Safe and promising outcomes of in-hospital preoperative rehabilitation for coronary artery bypass grafting after an acute coronary syndrome.

OBJECTIVE: In patients with stable hemodynamic status after an acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) after preoperative investigations can provide outcomes comparable to those of emergency surgery. However, no established guidelines exist regarding the preparation period before surgery. We report the results of the use of an inpatient cardiac rehabilitation program followed by CABG after an ACS to improve post-operative outcomes and prognosis after discharge. METHODS: From 2005 to 2017, 471 patients underwent either isolated or combined CABG at our institution, and of those, the 393 who received isolated CABG were included in the analysis. Twenty-seven patients (6.9%) were admitted with ACS and underwent preoperative rehabilitation before undergoing CABG, with a subsequent review of surgical morbidity and mortality rates. Propensity score matching yielded a cohort of 26 patients who underwent preoperative rehabilitation (group A) and 26 controls (group B). Preoperative characteristics were similar between groups. RESULTS: The completion rate of the rehabilitation program was 96.3%. All programs were conducted with inpatients, with an average length of stay of 23 ± 12 days. All patients completed in-bed exercises, and 85% completed out-of-bed exercises. The 30-day postoperative mortality was 0% in both groups A and B, and the rate of postoperative major adverse cardiac or cerebrovascular events at 12 months did not differ significantly between groups (7.7% vs 3.9%, respectively; p = 1.0). The duration of mechanical ventilation (1.3 ± 0.3 vs 1.5 ± 0.3 days, respectively; p = 0.633), length of intensive care unit stay (4.4 ± 2.1 vs 4.8 ± 2.3 days, respectively; p = 0.584) and length of hospital stay (25 ± 13 vs 22 ± 9 days, respectively; p = 0.378) did not differ significantly between groups. CONCLUSIONS: No complications of preoperative rehabilitation were observed, suggesting that it is an acceptable option for patients who experience ACS and undergo CABG. These results are promising in offering more robust designs of future trials.

[Left Atrial Appendage Closure with Various Types of Surgical Technique and Its Results].

BACKGROUND: Occlusion of the left atrial appendage( LAA) may prevent stroke in patients with atrial fibrillation. In this study, we reviewed various types of LAA occlusion techniques and results of patients underwent surgical LAA closure. METHODS: Between 2004 and 2022, 182 patients who underwent surgical LAA closure were enrolled in this study. RESULTS: The surgical LAA closure consisted of 90 cases of closure device, AtriCure, 63 cases of surgical excision, 13 cases of stapler excision, 3 cases of ligation, and 13 cases of internal suture ligation. During the follow-up period, there were no deaths owing to cardiogenic emboli and no cerebral infarctions. CONCLUSIONS: Regardless of the surgical techniques, LAA closure was effective in preventing cardiogenic stroke. The AtriClip is a safe, simple, and effective and thoracoscopic LAA closure using AtriClip is expected as a less-invasive LAA management.

[Surgical Treatment of Extensive Annular Defects by Aortic Valve Infective Endocarditis Using Stentless Bioprosthesis].

BACKGROUND: The optimal surgical technique and valve prosthesis in patients with active aortic valve infective endocarditis with annular abscess is controversial. If extensive annular defects occur after debridement, standard techniques are difficult;more complex aortic root replacement is inevitable. The SOLO SMART stentless bioprosthesis is specially designed for supra-annular implantation without annular stitches. METHODS: Since 2016, 15 patients with active aortic valve infective endocarditis underwent aortic valve surgery. Of these, we performed aortic valve replacement using the SOLO SMART valve in six patients with extensive annular destruction and complex aortic root pathologies requiring reconstruction. RESULTS: Although more than two-thirds of the annular structure was missing after radical debridement of infected tissues, supra-annular aortic valve replacement with the SOLO SMART valve could be performed successfully in all six patients. All patients are doing well without prosthetic valve dysfunction and/or recurrent infection. CONCLUSIONS: The supraannular aortic valve replacement using the SOLO SMART valve is considered to be a useful alternative to standard aortic valve replacement in patients complicated with extensive annular defect. It is a simple and technically less demanding alternative to aortic root replacement.

Endovascular Repair for Abdominal Aortic Aneurysm Rupture With Neurofibromatosis Type 1.

BACKGROUND: Neurofibromatosis type 1 (NF1), also known as von Recklinghausen disease, is a rare congenital disorder with an autosomal dominant inheritance. Severe perioperative complications owing to the congenital fragility of the vascular wall in NF1 patients have been reported. The optimal vascular surgical approach remains controversial. We describe endovascular aortic repair of an abdominal aortic aneurysm rupture in a patient with NF1. CASE PRESENTATION: A 78-year-old woman with NF1 was transferred to our institution with a diagnosis of ruptured abdominal aortic aneurysm. The patient showed multiple café-au-lait spots, numerous neurofibromatosis, and severe scoliosis. Emergency endovascular aortic repair was performed, without technical difficulty. Despite an uneventful postoperative course, she developed an idiopathic left cervical hematoma caused by hemorrhage, and required tracheostomy due to severe airway obstruction. In addition, postoperative CT showed a newly developed saccular aneurysm at the proximal end of the stent graft. On postoperative day 40, she was transferred to a rehabilitation hospital, without recurrent bleeding and saccular aneurysm enlargement. CONCLUSION: In patients with NF1 who require a vascular surgical procedure, surgeons should consider the vascular wall fragility in selecting the optimal treatment strategy and the possible complications.

Efficacy of Short-Term Oral Prednisolone Treatment in the Management of Pericardial Effusion Following Pediatric Cardiac Surgery.

A standard treatment for pericardial effusion without cardiac tamponade after pediatric cardiac surgery has not been established. We evaluated the efficacy of short-term oral prednisolone administration, which is the initial treatment for postoperative pericardial effusion without cardiac tamponade at our institution. Between October 2008 and March 2020, 1429 pediatric cardiac surgeries were performed at our institution. 91 patients required postoperative treatment for pericardial effusion. 81 were treated with short-term oral prednisolone. Pericardial effusion was evaluated using serial echocardiography during diastole. Pericardial drainage was performed for patients with circumferential pericardial effusion with a maximum diameter of ≥ 10 mm or signs of cardiac tamponade. Short-term oral prednisolone treatment was administered to patients with circumferential pericardial effusion with a maximum diameter of < 10 mm or localized pericardial effusion with a maximum diameter of ≥ 5 mm. Patients with localized pericardial effusion with a maximum diameter of < 5 mm were observed. Prednisolone (2 mg/kg/day) was administered orally for 3 days, added as needed. Short-term oral prednisolone treatment was effective in 71 cases and 90% of patients were regarded as responders. The remaining patients were deemed non-responders who required pericardial drainage. Overall, 55 responders were deemed early responders whose pericardial effusion disappeared within 3 days. There were no cases of deaths, infections, or recurrence of pericardial effusion. The amount of drainage fluid on the day of surgery was higher in the non-responders. In conclusion, short-term oral prednisolone treatment is effective and safe for treating pericardial effusion without cardiac tamponade after pediatric cardiac surgery.

Unexpected migration of a sternal pin: A word of caution.

BACKGROUND: Sternal pins are adjuncts used to enhance sternal stability after sternotomy, but only a few complications associated with them have been previously reported. MATERIAL, METHODS AND RESULTS: A 42-year-old woman underwent pulmonary valve replacement through re-sternotomy for pulmonary valve regurgitation after repaired tetralogy of Fallot. Because of severe sternal deformity, the sternum was refixed using a sternal pin in addition to sternal wires. However, postoperative computed tomography unexpectedly revealed migration of the sternal pin towards the right coronary artery, necessitating emergency surgical removal of the pin. DISCUSSION: Sternal pins may not adequately fit the deformed sternum, resulting in sternal pin-induced sternal injury. CONCLUSION: Sternal pins are considered useful for sternal stabilization after sternotomy, we should take special care in applying sternal pins to patients presented severe sternal deformity.

Constrictive pericarditis caused by pericardial substitution using expanded polytetrafluoroethylene.

BACKGROUND: Expanded polytetrafluoroethylene (ePTFE) is commonly used as a pericardial substitute during cardiac surgery to prevent cardiac injury during re-sternotomy. However, although rare, constrictive pericarditis associated with ePTFE has been reported. MATERIAL, METHODS AND RESULTS: Here, we report a rare case of constrictive pericarditis developed due to severe restriction of cardiac motion associated with the ePTFE membrane used as a pericardial substitute. Hemodynamic improvement has been achieved by surgical removal of the ePTFE membrane and exudates within the overlapped portion of the ePTFE membranes, and dissection of the epicardial fibrous thickening. CONCLUSION: Considering the risk of constrictive pericarditis, we believe that the use of ePTFE membranes as a pericardial substitute should be carefully indicated for only selected patients.

[Successful Surgical Repair for Adult Ebstein Disease Using Cone Reconstruction Combined with One and a Half Ventricle Repair].

A 67-year-old woman presented with dyspnea on effort and cyanosis due to massive tricuspid regurgitation and an atrial septal defect with right to left shunt. She was diagnosed with Ebstein disease at the age of 53 when she underwent surgery for varicose veins. Echocardiography showed the severe apical displacement of the septal and posterior leaflet. The anterior leaflet also partially displaced to the apex and demonstrated tethering caused by a dilated right ventricle. Cardiac magnetic resonance imaging showed a dilated right atrium and an enlarged atrialized right ventricle, in addition to marked low cardiac output in the dilated right ventricle. The surgical findings corresponded to Carpentier classification type C. Cone reconstruction was performed. Bidirectional Glenn anastomosis was reguired because of low cardiac output in the remaining functional right ventricle after Cone reconstruction. The patient's postoperative course was uneventful, and tricuspid regurgitation and stenosis remained mild. The patients had no occurrence of right heart failure or arrhythmia for two years after surgery.

[Successful Surgical Repair of Left Coronary Ostial Aneurysm after Modified Bentall Procedure Using the Carrel Patch Technique].

A 38-year-old woman underwent aortic root surgery using the Carrel patch technique at the age of 14 years for annuloaortic ectasia of 59 mm. Although there were no clinical findings of Marfan syndrome or bicuspid aortic valve, the pathological findings of the aortic aneurysmal wall showed degeneration of the media. After 24 years, contrast-enhanced computed tomography (CT) showed an enlargement of the left coronary ostial aneurysm of 17 mm with saccular formation. Re-coronary reconstruction with the Piehler technique using an 8 mm Dacron graft was performed. The post-operative course was uneventful, and post-operative CT showed no pseudoaneurysm or stenosis at the anastomosis sites. The Carrel patch coronary ostial reconstruction has been shown to reduce coronary anastomotic pseudoaneurysms and to improve aortic root surgical outcomes. However, coronary ostial aneurysm is a true aneurysm and one of the later complications after the modified Bentall procedure using the Carrel patch technique. Although it is common in Marfan syndrome, the consensus on diagnosis, operative indication, and surgical procedure have not yet been established. Not only in Marfan syndrome, but also after coronary artery reconstruction using the Carrel patch technique, longer-term follow-up is necessary to take care for aneurysmal formation at coronary ostium.

[Aortic Root Replacement with Patch Closure of Membranous Ventricular Septal Aneurysm].

Membranous ventricular septal aneurysm (MSA) complicated with annuloaortic ectasia (AAE) is rare in adults. Herein, we reported two successful surgical cases of this setting. One case is 50-year-old man with extensive infective endocarditis with underwent aortic coarctation repair in childhood. MSA was incidentally diagnosed at preoperative examination. The other patient is 53-year-old man who had severe aortic regurgitation complicated with AAE and membranous type ventricular septal defect with MSA. Simultaneous surgery comprising patch closure of MSA and aortic root replacement was performed in both patients. As for patch closure of MSA, the technical modification should be necessitated according to the fragility of the upper margin of the MSA.

[Stanford Type B Acute Aortic Dissection Associated with Transcatheter Aortic Valve Implantation:Report of a Case].

Transcatheter aortic valve implantation (TAVI)-related Stanford type B aortic dissection is an extremely rare but potentially fatal complication. Here, we present a case of 82-year-old man who developed acute type B aortic dissection during transfemoral TAVI. During successful TAVI procedure, dissection in the descending aorta was demonstrated by transesophageal echocardiography. Computed tomography( CT) clearly showed Stanford type B aortic dissection and an intimal tear in severely tortuous part of the descending aorta. Cause of aortic dissection was supposed to be related to the guidewire or the device that passed across affected position. The patient showed no complication associated with aortic dissection, such as rupture or malperfusion. Therefore, he was treated conservatively, and follow-up CT confirmed progressive clotting of the false lumen. Although the indication for TAVI has got broaden recently, physicians should be always aware of possible aortic dissection.

Step-by-step aortic clamping technique for safe retrieval of the elephant trunk.

Staged repair of the aortic arch and downstream aorta using the elephant trunk technique is widely accepted for extensive aortic disease. However, elephant trunk retrieval is challenging in patients with unclampable descending aorta caused by extreme aneurysmal dilation or surrounding tissue adhesion. Here, we introduce a new elephant trunk retrieval technique using the step-by-step aortic clamping in descending aortic replacement of dissecting aortic aneurysm. This technique is a safe and feasible method of elephant trunk retrieval that consists of staged clamping and intraoperative ultrasound assessment of blood flow in the aorta.

[Total Arch Replacement with Brain Isolation Technique for Arch Aneurysm with Shaggy Aorta].

A shaggy aorta with a mobile atheromatous plaque in a thoracic lesion is considered a risk factor for cerebral infarction during aortic arch surgery. The brain isolation technique was introduced to prevent embolic stroke either by manipulating the severely atheromatous aorta, or by producing a sandblasting effect using the arterial jet in cardiopulmonary bypass. We performed total arch replacement with the aid of a brain isolation technique in four patients with aortic arch aneurysm complicated with a shaggy aorta between 2016 and 2020. Antegrade selective cerebral perfusion was established prior to systemic perfusion of the cardiopulmonary bypass. Total arch replacement using the frozen elephant technique was performed in all patients. There was no operative mortality, and all patients were discharged without major neurological complications. Therefore, the brain isolation technique could be a useful adjunctive method to prevent embolic stroke in patients who undergo total arch replacement for aortic arch aneurysm with a shaggy aorta.

[Patch Closure of Posterior Type Ventricular Septal Perforation with Posterior Left Ventricular Aneurysm through Right Ventricular Incision].

We report a case of patch closure of posterior type ventricular septal perforation (VSP) with posterior left ventricular aneurysm (PLVAN) through right ventricular incision. A 70-year-old man was transferred to our hospital because of persistent epigastric pain. He was diagnosed with inferior acute myocardial infarction, and percutaneous coronary intervention was performed to the right coronary artery[ atrio-ventricular(AV)]. After 2 weeks, he developed congestive heart failure and was treated with inotropic support and intra-aortic balloon pumping. Echocardiography and computed tomography (CT)showed posterior type VSP between PLVAN and the right ventricle. The operation was performed via standard median sternotomy and under cardiopulmonary bypass. After right ventricle incision parallel to the left anterior descending artery, there was VSP (20×20 mm) behind the trabecular septmarginalis (TSM). We closed VSP with a 2-layer patch (40×40 mm) consisted of Dacron and bovine pericardial patches. Postoperative echocardiography showed no residual shunt, and postoperative CT showed no enlargement of PLVAN. He was discharged home on foot without right heart failure and has been well without major complications.

Solo Smart Stentless Bioprosthesis for Infective Valve Endocarditis with Aortic Annular Abscess.

So far, there is still controversy regarding the optimal prosthetic valve for patients with active infective valve endocarditis with annular abscess. Here, we report the case of a 65-year-old woman who was diagnosed with infective endocarditis associated with extensive annular abscess. The patient underwent debridement of the abscess cavity followed by aortic valve replacement using a Solo Smart (SS) stentless bioprosthesis. Postoperative recovery was uneventful, with no signs of recurrent infection. Since the SS valve is designed for supra-annular and subcoronary implantation, it is considered to be an alternative to conventional prosthetic valves in patients with infective endocarditis with aortic annular abscess.

[Surgical Experience of Mitral Valve Plasty in Patient with Persistent Left Superior Vena Cava;Report of a Case].

A 45-year-old man diagnosed with severe mitral regurgitation was admitted to our hospital for surgical treatment. Preoperative computed tomographic imaging revealed a persistent left superior vena cava. At operation, cardiopulmonary bypass was established with ascending aortic and bicaval cannulation. In addition to 2 venous cannulas, we directly cannulated to the left superior vena cava for sufficient venous drainage. Mitral valve plasty consisted of triangular resection of P2 segment was performed through the right side left atriotomy. Postoperative course was uneventful and echocardiography 3 months after the operation showed trivial mitral regurgitation. Precise preoperative evaluation concerning the persistent left superior vena cava should be mandatory for appropriate management of cardiopulmonary bypass.

[Surgical Experience of Distal Aortic Arch Aneurysm Suspected to be Associated with Pre-existing Coarctation of the Aorta].

A 45 year-old-man who had undergone ventricular septal defect repair during childhood presented with hoarseness. He was diagnosed as having a distal aortic arch aneurysm by using computed tomography, and was referred to our hospital for surgical treatment. The operation was performed via a 4th intercostal thoracotomy in the right lateral position. The aortic aneurysm occupied the upper pleural cavity. The aortic arch was pressed up by the aortic aneurysm, so visual identification and clamping of the proximal aorta and the left subclavian artery were extremely difficult. Extracorporeal circulation was established via the right femoral artery and vein. Aneurysmal resection and graft replacement were performed using the open proximal method and retrograde cerebral circulation. The aneurysmal wall and proximal aorta were fragile and the proximal aorta was narrow, although the distal aorta was normal. The difference in diameters between the proximal and distal aorta suggested the presence of coarctation of the aorta.

[Surgical Results of Aortic Root Replacement;Technical Modification and Geometric Analysis of Aortic Root after Aortic Valve-sparing Procedure].

BACKGROUND: The Bentall procedure is a reliable treatment of various types of aortic root pathology. Furthermore, the aortic valve-sparing aortic root replacement also has been accepted as an ideal procedure especially in young patients. Recently, we have developed a simple valve-sparing operation focused on standardization and reproducibility. METHODS: From 2011 to 2017, 44 consecutive patients underwent aortic root replacement( Bentall 17, David 27)in our institution. Surgical results of these patients were evaluated retrospectively. Geometric parameters of reconstructed aortic root were analyzed to evaluate aortic valve function. RESULTS: There were 2 operative death( Bentall 2, David 0). Valve-sparing procedure was completed without conversion to valve replacement and no significant aortic insufficiency was noted soon after the operation. Patients underwent David operation were divided into 2 groups according to the annular diameter. There were 15 patients with large annulus and 12 with small annulus. The postoperative valve function was reproduced in both large and small annulus groups. From the results of geometric analysis of the aortic root, patients with large annulus and sino-tubular(ST) junction were anatomically more suitable and better treated with reimplantation technique. On the other hand, even in patients with small annulus, effective plication of ST junction and adequate suspension of commissure posts might be contribute to restore the valve competency with reimplantation technique. Two patients had aortic valve replacement 6 and 12 months after reimplantation, respectively. CONCLUSIONS: The acceptable outcome was demonstrated in patients underwent aortic root replacement. Aortic valve was reproduced well with our simple modification of valve-sparing operation. Although our modified technique is considered to be safe, reproducible and technically less demanding, close observation would be mandatory in this particular circumstance.

[Clinical Experience of Aortic Valve Replacement Using the New Stentless Bioprosthesis].

BACKGROUND: The SOLO SMART valve is a bovine pericardial stentless bioprosthesis which shows superior hemodynamic performance compared to the stented valves. It is designed for supraannular and subcoronary implantation. We report our surgical experience and results in patients undergoing aortic valve replacement(AVR) with this new bioprosthesis. METHODS: Since June 2016, 19 patients with various types of aortic valve disease (mean age:72±7 years, 58% males) have undergone AVR with a SOLO SMART stentless bioprosthesis. Fourteen patients(74%)showed aortic stenosis( AS) and 9 patients(47%)had concomitant procedures;coronary bypass grafting (n=4), mitral valve surgery (n=3), total arch replacement (n=1), and pulmonary venous isolation( n=1). There was 1 patient with active infective valve endocarditis( IE) complicated with annular abscess and 1 patient was a redo AVR case. Surgical results of these patients were evaluated retrospectively. The hemodynamic performance was investigated with transthoracic echocardiography in pre and postoperative period. RESULTS: There was no operative death and 1 hospital death (postoperative subdural hematoma;Heyde syndrome). One patient showed a mild trans-prosthetic valve leak. No patient required reoperation. Although postoperative transient thrombocytopenia was noted, it had cured at the time of discharge. At the last echocardiographic evaluation, the peak and mean gradients in the patients undergoing AVR for AS were 17±7 and 9±5 mmHg, respectively. No prosthesis-patient mismatch (PPM) occurred in any patient. CONCLUSIONS: AVR using a SOLO SMART stentless bioprosthesis was performed with acceptable morbidity and mortality. The SOLO SMART stentless bioprosthesis showed excellent hemodynamic performance and early results. Because of favorable effective orifice area, the valve is attractive for patients at risk for PPM. Furthermore, it is expected to contribute to more complex AVR with concomitant mitral valve surgery, active IE or redo situation.

[Surgical Outcomes of Aortic Root Repair in Type A Acute Aortic Dissection].

We carried out a retrospective evaluation of the early and long-term outcomes of aortic root reconstruction for type A acute aortic dissection. Between January 2001 and March 2015, a total of 21 patients underwent aortic root reconstruction. Bentall operation was performed in 9 patients( B group) and Patch plasty of sinus of Valsalva patients was performed in 12 patients (V group). There were 3 in-hospital deaths due in the B group and 1 death due in the V group. Overall survival in the V group was 72.9% and was not significantly different from survival in the B group(66.7%). In conclusion, our study demonstrated good early and long-term outcomes for patch plasty of sinus of Valsalva for type A acute aortic dissection. There was no postoperative patch-related complication in the V group. Thus, a patch plasty of sinus of Valsalva for type A acute aortic issection may be acceptable.