A functional evaluation of cerebral perfusion for coronary artery bypass grafting patients.

We evaluate the utility of providing a pulsatile blood flow by applying off-pump coronary artery bypass grafting (CABG) or intra-aortic balloon pumping (IABP) with conventional CABG to prevent perioperative stroke in patients with cerebral hypoperfusion on single-photon emission-computed tomography (SPECT). A total of 286 patients underwent isolated CABG with a cerebral magnetic resonance angiography (MRA) evaluation between 2006 and 2015. Seventy-five had significant stenosis and/or occlusion of craniocervical vessels; the other 211 had no significant stenosis. Cerebral SPECT was performed for 49 (SPECT group) of the 75 patients. The SPECT group was further divided into a normal perfusion (NP) (n = 37); and a hypoperfusion (HP) (n = 12). In the present study we compared the NP group and the 211 patients with no significant stenosis (as a control group) to the HP group. No strokes occurred in the HP group, and 1 stroke occurred at the time of operation in the control group. Postoperative stroke within 30 days occurred in 3 patients in the control group; the difference was not statistically significant. The long-term stroke-free rates of the HP and Control group did not differ to a statistically significant extent. The functional evaluation of cerebral perfusion by SPECT is important when patients have significant stenotic lesions on cerebral MRA. Maintaining an adequate pulsatile flow by off-pump CABG or IABP with conventional CABG will help prevent perioperative stroke, even if cerebral hypoperfusion is detected by SPECT.

[Intra-operative Acute Aortic Dissection during Aortic Root Reimplantation and Mitral Valve Reconstruction Surgery in a Patient with Marfan Syndrome;Report of a Case].

In patients with Marfan syndrome, cardiovascular complication due to aortic dissection represents the primary cause of death. Iatrogenic acute aortic dissection during cardiac surgery is a rare, but serious adverse event. A 51-year-old woman with Marfan syndrome underwent elective aortic surgery and mitral valve reconstruction surgery for the enlarged aortic root and severe mitral regurgitation. We replaced the aortic root and ascending aorta based on reimplantation technique. During subsequent mitral valve reconstruction, we found the heart pushed up from behind. Trans-esophageal echocardiography revealed a dissecting flap in the thoracic descending aorta. There was just weak signal of blood flow in the pseudolumen. We did not add any additional procedures such as an arch replacement. Cardio-pulmonary bypass was successfully discontinued. After protamine sulfate administration and blood transfusion, blood flow in the pseudolumen disappeared. The patient was successfully discharged from the hospital on 33th postoperative day without significant morbidities.

[Aortic Valve Replacement of Quadricuspid Valve with Regurgitation].

Congenital quadricuspid aortic valve is a very rare malformation. In most cases it has been found incidentally at aortic valve surgery or at autopsy. It frequently causes aortic regurgitation, which may become manifest in adulthood and require surgical treatment. We reported 4 cases of aortic regurgitation with quadricuspid aortic valve. In all cases, aortic valve replacement was preformed with prosthetic valve, and their postoperative courses were uneventful. Two were Hurwitz's classification type b, one was type a and the last patient was type c. Although quadricuspid aortic valve is a rare anomaly, its potential for severe valve failure in adulthood should be kept in mind.

The number of cardiovascular surgeries in Japan may decrease after 2020.

The expected future number of cardiovascular operations is estimated based on the predicted Japanese population and the rate of cardiovascular surgery performance calculated from 16845 cases treated by the Nagoya University group of hospitals between 2001 and 2013. The population of <20-year-old individuals has decreased since 1990, while that of 20-64-year-old individuals has also decreased since 2000. The population of 65-79-year-old individuals is expected to peak in 2020, with only the population of ≥80-year-old individuals expected to increase until 2040. The performance rate of cardiovascular surgery per 100,000 population is low in the 20-64-year-old group and increases to reach a peak in the elderly population of 70-74-year-old individuals in valvular heart disease (55.5), ischemic heart disease (54.5) and thoracic aortic aneurysm (31.9) and decreases to about half those values in the ≥80-year-old age group. The number of cardiovascular operations (all types) per 100,000 was 40.6 in 2002, 42.1 in 2006 and 46.6 in 2010. The total number of expected cardiovascular operations is increasing slightly and will reach a peak in 2020 with an estimated 61,506 operations. It then decreases gradually to reach 55966 in 2035, on the premise that the cardiovascular surgery performance rate does not change from the present time. In order to maintain and expand to meet the medical needs of cardiovascular surgery, it is crucial that an effort be made to increase the cardiovascular surgery performance rate, especially in octogenarian patients.

Impact of the intraoperative use of fibrinogen concentrate for hypofibrinogenemia during thoracic aortic surgery.

Thoracic aortic surgery often causes massive bleeding due to coagulopathy. Hypofibrinogenemia is one of the major causative factors, but the utility of the intraoperative administration of fibrinogen concentrate has not yet been proven. The aim of this study was to estimate incidence of hypofibrinogenemia and to evaluate efficacy of using fibrinogen concentrate intraoperatively. The perioperative serum fibrinogen levels (SFL) had routinely been measured in consecutive 216 thoracic aortic surgeries performed from 2010 to 2012. Fibrinogen concentrate was principally used for hypofibrinogenemia (< 150 mg/dl of SFL) at cardiopulmonary bypass (CPB) termination. The patients who received fibrinogen concentrate (FIB group) were compared with the patients who did not received (non Fib group). There were 147 patients (68%) in FIB group at a dose of 5.5±3.5 g. The SFL were dramatically decreased with values of 164±71 mg/dl at CPB termination, compared to the preoperative SFL of 352±131 mg/dl. In the FIB group, the intraoperative and postoperative SFLs were 139±53 and 262±75 (mg/dl), respectively. Thus the SFL was recovered quickly by the administration. 110 cases (51%) showed hypofibrinogenemia at the termination of CPB. The predictors of hypofibrinogenemia were preoperative SFL < 250 mg/dl, emergency surgery and thracoabdominal aortic surgery. Hypofibrinogenemia frequently was observed at the termination of CPB during thoracic aortic surgery. Administering intraoperative fibrinogen concentrate appears to be a useful option to treat coagulopathy.

An Epicardial Mesothelial Cyst Attached to the Ascending Aorta.

An epicardial mesothelial cyst, which can be defined as a mesothelial cyst attached to the epicardium surrounding the heart and the great vessels inside the pericardial sac, is a rare condition. We herein report a case of epicardial cyst, which was attached to the ascending aorta. The patient was a 76-year-old male who underwent coronary artery bypass surgery, and the cyst was found incidentally. It was approximately 5 cm in diameter, and histological examination confirmed mesothelial cell origin. The ascending aorta has not previously been reported as the origin of an epicardial mesothelial cyst. This case gives new insight into the embryology of these cysts.

[Traumatic Thoracic Aortic Injury].

Thoracic aortic injuries need emergency treatment, but have a high mortality rate. Prompt appropriate diagnosis is crucial to rescue the patient. Endovascular repair has been a useful approach for patients who suffer from hemodynamic instability due to massive bleeding and multiple traumatic injuries. However, open repair can be applied on patients who are inappropriate for thoracic endovascular aortic repair (TEVAR) or in hemodynamic stability. We present 3 cases of blunt aortic injury, who treated by TEVAR in 2 cases and open repair in 1 case.

Long-term outcome of complete cardiovascular implantable electronic device removal with cardiopulmonary bypass.

Definitive endovascular techniques have been developed for pacemaker lead extraction; however, a few patients require immediate secondary open heart surgery because of incomplete transvenous lead extraction. This study examined the safety, effectiveness, and long-term outcome of the removal of cardiovascular implantable electronic device (CIED) via median sternotomy under cardiopulmonary bypass. The removal of CIED was performed in 6 patients (mean age 57 ± 16 years, 5 males and 1 female), from September 2000 to April 2011. The reasons for removal included eradication of an infection in 5 patients and elimination of pacemaker component allergy in 1. Positive culture results, including methicillin-sensitive Staphylococcus aureus (MSSA, n = 2), methicillin-resistant S. aureus (MRSA, n = 1), coagulase-negative staphylococci (CNS, n = 1), and methicillin-resistant S. epidermidis (MRSE, n = 1) were observed in all 5 infected patients. Mitral annuloplasty (n = 1), mitral valvuloplasty (n = 1), tricuspid annuloplasty (n = 3). Implantation of myocardial pacing leads (n = 5) were performed concomitantly (n = 4), or secondarily (n = 1). All 6 patients were alive in good condition at 72 ± 55 months following CIED removal. New device infection occurred in 1 patient during long-term follow up. Complete surgical removal of pacing systems via median sternotomy with cardiopulmonary bypass is, therefore, considered to be safe and feasible with acceptable long term results.

A comparative study of two types of sternal pins used for sternal closure: poly-L-lactide sternal pins versus uncalcined hydroxyapatite poly-L-lactide sternal pins.

Bioabsorbable poly-L-lactide (PLLA) sternal pins are applied to reinforce sternal closure during cardiac surgery. However, these pins lack osteoconductivity. A new bioabsorbable sternal pin with osteoconductivity, made of uncalcined hydroxyapatite and poly-L-lactide (u-HA-PLLA) has been developed. This study was conducted to compare the two types of sternal pins in terms of sternal stability and healing after median sternotomy. Between October 2006 and January 2012, 105 patients underwent aortic surgery for aortic aneurysms or dissection via median sternotomy and sternal closure with sternal pins. Among these patients, 75 were followed for 12 months using serial computed tomography (CT). PLLA sternal pins were used in 30 patients (group A) and u-HA-PLLA sternal pins were used in 45 patients (group B). The incidence rates of transverse sternal dehiscence, anteroposterior displacement and complete sternal fusion were evaluated using CT. The cross-sectional cortical bone density area (CBDA) of the sternum around the sternal pins was examined to evaluate the osteoconductivity of the sternal pins. There were no significant differences between groups A and B in the sternal dehiscence rate (6.7 vs 4.4 %), sternal displacement rate (6.7 vs 2.2 %) or 12-month sternal fusion rate (63.3 vs 73.3 %). The CBDA around the sternal pins significantly increased between discharge and 12 months after surgery in group B (P < 0.001) but not in group A. These results show that u-HA-PLLA sternal pins exhibit certain osteoconductivity; however, both PLLA and u-HA-PLLA sternal pins provide comparable clinical outcomes regarding sternal stability and healing.

[Surgical strategy for extended aortic arch aneurysm].

The management of an extended aortic arch aneurysm still remains a clinical challenge. Open surgery can be invasive for the patients with comorbidities. Since thoracic endovascular aneurysm repair (TEVAR) was introduced, hybrid therapy has been applied for the extended arch aneurysm. From 1997 to 2013, 379 patients have undergone aortic arch surgery. Of those, 241 patients of non-dissection aneurysm were studied. Open surgical repair with L-shaped thoracotomy was done in 28 patients, frozen elephant trunk( FET) in 30 patients, long elephant trunk( LET) with 2nd TEVAR in 21 patients, debranched TEVAR in 10 patients and standard arch grafting in 152 patients as a control group. The brain infarction rate was high in debranched TEVAR (40%) and L-shaped group (25%). The paraplegia rate was high in FET group( 23.3%). The respiratory failure rate was high in the L-shaped group and the LET group. In-hospital mortality was 0.0% in the L-shaped group, 6.7% in the FET group, 4.8% in the LET group, 20% in the debranched group and 0.7% in the control group. The debranched TEVAR group is our early experience, and the recent outcomes of this procedure have improved. The management of extended aortic arch aneurysm has changed with hybrid approach combined with TEVAR. Open repair is still the gold standard, but hybrid therapy is used for high-risk patients. Off-pump debranched TEVAR tends to be applied for extended arch aneurysm.

[Recurrence of cardiac myxoma in the left atrial after 28 years; report of a case].

We presented a rare surgical case of recurrent multiple left atrial myxomas, who had a history of surgery for multiple left ventricular myxomas 28 years ago. The case was a 42-year-old female. She developed dyspnea, cough, and palpitation due to functional mitral valve obstruction by myxoma. There were a 30 mm large pedunculated tumor on the left atrial septum and 2 small tumors near the orifice of the right upper pulmonary vein. These tumors were excised with the left atrial endothelium and the defect was reconstructed with a bovine pericardium.

Successful Treatment of Whole Coronary Artery Spasm after Off-Pump Coronary Artery Bypass Grafting.

Coronary artery spasm after coronary artery bypass grafting is a rare but life-threatening condition. Herein, we report the case of a 77-year-old man who received off-pump coronary artery bypass grafting. An hour after surgery, there was a sudden hemodynamic compromise due to coronary artery spasm, prompting emergent coronary angiography with extracorporeal membrane oxygenation support. Because the angiography results showed diffuse severe spasm of the entire native coronary artery, the patient was treated with an intracoronary injection of vasodilators. The patient recovered in 7 days with mechanical support, catecholamines, and vasodilators, and he was discharged on postoperative day 30. Although coronary artery spasm after off-pump coronary artery bypass surgery is a rare condition, it must be suspected when sudden circulatory collapse occurs.

Two-stage hybrid repair with over-the-scope clip for atrioesophageal fistula after catheter-based ablation.

In this report, we present a case in which we successfully performed two-stage hybrid repair of heart surgery and endoscopic treatment with over-the-scope-clip system for atrio-esophageal fistula after catheter based ablation.

Surgical and multitreatment approach in a case of primary cardiac angiosarcoma: A case report.

INTRODUCTION AND IMPORTANCE: Primary cardiac angiosarcoma is extremely rare, and its prognosis remains poor, with a mean life expectancy of only a few months. Here, we report a case of primary cardiac angiosarcoma. CASE PRESENTATION: A 49-year-old Japanese woman with a month-long history of dyspnea was admitted to our hospital for pericardial effusion. Chest computed tomography and cardiac magnetic resonance imaging showed a mass in the right atrium. The patient underwent surgical resection of the tumor, and the pathological diagnosis was angiosarcoma. The patient received radiotherapy after surgery. Six months following surgery, she underwent chemotherapy following the diagnosis of lung metastasis. The patient died 18 months after the initial diagnosis. CLINICAL DISCUSSION: Cardiac angiosarcoma is rare and difficult to diagnose early because it is associated with few symptoms. Moreover, there are currently no established guidelines for the treatment of this disease because of its rarity and sparse descriptive literature Therefore, multidisciplinary therapies should be considered, including surgery, radiotherapy, and chemotherapy. CONCLUSION: There is no standard treatment for cardiac angiosarcoma, but surgical resection, chemotherapy, radiation therapy, or a combination of these therapies may be useful.

Pathogenesis of paravalvular leakage as a complication occurring in the late phase after surgery.

Paravalvular leakage (PVL) remains an unavoidable late complication after valve surgery. We indicate surgery only cases with progressive congestive heart failure and/or hemolytic anemia. We review our clinical experiences of PVL surgery. Between 1992 and 2009 we experienced 8 cases of aortic PVL-6 subjects after primary aortic valve replacement (AVR) and 2 subjects after re-AVR-and 10 subjects with mitral PVL-5 cases after primary mitral valve replacement (MVR) and 5 cases after re-MVR. Mitral PVL began in the later phases after surgery and had more severe symptoms, because of heart failure and/or hemolytic anemia, than aortic PVL. Aortic PVL occurred more frequently because of laxation of sutured threads without frequent sites. Conversely, mitral PVL was mainly caused by cutting annulus tissue around the anterior commisurae after primary MVR, and by a valve-on-valve structure on the middle scallop of the posterior leaflet or circumferentially after re-MVR. All operations were performed safely and all patients were discharged uneventfully. No cases experienced recurrence of PVL in the follow-up period. The symptoms of PVL became exacerbated, and our surgical indications based on these symptoms were validated. Valve-on-valve replacement, which was a major cause of PVL after re-MVR, should be avoided in a re-MVR procedure. Cautious follow-up is necessary, even in the late phase after surgery, especially for patients who have undergone MVR.

[Surgical strategy for mitral regurgitation in ischemic cardiomyopathy].

OBJECTIVE: Surgical strategy for the mitral regurgitation (MR) in patients with ischemic cardiomyopathy (ICM) still remains controversial. The purpose of this study is to evaluate the operative outcome and long-term survival in patients with ICM, MR. METHODS: Perioperative data and surgical results of 35 patients with ischemic MR were collected. Mitral annuloplasty with artificial ring (MAP) was performed in 27 patients and mitral valve replacement (MVR) in 8 patients. Preoperative left ventricular ejection fraction (LVEF) in MVR was significantly lower (23.1 +/- 11.8 : 33.4 +/- 10.3%, p < 0.05) and the left ventricular diastolic dimension (LVDd) was dilated (73.7 +/- 9.3: 64.2 +/- 7.0 mm, p < 0.01). Concomitant procedures including coronary artery bypass grafting and/or left ventricular reconstruction were performed in more than half patients. RESULTS: No operative death was observed in both groups. Postoperative data showed that MVR still remained in low left ventricular (LV) function. Six of 27 patients in MAP developed more than grade 2 MR during follow up period and 1 required reoperation. No significant difference was observed in survival and in freedom rate from cardiac event between groups. CONCLUSIONS: MAP had no impact on operative outcome and long-term survival in patients with ICM, MR. MVR should be considered in patients with severely impaired LV function to avoid the risk of recurrence of MR.

Surgical Strategy for Huge Right Coronary Artery Aneurysm Combined with Left Ventricular Fistula.

Coronary artery aneurysms combined with left ventricular fistulas are rare; coronary revascularization strategy after coronary artery aneurysm resection is complex in such cases. We report the surgical repair of a giant right coronary artery aneurysm with a fistula in the left ventricle in a 79-year-old woman diagnosed with an aneurysm 50 mm in diameter. Surgical repair included resection of the coronary artery aneurysm, coronary artery bypass grafting to the posterior descending artery, and isolation of reconstructed right coronary circulation from the fistula. The postoperative course was uneventful; postoperative coronary angiography revealed a patent bypass graft unconnected to the left ventricle.

Left Ventricular Outflow Tract Obstruction of Double Valve Re-Replacement Using Bioprosthesis.

We present a case of left ventricular outflow tract (LVOT) obstruction after double valve re-replacement with bioprostheses. A 72-year-old man, who had undergone double valve replacement (DVR) with bioprosthetic valves 9 years previously, underwent re-replacement of valves because of structural valve deterioration. However, owing to LVOT obstruction related to the bioprosthesis in the mitral position, acute pulmonary edema occurred immediately after surgery. LVOT obstruction was diagnosed by emergent cardiac catheterization. So prompt re-replacement surgery using a mechanical prosthesis was performed.

[Comparative study between cryoablation and radiofrequency ablation for surgical intervention of atrial fibrillation associated with mitral valve disease].

OBJECTIVES: Recently, bipolar radiofrequency (RF) ablation has been introduced as a potential option to replace many of the Cox-maze incisions. We compared the surgical outcomes of maze procedures in patients who had undergone cryoablation and RF ablation and mitral valve surgery. METHODS: From January 2004 to August 2009, a total of 40 patients underwent the maze procedure and concomitant mitral operation as a 1st operation. Of these, the cryoablation maze procedure (n = 20) and RF ablation procedure (n = 20) were performed in the patients with similar background, although more patients in the RF group had undergone mitral valve repair (n = 15) compared to the cryoablation group (n = 8) [p = 0.025]. RESULTS: The peri-operative data, such as operative duration, cardiopulmonary bypass time, aortic cross-clamp time, postoperative ventilation time, and the duration of intensive care unit (ICU) stay did not show any significant difference between cryoablation group and RF group. Both ablation procedures were similarly effective in restoring sinus rhythm at the early post-operative period (cryoablation: 80%, RF: 70%). Nine patients in the cryoablation group and 13 patients in the RF ablation group required anti-arrhythmic medication. CONCLUSIONS: The RF ablation technique is simpler and equally effective in controlling atrial fibrillation compared to the cryoablation for the maze procedure of concomitant mitral valve surgery.

Effect of an artificial ring on mitral valve function.

Differences of the effect of annuloplasty rings on the mitral annulus and leaflets, and differences between types of annuloplasty rings are not well known. We analyzed annular motion and leaflet movement with a rigid or flexible ring and without a ring using an isolated swine working heart model. Hearts of 10 swine (weight: 40-50 kg) were used for a rigid ring (n=5) and a flexible ring (n=5). Four ultrasound crystal tips were fixed around the annulus and an annuloplasty ring was implanted in the isolated heart. In the working heart mode, measurement of mitral annular dimension was acquired by sonomicrometry. Images of mitral valve motion were acquired by a high-speed video camera. The same analyses were performed after removing the artificial ring. The antero-posterior diameter of the diastole distance was significantly reduced in the flexible ring (21.59±0.71 mm) and rigid ring (15.93±1.88 mm) compared with no ring (23.51±2.01 mm). The flexible ring made the transverse diameter shrink significantly more than did the rigid ring. The contraction range of the transverse diameter was significantly smaller in the flexible ring compared with no ring. The duration of opening to closing of the mitral leaflet with the rigid (124.7±4.4 ms) and flexible rings (107.9±3.5 ms) was significantly shorter than that with no ring (168±36.5 ms). Annuloplasty rings allow simplicity of leaflet motion, regardless of the type of artificial ring. In a flexible ring, the mitral annulus shows a vertically long shape, suggesting preservation of posterior annular movement.