of progression and postoperative data in adults are limited. We report a case of a 30-year-old woman, who was referred to our institution because of chest pain and loss of consciousness. Echocardiography revealed DSS with LVOTO (peak gradient 81 mmHg) and mild aortic regurgitation. Increased age at the time of diagnosis, female sex and preoperative left ventricular outflow tract(LVOT) gradient ≥80 mmHg were thought to be predictors for reoperation, therefore the obstructing membrane was circumferentially excised and concomitant localized myectomy of the ventricular septum was performed to achieve complete relief of the LVOT obstruction. Her postoperative course was uneventful, and she was discharged on the 5th postoperative day.

Surgical treatment of cardiac myxosarcoma.

A 36-year-old man suffering from exertional dyspnea was admitted to our hospital. An echocardiogram showed a left atrial tumor, which was excised via the left atrial approach. Histological examination of the surgical specimen revealed that it was a myxosarcoma. Twelve months after the surgery, the tumor recurred in the left atrium, and metastatic tumors were found in the right atrium and right ventricle. Surgery was performed once again, but examinations 5 months after the second surgery showed local recurrences and multiple metastases. Although the patient had received chemotherapy, he died 30 months after the first operation.

Can 64-row computed tomography replace angiography after coronary bypass?

Multi-detector (64-row) computed tomography has become an alternative to coronary angiography to diagnose graft occlusion and stenosis after coronary artery bypass. We compared the power of evaluation of multi-detector computed tomography with that of conventional coronary angiography in 60 patients who underwent coronary artery bypass with 135 grafts and 210 graft anastomoses. The diagnostic power of multi-detector computed tomography for graft occlusion was: 100% (2/2) sensitivity, 98.5% (131/133) specificity, 50% (2/4) positive predictive value, and 100% (133/133) negative predictive value; there were no significant differences in rates of occlusion among the different types of graft. The diagnostic power of multi-detector computed tomography for stenosis of the graft anastomosis was: 100% (2/2) sensitivity, 95.1% (194/204) specificity, 16.6% (2/12) positive predictive value, and 100% (194/194) negative predictive value, with no significant differences among grafts. Multi-detector computed tomography permits evaluation of bypass grafts and is much less invasive for the patients.