Preoperative Computed Tomography of the Right Gastroepiploic Artery for Coronary Artery Bypass Grafting.

BACKGROUND: Grafting the right gastroepiploic artery (GEA) to the right coronary artery (RCA) is effective, but preoperative evaluation of arterial conduit availability has not been established. By comparing the midterm graft results, we aimed to assess the efficacy of preoperative evaluation of the GEA using computed tomography (CT).Methods and Results: We retrospectively examined patients who underwent isolated coronary artery bypass grafting surgery between April 2010 and December 2020, and those whose GEA was grafted to the RCA were selected: 55 patients were included in the study analysis. Postoperative evaluations were performed during the early phase, 1 year postoperatively, and at follow-up evaluations. The outer diameter of the proximal GEA was compared with the midterm graft patency grade on CT and patients were classified as Functional (Grade A) or Dysfunctional (Grades O or B). The proximal GEA outer diameters were significantly different between the Functional and Dysfunctional groups (P<0.001). Furthermore, multivariate Cox regression analysis revealed that this diameter was an independent predictor of graft functionality (P<0.001). Patients with outer proximal diameters larger than the cutoff value had superior graft results at 3 years postoperatively. The rate of freedom from a dysfunctional graft at 3 years postoperatively was 95.5% and 45.5% for the Larger and Smaller diameter subgroups, respectively (P<0.001). CONCLUSIONS: Preoperative evaluation of the outer diameter of the proximal GEA, excluding calcified GEA, using CT is a minimally invasive and useful method, and may improve midterm results of in-situ GEA grafting, even in severe stenotic lesions.

Multiple mycotic aneurysms with infective endocarditis: A case report.

Mycotic aneurysms are sometimes seen in patients with infective endocarditis. We report a case of infective endocarditis with multiple mycotic aneurysms. Although antibiotics were effective, mycotic aneurysms appeared in the cerebral, hepatic, and gastroepiploic arteries. A 55-year-old man presented with mitral valve endocarditis due to Streptococcus oralis. Surgical treatment was deferred because of cerebral hemorrhage. After antibiotic initiation, his fever and C-reactive protein levels declined, and blood culture was negative. However, he experienced repeated cerebral hemorrhage and the number of cerebral mycotic aneurysms increased. Additionally, his spleen ruptured and the number of mycotic aneurysms in the hepatic and gastroepiploic arteries increased. After embolization for mycotic aneurysm and mitral valve replacement, no mycotic aneurysms appeared. Regardless of whether laboratory data improve or not, multiple mycotic aneurysms sometimes appear, and cardiac surgery for infection control should be considered in the early phase.

A prospective randomized controlled study to assess the effectiveness of super FIXSORB WAVE® for sternal stabilization after sternotomy.

BACKGROUND: We developed a new sternal fixation device, Super FIXSORB WAVE®, a corrugated plate made of u-HA/PLLA, to improve sternal stability after sternotomy. This present study aimed to evaluate the new device clinically. METHODS: This prospective, single-blinded, multicenter trial randomized 69 patients to either wire cerclage only (group C, n = 30) or wire cerclage plus Super FIXSORB WAVE® (group W, n = 39). The primary endpoint was a degree of sternal displacement at six months. Displacement of the sternal halves in the anteroposterior and lateral directions was measured using computed tomography horizontal section images at the third costal and fourth intercostal levels. The secondary endpoints were sternal pain and quality-of-life over 6 months. RESULTS: Group W showed significantly reduced sternal anteroposterior displacement at both the third costal (0 [0-1.9] mm vs. 1.1 [0-2.1] mm; P = 0.014) and fourth intercostal (0 [0-1.0] mm) vs. 1.0 [0-1.8] mm; P = 0.015) levels than group C. In group W, lateral displacement was suppressed without a significant increase from 2 weeks to 6 months, while it increased in group C. There was no significant difference in postoperative sternal pain and quality-of-life between the two groups. No adverse events, such as infection, inflammation, or foreign body reaction, were observed with this device. CONCLUSIONS: Using Super FIXSORB WAVE®, sternal displacement was significantly suppressed in both the anteroposterior and lateral directions. The use of this device results in safe and easy sternal reinforcement without any adverse events, and sternal healing can be accelerated. CLINICAL TRIAL REGISTRY NUMBER: This study was registered in the Japan Registry of Clinical Trials (February 21, 2019; jRCTs032180146).

Therapeutic-Dose Warfarin (International Normalized Ratio >1.6) Plus Aspirin Improved Long-Term Patency of Saphenous Vein Graft without Bleeding Complication.

PURPOSE: Saphenous vein graft (SVG) is the most commonly used conduits in coronary artery bypass grafting (CABG), but the disadvantage of SVG is its tendency for progressive failure. We hypothesized that therapeutic-dose warfarin (international normalized ratio [INR] >1.6) plus aspirin improve SVG patency. This study aimed to evaluate the factors contributing to SVG patency. METHODS: Since 2010-2020, 199 patients who underwent isolated CABG using SVG were divided into two groups according to their INR values in the first year: group T (INR >1.6) and group L (INR <1.6). RESULTS: Group T had 162 SVGs (105 patients) and group L had 151 SVGs (94 patients). The 1-, 4-, and 7-year SVG patency rates were higher in group T than in group L (99%, 96%, and 92% vs. 93%, 86%, and 79%, respectively; p = 0.00378). The 1-, 4-, and 7-year freedom from repeat-revascularization was higher in group T than in group L (100%, 100%, and 99% vs. 98%, 95%, and 87%, respectively; p = 0.0264). Multivariate analysis showed that therapeutic-dose warfarin (p = 0.00204) and target vessel diameter (p <0.0001) were independent risk factors of SVG occlusion. CONCLUSION: Therapeutic-dose warfarin (INR >1.6) plus aspirin after CABG improved the long-term patency of SVG and decreased repeat-revascularization rate.

Left atrial schwannoma in schwannomatosis: a case report.

BACKGROUND: Primary cardiac schwannoma in the left atrium and schwannomatosis are rare diseases. CASE PRESENTATION: We report the case of a 46-year-old asymptomatic man who had tumor resection for parapharyngeal schwannoma at another institute 1 year ago. He was presented to our hospital for further evaluation of an abnormal cardiac shadow that was found incidentally. Computed tomography and transesophageal echocardiography revealed a cardiac tumor originating from the posterior wall of the left atrium, an atrial septal defect, and two other mediastinal tumors. The cardiac mass was completely excised with normal margins of the surrounding atrial wall. The post-resection defect and atrial septal defect were repaired using bovine pericardium. Pathological findings were compatible with benign schwannoma, and a diagnosis of schwannomatosis was made based on his medical history. CONCLUSION: Primary cardiac schwannoma is an exceedingly rare tumor, and the incidence in schwannomatosis has not been reported in the literature.

Cardiac Magnetic Resonance Imaging of Very Late Intrapericardial Hematoma 8 Years after Coronary Artery Bypass Grafting.

A 55-year-old man presented with dyspnea, edema, and appetite loss. He had undergone coronary artery bypass grafting 8 years previously. He had jugular venous distention and Kussmaul's sign. Contrast-enhanced cardiac magnetic resonance imaging (CMRI) demonstrated an intrapericardial mass compressing the right ventricular (RV) cavity. T1- and T2-weighted black-blood images showed a mass with heterogeneous high signal intensity and a thick and dark rim. The mass was considered to be a chronic hematoma. After pericardiotomy with surgical removal of the hematoma, CMRI showed the marked improvement of the RV function. Late intrapericardial hematoma is rare and CMRI is useful for making a differential diagnosis.

Analysis of pulmonary nodules in patients with high-grade soft tissue sarcomas.

Nowadays, small pulmonary nodules are easily detectable in patients with soft tissue sarcomas (STSs) because of highly improved computed tomography (CT) technologies. The purpose of this study was to determine the frequency and significance of the pulmonary nodules detected by CT in high-grade STS patients. 124 patients with high-grade STS were retrospectively reviewed. There were 72 males (57%) and 52 females (43%). Patients' average age was 61 years (median (quartiles) 66 years (48-75), range 8-94 years). Pulmonary nodules were detected in 49 (39.5%) of 124 patients by CT scanning at first presentation. Of 49 patients with nodules at first presentation, 34 (69.4%) had benign lesions, and 13 (26.5%) had metastatic nodules. One patient (2%) had primary lung cancer and the remaining one with one nodule could not be definitively diagnosed due to a short follow-up time. 30 patients (24.1%) of 124 patients developed pulmonary nodules during their clinical progression. Seven (23.3%) had benign lesions, whereas 21 (70%) had metastatic lesions. Primary lung cancer was detected in two patients (6.7%). The size and timing of detection of a pulmonary nodule significantly affected the final clinical diagnosisby multivariate analysis. We conclude that pulmonary nodules can be detected highly frequently in patients with high-grade STSs because of improved CT technologies. Careful follow-up is needed if nodules are detected after initial treatment or during the clinical course of the disease.

[Endoscopic radial artery harvesting].

The radial artery is a popular arterial conduit for coronary artery bypass grafting (CABG). However, the traditional open harvesting technique requires a long incision, and is therefore associated with some wound complications and cosmetic problems. In order to solve them, we introduced the endoscopic radial artery harvesting (ERAH) at our institution in February 2004 utilizing the VasoView system. The ERAH technique was performed as safely as the traditional open technique and the harvested radial arteries were acceptable as CABG conduits. In particular, patients are satisfied with the excellent cosmetic results of the procedure. Herein, we focus surgical technique, complications of ERAH and ways to prevent them by describing our initial experience and short-term clinical follow-up of the ERAH patients.

Endoscopic radial artery harvesting: our initial experience and results of the first 25 patients.

BACKGROUND: The radial artery has become an increasingly popular arterial conduit for coronary artery bypass grafting (CABG). However, the traditional open harvesting technique requires a long incision, and is therefore associated with some wound complications and cosmetic problems. Here, we describe our experience of endoscopic radial artery harvesting (ERAH) through a small incision in 25 patients who underwent CABG. MATERIALS AND METHODS: Between February 2, 2004 and January 7, 2005, a total of 25 patients (4 females; mean age: 64+/-10 years) underwent ERAH using the VasoView System (Guidant Corporation, Indianapolis, IN) at our institution. All patients underwent a preoperative Allen test to assess the competence of the palmer arch. Twenty-four radial arteries were harvested from the nondominant arm and one from the dominant arm. The mean clinical follow-up was 8+/-2.9 months. RESULTS: All radial arteries were harvested through a 2-cm incision at the wrist, successfully removed with ERAH and successfully used as CABG conduits. The mean harvest time was 59+/-11 min, and the mean harvested length was 17+/-1.7 cm. No adjunctive procedures were required during vessel harvesting, and no conversions to the open technique were necessary. Harvesting complications included 2 cases of postoperative hematoma and 7 cases of superficial radial nerve paresthesia. Five postoperative angiographies were performed and all radial arteries were patent. Overall, 24/25 (96%) patients were satisfied with the procedure. CONCLUSION: The ERAH technique was performed as safely as the traditional open technique and the harvested radial arteries were acceptable as CABG conduits. In particular, patient satisfaction with the procedure regarding the cosmetic results was excellent.

Retrograde ascending aortic dissection after thoracic endovascular aortic repair.

Thoracic endovascular aortic repair is a valuable alternative treatment option for patients with thoracic aortic aneurysms and type B dissections. However, thoracic endovascular aortic repair is associated with the risk of previously unanticipated severe complications including retrograde ascending aortic dissection. We report the case of an 86-year-old man who developed retrograde ascending aortic dissection as a delayed complication of thoracic endovascular aortic repair. Open surgical repair resulted in a successful outcome.

Oxygen pressure measurement during grip exercise reveals exercise intolerance after radial harvest.

BACKGROUND: Exercise intolerance of the hand after harvest of the radial artery is not well understood, although mild reductions of blood flow to the hand are reported. To ascertain its prevalence, patient symptoms implying potential exercise intolerance were evaluated by measuring transcutaneous oxygen pressure of the hand during grip exercise. For ascertaining predictive values, we verified ulnar flow reserve measured by Doppler ultrasonography before the harvest of radial artery. METHODS: Forty patients whose radial artery was harvested for coronary bypass graft, were interviewed and tested 1 year after operation, and their preoperative ultrasonographic data compared. RESULTS: Five patients (12.5%) had mild symptoms implying exercise intolerance. Exercise tests revealed severe decreases in tissue oxygenation in 7 patients (17.5%), but in accordance with symptoms (p = 0.0018). Tissue oxygenation in the operated hand was lower than in the nonoperated even in asymptomatic patients (p = 0.0011). Preoperative Doppler echography revealed that ulnar arteries of symptomatic patients were smaller (p = 0.0019) and carried lower blood flows during manual compression of the radial artery (p = 0.0004) compared with those of asymptomatic patients. Smaller ulnar arteries (less than 1.4 mm/m(2)) with poor flow reserves (less than 60 mL x min(-1) x m(-2) during radial compression) appear to indicate risks for exercise intolerance (p = 0.0004). CONCLUSIONS: More than 10% of patients after harvest of radial arteries had mild symptoms implying exercise-intolerance, which accorded with abnormal tissue oxygenation during grip exercise. Work habits of patients should be considered in radial harvest decisions, especially if preoperative Doppler echography indicates lower flow reserves for the ulnar artery.

Long-term outcome of active infective endocarditis with renal insufficiency in cardiac surgery.

BACKGROUND: The relation between infective endocarditis (IE) and renal insufficiency is uncertain. The aim of this study was to investigate active IE with renal insufficiency in cardiac surgery. PATIENTS AND METHODS: A retrospective record review was conducted of all cases with IE from January 1998 to July 2009. We identified 38 patients who had undergone surgical intervention (25 males and 13 females, mean age 57.3 ± 15.2 years, range 23-83 years) of IE as defined by the modified Duke criteria. Indications for surgical intervention included new, severe valvular regurgitation with heart failure, intracardiac abscesses, and recurrent embolic events. All patients were divided two groups; one group comprised patients without renal insufficiency (group N, n = 28), the other, those with renal insufficiency (group R, n = 10). RESULTS: Mean age of patients in group R was larger than that in of group N (66.3 ± 10.6 vs. 54.1 ± 15.4 years, p = 0.0268), and mean hemoglobin in group R than in group N (8.4 ± 0.9 vs. 10.3 ± 2.5 g/dl, p = 0.0215). In the early outcome, hospital death was greater in group R than in group N (20.0% vs. 0.0%, p = 0.0143). The 8-year survival was significantly worse in group R than in group N (50.0% vs. 96.4%, log rank test: p = 0.0042). Moreover, the 8-year actuarial freedom from cardiac events was significantly worse in group R than in group N (0.0% vs. 60.3%, log rank test: p = 0.0003), too. Renal insufficiency predicted an increase in long-term mortality (OR 12.104, 95%CI 1.349-108.641, p = 0.0259) and morbidity (OR 10.540, 95%CI 2.173-51.129, p = 0.0035). CONCLUSIONS: In IE, renal insufficiency may allow for risk stratification of patients undergoing surgical intervention.

A case of abdominal aortic aneurysm with horseshoe kidney.

A 69-year-old male who had an abdominal aortic aneurysm with horseshoe kidney is reported. Preoperative 3-dimensional computed tomoangiography (3DCTA) images confirmed two accessory renal arteries diverging from the aneurysm to the isthmus. We operated on the abdominal aortic aneurysm using the left retroperitoneal approach, which provided excellent exposure of the aneurysm without dividing the renal isthmus. This exposure showed us the accessory arteries, so we could easily recognize these arteries visualized by 3DCTA, and we could reconstruct the larger one of two accessory arteries. Preoperative 3DCTA was very useful for the operation of the abdominal aortic aneurysm with horseshoe kidney. The postoperative course was uneventful.

Verapamil and nitroglycerin improves the patency rate of radial artery grafts.

The best way to prevent spasm of the radial artery is still under investigation. We retrospectively compared the effectiveness of topical verapamil-nitroglycerin with papaverine in preventing graft spasm in 215 patients who underwent isolated conventional coronary artery bypass using a radial artery. Postoperative angiographic data were successfully collected in 116 patients. Perioperative radial artery graft spasm was observed in 2 patients in the papaverine group and 1 in the verapamil-nitroglycerin group; this difference was not considered significant. Complete or functional occlusion was detected by postoperative angiography in 13 grafts (10 in the papaverine group and 3 in the verapamil-nitroglycerin group). Multivariate regression analysis revealed that topical papaverine and grafting to the right coronary artery significantly increased the rate of occlusion of radial artery grafts. Although further studies are needed, our data support the view that topical verapamil-nitroglycerin reduces the incidence of radial artery graft occlusion.

Inferior vena cava occlusion secondary to an inflammatory abdominal aortic aneurysm.

Inflammatory abdominal aortic aneurysms (IAAAs) represent 3% to 10% of all AAAs. However, inferior vena cava occlusion secondary to an IAAA is rarely reported. We report a case of inferior vena cava occlusion secondary to an IAAA presenting deep venous thrombosis. As it is crucial to avoid pulmonary embolism and excessive blood loss during an operation, we pre-operatively implanted a venous filter and minimized intra-operative dissection that allowed successful operative repair.

A new multisuction cardiac positioner for multivessel off-pump coronary artery bypass grafting.

OBJECTIVE: : To accomplish successful multivessel off-pump coronary artery bypass grafting, safe, reproducible, and effective exposure of all coronary territories is essential. For this purpose, we developed a new, simple, multisuction cardiac positioner. METHODS: : This new cardiac positioner consists of 3 small independent suction cups and suction tubes made of silicone. Unlike an apical suction cardiac positioner, this positioner has no arm. The suction cups can be applied with negative pressure of 300 mm Hg to various surfaces of the ventricle, including not only the apex but also the lateral, inferior, and right ventricular walls, according to surgeon preference. We applied this positioner in 15 clinical multivessel off-pump coronary artery bypass procedures. RESULTS: : In all cases, all target vessels including those on the lateral or inferior wall were successfully exposed and grafted without hemodynamic compromise. Surgical exposure, especially on the lateral and inferior walls, was quite similar to that of conventional coronary artery bypass graft procedures performed during cardiopulmonary bypass. CONCLUSIONS: : The multisuction cardiac positioner provided reproducible and easy access in multivessel off-pump coronary artery bypass surgery. This simple, variable, and inexpensive cardiac positioner may be used as a new tool to aid in the performance of successful multivessel off-pump coronary artery bypass surgery.

Effects of the postoperative administration of diltiazem on renal function after coronary artery bypass grafting.

BACKGROUND: Radial artery grafts are used for coronary artery bypass grafting (CABG), and postoperative antispasm therapy with diltiazem is performed widely. Some investigators have warned that diltiazem administration after cardiac surgery is harmful to renal function. We designed a retrospective study to investigate the renal and hemodynamic effects of the postoperative administration of diltiazem in patients undergoing CABG. METHODS: Subjects were 90 consecutive CABG patients. All were treated with diltiazem during surgery (a 0.1 mg/kg bolus injection followed by continuous infusion at 2 microg x kg(-1) x min(-1)). In the 50 patients (diltiazem group) with a radial artery graft, intravenous diltiazem administration was continued until the oral intake of diltiazem (90 mg/d) was begun to avoid graft spasms. In the remaining 40 patients without a radial artery graft, diltiazem was not continued postoperatively (control group). Postoperative renal function, assessed by serum creatinine level and creatinine clearance, and hemodynamic variables (heart rate, arterial pressure, pulmonary wedge pressure, cardiac index, left ventricular stroke work index) was compared between the two groups. RESULTS: Renal function: Serum creatinine concentrations on postoperative days 1 through 7 were lower, and the endogenous creatinine clearance in the early postoperative period was higher in diltiazem group than in control group, although the differences were not significant. Hemodynamics: Heart rate was lower in diltiazem group than in the control group, but blood pressure, pulmonary wedge pressure, cardiac index, left ventricular stroke work index, and urinary output were similar between the groups. CONCLUSIONS: Our results confirmed that intravenous diltiazem treatment in patients undergoing CABG is not harmful to renal function.