[Successful Open Surgical Repair of Asymptomatic Coronary Artery Fistula with Giant Aneurysm: Report of a Case].

Coronary artery fistula is an uncommon congenital anomaly of the coronary arteries, and there are lots of variations. We present a-46-year-old male patient with abnormal cardiac silhouette on chest X-ray. Coronary computed tomography (CT) angiography showed coronary artery (left anterior descending artery)-to-pulmonary artery fistula with a giant aneurysm( 55 mm). Considering the risk of rupture, surgery was indicated. The patient underwent surgical repair through median sternotomy under cardiopulmorary bypass and cardiac arrest antegrade myocardial protection. Fistulas were dissected and ligated proximally and distally, then the aneuysm was resected. By flushing bloody cardioplegic solution, we confirmed that there was no residual blood inflow to the aneurysm. Post-operative course was unevenful without evidence of myocardial injury. The patient discharged home on 10th postoperative day.

Papillary-Ventricular Complex Tugging for Ischemic/Functional Mitral Regurgitation.

Surgical restoration of subvalvular geometry is very important to prevent recurrence of ischemic/functional mitral regurgitation. We evaluated an approach to the radical repair of left ventricular (LV) remodeling for three different cases with responsible coronary lesions. Leaflet tethering was corrected by tugging of the papillary-ventricular complex, which consists of the base of papillary muscles and posterior LV wall. The main lesion of the postinfarction scar was concomitantly excluded. Restoration of LV remodeling diminished mitral regurgitation with minimal leaflet tethering and improved systolic LV function. This technique may be an aggressive and encouraged approach for patients with ischemic/functional mitral regurgitation.

Successful Handmade Monobloc Aortomitral Valve Replacement for Extensive Aortic Root Abscess.

Aortic root abscess is one of the most catastrophic complications of aortic valve endocarditis. Complete débridement is recommended regardless of the kind of infected lesion. A 37-year-old man with extensive aortic root abscess due to prosthetic aortic valve endocarditis was surgically treated. The main lesion was the aortomitral continuity extending to the commissure between the left and right coronary cusps. After débridement, the aortic annulus underneath the left coronary artery was reconstructed using a handmade aortomitral monobloc valve without aortic annuloplasty. This valve was required for the extensive root abscess of the left and noncoronary sinus to achieve complete débridement.

Endocardial Hemangioma of the Right Ventricle: Complete Excision With Right Ventricular Restoration.

Primary cardiac tumor can arise from any location in the right and left cardiac chamber. Complete excision is generally recommended because of uncertainty regarding malignancy; however it is important to minimize the resultant functional deterioration after surgery. We report a case of endocardial hemangioma (4 × 3 × 3 cm) on the free wall of the right ventricle, located between the anterior and posterior papillary muscles. We describe details of the procedure to preserve the right ventricular volume and competence of the tricuspid valve.

Penetrating thoracic ice pick injury extending into pulmonary artery: Report of a case.

INTRODUCTION: Penetrating thoracic traumas have a wide spectrum, ranging from mild traumas to life-threatening injuries. PRESENTATION OF CASE: This paper illustrates a 40-year-old male with a penetrating pulmonary artery injury that was successfully treated with emergency surgery. The patient visited local hospital by foot complaining of moving object on his chest and was found that an ice pick was penetrating the man's left chest. An ambulance took the patient to our emergency department. Computed tomography of the chest showed linear metallic density in the pulmonary trunk and a small amount of pericardial fluid. Emergency surgery for removal of the object and repair of the pulmonary artery was performed. The ice pick had been stuck in the main pulmonary artery through the pericardium without any injury to the left lung or internal thoracic artery. Postoperative course was uneventful. DISCUSSION: A multidisciplinary team designed our treatment strategy, enabling us to select the optimal treatment, including diagnostic techniques and surgical approach. A successful trauma management depends on whether a life-threatening conditionexists. Major vascular injury should be rapidly assessed in these cases. Psychiatric aspects of the case are also discussed. CONCLUSION: Early removal of the foreign body is recommended to prevent further damage to the heart.

[Full Sternotomy with Lower Skin Incision for Coronary Artery Bypass Grafting with Permanent Tracheostomy].

A 68-year-old man who previously underwent a permanent tracheostomy was referred to us for coronary artery bypass grafting(CABG). Off-pump CABG was successfully performed with full sternotomy through a limited skin incision. The postoperative course was uneventful. This technique seemed useful for a patient with permanent tracheostomy who is scheduled for CABG. Preoperative computed tomography(CT) scan was useful for the assessment of this procedure.

[Predictors of chronic aortic events associated with uncomplicated type B aortic dissection].

OBJECTIVE: Stent-graft repair may emerge as a first-line therapy for acute complicated type B dissection(C-TBD), while debate continues over thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (U-TBD). Aggressive medical therapy, which confers a 1-year survival rate of 80-90%, is deemed appropriate for most of these patients. However, it is reported that aortic complications occur in ≤ 50% patients within 5 years after surgery. Subgroups of patients with U-TBD may benefit from early stent-graft placement, but identification of these patients remains difficult. Therefore, we assessed the predictors of chronic aortic events associated with U-TBD. METHODS: Between January 2001 and April 2012, 49 patients diagnosed with communicating U-TBD without aneurysm formation were admitted to our hospital. These patients were divided into 2 groups:group AC (n=25) with chronic aortic complications (aneurysm formation, aortic diameter expansion of 5 mm/0.5 year, re-dissection, and rupture) and group NC (n=24)with no aortic complications. We assessed and compared patient profiles and imaging findings between the 2 groups. RESULTS: Aortic diameter ≥ 40 mm was more often seen in group AC than in group NC (p=0.018). In addition, intimal tear in the distal arch was more often seen in group AC than in group NC ( p=0.002). Initial aortic diameter was significantly larger in group AC than in group NC (p=0.004). There was no significant difference in the length of communicating false lumen between the 2 groups ( p=0.107). CONCLUSIONS: Early endovascular intervention may be appropriate for U-TBD in cases displaying an initial aortic diameter ≥ 40 mm and an initial tear in the distal arch. It is expected that randomized studies, including ADSOAB study (a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta.), will resolve the limitations of our retrospective study.

Effect of antifibrinolytic therapy with tranexamic acid on abdominal aortic aneurysm shrinkage after endovascular repair.

OBJECTIVE: The long-term outcomes of endovascular abdominal aortic aneurysm repair (EVAR) remain to be determined, but patients with aneurysm shrinkage after EVAR appear to have a good prognosis. We previously observed that antiplatelet therapy is a risk factor for lack of aneurysm shrinkage, a finding suggesting that coagulation and fibrinolysis play roles in shrinkage. We therefore studied the effect of antifibrinolytic therapy with tranexamic acid (TXA) on aneurysm shrinkage after EVAR. METHODS: From May 2007 to May 2012, EVAR was performed in 187 patients, 165 of whom had an enhanced computed tomographic evaluation 6 months after their procedure. Six of the 165 patients were excluded from the study because they had a type Ia endoleak or coil embolization to treat a type II endoleak ≤ 6 months after EVAR. Of the remaining 159 patients, 110 underwent EVAR before we started to use TXA in our centers. TXA therapy (1500 mg/d for 6 months) began in January 2011, and 48 patients completed the treatment regimen. Patients not treated with TXA were compared with those given TXA. Analyses to identify risk factors for lack of aneurysm shrinkage were performed. RESULTS: No patient had a thromboembolic event. There were no significant differences between the no-TXA and TXA groups in demographics, aneurysm characteristics, prosthesis implanted, type II endoleak occurrence during EVAR or 1 or 6 months afterward, or aneurysm shrinkage at 1 month. However, at 6 months after EVAR, the TXA group had significantly greater aneurysm shrinkage (P = .035) and a significantly higher percentage of patients with >4 mm in shrinkage (P = .010). Multiple regression analysis showed aneurysm diameter, type II endoleak 6 months after EVAR, and TXA treatment were independently associated with aneurysm shrinkage or lack of shrinkage. CONCLUSIONS: Antifibrinolytic therapy with TXA was associated with aneurysm shrinkage after EVAR. Studies to identify the dosage of TXA that is optimally safe and effective in this application, as well as investigations of the best timing and route (parenteral vs oral) for TXA administration, are warranted.

Clinical benefits of methylprednisolone in off-pump coronary artery bypass surgery.

BACKGROUND: It has not been established whether off-pump coronary artery bypass grafting (OPCABG) is less invasive than conventional CABG. In our experience, OPCABG has several advantages such as shorter operative duration, decreased requirement of blood transfusion and myocardial protection compared with conventional CABG. However, frequency of postoperative paroxysmal atrial fibrillation (PAF) is similar between these techniques and early postoperative C-reactive protein (CRP) levels have been shown to be significantly higher in OPCABG. We hypothesized that preoperative steroid administration, routinely used only in conventional CABG, may alleviate high postoperative PAF and CRP levels. Therefore, a prospective, double-blind, clinical trial was conducted in OPCABG patients to investigate the clinical effects of preoperative steroid administration. METHODS: Thirty OPCABG patients were randomly divided into 2 groups: control (Group C: n = 15) and methylprednisolone (Group M: n = 15) groups. Group M patients were intravenously administered 1000 mg methylprednisolone during anesthesia induction. RESULTS: Hospital death and infectious complication such as mediastinitis were not observed in either group. Postoperative PAF occurred in 47 % (7/15) of patients in group C but in only 1 patient in group M (7 %, P = 0.013). Early postoperative CRP levels were significantly lower in group M than in group C (peak values on postoperative day 2: group M 15 ± 6 mg/dL vs. group C 23 ± 4 mg/dL; P = 0.0002). CONCLUSIONS: Preoperative steroid administration in OPCABG patients significantly suppresses CRP elevation and prevents postoperative PAF without increasing in-hospital mortality or infectious complications.

[Operative invasiveness of off-pump coronary artery bypass grafting].

OBJECTIVE: In our institution, steroid is administrated intravenously during the anesthesia induction for conventional coronary artery bypass grafting( CABG) to prevent the inflammatory response due to cardiopulmonary bypass and reperfusion injury, however, steroid is not used for off-pump CABG (OPCAB) with expectation of less invasiveness of the procedure. We evaluated the early outcomes and postoperative inflammatory response of conventional CABG with preoperative steroid use and OPCAB. METHODS: From May 2004 to April 2010, 120 patients underwent elective CABG requiring the ventricle elevation to expose the target vessels. Twenty eight patients(group C)treated with conventional CABG and 92 patients (group O) with OPCAB. Perioperative course was analyzed and compared between the 2 groups. RESULTS: OPCAB had several advantages such as shorter operative duration, decreased requirement of blood transfusion and myocardial protection compared with conventional CABG. However, frequency of postoperative paroxysmal atrial fibrillation was similar between these techniques and early postoperative C-reactive protein levels were shown to be significantly higher in OPCAB. CONCLUSIONS: OPCAB has advantage over conventional CABG in blood loss during surgery and myocardial protection. However the inflammatory response was significantly severe in OPCAB. OPCAB might become less invasive with the anti-inflammatory medication.

[Distal anastomosis using parachute technique with 4 stay-sutures for Stanford type A acute aortic dissection].

OBJECTIVE: Distal anastomosis in total arch repair for type A acute aortic dissection is difficult because of fragile aortic wall and time-limiting procedure. Until 2008, distal anastomosis was performed with continuous suture technique at 20 ℃, and parachute technique with 4-stay sutures at 26 ℃ was introduced in our institution. This new technique was compared with previous distal anastomosis with continuous suture technique. METHODS: From May 1997 to December 2010, 40 patients underwent emergent arch repair for type A acute aortic dissection. Continuous suture technique was used in 23 patients (group C) and parachute technique with 4 stay-sutures was used in 17 patients( group P). RESULTS: Patient's demographics did not differ between the 2 groups and there was no difference in perioperative or hospital death in the 2 groups. Lower limb ischemic time, cardiac ischemic time, cardiopulmonary bypass time and operation time were significantly shorter in group P. CONCLUSIONS: Distal anastomosis using parachute technique with 4-stay sutures in arch repair for type A acute aortic dissection seems to be useful compared with continuous suture technique.

Effect of type II endoleaks and antiplatelet therapy on abdominal aortic aneurysm shrinkage after endovascular repair.

OBJECTIVE: Endovascular repair of abdominal aortic aneurysm (EVAR) has been shown to be safe, and its use is increasing rapidly, but the long-term results of this procedure remain unclear. A decrease in the diameter of the aneurysm sac is considered to represent successful exclusion of the aneurysm from the circulation, but it has been reported that aneurysm shrinkage occurs in only about 60% of patients who have undergone EVAR. We analyzed several factors to determine whether they were related to aneurysm shrinkage after EVAR. METHODS: From March 2007 to January 2010, EVAR was performed in 65 patients, 58 of whom underwent an enhanced computerized tomographic evaluation 6 months after the procedure. One patient was found to have a type Ia endoleak and was excluded from the study. In the remaining 57 patients, univariate and multiple regression analyses were used to determine whether there was a relationship between aneurysm shrinkage and various patient characteristics, aneurysm dimensions, and procedural outcomes. Aneurysm shrinkage was defined as a decrease in diameter of at least 4 mm. RESULTS: On univariate analysis, a lack of aneurysm shrinkage by 7 days and 6 months after EVAR was significantly associated with hyperlipidemia, ongoing multiagent antiplatelet therapy with clopidogrel, ticlopidine, or cilostazol as well as aspirin, length of the proximal neck of the aneurysm, preprocedure maximum aneurysm diameter, and the presence of a type II endoleak. On multiple regression analysis, only multiagent antiplatelet therapy and type II endoleak were significantly related to a lack of aneurysm shrinkage 6 months after EVAR. Multiagent antiplatelet therapy and type II endoleak 6 months after EVAR were not significantly associated with each other. CONCLUSION: Patients with a persistent type II endoleak and patients undergoing multiagent antiplatelet therapy are at an increased risk of a lack of aneurysm shrinkage 6 months after EVAR.

Endovascular repair and pharmacotherapy of an inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula.

An inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula was successfully treated by stent grafting. Pharmacotherapy with octreotide after endovascular aneurysm repair was also performed with the expectation of spontaneous and rapid closure of the fistula. Gastrointestinal endoscopy performed 10 days after endovascular aneurysm repair showed closure of the large aortoduodenal fistula, and oral intake was started on the operative day 16. To date, 16 months after the initial operation, the patient is doing well without any symptoms or signs of infection and without any antibiotic therapy.

Bronchial and cardiac ruptures due to blunt trauma.

Tracheobronchial and cardiac injuries following blunt thoracic trauma are uncommon but can be life-threatening. We report a case in which the patient with bronchial and right atrial ruptures due to blunt trauma survived after emergent repairs. An 18-year-old female driver was transported to our hospital after a traffic accident and was hemodynamically stable on arrival. Chest computed tomography revealed cervicomediastinal emphysema and hemopericardium, and fiberoptic bronchoscopy showed a tear in the right main bronchus. She was intubated with a double-lumen endotracheal tube guided by bronchoscopy. A median sternotomy was undertaken, and a laceration of the right atrium was oversewn without the use of cardiopulmonary bypass. After that, right-sided thoracotomy was performed. The tear in the membranous portion of the right main bronchus was repaired with interrupted sutures, and the suture lines were wrapped with a pedicled flap of intercostal muscle.

Endovascular management for ruptured Stanford B acute aortic dissection.

Surgery for a complicated Stanford B acute aortic dissection, such as rupture or malperfusion, is still a challenge. We undertook endovascular therapy for ruptured Stanford B acute aortic dissection in two patients. A homemade stent graft was deployed in an 84-year-old woman with a massive mediastinal hematoma; and an aortic extender of Excluder was used for a 76-year-old man with left hemothorax. Both patients recovered without major complications. Careful follow-up is mandatory. Endovascular therapy for a ruptured Stanford B acute aortic dissection seems feasible and efficient.

Evaluation of the appropriate root pressure for maintaining heartbeat during an aortic cross-clamp for primary repair of the aortic arch in premature infants with associated cardiac anomalies.

We developed a new cardiopulmonary bypass (CPB) method to minimize myocardial damage during aortic arch reconstruction. In this method, coronary flow and heartbeat were stabilized by maintaining the aortic root pressure with an adjusted preload of the ventricle during aortic cross-clamping. This study was performed to determine the appropriate root pressure to maintain the heartbeat without causing deterioration of ventricular function. Study 1. Under partial CPB, the ascending aorta was cross-clamped in 6 pigs (group 1). Experimental data at various systolic aortic root pressures was analysed to determine the appropriate root pressure. Study 2. In group 2 (control, n＝6), the aorta was not clamped, while in group 3 (n＝6), the aorta was cross-clamped for 60 min and the systolic aortic root pressure was maintained at the pressure determined in study 1. Study 1. The diastolic coronary flow was stabilized at values comparable to that before initiation of CPB (6.6±1.4 ml/beat) when the systolic aortic root pressure was above 80 mmHg. Intracardiac pressure and the myocardial oxygen consumption (MvO2) seemed to be acceptable when the systolic aortic root pressure was below 100 mmHg. Therefore, 90 mmHg was selected for study 2. Study 2. Perioperative cardiac function did not differ between the groups. We concluded that 90 mmHg was the systolic aortic root pressure appropriate for this method.

Circulatory load during hypoxia impairs post-transplant myocardial functional recovery in donation after cardiac death.

BACKGROUND: Circulatory load during hypoxia is unavoidable in donation after cardiac death (DCD) hearts, but it causes severe myocardial damage. The impact of circulatory load on donor heart function has not been investigated. The purpose of this study was to evaluate its effect on post-transplant functional recovery of DCD hearts. METHODS: Twelve donor pigs (20 kg) were used. Cardiac arrest was induced by asphyxiation (turning off the ventilator) in the load group (n = 6) and by exsanguination (dividing the vena cava) in the unload group (n = 6). Left ventricle end-diastolic volume (LDEDV) and end-systolic pressure (LVESP) were monitored until cardiac arrest. Orthotopic transplantation was performed after 30-minute warm ischemia following cardiac arrest. After weaning from cardiopulmonary bypass, left ventricular end-diastolic pressure-volume ratio (LV Emax) and creatine kinase (CK-MB) were measured while on 0.1 microg/kg/min epinephrine. RESULTS: During the agonal period, the maximum LVEDV and LVESP in the load group were 132 +/- 1% of baseline at 10 minutes and 148 +/- 16% of baseline at 4 minutes, respectively. Recovery rates of post-transplant cardiac function in the load group were worse than in the unload group (LV Emax: 64 +/- 8 vs 84 +/- 5%, p < 0.05). Levels of post-transplant CK-MB in the load group were higher than in the unload group (639 +/- 119 vs 308 +/- 70 IU/liter, p < 0.05). CONCLUSIONS: Cardiac arrest with circulatory load by asphyxiation caused more myocardial damage than unloaded arrest. This difference between the modes of death should be considered when evaluating the DCD hearts for clinical application.

Forty-year survival with Smeloff-Cutter and Starr-Edwards prostheses.

This case study describes a 40-year follow-up of a man who had a double valve replacement with Smeloff-Cutter aortic (Cutter Laboratories, Berkeley, CA) and Starr-Edwards mitral prostheses (Edwards Laboratories, Santa Ana, CA) when he was 34 years old. Double valve replacement was performed for aortic and mitral valve stenosis and insufficiency. To date, no surgical treatment has been required except a pacemaker implantation. The patient presented with a New York Heart Association functional class of I to II. Echocardiography revealed intact prostheses.

Efficacy of MCI-186, a free-radical scavenger and antioxidant, for resuscitation of nonbeating donor hearts.

OBJECTIVE: Oxygen-derived free radicals are responsible in part for reperfusion injury in globally ischemic myocardium. In this study, the efficacy for resuscitation of nonbeating donor hearts of MCI-186, a free-radical scavenger and antioxidant, was investigated in a pig transplantation model. METHODS: Cardiac arrest was induced by asphyxiation. After 30 minutes of global ischemia, the hearts were excised and immediately reperfused from the aortic root with normoxemic blood cardioplegia (PO2 100 mm Hg) for 20 minutes, followed by perfusion with hyperoxemic blood (PO2 300 mm Hg). MCI-186 (3 mg/kg) was administered into the aortic root for the first 30 minutes of reperfusion in the treated group (n = 6), and untreated hearts were used as a control group (n = 6). Transplantation was performed with the heart beating. RESULTS: Posttransplantation recovery of cardiac output, end-systolic pressure-volume ratio, and first derivative of pressure of the left ventricle in the treated group were significantly better than those in the control group. The coronary sinus-aortic root difference in malondialdehyde levels remained low throughout reperfusion in the treated group but abruptly increased after initiation of oxygenated blood perfusion in the control group. The MCI-186-treated hearts showed low degree of edema and well-preserved ultrastructure with normal-appearing organelles, whereas the untreated hearts had marked swelling of mitochondria and scant glycogen granules. CONCLUSION: MCI-186 exerts a cardioprotective action at least partly by inhibition of lipid peroxidation. Antioxidant therapy at the initial reperfusion is essential to successful resuscitation of nonbeating hearts by continuous myocardial perfusion.