Surgical Management of Cardiac Implantable Electronic Device Complications in Patients Unsuitable for Transvenous Lead Extraction.

BACKGROUND: Although surgical approaches for infected or failing cardiac implantable electronic device (CIED) leads are more invasive than transvenous approaches, they are still required for patients considered unsuitable for transvenous procedures. In this study, surgical management with transvenous equipment for CIED complications was examined in patients unsuitable for transvenous lead extraction.Methods and Results: We retrospectively examined 152 consecutive patients who underwent CIED extraction between April 2009 and December 2021 at the Department of Cardiovascular Surgery, Nippon Medical School. Nine patients (5.9%; mean [±SD] age 61.7±16.7 years) who underwent open heart surgery were identified as unsuitable for the isolated transvenous approach. CIED types included 5 pacemakers and 4 implantable cardioverter-defibrillators; the mean [±SD] lead age was 19.5±7.0 years. Indications for surgical management according to Heart Rhythm Society guidelines included failed prior to transvenous CIED extraction (n=6), intracardiac vegetation (n=2), and severe lead adhesion (n=1). Transvenous CIED extraction tools were used in all patients during or before surgery. Additional surgical procedures with CIED extraction included epicardial lead implantation (n=4) and tricuspid valve repair (n=3). All patients were discharged; during the follow-up period (mean 5.7±3.7 years), only 1 patient died (non-cardiac cause). CONCLUSIONS: Surgical procedures and transvenous extraction tools were combined in the removal strategy for efficacious surgical management of CIED leads. Intensive surgical procedures were safely performed in patients unsuitable for transvenous extraction.

[Mitral Valve Repair in a Patient with Two Aneurysms of the Mitral Valve Due to Infective Endocarditis;Report of a Case].

Echocardiography revealed 2 aneurysms in the mitral valve with mitral regurgitation and aortic regurgitation,in a 42-years-old man. He had had infective endocarditis due to Streptococcus 9 months before. A prolapse in the right coronary cusp without vegetation and 2 aneurysms in the anterior mitral leaflet were found intraoperatively. Aortic valve was replaced, and then mitral aneurysms were resected and repaired using his own pericardium. There has been almost no regurgitation or recurrence of infection over 3 years.

[Minimally Invasive Cardiac Surgery with Lower Partial Sternotomy for Combined Valve Disease;Report of a Case].

Combined valve surgery is usually performed with standard sternotomy although the efficacy and safety of single valve surgery with partial sternotomy has been established. We report a successful case of triple valve surgery with lower partial sternotomy. A 69-year-old woman underwent aortic valve replacement, mitral and tricuspid valve repair via lower partial sternotomy for moderate aortic and mitral valve regurgitation as well as severe tricuspid valve regurgitation. The operation was successfully performed with enough surgical field, without using any specific technical devises for minimally invasive cardiac surgery or blood transfusion. The ascending aorta, the superior vena cava and the right femoral vein were cannulated for cardiopulmonary bypass. The procedure was completed as in a conventional approach, except for a small incision for the femoral vein. This approach has several advantages;less trauma, less pain, earlier recovery, and better cosmetic outcomes. Triple valve surgery can be completed using lower partial sternotomy with benefits.

[Massive Pulmonary Hemorrhage During Cardiac Operation;Report of a Case].

The incidence of pulmonary hemorrhage during cardiac operation is not freqent but one of severe and lethal complications. We report a case of massive pulmonary hemorrhage, hemoptysis, suspected to be induced by a Swan-Ganz catheter. The patient had satisfactory progress postoperatively. An 80-year-old female patient underwent mitral valve replacement, tricuspid annuloplasty, and maze procedure. A Swan-Ganz catheter was inserted via the right jugular vein and fixed just at 40 cm as in usual preoperative induction. Operative procedures were uneventful, but active and massive airway hemorrhage started while weaning off cardiopulmonary bypass. A hematoma spreading under the visceral pleura of the right middle-lobe lung was found. We immediately replaced the endotracheal tube with a double-lumen one, and promptly decided to do lung lobectomy. These strategies were very helpful to rescue the patient, and led to her good recovery after the severe pulmonary hemorrhage, possibly induced by a catheter.

[Surgical technique of saphenous vein harvesting using a Cusco vaginal speculum].

We used Cusco vaginal speculum in harvesting saphenous vein graft (SVG) as an assist device for making a skin tunnel. After making 2 incisions of 3 to 4 cm, the SVG was dissected in a usual procedure. Then Cusco vaginal speculum was inserted into the skin tunnel between the 2 incisions. The SVG was dissected in a usual fashion under direct vision with the speculum. This procedure requires only small incisions, short learning curve and low cost. The new technique using Cusco vaginal speculum can be a reliable option for harvesting SVG.

A novel technique for H-shaped reinforcement of double-barreled aorta in surgical treatment of chronic aortic dissection.

Anastomosis of the prosthetic graft to the double-barreled aorta with intimal flap fenestration is a useful technique in surgery for chronic aortic dissection. Conversely, anastomosis to the false lumen's outer wall is prone to complications such as pseudoaneurysms, but little is known about the technique of reinforcing the double-barreled aorta. In this report, we describe a surgical case of chronic aortic dissection in which an H-shaped prosthetic graft was sutured to both aortic lumens, including the intimal flap, to prevent complications at the anastomosis site.

Off-Pump Minimally Invasive Coronary Artery Bypass Grafting With a Heart Positioner: Direct Retraction for a Better Exposure.

OBJECTIVE: Lateral and inferior territories are difficult to expose during off-pump minimally invasive coronary artery bypass grafting (MICS CABG). The use of cardiopulmonary bypass is required at times. We initiated a direct retraction method by using a cardiac positioner for a better exposure, in order to complete off-pump, multivessel MICS CABG safely. METHODS: We recently initiated multivessel MICS CABG, performed via a 6- to 9-cm left thoracotomy. For distal anastomoses, the lateral pericardial edge was pulled to the chest wall to optimize exposure of the lateral and inferior area. Next, a single- or multisuction cardiac positioner was put on the sides of the target vessel through the small thoracotomy and pulled directly toward the incision. Finally, a distal anastomosis was made with an epicardial stabilizer via the thoracotomy, as in standard off-pump CABG. RESULTS: There was no mortality or conversion to sternotomy. A total of 10 cases were targeted for off-pump multivessel MICS CABG with this approach. Nine were completed, while 1 still required pump assist. The average number of distal anastomoses was 2.8 ± 0.8. Two were successful off-pump quadruple bypass grafting with sequential anastomoses. All patients were discharged and remain well to this day. CONCLUSIONS: Most multivessel MICS CABG was feasible without pump assist even at the initiation period. This approach is easy and helpful in providing good exposure of target vessels without requirement of additional incisions.

Minimally Invasive Coronary Artery Bypass Grating Using Bilateral In Situ Internal Thoracic Arteries.

When performing minimally invasive coronary artery bypass grafting (MICS CABG), it is difficult to access the right internal thoracic artery (ITA) under direct vision. We successfully performed off-pump MICS CABG using the bilateral in situ ITAs through a 8-cm left thoracotomy under direct vision for a 76-year-old man. His postoperative course was uneventful and all the grafts were patent. This novel, minimally invasive approach safely preserves the sternum and delivers the benefits of bilateral in situ ITA grafting, providing an alternative to conventional CABG and off-pump CABG.

Aortic valve reconstruction with autologous pericardium for dialysis patients.

OBJECTIVES: This study aimed to report on original aortic valve reconstruction for patients on dialysis. METHODS: Aortic valve reconstruction has been performed on 404 cases from April 2007 through September 2011. Among them, 54 cases on haemodialysis were retrospectively studied. Forty-seven patients had aortic stenosis, 5 had aortic regurgitation (AR), and 2 had infective endocarditis. Mean age was 70.2 ± 8.5 years. There were 35 males and 19 females. There were 27 primary aortic valve reconstructions, 11 with CABG, 6 with ascending aortic replacement, 5 with mitral valve repair and 4 with maze. First, in the procedure, harvested pericardium was treated with 0.6% glutaraldehyde solution. After resecting the cusps, we measured the distance between commissures with original sizing instrument. Then, the pericardium was trimmed with the original template. Three cusps were sutured to each annulus. RESULTS: Peak pressure gradient averaged to 66.0 ± 28.2 mmHg preoperatively, and decreased to 23.4 ± 10.7, 13.8 ± 5.5 and 13.3 ± 2.3 mmHg, 1 week, 1 year, and 3 years after the operation, respectively. No calcification was detected with echocardiographic follow-up. Recurrence of AR was not recorded with the mean follow-up of 847 days except for 1 case reoperated on for infective endocarditis 2.5 years after the operation. Three hospital deaths were recorded due to non-cardiac causes. Other patients were in good condition. There was no thromboembolic event. CONCLUSIONS: Medium-term results are excellent. Since warfarin for dialysis patients becomes problematic, a postoperative warfarin-free status is desirable. Aortic valve reconstruction can provide patients with a better quality of life without warfarin.

Aortic valve reconstruction of unicuspid aortic valve by tricuspidization using autologous pericardium.

BACKGROUND: Unicuspid aortic valve is a rare anatomic variant, but patients may require intervention for severe valve dysfunction at a young age. We introduce a new reconstructive technique for diseased unicuspid valve by tricuspidization with glutaraldehyde-treated autologous pericardium. METHODS: From April 2007 through January 2011, we performed 304 cases of aortic valve reconstruction using glutaraldehyde-treated autologous pericardium. During the same period, we encountered 9 patients with unicuspid aortic valve, including 8 male patients and 1 female patient. Mean age was 48.9±19.9 years (14-78 years). Two patients had aortic stenosis (AS), 1 had aortic regurgitation (AR), and 6 patients had both. Our original aortic valve reconstruction technique is characterized by the independent replacement of 3 leaflets with separate measurement of length between each commissure. In the case of a unicuspid aortic valve, we create a new commissure at a higher point along the raphe at the same level with the 1 normally existing commissure. RESULTS: No early mortality or major morbidity was recorded. Postoperative echocardiography showed trivial or no AR, with the peak pressure gradients averaging 10.6±3.3 mm Hg. One-year follow-up echocardiography revealed that the peak pressure gradients averaged 8.6±3.7 mm Hg, with trivial or no AR. The mean follow-up period was 551.1±51.4 days. All 9 patients are in good condition. No reoperation or any additional intervention has been necessary. CONCLUSIONS: Diseased unicuspid aortic valves were treated by our original aortic valve reconstruction technique with excellent early results. We continue to study the long-term results.

Angioplasty with autologous pericardium for bilateral coronary ostial stenosis in Takayasu disease.

Coronary ostial stenosis is usually treated by conventional coronary artery bypass graft surgery. Although patch angioplasty is a widely accepted alternative surgical treatment, it has been reported sporadically. We encountered bilateral ostial stenosis with Takayasu disease. This report describes successful patch angioplasty using glutaraldehyde-treated autologous pericardium of bilateral coronary ostial stenosis owing to Takayasu disease.

Aortic valve reconstruction using self-developed aortic valve plasty system in aortic valve disease.

Aortic valve disease is usually treated by prosthetic valve replacement. We have performed aortic valve plasty (AVP) using glutaraldehyde-treated autologous pericardium. AVP was performed for 88 patients from April 2007 through August 2009. Sixty-five patients had aortic stenosis, and 23 patients had aortic regurgitation (AR). Twenty-one patients showed bicuspid aortic valves, and one patient showed quadricuspid valve. There were 43 males and 45 females. Their mean age was 70.6±10.5 years old. First, diseased leaflets excised. Then, the distance between each commissure was measured. The new leaflet were trimmed with an original template from a glutaraldehyde-treated autologous pericardium sample. Finally, the annular margin of the pericardial leaflet was running sutured to each annulus. There was no operative mortality or embolic event. Postoperative echocardiography revealed a mean peak pressure gradient (PG) of 19.0±9.1 mmHg one week after surgery. Thirty-two patients had echocardiography one year after surgery. The peak PG became 12.9±5.8 mmHg. Ten patients showed no AR, 20 patients showed trivial AR, and two patients showed mild AR. Freedom from reoperation is 100% at three years follow-up.

Original aortic valve plasty with autologous pericardium for quadricuspid valve.

Quadricuspid aortic valves represent a very rare pathology. Most cases have been discovered incidentally during heart operations or at autopsy. Patients may become symptomatic with aortic regurgitation. We encountered a symptomatic patient with aortic regurgitation and a quadricuspid aortic valve. Successful aortic valve plasty was done with our original technique of tricuspid replacement by glutaraldehyde-treated autologous pericardium.