[Staged Hybrid Treatment for a Coronary Artery Pseudoaneurysm after Percutaneous Coronary Intervention;Report of a Case].

We herein report a case of a coronary artery pseudoaneurysm caused by previous catheter intervention, who was treated with a staged hybrid procedure of coronary artery bypass grafting (CABG) and subsequent percutaneous catheter intervention. A 59-year-old man underwent an urgent percutaneous coronary stent placement for acute myocardial infarction at segment 1 of the right coronary artery, where later coronary pseudoaneurysm developed. Prior to closure of the aneurysm by covered stent placement, he underwent CABG to segment 3 using the right internal thoracic artery graft, in case the implanted covered stent should acutely thrombose in the future. The graft flow was increased by producing an artificial stenosis just proximal to the anastomosis. The present technique would be a safe and viable option of therapeutic strategy to fix coronary artery pseudoaneurysms that have been formed at the proximal segment of main coronary arteries.

Thoracoscopic infrared ablation to create a box lesion as a treatment for atrial fibrillation.

BACKGROUND: Creating a box lesion in the posterior wall of the left atrium from the epicardial side of the beating heart remains a challenge. Although a transmural lesion can be created by applying radiofrequency (RF) energy at clampable sites, it is still difficult to create a transmural lesion at unclampable sites because the inner blood flow in the unclampable free wall weakens the thermal effect on the outside. Our aim was to apply the newly developed infrared coagulator to create linear transmural lesions on the beating heart thoracoscopically to treat atrial fibrillation (AF). CASE PRESENTATION: A 71-year-old male was referred to our hospital with a diagnosis of hypertrophic cardiomyopathy and permanent atrial fibrillation. The patient was first diagnosed with atrial fibrillation 20 years before. Direct current cardioversion had been performed every few years a total of four times, but sinus rhythm restoration had always been temporary. On February 27, 2020, thoracoscopic PV isolation together with infrared roof- and bottom-line ablation to create a box lesion and left atrial appendage amputation (LAAA) were performed. The coagulator could be applied to clinical thoracoscopic surgery to successfully create a box lesion without any complication. The patient restored a regular sinus rhythm, it has been maintained for eleven months, and there have been no adverse events. CONCLUSIONS: The infrared coagulator might have enough potential to create transmural lesions on the beating heart in thoracoscopic AF surgery.

En Bloc Left Pulmonary Vein and Appendage Isolation in Thoracoscopic Surgery for Atrial Fibrillation.

BACKGROUND: We evaluated the safety and rhythm control effectiveness in en bloc isolation of the left pulmonary vein (PV) and appendage conducted as part of the thoracoscopic procedure for bilateral PV isolation, non-PV ablation, and appendage closure for atrial fibrillation (AF). METHODS: Procedural safety was evaluated by reviewing the surgical records. Rhythm control was examined in accordance with the Heart Rhythm Society guidelines at postoperative months 1, 3, 6, and 12, and yearly thereafter. The sinus rhythm rates at postoperative years 1 and 2 were compared with the corresponding data from our previous procedure without the en bloc technique. RESULTS: Starting in 2014, the en bloc technique was applied to 238 nonvalvular AF patients and successfully performed in all but 23 patients. The mean operation time was 88 minutes. There were no hospital deaths or major procedure-related complications. The mean follow-up period was 1.7 years. The sinus rhythm rates at postoperative years 1 and 2 were 85% and 80% in paroxysmal, 76% and 70% in persistent, and 67% and 61% in long-standing persistent AF, respectively, without antiarrhythmic drug use. Compared with the previous procedure (n = 324), sinus rhythm rates were higher in long-standing persistent AF (67% vs 50% at 1 year and 61% vs 40% at 2 years; p = 0.04). No patients suffered cardiogenic thromboembolisms without anticoagulation. CONCLUSIONS: Thoracoscopic en bloc left PV and appendage isolation was safely achieved in most patients. Using this technique may contribute to better rhythm control results than not using it in cases of long-standing persistent AF.

Thoracoscopic stapler-and-loop technique for left atrial appendage closure in nonvalvular atrial fibrillation: Mid-term outcomes in 201 patients.

BACKGROUND: Left atrial appendage (LAA) closure can be an alternative to oral anticoagulation to prevent cardiogenic thromboembolisms in patients with nonvalvular atrial fibrillation. OBJECTIVE: The purpose of this study was to retrospectively evaluate the safety, completeness, and mid-term prevention of our thoracoscopic stapler-and-loop technique for LAA closure. METHODS: Patients operated on between October 2008 and February 2017 were reviewed. Endoscopic stapler and ligation loops were used. Patients received 1 month of anticoagulation before discontinuation. Hospital death and procedure-related major complications (thromboembolism, hemorrhagic events, phrenic palsy) were the primary composite endpoint for safety, and cardiogenic thromboembolisms were the endpoint for prevention. Brain magnetic resonance imaging investigated new thromboembolic spots 1 year after surgery. RESULTS: There were 201 patients (118 men, 83 women) with a mean age of 74 years (range 68-94) years, mean CHA2DS2-VASc score (± SD) 4.1 ±1.4, and mean HAS-BLED score 2.9 ± 1.0. Mean operation time was 28 minutes. All LAAs were removed, and intraoperative transesophageal echocardiography confirmed completeness of the closure in each patient. No hospital deaths or major procedure-related complications occurred. Follow-up results for 198 patients (98%) over a mean period of 48 months (range 12-110) revealed that 2 patients developed cardiogenic thromboembolisms (0.25 event per 100 patient-years). Magnetic resonance imaging of 51 patients with a mean CHA2DS2-VASc score of 4.7 ± 1.6 revealed 1 new small spot in each of 2 patients (3.9%; 3.9 spots per 100 patient-years). CONCLUSION: Our thoracoscopic stapler-and-loop technique swiftly, safely, and completely closed LAAs in patients with nonvalvular atrial fibrillation and provided acceptable mid-term prevention without anticoagulation.

Ventricular Septal Perforation: A Rare but Life-Threatening Complication Associated with Takotsubo Syndrome.

A 71-year-old woman was admitted with dyspnea. An electrocardiogram revealed ST-segment elevation, and echocardiography showed akinesis in the left ventricular apex with hyperkinesis of the base. Coronary angiography revealed no stenosis, and left ventriculography indicated ballooning of the left ventricular apex and apical ventricular septal perforation. We diagnosed the patient with Takotsubo syndrome complicated by ventricular septal perforation, which was surgically repaired. Although ventricular septal perforation is recognized as a life-threatening complication after acute myocardial infarction, it can also occur after Takotsubo syndrome. The early recognition and management of this condition can help prevent morbidity and mortality.

A Mass Filling the Right Atrium: Primary Cardiac Rhabdomyosarcoma.

A 43-year-old woman presented with worsening shortness of breath and lower-extremity edema. Echocardiography and computed tomography showed obstruction of blood flow due to a mass filling the right atrium. Emergency surgery was performed for circulatory failure. Primary cardiac rhabdomyosarcoma was diagnosed based on a histological examination. The patient died about two months after the diagnosis despite surgical excision and radiation therapy. The poor prognosis may have resulted from the grossly incomplete removal of the tumor and chemotherapy intolerance. We herein report a case of primary cardiac rhabdomyosarcoma filling the right atrium and offer possible reasons for the poor prognosis.

Sternum lifting technique for thoracoscopic internal thoracic artery harvest.

We employed the Laparolift and Laparofan (Origin Medsystems Inc., CA, USA) and developed a sternum lifting technique to create a sufficient intra-pleural space between the heart and the sternum in which the left internal thoracic artery (ITA) in situ graft could be thoracoscopically mobilized. Between June and December 2004, this technique was applied to 12 consecutive patients (eight men, four women, aged 68.5+/-9.6 years) undergoing minimally invasive coronary artery bypass grafting via a left mini-thoracotomy. The Laparofan, connected to the arm of the lift machine (Laparolift), was introduced through a subxyphoidal entry and opened beneath the sternum. The sternum was elevated by about 5 cm until a sufficient working space was created under the sternum. With left hemipulmonary collapse, the left ITA was thoracoscopically taken down through the axillary ports. There was no procedural conversion to direct harvesting. The mean thoracoscopic harvesting time was 34.5+/-7.7 min. There was no mortality and no instrument-related morbidities. Patency of each ITA graft was angiographically confirmed. In conclusion, despite the limited experience, the present sternum elevation technique using the Laparolift system is a viable method for increasing the intra-pleural working space beneath the sternum during thoracoscopic ITA harvesting.

VATS thoracic-duct division for aortic surgery-related chylous leakage.

Traumatic chylothorax is a serious morbidity due to aortic surgery. We treated this complication successfully by supradiaphragmatic thoracic-duct division in five adults (three men, two women, aged 61.5+/-19.5 years) and a 3-year-old male infant after an average interval of 4.1+/-1.8 days following initial aortic surgery: graft-replacement of subclavian or descending aortic aneurysm in the adults, and correction of aortic coarctation in the infant. A right thoracoscopic approach was used in the adults and the left thoracotomy was re-used in the infant. Individual exposure and division of the thoracic duct was accomplished using an ultrasonic coagulator. The operating time was 22+/-5.5 min for the thoracoscopy cases, and 70 min for the infant. There was no mortality and no procedure-related morbidity, and chylous leakage ceased immediately in all patients. There was no recurrence of chylothorax during a mean follow-up period of 17+/-9.7 months. Despite our limited experience, we conclude that the present supradiaphragmatic thoracic duct division technique (right thoracoscopy in adults) is safe and perfectly effective, and therefore prompt application of this method is recommendable for treatment of aortic surgery-related traumatic chylo-leakage, particularly in vulnerable elderly or infant patients.

Influence of PMEA-coated bypass circuits on perioperative inflammatory response.

BACKGROUND: Poly(2-methoxyethylacrylate) (PMEA) is a new coating material, and several experimental studies have revealed excellent biocompatibility of PMEA-coated cardiopulmonary bypass circuits. The clinical utility of the PMEA-coated circuits was compared with that of uncoated circuits, focusing on perioperative inflammatory response. METHODS: Twenty-two patients were randomized to PMEA-coated (group P; Capiox RX25; n = 11) or uncoated (group U; Capiox SX10; n = 11) circuit group, and underwent coronary artery bypass grafting and/or valve operations. The following markers, as well as clinical outcomes, were analyzed perioperatively: (a) complement activation by C3a (including C3a-desArg) concentrations; (b) leukocyte activation by polymorphonuclear-elastase concentrations; (c) acute phase inflammatory response by interleukin-6 concentrations; and (d) platelet preservation by number of platelets. RESULTS: The maximal values of C3a and polymorphonuclear-elastase were significantly lower in group P than in group U. The intergroup difference of interleukin-6 was not significant. Although preservation of platelets was significantly better in group P until 1 hour after initiating cardiopulmonary bypass, no significant intergroup difference was observed thereafter. The duration of postoperative mechanical ventilation revealed no significant intergroup difference. CONCLUSIONS: The PMEA-coated circuits exhibited better suppression of perioperative complement and leukocyte activation than the uncoated circuits. In addition, the price of the PMEA-coated circuits is the same as that of the uncoated circuits. Therefore, we judged that the clinical utility of the PMEA-coated circuits is superior to those of the uncoated circuits.

Left atrial dissection after double valve replacement.

Left atrial dissection, a rare complication occurring mainly after mitral repair, is reported after double valve replacement in a patient with a connective tissue disease. A 63-year-old woman with systemic sclerosis underwent double valve replacement. Laceration of the tissue between the two mechanical prostheses and dissection of the left atrial wall emerged postoperatively and regurgitation through the dissection caused heart failure, which later improved without surgery. The possible causes of the dissection were thought to be shear forces against the tissue between the two prostheses and tissue fragility due to systemic sclerosis and corticosteroid therapy.

Valve-sparing operation for aortic root aneurysm in patients with bicuspid aortic valve.

Aortic root aneurysms are not rare in patients with bicuspid aortic valve, but valve-sparing operations to treat them remain challenging. We describe our surgical method of reconstructing only two commissures, which is extremely simple and easy to reproduce without aortic stenosis.

Conventional repair and operative stent-grafting for acute and chronic aortic dissection.

Conventional graft replacement of the ascending aorta and surgically endovascular stent-grafting of the proximal descending aorta were performed concomitantly in a 82-year-old woman with an acute DeBakey type II aortic dissection and a chronic DeBakey type IIIb aortic dissection. Postoperative computed tomography and angiography showed the adequately replaced ascending-aortic prosthesis, the well-expanded stent-graft, and the thrombosed false lumen in the descending aorta.

Needle-guided mini-entry in video-assisted coronary artery bypass.

In minimally invasive coronary artery bypass (MICAB), a video-assisted needle-guided technique was used to make a mini-thoracotomy or an access-port just above the target site in the left anterior descending coronary artery (LAD). After thoracoscopic preparation of the left internal thoracic artery (LITA) and pericardiotomy, a 7-cm, 23-gauge needle was used to examine the skin-point where the needle vertically penetrated the chest wall and thoracoscopically indicated the target site in the LAD. This point was used as the mid-point of the skin incision for a 6-cm thoracotomy (six cases) or a 33-mm access-port (four cases). Consequently, there was no conversion of approach except in the patient with pulmonary dysfunction, and each LITA-LAD anastomosis was completed directly through the mini-entry. There was no mortality and no procedure-related morbidity. Patency of each graft was confirmed within a week after surgery. After a mean follow-up period of 12.5+/-7.8 months, all of the patients except one, who died of stroke 1 year after surgery, are alive with no ischemic events. Although our experience is limited, the present video-assisted needle-guided technique can be a simple method to facilitate appropriate positioning of a mini-entry in MICAB to the LAD with a thoracoscopically prepared LITA graft.

A new needle driver for minientry coronary artery bypass.

PURPOSE: This article describes our clinical experience with a new needle driver (Olympus, Tokyo, Japan), which we have produced to facilitate minithoracotomy or port-access coronary artery anastomosis with the running suture technique. METHODS: The needle driver is 21 cm long, weighs 38 g, and has a grip shaft 1.4 cm in diameter. The device is held like a pencil. A side lever and a revolving disk in the shaft are manipulated with the fingers; a fine needle with a 7-0/8-0 monofilament suture can be grasped/released and driven to penetrate the coronary arterial wall. This device was employed in 10 consecutive patients (8 men, 2 women, 73 +/- 7.5 years old), and off-pump bypass to the left anterior descending artery was achieved using the left internal thoracic artery or vein via a minithoracotomy (4.2 +/- 0.6 cm long). RESULTS: There was no instrument-related injury during each anastomosis. The mean sewing time per anastomosis was 12 minutes (range, 8-18 minutes). Angiography confirmed the patency of the graft in all cases. CONCLUSIONS: Although our experience is limited, we consider the present needle driver to be a viable device for facilitating off-pump, minientry coronary artery anastomosis with the suturing technique.

Open retroperitoneal irrigation for graft infection after thoracoabdominal aortic aneurysm repair.

A successfully-treated case of graft infection after thoracoabdominal aortic repair is reported. A 61-year-old male underwent graft replacement of a Crawford type IV thoracoabdominal aortic aneurysm and developed graft infection due to methicillin-resistant Staphylococcus aureus. After 35 days' open retroperitoneal irrigation, the culture around the graft turned negative, and omental transposition and skin flap transfer were successfully conducted. The long-term open retroperitoneal irrigation could be conducted without significant complications, and it was very effective in controlling the severe infection.

Total aortic arch aneurysm repair using a stent graft without cardiac or cerebral ischemia.

A 74-year-old man with an aortic arch aneurysm and a chronic type IIIb aortic dissection underwent total aortic arch repair without cerebral or cardiac ischemia. After confirming no atheromatous change in the ascending aortic wall, a custom-designed 4-limbed graft, prepared for both arterial return of cardiopulmonary bypass and reconstruction of the arch vessels, was anastomosed onto the right side of the ascending aorta. The 3 arch vessels were then bypassed sequentially during systemic cooling and monitoring cerebral perfusion with near-infrared oxymetry. After aortic cross-clamping, a stent graft was inserted into the distal arch from the distal ascending aorta, maintaining cerebral and cardiac perfusion. This procedure is indicated especially in a high-risk patient who has an aortic arch aneurysm without severe atheromatous change in the ascending aorta and the arch vessels.

Thoracoscopic stand-alone left atrial appendectomy for thromboembolism prevention in nonvalvular atrial fibrillation.

OBJECTIVES: This study sought to evaluate thoracoscopic stand-alone left atrial appendectomy for thromboembolism prevention in nonvalvular atrial fibrillation (AF). BACKGROUND: Closing the left atrial appendage (LAA) is an efficacious alternative to oral anticoagulation as prevention against AF-induced thromboembolism, provided that the procedure is safe and complete. METHODS: Thirty patients (mean age, 74 ± 5.0 years) who had had thromboembolisms were selected. A subgroup of 21 patients (mean age, 75 years; mean CHA2DS2 VASc score, 4.5) urgently needed an alternative treatment to anticoagulation: warfarin was contraindicated due to hemorrhagic side effects in 13, the international normalized ratio was uncontrollable in 7, and transient ischemic attacks had developed immediately after the warfarin dose was reduced for oncological treatment in 1. The LAA was thoracoscopically excised with an endoscopic cutter. RESULTS: Thoracoscopic appendectomy (mean operating time, 32 min, switched to mini-thoracotomy in 2 cases) led to no mortality and no major complications. Three-month post-operative 3-dimensional enhanced computed tomography, performed with patients' consent, confirmed the completeness of the appendectomy. Patients have been followed for 1 to 38 months (mean, 16 ± 9.7 months [18 ± 9.4 months for the subgroup]). One patient died of breast cancer 28 months after surgery. Despite discontinued anticoagulation, no patients have experienced recurrence of thromboembolism. CONCLUSIONS: Thoracoscopic stand-alone appendectomy is potentially safe and may allow surgeons to achieve relatively simple, complete LAA closure. Further experience may demonstrate this technique to be a viable option for thromboembolism prevention in nonvalvular AF.

Type A aortic dissection with transient myocardial ischemia caused by intimal flap inverting into the left ventricle.

A 41-year-old man with sudden onset of chest oppression and downslope ST depression was diagnosed as having type A aortic dissection with angina pectoris and aortic regurgitation. Intraoperative transesophageal echocardiogram (TEE) showed intimal flap inverting into the left ventricle through the aortic valve. This case was rare in that transient myocardial ischemia was induced not by dissection of the aortic root reaching the coronary ostia but by back-and-forth movement of the intimal flap, covering the coronary ostia and interrupting the coronary artery flow. TEE was important for correct diagnosis.