[Surgery for a Missile Embolus in the Right Ventricle].

Ballistic embolism represents an unusual complication of vascular by a flying object injury. Because embolus is remote from injury site, the occurrence of missile embolus may be overlooked and lead to delay in diagnosis of significant ischemia or embolism. We herein report a successful surgical removal of a rare missile embolus from the upper arm in the right ventricle. A 44-year-old man visited our hospital because of pulsatile bleeding from the left upper arm due to injury by a flying metal fragment of a hammerhead. Chest roentgenogram and computed tomography (CT) scan 9 days after the injury demonstrated a missile embolus in the right ventricle, which was thought to be ballistic embolism of the metal fragment. We underwent surgical removal of the retained object under cardiopulmonary bypass uneventfully, and discharged home ten days later.

Surgical repair of Kommerell's diverticulum and an aberrant subclavian artery.

PURPOSE: The coexistence of Kommerell's diverticulum and an aberrant subclavian artery (ASCA) is a rare congenital variation of the vascular structure. We report our experience of treating aneurysms associated with these anomalies. METHODS: Between June 2007 and November 2011, five consecutive patients underwent repair of an aneurysm associated with Kommerell's diverticulum and an ASCA at Shiga University Hospital. Four of the five patients had a right-sided aortic arch associated with the ASCA. One patient underwent emergency surgery for a ruptured thoracic aneurysm. The operations performed were descending aorta replacement through right thoracotomy in one patient and total arch replacement through a median thoracotomy, under deep hypothermic circulatory arrest and selective cerebral perfusion, in four patients. No staged operation was required. RESULTS: One patient died of mediastinitis, subsequent to a ruptured Kommerell's diverticulum, 45 days postoperatively. There were no other deaths in the early or late (6-58 months) postoperative period. One patient required re-exploration for bleeding, but none of the patients suffered neurologic complications. CONCLUSIONS: Aortic disease with an ASCA and Kommerell's diverticulum can be repaired safely under elective conditions.

Tricuspid valve relocation with endomyocardial fibrosis removal for Löeffler's endocarditis.

Löffler endocarditis with hypereosinophilic syndrome is rare but can cause critical ventricular obliteration by endomyocardial fibrosis. A 52-year-old woman experienced severe right heart failure with extreme shrinkage of her right ventricle, severe tricuspid regurgitation and marked right atrial enlargement. Preoperative tests showed identical pressures in the right atrium and pulmonary artery. Endocardial stripping was done, and to enlarge the right ventricle, we relocated the anterior and posterior tricuspid leaflets cephalad, up the right atrium wall, to 'ventricularize' a portion of the right atrium, with autologous pericardial augmentation of the tricuspid leaflets. An annuloplasty ring was added to reinforce the relocated tricuspid attachment. Right heart pressures normalized postoperatively. The patient recovered uneventfully. She has received corticosteroid therapy continuously and has shown no recurrence of heart failure in the 5 years since surgery.

Renal sinus fat volume on computed tomography in middle-aged patients at risk for cardiovascular disease and its association with coronary artery calcification.

OBJECTIVE: Renal sinus fat (RSF) behaves as one of the perivascular fats, however RSF volume (RSFV) is considerably affected by visceral adipose tissue volume (VTAV). The ratio of RSFV to VATV (RSFV/VATV ratio) can be an index of regional perivascular fat accumulation corrected for the influence of VATV. The aim of this study was to investigate the relation between RSFV/VATV ratio and coronary artery calcium (CAC) in patients with suspected coronary artery disease. METHODS: One hundred and eighty-nine patients (mean age 66.7 ± 10.2; 72% men) underwent ECG-gated cardiac computed tomography (CT) and unenhanced abdominal CT. CAC score (CACS) was assessed using axial CT images. RSFV was measured by partially manipulated segmentation of the right kidney. VATV was automatically quantified in the upper abdomen. Logistic and correlation analyses were performed to examine the correlations between CAC, RSFV/VATV ratio, and risk factors of cardiovascular diseases in total and subgroups classified by the patients' age. RESULTS: Log-transformed RSFV/VATV ratio was associated with CAC presence in 112 middle-aged patients less than 69 years of age as well as total. This association remained significant after multivariate adjustment only in the middle-aged patients (OR 15.9, 95% CI 1.15-218.8). In total, RSFV/VATV ratio (r = 0.228, p = 0.002) and age (r = 0.316, p < 0.001) correlated with CACS on univariate analyses, but only age correlated on multivariate analyses. RSFV/VATV ratio correlated with CACS in the middle-aged patients (r = 0.418, p < 0.001), as well as on multivariate analyses. CONCLUSIONS: We demonstrated that RSFV/VATV could be an independent risk indicator of CAC in the middle-aged patients.

Data set for renal sinus fat volume and visceral adipose tissue volume on computed tomography.

Renal sinus fat is partially characteristic of peri-vascular adipose tissue, however, RSF volume (RSFV) is associated with visceral adipose tissue (VATV). Therefore, the ratio of RSFV to VATV (RSFV/VATV ratio) can distinguish the importance of RSF as an extension of VAT versus its perivascular effects. We assessed the association of RSFV/VATV ratio with coronary artery calcification score (CACS) in 189 patients with suspected coronary artery disease. RSFV of the right kidney and VATV were quantified by using image data of unenhanced abdominal CT. CACS were measured on unenhanced ECG-gated CT images. This article contains data on explanatory scheme of how to measure RSFV on unenhanced abdominal CT, CT indication and exclusion criteria of study population, sex-adjusted association between RSFV with risk factors of coronary vascular diseases and metabolic indices, multivariate linear regression analysis with CACS as the dependent variable in the total study population. The data are supplemental to our original research article describing detailed association between RSFV/VATV ratio and CACS including sub-groups analyses classified by the age of 70 "Renal sinus fat volume on computed tomography in middle-aged patients at risk for cardiovascular disease and its association with coronary artery calcification" Murakami et al. [1].

Impact of Total Arterial Reconstruction on Long-Term Mortality and Morbidity: Off-Pump Total Arterial Reconstruction Versus Non-Total Arterial Reconstruction.

BACKGROUND: We were interested in how favorable an influence total arterial reconstruction has on the clinical outcome of patients undergoing off-pump coronary artery bypass graft surgery. METHODS: From January 2002 to December 2013, a total of 1,064 patients underwent isolated off-pump coronary artery bypass graft surgery at our institution. Of these 1,064 patients, 763 underwent total arterial revascularization (AR) and 301 underwent a combination of artery and vein revascularization (AVR). We compared the clinical results between the two groups using the propensity score matching technique. RESULTS: In all, 260 cases from the AVR group and 520 from the AR group were successfully matched. All procedures were performed using the off-pump technique without conversion to on-pump. Eight patients in the AVR group (3.1%) and 5 in the AR group (1.0%) died in hospital. Multivariate analysis revealed that chronic kidney disease (odds ratio 6.9, p < 0.001), urgency (odds ratio 7.3, p < 0.001), and body mass index (odds ratio 1.3, p = 0.02) were independent risk factors for hospital death. Follow-up was complete for 97.6% of the patients to a maximum of 13 years. According to the Kaplan-Meier method, the rate of 12-year freedom from all causes of death was 69.7% for the AVR group and 72.6% for the AR group (p = 0.002), and the corresponding rates for major adverse cardiac events were 83.9% and 87.7% (p = 0.009). By multivariate Cox regression analysis, total arterial reconstruction was identified as a preventive factor for late cardiac events. CONCLUSIONS: Total arterial revascularization has some degree of favorable effect on the long-term clinical outcome of patients undergoing off-pump coronary artery bypass graft surgery.

Similar outcome in insulin-dependent and noninsulin-dependent diabetic patients after off-pump coronary artery bypass grafting with multiple skeletonized arterial conduits.

BACKGROUND: We were interested in whether current multiarterial off-pump coronary artery bypass graft surgery can improve the clinical outcome for insulin-dependent diabetes mellitus patients. METHODS: Between January 2002 and December 2013, 1,064 consecutive patients underwent isolated off-pump coronary artery bypass surgery at our hospital; 551 of these patients had diabetes. Of these 551 patients, 166 had insulin-dependent diabetes (IDM) and the remaining 385 had noninsulin-dependent diabetes (NIDM). The propensity score was calculated to achieve one-to-two matching sets (IDM 143 versus NIDM 286). RESULTS: Ten patients (3.5%) in the NIDM group and 2 patients (1.4%) in the IDM group died in hospital (p = 0.18). Insulin dependency was not an independent risk factor for any early death or major complications. Follow-up was complete for 96.5% of the patients, with a mean follow-up of 4.6 ± 3.8 years. Overall survival rate at 10 years was 76.3% for the NIDM group and 73.1% for the IDM group (p = 0.79). The rate of 10-year actuarial freedom from major adverse cardiac events was 89.6% in the NIDM group and 86.3% in the IDM group (p = 0.72). Multivariate Cox proportional hazard regression analysis revealed that female sex, congestive heart failure, previous myocardial infarction, lower ejection fraction, and at least one major complication were independent risk factors for combined cardiac events. Insulin dependency did not affect any outcome in the long term. CONCLUSIONS: Early and long-term outcomes after off-pump skeletonized multiarterial coronary artery bypass graft surgery were similar among the IDM and NIDM patients.

Outcome of total arch replacement with coronary artery bypass grafting.

OBJECTIVES: There are few reports on the outcome of total arch replacement (TAR) with concomitant coronary artery bypass grafting (CABG); the present study was aimed at analysing outcomes after TAR with CABG at our institute. METHODS: Between January 2002 and December 2012, 123 consecutive patients underwent elective TAR with or without CABG. The patients were divided into two groups: 46 who had concomitant CABG (Group T/C) and the rest, who had TAR only (Group T). TAR was performed under mild hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP) using a four-branched arch graft. RESULTS: The number with a low ejection fraction (<50%) was higher in Group T/C, in which the additive and the logistic EuroSCORE were also higher. The mean number of coronary anastomoses was 1.6 ± 0.8 in Group T/C. The mean durations of surgery (P < 0.01), cardiopulmonary bypass (P < 0.01), cardiac ischaemia (P < 0.01) and SACP (P < 0.01) were significantly longer in Group T/C. The early graft patency of bypass grafts was 96.7%. Between Group T and Group T/C, there were no significant differences in the incidence of stroke (3.9 and 10.9%, P = 0.13), perioperative myocardial infarction (0 and 2.2%, P = 0.37) and in-hospital mortality (2.6 and 8.7%, P = 0.14). There was one case of 30-day mortality in each group. Preoperative haemodialysis, NYHA III/IV and operation time were multivariate predictors (P < 0.05) of in-hospital mortality. CONCLUSIONS: Although concomitant CABG in TAR patients had higher operative risk, it can be safely performed with favourable outcomes.

Risk factors for acute kidney injury in aortic arch surgery with selective cerebral perfusion and mild hypothermic lower body circulatory arrest.

OBJECTIVES: Previous studies have reported a high incidence of acute kidney injury (AKI) after thoracic aortic surgery. However, the incidence of AKI in patients undergoing total arch replacement (TAR) with selective cerebral perfusion (SCP) and mild hypothermic lower body circulatory arrest (mild HLBCA) with a tympanic temperature of 25°C remains unknown. We studied AKI incidence and associated risk factors, as defined by the Acute Kidney Injury Network (AKIN). METHODS: We examined 116 consecutive patients with aortic arch aneurysm undergoing non-emergency TAR. Our surgical method is standardized to use systemic cooling of the tympanic membrane temperature to 25°C for circulatory arrest, followed by SCP and myocardial protection by cold blood cardioplegia. Anastomoses were sequentially constructed at the distal arch, the proximal root, the left sub-clavian artery, the left carotid artery and the right brachiocephalic artery. Bladder temperature was generally around 30°C at the start of lower body circulatory arrest (mild HLBCA) until reperfusion of the distal aorta. The incidence of AKI was investigated, with multivariate analysis of its risk factors. RESULTS: The mean operation time, cardiopulmonary bypass (CPB) time, mild HLBCA time and SCP time were 270.6 ± 72.5, 151.0 ± 46.4, 53.1 ± 20.1 and 99.0 ± 28.4 min, respectively. Hospital mortality occurred in 2 cases (1.7%). AKI occurred in 50 cases (43.1%); of which, 2 cases required renal replacement therapy (RRT). However, AKI had subsided in 44 cases by discharge. For contemporary perspective, the incidence of AKI was 32.8% in off-pump coronary bypass grafting and 38.9% in aortic valve replacement. Multivariate analysis of risk factors for AKI identified chronic kidney disease (CKD) (eGFR <60 ml/min/1.73 m(2)) and mild HLBCA time >60 min. CONCLUSIONS: Our method of TAR was associated with low mortality and low rate of kidney injury by discharge. However, prolonged mild HLBCA and preoperative CKD might need additional consideration.

Combined total arch replacement and bypass from the ascending aorta to the bilateral profunda femoris arteries.

A 72-year-old woman who had aortic arch aneurysm was admitted. The patient was unable to walk without assistance because of aortoiliac occlusive disease. Total arch replacement and the ascending aorta to the bilateral profunda femoris artery bypass were performed during the same operation. On outpatient visits, the patient was able to walk with a cane and the ankle-brachial pressure index was markedly improved. This combined procedure is an option for patients with aortoiliac occlusive disease who are not candidates for alternate inflow procedures, especially when the patient has another indication for median sternotomy.

Selective cerebral perfusion with mild hypothermic lower body circulatory arrest is safe for aortic arch surgery.

OBJECTIVES: The antegrade selective cerebral perfusion (SCP) technique, which extends the safe time limit for arch surgery, has now gained acceptance. However, neither the optimal hypothermic temperature nor the optimal SCP flow rate has been clearly determined. METHODS: From January 2008 to February 2012, a total of 105 patients underwent total arch replacement under a single surgeon (A.T.) at Shiga Medical University Hospital. The patients were 85 males and 20 females with a mean age of 73 years (range 41-88). The cause of the aneurysm was atherosclerosis in 90 patients and dissection in 15. Eighty-one patients with chronic lesion underwent elective surgery and 24 underwent emergent surgery. Univariate analysis of postoperative neurological dysfunction and early mortality was performed. RESULTS: The mean operation time, cardiopulmonary bypass (CPB) time, coronary ischaemic time, lower body circulatory arrest (CA) time and SCP time were 277 ± 83 min, 164 ± 40 min, 92 ± 33 min, 58 ± 22 min and 95 ± 28 min, respectively. Thirty-day mortality occurred in 1 ruptured emergent case (1%). Hospital mortality (>30 days) occurred in 3 cases (3%), 2 due to multisystem organ failure following emergent rupture and the other to cerebrovascular accident in an elective surgery case. Permanent neurological dysfunction (PND) occurred in 3 patients (3%) and temporary neurological dysfunction (TND) also in 3 patients (3%). CONCLUSIONS: SCP under mild hypothermia can be safely applied to aortic arch surgery and is associated with a low rate of hospital mortality and morbidity. However, prolonged SCP time is associated with incidences of postoperative neurological deficit.

Early and long-term patency of in situ skeletonized gastroepiploic artery after off-pump coronary artery bypass graft surgery.

BACKGROUND: There is at present no accurate figure for the long-term patency rate of the skeletonized gastroepiploic artery (GEA). METHODS: From January 2002 to July 2012, 956 consecutive patients underwent isolated off-pump coronary artery bypass graft (OPCABG) surgery at our institution. Of these, the 424 who underwent GEA grafting and postoperative GEA graft evaluation were the subjects of the present study. Of these 424 subjects, 155 (36.6%) underwent long-term outpatient evaluation using multidetector computed tomography angiography. RESULTS: No patient was converted from off pump to on pump surgery. Overall 30-day mortality was 0.5% (2 of 424). The overall early (4 to 21 days after surgery) patency rate of the skeletonized GEA was 98.2% (599 of 610 anastomoses). A total of 215 GEA anastomoses, including 55 sequential bypasses, were followed for long-term evaluation, of which 12, including three sequential bypasses, were found to be occluded. The overall patency rate in skeletonized GEA grafting over a mean follow-up period of 73 months was 94.4% (203 of 215). The cumulative patency rate of the skeletonized GEA was 97.8% at 30 days, 96.7% at 1 year, 96.0% at 3 years, 94.7% at 5 years, and 90.2% at 8 years after surgery. Multivariate Cox proportional hazard regression analysis showed that target vessel stenosis (p = 0.008, hazard ratio 0.086, 95% confidence interval: 0.014 to 0.53) was the only independent predictor of late graft occlusion. CONCLUSIONS: We demonstrated an accurate long-term patency rate for the skeletonized GEA superior to that for pedicled GEA or saphenous vein graft. A low-grade degree of target vessel stenosis was the only risk factor for late GEA occlusion.

Off-pump coronary artery bypass grafting using skeletonized in situ arterial grafts.

Skeletonization is an advanced technique of graft harvesting for coronary artery bypass grafting (CABG), and while it requires meticulous attention, it has many advantages. For example, skeletonization of internal thoracic artery (ITA) can minimize sternal ischemia and lower the risk of mediastinitis, and is longer and larger than pedicled ITA. In this article we describe the surgical techniques demonstrated in our video, which details our techniques of skeletonization of arterial grafts and off-pump coronary artery bypass (OPCAB) exclusively using these in situ grafts. Our method of right gastroepiploic artery (GEA) skeletonization has only three technical steps. The first step is to pass thin vessel loops under the GEA. The second step is to unroof the tissue surrounding the GEA. The last step is to seal and sever all the branches. Skeletonization of the GEA not only prevents vasospasm but also leads to GEA dilatation, and facilitates inspection and makes sequential anastomosis easier. Bilateral use of the skeletonized ITA and use of the skeletonized GEA can cover most coronary artery target sites without any manipulation of the ascending aorta. In our consecutive series of over 1,000 patients, the stroke rate was 0.5%. Our method helps to make the technique simple and secure in this technically demanding operation, and we believe that OPCAB with these grafts provides the best possible coronary revascularization.

Mid-term results for the use of the extended sandwich patch technique through right ventriculotomy for postinfarction ventricular septal defects.

OBJECTIVES: Postinfarction ventricular septal defect (VSD) is a rare, but feared, complication after acute myocardial infarction. Although numerous techniques and materials have been used, the best technique has not yet been settled upon. We present a novel technique of VSD closure through the VSD via right ventricular (RV) incision and assess short- and mid-term outcomes. METHODS: Between April 2008 and March 2012, 15 consecutive patients presenting with postinfarction VSD underwent surgical repair using this technique in our department. RESULTS: Thirty-day mortality was 20% (3 patients). Two patients died from low cardiac output. No early complications related to the VSD repair were observed, such as shunt recurrence, severe septal dyskinesia or pseudoaneurysmal change in the left ventricular myocardium. The left ventricle was contracted well without mitral regurgitation. The mean follow-up period was 17 ± 15 months. The Kaplan-Meier estimate of 3-year cumulative survival is 76%. At the mid-term stage, one trivial residual leak was noted, but no patient required reoperation. RV function was within the normal range after the operation. CONCLUSIONS: This method of VSD repair using right ventricle incision and trans-VSD approach is safe and simple and reduces the postoperative recurrence of VSD.

Successful surgical management of coronary perforation requiring pulmonary artery separation.

A 73-year-old woman with type III coronary perforation caused by failed angioplasty underwent emergency operation. It was impossible to stop the bleeding from the beating heart because the proximal Cx, which was the perforation site, was behind the main pulmonary artery. After establishing cardiopulmonary bypass, we separated the main pulmonary artery to secure hemostasis and performed coronary artery bypass grafting to the distal Cx. The postoperative course was uneventful therefore the patient was discharged on the tenth postoperative day. Surgical strategies are not standardized for coronary perforation and depend mainly on the surgical anatomy. In a situation like the present, which appears not to have been described previously, it is important to save the life of the patient by whatever means.

Successful management of refractory lethal coronary spasm after off-pump coronary bypass grafting.

Coronary artery spasm after coronary artery bypass grafting is a rare cause of acute myocardial infarction. A 68-year-old man who successfully tolerated off-pump coronary artery bypass grafting had a life-threatening spasm at 16 hours postoperatively. Emergent coronary angiography was performed and demonstrated whole vessel spasm of the bilateral coronary arteries and completely patent grafts. Several transcatheter intracoronary injections of vasodilators failed to relieve the spasm completely. After observation in ICU for 4 days with intra-aortic balloon pumping and a high dose of catecholamine, cardiac function was re-established and the patient recovered.