Safety and outcomes of surgical treatment of atrial fibrillation in emergency surgery cases.

BACKGROUND: Recent developments in surgical devices, including left atrial appendage closure, have enabled surgeons to perform aggressive operations for atrial fibrillation (AF). However, the outcomes of AF surgery in emergent cases have not been extensively studied. OBJECTIVE AND METHODS: The present study aimed to investigate the effectiveness of AF surgery in emergency surgery cases associated with cardiovascular events. We enrolled 18 patients who underwent various types of AF surgery due to emergencies, including acute aortic dissection (n = 6), acute myocardial infarction (n = 5), bleeding due to perforation from radiofrequency catheter ablation (n = 4), acute mitral regurgitation (n = 2), and cardiac tumor (n = 1). Four and ten patients underwent the full maze procedure and pulmonary vein isolation, respectively. Ganglionated plexi ablation was also performed in three patients as part of a combined procedure. The left atrial appendage was solely closed in four patients. RESULTS: There was no surgical mortality or major adverse cardiac and cerebrovascular events in our patient series. The rates of freedom of recurrence of AF or atrial tachycardia at 1 and 3 years were 92.9% and 82.5%, respectively. After a mean follow-up period of 46.7 ± 25.8 months, no thromboembolism events were observed in the patients. Furthermore, no cardiovascular death was recorded. CONCLUSION: The surgical procedures for AF are safe and effective in cases requiring emergency surgery.

Multiple cardiac surgical procedures in a case of an octogenarian with essential thrombocythemia.

BACKGROUND: Essential thrombocythemia (ET) is a chronic myeloproliferative disorder characterized by an elevation of platelet counts with a tendency for thrombosis and hemorrhage. The perioperative management of cardiovascular surgery of an ET patient is complicated. There is limited literature on the perioperative management of patients with ET undergoing cardiovascular surgery, particularly those requiring multiple procedures. CASE PRESENTATION: An 85-year-old woman with a history of essential thrombocythemia (ET), which resulted in an abnormally high platelet count, was diagnosed with aortic valve stenosis, ischemic heart disease and paroxysmal atrial fibrillation. She underwent aortic valve replacement, coronary artery bypass grafting, and pulmonary vein isolation. The postoperative course was uneventful, nor hemorrhage and thrombosis. CONCLUSIONS: We represent a case of perioperative management and successful treatment of three combined cardiac surgery for an octogenarian ET patient who is the oldest case ever reported.

On-pump beating-heart technique for managing a ruptured left coronary artery aneurysm.

We present the case of an 86-year-old woman with a ruptured left coronary artery aneurysm associated with coronary-pulmonary artery fistula. She was transferred to our hospital with complaints of chest discomfort. Echocardiography revealed cardiac tamponade, and subsequently, a bloody pericardial effusion was drained. Coronary angiography and computed tomography revealed a ruptured left coronary artery aneurysm originating from a branch of the proximal left anterior descending artery and a coronary-pulmonary artery fistula. In the emergency operation, under cardiopulmonary bypass, the inlet and outlet vessels were ligated, and the aneurysm was closed without arresting the heart. By utilizing cardiopulmonary bypass, the pulmonary trunk was easily decompressed, and dissection around the aneurysm and identification of the inlet and outlet vessels was facilitated without cardiac arrest. Thus, to conclude, an on-pump beating-heart technique should be considered in such cases.

A Case of Contained Rupture of the Common Iliac Artery with Idiopathic Retroperitoneal Fibrosis: Efficacy of Surgical Treatment and Immunosuppressive Therapy at 2-Year Follow-Up.

Rupture of inflammatory aortic aneurysm associated with retroperitoneal fibrosis (RF) is rare. We report a 62-year-old man with an inflammatory abdominal aortic aneurysm (IAAA) complicated with idiopathic RF, resulting in a contained rupture of the common iliac artery. The patient also presented with mild renal insufficiency due to urethral obstruction and left hydronephrosis. Surgical procedures including graft replacement and ureterolysis relieved the symptoms. Postoperative immunosuppressive treatment using corticosteroid and methotrexate successfully maintained clinical remission without signs of recurrence of RF and IAAA at the 2-year follow-up.

Case of left ventricular thrombus managed with thrombectomy with left ventricular reconstruction in a patient who had coronavirus disease 2019 infection.

BACKGROUND: Intracardiac thrombus is relatively rare in patients with coronavirus disease 2019 (COVID-19). However, if it occurs, thrombotic complications are likely to develop. In this case, we performed a successful thrombectomy on a patient who developed left ventricular thrombus after COVID-19 infection without complications. CASE PRESENTATION: A 52-year-old man sought medical care due to fever, dyspnea, and abnormalities in the taste and smell that persisted for 2 weeks. The patient was diagnosed with COVID-19 and was treated with remdesivir, baricitinib, and heparin. Three weeks after hospitalization, electrocardiogram revealed angina pectoris, and cardiac catherization showed left anterior descending coronary artery stenosis. In addition, global hypokinesis and a thrombus at the left ventricular apex were observed on echocardiography. Left ventricular reconstruction concomitant with coronary artery bypass grafting was performed. A thrombus in the left ventricle was resected via left apical ventriculotomy, and the bovine pericardium was covered and sutured on the infarction site to exclude it. The patient was extubated a day after surgery and was transferred to another hospital for recuperation after 20 days. He did not present with complications. CONCLUSIONS: Thrombotic events could be prevented via thrombectomy with left ventricular reconstruction using an intraventricular patch to exclude the residual thrombus.

Surgical Treatment of a Giant Popliteal Venous Aneurysm and Arteriovenous Fistula on the Adjacent Femoral Vein and Its Postoperative Findings.

A case of a giant popliteal venous aneurysm that caused massive pulmonary thromboembolism with an arteriovenous fistula draining into the adjacent proximal femoral vein is reported herein. Deep veins in the lower leg were occluded by thrombi. The inlet and outlet orifice inside the aneurysm was closed and aneurysmorraphy was performed. The fistula was retained on the estimation that it would maintain the blood flow and prevent thrombus formation inside the femoral vein. The aneurysm was shrunk, the femoral vein was patent, and the fistula was not observed 1 year later, although it still existed 1 week after the operation.

Combined cardiac surgery in a Marfan syndrome patient with severe scoliosis via lower hemisternotomy: a case report.

BACKGROUND: Scoliosis is one of the symptoms manifested by patients with Marfan syndrome (MFS). Deformity of the thoracic cavity due to severe scoliosis may cause difficulty during cardiac surgery in terms of the surgical approach and instrument manipulation; however, only a few reports have been available regarding the surgical case of MFS with severe scoliosis. Here, we report a case of combined aortic valve replacement and left atrial appendage closure in a patient with MFS who had severe scoliosis using lower hemisternotomy. CASE PRESENTATION: A 62-year-old female with MFS was referred to our hospital after being diagnosed with severe aortic regurgitation and paroxysmal atrial fibrillation with a history of cerebral thromboembolism. The aortic valve showed severe insufficiency due to cusp prolapse, whereas the aortic root was moderately dilated (42 mm). Echocardiography revealed severe regurgitation with reduced left ventricular ejection function (32%) and massive left ventricular diastolic dimension (88 mm). Moreover, combined aortic valve replacement and left atrial appendage closure was indicated. However, the patient had chest deformity due to severe scoliosis. Thus, conventional full sternotomy or thoracotomy was considered an inappropriate surgical approach. Lower hemisternotomy was selected on the basis of three-dimensional reconstruction imaging of the aorta, left atrial appendage, sternum, and rib. Sternal elevation and rib retraction with the costal arch folded back provided enough surgical field for the combined procedures to be safely conducted. The postoperative course was uneventful, except for predicted prolonged mechanical ventilation with the assistance of intraaortic balloon pumping. Thereafter, the patient has been free from any cardiac and cerebrovascular event. CONCLUSIONS: Lower hemisternotomy can be useful for combined cardiac surgery in MFS with severe scoliosis.

Postoperative Changes in Pulmonary Function after Valve Surgery: Oxygenation Index Early after Cardiopulmonary Is a Predictor of Postoperative Course.

OBJECTIVE: To determine pulmonary functional changes that predict early clinical outcomes in valve surgery requiring long cardiopulmonary bypass (CPB). METHODS: This retrospective study included 225 consecutive non-emergency valve surgeries with fast-track cardiac anesthesia between January 2014 and March 2020. Blood gas analyses before and 0, 2, 4, 8, and 14 h after CPB were investigated. RESULTS: Median age and EuroSCORE II were 71.0 years (25-75 percentile: 59.5-77.0) and 2.46 (1.44-5.01). Patients underwent 96 aortic, 106 mitral, and 23 combined valve surgeries. The median CPB time was 151 min (122-193). PaO2/FiO2 and AaDO2/PaO2 significantly deteriorated two hours, but not immediately, after CPB (both p < 0.0001). Decreased PaO2/FiO2 and AaDO2/PaO2 were correlated with ventilation time (r2 = 0.318 and 0.435) and intensive care unit (ICU) (r2 = 0.172 and 0.267) and hospital stays (r2 = 0.164 and 0.209). Early and delayed extubations (<6 and >24 h) were predicted by PaO2/FiO2 (377.2 and 213.1) and AaDO2/PaO2 (0.683 and 1.680), measured two hours after CPB with acceptable sensitivity and specificity (0.700-0.911 and 0.677-0.859). CONCLUSIONS: PaO2/FiO2 and AaDO2/PaO2 two hours after CPB were correlated with ventilation time and lengths of ICU and hospital stays. These parameters suitably predicted early and delayed extubations.

Surgical retrieval of an entrapped stent and a stuck snare device during percutaneous coronary intervention.

A 69-year-old male patient with a history of percutaneous coronary intervention (PCI) to the proximal left anterior descending coronary artery (LAD) underwent another PCI to the stenosis of the medium LAD as part of therapy for angina pectoris. Interruption of stent delivery because of past stent led to stent entrapment and a stuck guidewire. A snare catheter device was applied to retrieve the stent; however, the device lost mobility. Surgical removal and coronary artery bypass grafting (CABG) were required. We herein report some surgical techniques for resolving this complication of PCI. .

[Overwhelming Postsplenectomy Infection after Cardiac Surgery in a Patient with Immune Thrombocytopenia;Report of a Case].

Splenectomy for immune thrombocytopenia (ITP) can increase the number of platelets. However, patients without functioning spleen become vulnerable to bacteria. Overwhelming post-splenectomy infection( OPSI), its most fulminant form, is rapidly progressive and is highly fatal. A 76-year-old male, who had undergone splenectomy for refractory ITP and taken a vaccination for treptococcus pneumoniae 4 years previously, was admitted to undergo cardiac surgery for severe aortic regurgitation and coronary disease. Prior to operation, high dose intravenous immunoglobulin therapy (400 mg/kg/day) for 5 days successfully increased platelet count. Surgery and early postoperative course were satisfactory. However, on 6th postoperative day, the patient had sudden high fever and became septic. After adequate antibiotic treatment for OPSI, the patient recovered well. Blood culture yielded methicillin-susceptible Staphylococcus aureus (MSSA). The patient discharged in good condition 30 days after the operation.

Early extubation in current valve surgery requiring long cardiopulmonary bypass: Benefits and predictive value of preoperative spirometry.

BACKGROUND: Early extubation (EEx) after cardiac surgery has been essentially studied in patients with short cardiopulmonary bypass (CPB). Whether preoperative spirometry can predict EEx remains controversial. OBJECTIVES: To investigate whether EEx can be a goal and predicted by preoperative spirometry in valve surgery requiring long CPB. METHODS: Nonemergent consecutive 210 patients who underwent valve surgery from January 2014 to August 2019 were investigated retrospectively. RESULTS: EEx (<8 h) was achieved in 93 (44.3%) patients without increasing adverse events. Patients with EEx had shorter ICU and hospital stays than those without EEx. Multivariate analysis showed that higher estimated glomerular filtration rate and mitral valve repair were significant protective factors for EEx. Conversely, moderate and severe chronic obstructive pulmonary disease defined by spirometry, longer operation, CPB, and aortic cross-clamp time were significant risk factors. CONCLUSIONS: EEx should be the goal in current valve surgery. Preoperative spirometry is a significant predictor.

A novel method of vein cuff creation for below-knee femoropopliteal bypass with a prosthetic graft.

Vein cuff anastomosis is beneficial in cases in which a prosthetic graft is anastomosed to a small and thickened peripheral artery. Various types of vein cuff are currently in use, although their design is insufficient when a size discrepancy exists between the two vessels and the angle of anastomosis requires adjustment. We report a case of a patient who underwent below-knee femoropopliteal bypass using a new design of vein cuff (boat-form vein cuff) that increases the ease of cuff creation and enables surgeons to adjust the anastomotic size and angle.

Surgical procedure for targeting arrhythmogenic substrates in the treatment of ventricular tachycardia associated with cardiac tumors.

BACKGROUND: Complete tumor resection is a standard strategy in the surgical treatment of ventricular tachycardia (VT) associated with cardiac tumors. Recently, an intraoperative electroanatomic mapping system (CARTO) has enabled surgeons to target the localized arrhythmogenic substrate for partial resection and/or cryoablation in nonresectable cardiac tumors. OBJECTIVE: The purpose of this study was to evaluate the surgical procedures and late outcomes of the treatment of VT associated with cardiac tumors. METHODS: We examined six patients (age 1-65 years) who had undergone surgical treatment of VT associated with cardiac tumors between 2010 and 2016. The 4 pathologies of the cardiac tumors were lipoma 2, fibroma 2, hemangioma 1, and lymphoma 1. Intraoperative epicardial mapping using CARTO was performed in 5 patients(80%). Surgical procedures and long-term outcomes were evaluated. RESULTS: Arrhythmogenic substrates with abnormal electrograms, such as fractionated or late potential, were identified locally or circumferentially beside the tumor in every patient. Complete tumor resection with cryoablation was performed in 3 patients. Two patients underwent partial tumor resection with cryoablation. Cryoablation without tumor resection was performed in 1 patient. No mortality and morbidity occurred. Additional catheter ablation was required in 2 patients to treat occurrence of nonclinical VT and induction of clinical VT during hospital stay. Mean follow-up time was 90 ± 52.5 months. There was no recurrence of clinical VT. CONCLUSION: The outcomes of surgical treatment of VT associated with cardiac tumors were excellent. Intraoperative CARTO mapping was beneficial to eliminate the VT substrates associated with nonresectable cardiac tumors.

Bovine three-portion pericardial patch for reconstruction of the aorto-mitral curtain in infective endocarditis.

BACKGROUND: Surgery for infective endocarditis involving the aorto-mitral curtain (AMC) is challenging and requires extensive incisions and complex reconstruction procedures. However, in patients with preserved aortic annulus, reconstruction of the AMC is possible using a simple technique with limited incisions. CASE PRESENTATION: A handmade bovine three-portion pericardial patch was used to reconstruct the AMC in a patient with severe endocarditis requiring double valve replacement; the technique allowed for steady anchorage of prosthetic valves without additional incisions other than conventional aortotomy and atriotomy. Postoperative echocardiography revealed normal cardiac function and no significant perivalvular leakage. The patient displayed complete recovery and was discharged on postoperative day 33. The patient was symptom-free at his 1-year follow-up and displayed normal laboratory and echocardiographic findings. CONCLUSION: The bovine three-portion pericardial patch is useful for reconstructing the AMC in patients with infective endocarditis accompanied by preserved aortic annulus.

Surgical outcomes of modified-maze procedures in adults with atrial septal defect.

PURPOSE: We examined the outcome of modified-maze procedures reflecting a single-center strategy in the treatment of atrial fibrillation (AF) associated with atrial septal defect (ASD) in adults. METHODS: A retrospective chart review was performed for 29 patients who underwent surgical ASD closure and 2 types of maze procedures (full and simplified maze procedures) for AF. The outcome related to the each procedure was examined. A Cox proportional hazards analysis was performed to assess the independent predictors of AF and atrial tachycardia (AT) recurrence. RESULTS: The rates of freedom from AF and AT recurrence at 1 and 4 years were 86.6% and 72.2% in the full maze group and 78.5% and 62.8% in the simplified maze group, respectively (p = 0.70). The only risk factor for recurrence was the age at the time of surgery. A receiver operating characteristic curve analysis gave an optimum cut-off value of 58 years of age for predicting recurrence within 2 years (58.4% for ≥ 58 years versus 5.9% for < 58 years, p = 0.003). CONCLUSIONS: Simplification of the maze procedure was not associated with AF or AT recurrence. The age at the time of surgery might be a clinical predictor of success or failure in adult patients.

Restoration of sinus rhythm and atrial transport function after the maze procedure: U lesion set versus box lesion set.

OBJECTIVE: In a U lesion set, the left atrium (LA) roof between the right and left superior pulmonary veins is not ablated, to allow activation to propagate across the posterior LA and to recruit this segment as a contractile atrial component. In contrast, the box lesion set isolates the entire posterior LA. METHODS: To compare the two lesion sets, postoperative freedom from atrial fibrillation (AF) and LA transport function were examined in 402 patients who underwent surgery for AF with a U lesion (n = 329) or box lesion (n = 73) set. Patients who underwent pulmonary vein isolation alone or other simplified procedures were excluded from the study. LA transport function was quantified at 20 ± 33 months postoperatively by the ratio of peak velocity of the A wave to the E wave (peak A/E) of the transmitral Doppler flow. RESULTS: In patients with long-standing persistent AF, freedom from AF was 85% with the U lesion set and 77% with the box lesion set at 5 years after the maze procedure, and 82% and 77%, respectively, at 10 years after the procedure. There was no significant difference between the U lesion set and box lesion set in patients with long-standing persistent AF (P = .30) and those with paroxysmal or persistent AF (P = .90). Proportional hazards analysis identified increased LA diameter (P = .003) and long-standing persistent AF (P = .03), but not the type of lesion set (P = .51), as predictive of postoperative AF recurrence. The postoperative peak A/E was significantly greater after the U lesion set than after the box lesion set (0.42 ± 0.22 vs 0.23 ± 0.17), and multiple regression analysis demonstrated that the type of lesion set and preoperative LA diameter significantly affected postoperative A/E. CONCLUSIONS: The U lesion set restores sinus rhythm frequently as the box lesion set and provides better LA transport function. A dilated LA is a risk factor for postoperative recurrence of AF and poor postoperative LA transport function.

Exploration of theoretical ganglionated plexi ablation technique in atrial fibrillation surgery.

BACKGROUND: Ganglionated plexi ablation during atrial fibrillation surgery is not technically standardized for precise ganglionated plexi locations or ablation sequence. We aimed to identify precise active ganglionated plexi locations in patients with structural heart disease and explore the feasibility of anatomic ganglionated plexi ablation without prior mapping in patients with atrial fibrillation. METHODS: Thirty patients with valvular disease-associated atrial fibrillation underwent ganglionated plexi ablation and a modified maze procedure. In 20 patients, ganglionated plexi mapping was performed to identify active plexi. According to mapping results, anatomically determined plexi were ablated without mapping in the final 10 patients. Ganglionated plexi ablation outcomes with and without prior mapping were compared between perioperative and early postoperative periods. RESULTS: Active ganglionated plexi common to more than 20% of patients were identified in the superior and inferior right pulmonary veins, superior left pulmonary vein, interatrial groove, and inferior left atrium. Inferior left atrial plexi ablation resulted in maximum vagal modulation. Compared with ablation using mapping, anatomic ablation yielded more vagal modulation in heart rate variability and decreased the requisite cardiopulmonary bypass time. CONCLUSIONS: The sequential pacing and ablation technique identified an optimal ablation sequence that best ensured vagal reflex elimination from all ganglionated plexi. Anatomic ablation using a predetermined ganglionated plexi map may be a viable alternative to individual plexus mapping before ablation.

[Overview of ablation devices for atrial fibrillation surgery].

Since Cox-maze procedure was first reported in 1987, ablation technology has made great progress and revolutionized atrial fibrillation surgery. Various energy sources have been introduced to facilitate creating conduction block within the atria. These sources include radiofrequency, cryothermia, microwave, laser, and high-frequency focused ultrasound( HIFU). They have been utilized both endocardially in the arrested heart and epicardially in the beating heart. The goal of all these sources is to create transmural lesions which enable irreversible conduction block. They have been reported to have clinical efficacy, but each of them have their own advantages and disadvantages, and their ability of creating transmural lesions are also different. It is important for surgeons that they fully understand these differences to make appropriate use of these technologies for achieving safe atrial fibrillation surgery and developing less invasive new procedures.

Histopathological study of tissue reaction to pacemaker electrodes implanted in the endocardium.

Limited information is available about histopathological reactions to the implanted endocardial electrodes of pacemakers (PM). Gross anatomic and histologic studies of tissue reactions to PM electrodes were made in thirteen autopsy cases (nine men and four women, ages 25 approximately 89 years, mean age 71.8) who died two months to twenty-one years after PM implantation. Nine of them had complete atrioventricular (AV) block, three had sick sinus syndrome, and one had bradycardia-tachycardia syndrome. The direct causes of death were not related to their PM. The tip with projecting tines was implanted in the right ventricle in all patients. At the contact area between the electrode and the endocardium, no tissue reaction was observed in one patient with a history of over sixteen years of PM implantation. However, cardiomyocytes under the tip had been replaced by fibrotic tissue in many other patients. In two patients in particular where the electrode had been implanted at the apex of each right ventricle, all cardiomyocytes had disappeared and only fibrotic tissue and adipose tissue were observed under the tip. These findings suggest that mechanical stress caused by attaching the tip tightly damages cardiomyocytes and brings about changes in the pacing thresholds. In three patients, a space was seen between the tip and the endocardium. A fibrous sheath covering the electrode extended to the tip and formed a thick fibrous cap. This non-excitable fibrous cap acted as a virtual electrode and possibly affected the elevation of the threshold in these patients. In four patients, extensive myocardial fibrosis due to disease, e. g. previous myocardial infarction, dilated cardiomyopathy, amyloidosis, or sarcoidosis, was found in the area surrounding the tip and also might affect the elevation of the threshold. We concluded that elevation of pacing thresholds after PM implantation is not due to reactive endocardial thickening. The space between the tip and the endocardium is occupied by a fibrous sheath, and an overly tight attachment damages cardiomyocytes causing replacement fibrosis. Thus, it is not desirable in some patients to insert the electrodes into the apex, where the myocardium is thin. To avoid the elevation of thresholds, development of further devices is necessary to allow electrode fixation to the endocardium with a more suitable pressure level.