ECPELLA as the bridge to surgery in patients with cardiogenic shock due to post-infarct papillary muscle rupture: management of mechanical circulatory support during operation.

Papillary muscle rupture is a fatal complication with a high operative mortality. Most patients experience cardiogenic shock and hypoxia due to pulmonary edema caused by severe mitral regurgitation. Although preoperative stabilization using a mechanical assist device potentially improves surgical outcomes, an appropriate strategy has not yet been established. ECPELLA, combining venoarterial extracorporeal membrane oxygenation and Impella, has the potential to stabilize preoperative status and improve outcome in patients with refractory cardiogenic shock due to papillary muscle rupture. Herein, we present 3 cases involving the efficacy of ECPELLA and our tips of surgical and ECPELLA management in patients with papillary muscle rupture.

[Result of Surgical Treatment for Active Infective Endocarditis at the Aortic Position].

Herein, we retrospectively review our experience with surgical treatment of active aortic valve infective endocarditis, particularly aortic annular abscess, and central nervous system complications. From 2012 to 2021, 46 consecutive patients underwent surgery during the active phase of infective endocarditis, 25 of which were performed at the aortic position. One patient died early (<30 days) due to low output syndrome and another 2 patients who were never discharged died because of general prostration. The actuarial survival rate was 84% at 1 year, and 80% at 3 and 5 years. Eleven patients [6 native valve endocarditis (NVE), 5 prosthetic valve endocarditis (PVE)] had valve annular abscess requiring removal of the infected tissue and reconstruction of a definite anatomic continuity, and aortic valve replacement was subsequently performed in 7 patients and aortic root replacement in 4 patients. Direct closure was performed in 4 patients with partial annulus defects, and reconstruction with an autologous nor bovine pericardium patch was performed in 6 patients with large annulus defects. Preoperative imaging revealed acute cerebral embolism in 10 patients. In eight cases, surgery was performed within 7 days after diagnosis of cerebral embolism. No patient had abnormal postoperative neurological findings. There were no reoperations and no recurrence of infective endocarditis.

Hemodynamic and clinical performance of the 25-mm Medtronic Mosaic porcine bioprosthesis in the mitral position.

The 25-mm Medtronic Mosaic porcine bioprosthesis (MB25) is the smallest bioprosthesis that has been approved for use in the mitral position in Japan. Various studies have reported satisfactory hemodynamic performance and good long-term outcomes of the Medtronic Mosaic porcine bioprosthesis. However, the hemodynamic and clinical performances of the MB25 in the mitral position remain unknown. This study aimed to evaluate the hemodynamic and clinical performance of the MB25 in mitral valve replacement (MVR). Twenty patients who underwent MVR using the MB25 between February 2013 and April 2018 were studied. We evaluated the hemodynamic performance of the MB25, cardiac chamber size, cardiac function, and systolic pulmonary artery pressure (PAP) using echocardiography during follow-up. The study outcomes were major adverse cardiac events (MACEs) and all-cause mortality. Sixteen patients (80%) had a patient prosthesis mismatch defined as an index effective orifice area of ≤ 1.2 cm2/m2. The left atrial dimension was significantly reduced after surgery (p = 0.0282). The mean pressure gradients (MPG) in the mitral position were 5.5 ± 1.7 mmHg at discharge and 4.2 ± 1.3 mmHg at 1 year postoperatively. The MPG in the mitral position significantly decreased during the follow-up period (p = 0.0489). Systolic PAP significantly improved postoperatively. The 1-, 3-, and 5-year survival rates were 87, 79, and 70%, respectively. No cardiac death occurred. There were no MACEs or reports of structural valve degeneration during the follow-up period. The hemodynamic and clinical performances of the MB25 in the mitral position were satisfactory as the smallest biological mitral valve. The MB25 is a reasonable option for MVR to reduce the surgical difficulty in high-risk patients with an advanced age, a small body size or MAC and when recurrent MVR or complex procedures are performed.

Stent graft placement guided by intravascular ultrasound for subclavian artery dissecting aneurysm.

Subclavian artery dissecting aneurysm is relatively rare and can be caused by traumatic, nontraumatic, and iatrogenic etiologies. Surgical management of subclavian artery dissecting aneurysm has been sparsely reported. Recently, due advances in endovascular techniques making them less invasive, these approaches have become more standard as treatments. Subclavian artery dissecting aneurysm management usually depends on whether there is ischemia of the tissues supplied by the subclavian artery. Furthermore, treatment strategies depend on which section of the artery is involved. In particular, treatment is difficult if the dissecting aneurysm has branching vessels. In this case report, we show that endovascular repair using a covered stent graft is a promising approach to repair a subclavian artery dissecting aneurysm. In this case, the stent graft was highly effective, and follow-up examinations showed good patency of the subclavian artery. Additional use of IVUS (Volcano Inc.; Rancho Cordova, CA, USA) is helpful to obtain the precise location of the true lumen of a dissecting aneurysm.

Evaluation of hemodynamics after mitral valve replacement with the St Jude Medical Epic bioprosthesis: a Japanese single-center experience.

To assess the early hemodynamics after mitral valve replacement (MVR) using the St Jude Medical (SJM) Epic bioprosthesis. MVR was performed using the SJM Epic bioprosthesis in 35 patients from June 2018 to April 2020; three patients were excluded because the postoperative transthoracic echocardiography (TTE) data were unavailable. Data from postoperative TTE at 1 week and 3 months after the procedure were reviewed. The mean mitral pressure gradient (mMPG) was calculated using a continuous wave Doppler method. Left ventricular outflow tract (LVOT) was calculated using a pulse wave Doppler method. The effective orifice area (EOA) was measured from pressure half time. There were 12 men (37.5%) and 20 women (62.5%) with a mean age of 75.9 years (61-88 years). The mean body surface area was 1.51 ± 0.22 cm2. The 25 mm and 27 mm valves were used in more than 50% of cases. The mMPG was 4.9 ± 1.7 mmHg and 5.4 ± 1.6 mmHg at 1 week and 3 months after surgery, respectively. EOA was 2.18 ± 0.50 cm2 and 2.31 ± 0.59 cm2 at 1 week and 3 months after surgery, respectively. The peak velocity of the LVOT (n = 22) was 103.3 ± 21.3 cm/s and 106.8 ± 27.4 cm/s at 1 week and 3 months after surgery, respectively. No findings suggested paravalvular regurgitation and LVOT obstruction. Using the SJM Epic bioprosthesis in MVR resulted in satisfactory hemodynamics in the early postoperative period, even with small valve sizes. Further accumulation of cases and evidence, including mid- to long-term results, is required in the future.

Clinical outcome of cardiac surgery in patients with remitted or active hepatocellular carcinoma.

PURPOSE: Hepatocellular carcinoma (HCC) is one of the most common primary cancers worldwide. HCC has unique characteristics such as co-existing chronic liver damage and a high recurrence rate. A negative impact on the surgical outcome due to these backgrounds could be expected. We aimed to evaluate the clinical outcomes of cardiac surgery in these patients. METHODS: Between January 2000 and December 2019, 16 patients with remitted cancer and 5 patients with active HCC who underwent open heart surgery were studied. The clinical data were retrospectively evaluated from hospital records. Follow-up information was collected via telephone interviews. RESULTS: The major cause of HCC was viral hepatitis. Eighteen patients (86%) were classified as having Child-Pugh class A cirrhosis. The mean model of end-stage liver disease (MELD) score was 7.2 ± 5.2. There was no 30-day mortality. During follow-up, 11 patients died due to HCC. The 1-, 3-, and 5-year survival rates were 80.0, 42.5, and 22.3%, respectively. A univariate analysis identified a higher preoperative MELD score and lower serum cholinesterase levels as prognostic factors for long-term survival. CONCLUSION: We could safely perform cardiac surgery in selected patients with remitted and active HCC. The postoperative life expectancy of these patients was limited but acceptable.

Multimodal imaging of cardiac-calcified amorphous tumor.

Cardiac-calcified amorphous tumor (CAT) is a rare non-neoplastic tumor and its origin and pathogenesis are still unclear. In addition, it is difficult to clinically diagnose as cardiac CAT without pathological findings. We present a case of a 78-year-male diagnosed with cardiac CAT after surgical resection. We could evaluate tumor aspects by multimodal imaging including echocardiography, contrast-enhanced computed tomography (CT), magnetic resonance image, and 18F-fluorodeoxyglucose-positron emission tomography/CT before surgery.

Aortic valve replacement with or without concomitant coronary artery bypass grafting in very elderly patients aged 85 years and older.

Degenerative aortic stenosis is the most common structural heart valve disease affecting the aging population. Catheter-based heart valve interventions are less invasive and very useful for very elderly patients. However, we often consider open heart surgery for these patients because of anatomical reasons and co-existing cardiac diseases, i.e., severe coronary artery disease. We aimed to analyze the outcomes of very elderly patients aged ≥ 85 years undergoing aortic valve replacement (AVR) with or without coronary artery bypass grafting (CABG). Twenty-nine very elderly patients aged ≥ 85 years who underwent AVR with CABG (n = 11, Group AC) or isolated AVR (n = 18, Group A) were examined. The overall mean age of the patients was 87.2 ± 2.6 (range 85-94) years. The estimated operative mortality rate, calculated using the Japan score, EuroSCORE II, and STS risk score, was 5.72%-10.88% in Group AC and 5.63%-8.30% in Group A. Aortic cross-clamp time (126.5 ± 29.0 vs. 96.9 ± 29.2 min, p = 0.016) was significantly longer in Group AC than in Group A. Although the major morbidity rate was higher in Group AC than in Group A (36% vs. 6%, p = 0.0336), the length of intensive care unit stay and hospital stay was comparable between both groups. There was no 30-day and hospital mortality in both groups. Eleven patients died during follow-up (senility, 5; cerebrovascular events, 2; renal failure, 1; unknown, 3). There were no significant differences in survival rates during follow-up (log-rank p value = 0.1051). The 1-, 2-, 3-, 4- and 5-year survival rates were 91%, 80%, 69%, 69% and 69%, respectively, in Group AC and 94%, 94%, 94%, 94% and 88%, respectively, in Group A. In conclusion, AVR with or without CABG could be safely performed in carefully selected very elderly patients with acceptable early- and long-term results. AVR with CABG in very elderly patients aged ≥ 85 offers similar results to isolated AVR in terms of 30-day mortality, hospital mortality, and long-term survival.

Left ventricular apical pseudoaneurysm with aortic prosthetic valve endocarditis.

We report an 83-year-old man with a mycotic left ventricular apical pseudoaneurysm and aortic prosthetic valve endocarditis caused by Enterococcus spp. Mycotic left ventricular pseudoaneurysm is very rare and is associated with a high risk of rupture. Here, we report the clinical presentation, diagnosis, prognosis, and treatment of a case of mycotic left ventricular pseudoaneurysm to raise awareness regarding this unusual and potentially fatal complication.

Activation of the AKT Pathway in the Ascending Aorta With Bicuspid Aortic Valve.

BACKGROUND: Dilatation of the ascending aorta affects those patients with bicuspid aortic valve (BAV), even after valvular surgery, possibly due to tissue fragility. The goal of the study was the molecular characterization of aorta with BAV compared to that with normal tricuspid aortic valve (TAV). Methods and Results: The subjects were patients who underwent surgery for aortic valve stenosis in 2013 and 2014. Nine patients with BAV and 13 with TAV were examined. There was no difference in the clinical characteristics or grade of aortic valve stenosis, but the diameters of the ascending aorta were significantly higher in the BAV group. The ascending aortic specimens were subjected to transcriptome analyses, which revealed the changes in receptor tyrosine kinase (RTK) pathway-related genes between TAV and BAV samples. Immunohistochemical study revealed higher staining of phosphorylated AKT (pAKT) in the media of the ascending aorta in the BAV group, regardless of the size of ascending aorta, whereas total AKT did not show such a difference. Immunofluorescence staining revealed the AKT activation was mainly in the medial vascular smooth muscle cells. CONCLUSIONS: The results showed that the RTK-AKT pathway in the medial layer of the ascending aorta is activated in aortae with BAV. Activation of this pathway may be associated with fragility and dilatation of the ascending aorta with BAV.

Aortic Valve Replacement in Dextrocardia and Anomalous Origin of the Coronary Artery.

Situs inversus totalis and anomalous origin of the left coronary artery are rare conditions. An 87-year-old woman with both conditions presented to the authors' hospital with symptomatic aortic stenosis. She underwent aortic valve replacement (AVR) and coronary artery bypass grafting (CABG; saphenous vein graft to the left main trunk). The operator mainly stood on the left side of the patient and performed surgery without difficulty. Both, AVR and CABG were successfully performed despite these two rare conditions. Open-heart surgery in a very elderly patient with both of these rare conditions has not previously been reported.

Evaluation of advancing the standard valve dysfunction by multidetector-row CT.

We evaluated the diagnostic usefulness of electrocardiographically gated multidetector-row computed tomography (MDCT) for prosthetic valve dysfunction (PVD) of an ATS valve. Twenty-four patients underwent MDCT following echocardiography and cineradiography. Echocardiography and cineradiography showed normal valve function in 17 patients and PVD in 7. PVD included aortic prosthetic valve obstruction in 4 patients, an aortic annular aneurysm with paraprosthetic regurgitation in one, and a blocked leaflet in the mitral position in 2. Among the 7 patients, 5 received reoperation after MDCT. MDCT revealed a subprosthetic mass in all 5 patients with PVD and in 4 patients with normal valve function in the aortic position. In addition to a subprosthetic mass, an annular aneurysm was found in one. Valvular masses were detected in 2 patients with mitral PVD. At reoperation, subprosthetic pannus in the aortic position was detected in 2 patients, subprosthetic pannus and annular aneurysm with paraprosthetic leaks in one, and mitral valve thrombosis in 2. These findings confirmed at reoperation matched to the findings observed on MDCT. The mean CT attenuation of the subprosthetic mass in 6 patients was 152 ± 12 HU and that of the subprosthetic pannus in 3 patients was 163 ± 17 HU. CT attenuation of the thrombus in the mitral valve in the 2 patients was 60 and 99 HU. Our study demonstrates that MDCT is a valuable and reliable diagnostic technique for PVD in an ATS valve and that MDCT may identify an abnormality causing PVD.

Preoperative management using Impella support for acute aortic dissection with left coronary malperfusion: a case report.

BACKGROUND: Acute aortic dissection (AAD) with impaired perfusion of the left coronary artery has a poor prognosis, even after urgent radical aortic surgery, due to extensive myocardial damage. Although Impella, a microaxial-flow catheter pump, is useful in managing acute myocardial infarction, it is generally contraindicated in patients with AAD because it is an intra-aortic device and the aortic structure is compromised in these cases. Here, we introduce a novel intervention that allowed a planned aortic repair after managing circulation using Impella and venoarterial extracorporeal membrane oxygenation in a case of AAD with left main trunk malperfusion. CASE PRESENTATION: A 40-year-old man presented with cardiogenic shock. Percutaneous coronary intervention was performed to address left main trunk obstruction using an intra-aortic balloon pump; however, circulatory instability persisted. The patient was transferred to our hospital after venoarterial extracorporeal membrane oxygenation. Impella CP™ was used to improve his circulatory status. However, a subsequent CT scan confirmed an AAD diagnosis. After 5 days of stable circulatory support, the patient underwent aortic root replacement and coronary artery bypass grafting. CONCLUSIONS: In patients with AAD and coronary malperfusion, adjunctive circulatory management with Impella may be a valuable therapeutic option.

Early thrombus formation including hypo-attenuated leaflet thrombosis after surgical bioprosthetic aortic valve replacement.

OBJECTIVE: To assess the occurrence, predictors, and outcomes of hypo-attenuated leaflet thickening (HALT) and thrombus outside the prosthetic valve following surgical aortic valve replacement. METHODS: A total of 118 patients underwent surgical aortic valve replacement with bioprosthetic valves between July 2020 and June 2022. Sixty-two (52.5%) patients, which is a fairly high number of patients, underwent cardiac computed tomography and transthoracic echocardiography one week after surgery. Patients were divided into two groups, those with HALT (n = 14) and those without HALT (n = 48). RESULTS: Of the 62 patients who underwent cardiac computed tomography, HALT was observed in 14 (22.5%) patients during the very early postoperative phase. Reduced leaflet motion was observed in two of the 14 patients. The low-attenuation areas were located outside the prosthetic valve in 10 cases (71.4%) in the HALT group and in 14 cases (29.2%) in the non-HALT group. More than 50% of patients (57.1%) with HALT and 79.2% without HALT were administered warfarin. Neither in-hospital deaths nor postoperative thromboembolic events were observed during hospitalization. No patient had a mean pressure gradient > 20 mmHg in either group. CONCLUSION: HALT was observed in one-fifth of the cases after surgical aortic valve replacement during the very early postoperative phase in an institution wherein administration of continuous heparin infusion after surgery is a standard practice. HALT did not affect the early prognosis or incidence of cerebral infarction.

Mitral valve repair using a semi-rigid posterior band: a 10-year Japanese single-center experience of 244 patients.

Background: Mitral valve repair (MVr) is an established procedure for patients who require surgery for primary mitral regurgitation (PMR). The Colvin-Galloway Future Band (CGFB) is a semi-rigid posterior band expected to improve the clinical outcomes of MVr. However, information on the hemodynamic and functional performance and long-term outcomes of CGFB is limited. We evaluated the quality, durability, and clinical performance after MVr using CGFB for PMR as the cohort study. Methods: A total of 244 patients who underwent MVr with CGFB were enrolled. Clinical and echocardiographic assessments were performed (mean follow-up period, 4.0±2.4 years). Results: Posterior mitral leaflet resection was the most common MVr procedure. CGFBs measuring 28 mm (35.2%) and 30 mm (36.5%) were used. The incidence of systolic anterior motion (SAM) was 1.6%. A total of 93.4% of the patients had no or trace MR at discharge. Over 90% of patients had no or mild MR at the last follow-up. The mean pressure gradient and mitral valve orifice area one year after MVr ranged between 2.6 and 3.6 mmHg and 2.3 and 3.4 cm2, respectively. At follow-up, 85.4% of the patients were New York Heart Association class I. Three patients underwent repeat mitral valve surgery. Conclusions: The CGFB demonstrates satisfactory quality and durability in MVr for PMR. Other advantages include a low occurrence of SAM and acceptable hemodynamic outcomes, particularly in patients requiring a smaller annuloplasty device.

Review of Implantable Left Ventricular Assist Devices.

Mechanical circulatory support has been an indispensable treatment for severe heart failure. While the development of a total artificial heart has failed, left ventricular assist devices (LVAD) have evolved from extracorporeal to implantable types. The first generation implantable LVAD (pulsatile device) was used as a bridge to transplantation, and demonstrated improvement in survival rate and activity of daily living. The evolution from the first-generation (pulsatile device) to the second-generation (continuous flow device: axial flow pump and centrifugal pump) has resulted in many clinical benefits by reducing mechanical failures and minimizing device size. Furthermore, third-generation devices, which use a moving impeller suspended by magnetic and/or hydrodynamic forces, have improved overall device reliability and durability. Unfortunately, there are still many device-related complications, and further device development and improvement of patient management methods are required. However, we expect to see further development of implantable VADs, including for destination therapy, in future.

Intimo-Intimal Intussusception due to Stanford Type A Acute Aortic Dissection Presenting as Cerebral Infarction.

Complete circumferential dissection is a rare clinical presentation of aortic dissection, wherein the dissected flap has the potential to cause intimo-intimal intussusception, which can lead to several catastrophic complications. We report a case of Stanford type A acute aortic dissection with intimo-intimal intussusception causing unstable cerebral ischemic symptoms. An 82-year-old man was taken to another hospital with severe intermittent dizziness. Head magnetic resonance imaging revealed multiple right-hemispheric cerebral infarctions. Computed tomography also showed a "missing flap," indicating that the intimal flap was observed in the aortic root and arch but not in the ascending aorta. The patient was referred to our hospital for emergent surgery. Intraoperatively, the intimal tear was found to be circumferential, and the transected intima was folded and superimposed from the origin of the brachiocephalic artery to the aortic arch. Ascending aortic replacement and aortic valve replacement were performed; the postoperative course was good.

Neurosurgical Treatment of Patients with Posterior Fossa Acute Subdural Hematoma Right after Cardiac Surgery.

As posterior fossa acute subdural hematoma (ASDH) right after cardiac surgery is extremely rare, the clinical course and optimal treatment strategy remain undetermined. We performed a retrospective analysis of patients with posterior fossa ASDH right after cardiac surgery requiring neurosurgical treatment at our institution over a 7-year period and, in this study, discussed the neurosurgical strategy and clinical course. Collected data included clinical history, laboratory results, time course, symptoms, neurosurgical treatment, outcome at discharge, and imaging studies. All six patients were women who had no history of head trauma and had received antithrombotic therapy during the perioperative period of cardiac surgery. All patients showed lower platelets count and were diagnosed with ASDH within 3 days (longest time 64 h) right after cardiac surgery. After discontinuation of anticoagulation therapy and administration of reversal agents, they underwent emergency hematoma evacuation craniotomy (n = 5) or burr hole drainage surgery (n = 1), which were performed in the prone (n = 4) or lateral (n = 2) positions. Four of these patients showed favorable outcomes, and two showed poor outcomes. One of the poor-outcome patients received three antithrombotic therapies, and another developed rapidly progressive ASDH. Posterior fossa ASDH associated with antithrombotic therapy right after cardiac surgery is frequently found in women, and emergent neurosurgical treatment with anticoagulation discontinuation and reversal agent administration can be performed safely. Burr hole drainage surgery might be acceptable in nonsevere cases. By contrast, we must pay attention to cases receiving both anticoagulant and antiplatelet drugs and rapid progression cases.