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.

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.

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.

Simple Retrieval Technique of the Elephant Trunk by Partial Aortic Clamping.

The frozen elephant trunk technique for various thoracic aortic diseases is widely accepted to facilitate future downstream aortic surgery. However, in some cases, the descending aorta is unsuitable for cross-clamping due to progressive aneurysmal changes or dense adhesions to surrounding structures, and frozen elephant trunk retrieval becomes challenging. This paper presents a case of successful frozen elephant trunk retrieval by partial clamping of the descending aortic aneurysm without dissection of peri-aneurysmal adhesions, and subsequent encircling.

[Surgical Strategy for Aortic Arch Aneurysms in Octogenarians].

BACKGROUNDS: The purpose of this study was to evaluate the short- and mid-term outcomes of open aortic arch surgery and debranching thoracic endovascular aortic repair( TEVAR) in octogenarians. METHODS: Between 2011 and 2019, 26 patients with atherosclerotic aortic arch aneurysms underwent surgery at our institution [open aortic arch surgery( group O):10 patients, debranching TEVAR(group D):16 patients]. RESULTS: There was no operative death in either group. The mean length of hospitalization and intensive care unit stay were 49 and 13 days in group O and 12 and 2 days in group O, respectively. Kaplan-Meier analyses of overall survival (1/6/12/24/36/48 months) showed mortality rates of 100/100/88/88/70/70% in group O and 100/100/87/61/43/26% in group D, respectively. CONCLUSIONS: The acceptable outcomes was demonstrated in octogenarians underwent both open aortic arch surgery and debranching TEVAR. Because of early postoperative recovery, debranching TEVER is considered to be a feasible alternative to conventional open aortic arch surgery in octogenarians.

Ruptured aneurysm of coronary arteriovenous fistula without aneurysmal coronary artery.

BACKGROUND: Approximately 25% of coronary arteriovenous fistulas present aneurysmal dilatation; however, spontaneous rupture of the aneurysm is rare. Most coronary arteries branching the feeding arteries demonstrate aneurysmal formation, possibly because of shunt flow. CASE REPORT: A 48-year-old woman was referred to our institution for surgical management of ruptured aneurysm of coronary arteriovenous fistula. The aneurysm was located on the left-anterior aspect of the pulmonary artery trunk, communicating with both left and right coronary arteries through two small feeding arteries draining into the pulmonary artery trunk. Both left and right coronary arteries showed normal diameter. The feeding arteries were ligated externally, and fistulous openings were closed within the aneurysm. Postoperative course was uneventful. CONCLUSION: Aneurysm of coronary arteriovenous fistula can occur in patients without aneurysmal coronary artery. Although the association of ruptured aneurysm with coronary fistulas is relatively rare, it should be considered a potential cause of acute cardiac tamponade.

[Successful surgical treatment for aortic valve regurgitation and thoracoabdominal aortic aneurysm in a patient with homozygous familial hypercholesterolemia; report of a case].

A 46-year-old woman with homozygous familial hypercholesterolemia was referred due to aortic regurgitation. The patient was introduced selective low density lipoprotein cholesterol(LDL)apheresis 20 years ago. Echocardiogram revealed severe aortic regurgitation, and computed tomography revealed thoracoabdominal aortic aneurysm. We considered 2 staged operations were necessitated. Firstly, aortic valve replacement was performed. Emergent coronary artery bypass grafting was also done because intraoperative myocardial ischemia was strongly suspected from left ventricular hypokinesis. One year later, replacement of thoracoabdominal aorta was performed. Post-operative course was uneventful and the patient was discharged at post-operative day 21. The patients with homozygous familial hypercholesterolemia must be strictly followed up because systemic atherosclerosis frequently exacerbates despite selective LDL apheresis.

[Bilateral pulmonary artery banding for complex congenital heart disease in a patient with trisomy 13; report of a case].

We described a case of a neonate of 13 trisomy with hypoplastic aortic arch and multiple ventricular septal defect (VSD). The patient presented symptoms of congestive heart failure due to pulmonary high flow. Because of ductal patency without prostaglandin infusion, bilateral pulmonary artery banding was performed for regulation of pulmonary high flow. Surgical intervention improved the clinical symptoms of the patient and permitted the patient to be discharged. We concluded that palliative surgery for the patient contributes to improve the quality of life both the patient and the family. This is the 1st report of bilateral pulmonary artery banding for a patient with 13 trisomy.

[Intraoperative cerebral malperfusion complicated with axillary artery cannulation].

To minimize the risk of malperfusion, axillary arterial cannulation which avoids retrograde flow, has been widely used in patients undergoing operations for various types of aortic pathologies. Despite several advantages of this technique, cerebral malperfusion is getting known and might be due to newly developed arterial damage or dissection. Eighty-four patients underwent cannulation of the axillary artery in recent 5 years. Malperfusion occurred in 3 patients with significant regional cerebral oxygen desaturation during operation. Axillary arterial perfusion was stopped and oxygen saturation was elevated immediately. The perfusion was switched to the femoral artery and following procedure was completed. Although axillary arterial cannulation is an attractive alternative, neither axillary nor femoral arterial perfusion is perfect to avoid the cerebral malperfusion. Whichever perfusion site is used, special care should be taken for intraoperative finding and appropriate use of each techniques.

[Our technical modification of aortic valve sparing operation focused on standardization and reproducibility].

BACKGROUND: The aortic valve-sparing operation has been accepted as an ideal procedure for the treatment of aortic root aneurysm, especially in young patients. However, this operation is thought to be technically difficult due to lack of conceptual understanding of the procedure for many surgeons. In order to overcome the surgical problem, we have developed a simple valve-sparing aortic root replacement focused on standardization and reproducibility. METHODS: Seven consecutive patients underwent the aortic valve-sparing operation in our institution.Our surgical strategy to restore valvular competency is based on the concept of inserting a dilated aortic annulus into small sized graft. Regardless of annular diameter, the Valvalva graft of 26 mm was used in all patients. Proximal end of the graft is secured on the outside of the left ventricular outflow tract with 12 mattress sutures. The 3 commissures are suspended upward inside the graft as possible. The remnants of aortic sinuses are sutured to the graft in U-shaped manner using continuous suture line. If necessary, aortic cusp repair was performed. Coronary arteries are reconstructed by Piehler's method. RESULTS: There was no operative death. Valve-sparing procedure was completed without conversion to valve replacement and no significant postoperative aortic insufficiency was noted. CONCLUSIONS: The excellent outcome was demonstrated with our simple modification. Although we recommend this technique of the aortic valve-sparing procedure which is reproducible and technically less demanding, close observation would be mandatory concerning with valvular durability in this particular circumstance.

[Re-do operation for coronary stenosis after Cabrol procedure; report of a case].

The Cabrol technique has been used to reimplant coronary arteries at the time of aortic root replacement. We describe a case of coronary stenosis after Cabrol procedure. A 42-year-old female with Marfan syndrome and chronic type B dissection who underwent aortic root replacement with Cabrol procedure complained of chest pain. Computed tomography( CT) showed extended thoraco-abdominal aortic aneurysm. Angiography revealed bilateral Cabrol limb stenosis at anastomotic sites. Re-do operation was performed under median re-sternotomy. Pannus around the coronary anastomosis was resected and patch extension using bovine pericardium was performed. Reconstruction of coronary arteries was completed by Piehler procedure and total arch replacement with elephant trunk technique was concomitantly performed. Post-operative course was uneventful. CT revealed the release from coronary stenosis.

Large cardiac wall hematoma with rapid growth: a case report of a potentially catastrophic complication during cardiac surgery.

BACKGROUND: Rapid growth of cardiac wall hematoma is a rare but potentially fatal complication of cardiac surgery. However, its pathophysiology and optimal management remain undefined. CASE PRESENTATION: Here we present a rare case of a large cardiac wall hematoma in the right ventricle during a thoracic aortic and valvular surgery. The hematoma expanded rapidly with epicardial rupture during cardiopulmonary bypass. We could establish non-surgical hemostasis and prevent further expansion of hematoma by early weaning of the cardiopulmonary bypass, followed by the administration of protamine and manual compression by hemostatic agent application. His postoperative recovery was uneventful and upon computed tomography analysis, the hematoma was observed to have absorbed completely at 1 week postoperatively. The patient is doing well 1 year after the surgery without evidence of recurrent cardiac wall hematoma on follow-up computed tomography. CONCLUSIONS: Cardiovascular surgeons should bear in mind this potentially catastrophic complication during cardiac surgery. Because of the vulnerability of the cardiac wall at the area of the hematoma, we believe that a hemostatic approach without sutures may be effective for this lethal complication.

Surgical repair of deep femoral artery aneurysm complicated by deep vein thrombosis and pulmonary embolism.

Isolated deep femoral artery aneurysms are rare and tend to be large at the time of diagnosis owing to their deep anatomic location. Deep femoral artery aneurysms are often complicated by rupture, with subsequent lower limb amputation. However, a large aneurysm can compress the surrounding deep femoral vein, leading to thrombosis. In the present report, we have described a rare surgical case of deep femoral artery aneurysm complicated by deep femoral vein thrombosis and pulmonary embolism. Preoperative inferior vena cava filter placement was effective for preventing perioperative worsening of the pulmonary embolism in this particular circumstance.

Aortic remodelling effect of the frozen elephant trunk technique on Stanford type A acute aortic dissection.

Total arch replacement using the frozen elephant trunk procedure is performed for true lumen expansion of the descending aorta in patients with type A acute aortic dissection. However, the remodelling effect of the frozen elephant trunk on the dissected descending aorta is unclear. We aimed to evaluate the effect of the frozen elephant trunk on postoperative descending aortic remodelling after surgery. Between December 2012 and January 2020, we retrospectively investigated 24 patients who underwent total arch replacement using the frozen elephant trunk for type A acute aortic dissection. Remodelling of the descending aorta was evaluated using computed tomography. The aortic remodelling effect, based on aortic true lumen ratio, was determined for (i) DeBakey type (type I versus type III retrograde); (ii) thoracic endovascular aneurysm repair reintervention status (reintervention versus no reintervention); and (iii) stent length of the frozen elephant trunk (60 vs 90 mm). Postoperative true lumen ratio significantly increased in the type I dissection group. The true lumen ratio in the no-reintervention group, which had many patients with the type I dissection, significantly increased after the frozen elephant trunk. Aortic remodelling due to the frozen elephant trunk can be expected after type I acute aortic dissections.

Spontaneous Lumbar Artery Injury Resulting in Retroperitoneal Hematoma Mimicking Abdominal Aortic Aneurysm Rupture.

A 73-year-old woman, who had previously undergone endovascular aortic repair (EVAR), developed severe back pain while shoveling snow. Preoperative computed tomography (CT) revealed marked retroperitoneal hematoma around the abdominal aortic aneurysm (AAA) with extravasation of contrast media. Intraoperative angiography demonstrated spontaneous lumbar artery injury (SLI). The bleeding lumbar artery was embolized using lipiodol, and deteriorated hemodynamics were stabilized. SLI is rare and can mimic the clinical symptoms and CT findings of AAA rupture. Vascular surgeons should focus on the status of the aneurysmal sac and the possibility of another retroperitoneal disease to determine appropriate treatment options, despite successful EVAR for AAA.

Left coronary button aneurysm presenting with progressive enlargement after aortic root replacement.

BACKGROUND: Aneurysmal degeneration of the coronary button after aortic root replacement using the button technique is a rare but potentially life-threatening complication. However, the appropriate management of this complication, including the indications for conservative and surgical treatment, is still unknown. CASE PRESENTATION: Here we present a 38-year-old woman who successfully underwent surgical repair of a left coronary button aneurysm using the graft interposition technique 24 years after aortic root replacement. Because follow-up computed tomography after aortic root replacement showed a progressively enlarging left coronary button aneurysm, the patient was judged an acceptable candidate for surgical treatment, considering the potential risk of aneurysmal rupture and subsequent myocardial infarction. The postoperative recovery was uneventful. The patient is doing well 1 year after the surgery. CONCLUSIONS: We believe that serial follow-up using computed tomography is mandatory for coronary button aneurysms, and surgical intervention may be considered if progressive enlargement of the aneurysm is observed, especially in younger patients.

Double left brachiocephalic vein in an adult patient who underwent cardiac surgery: a case report.

BACKGROUND: A double left brachiocephalic vein is an extremely rare venous anomaly. CASE PRESENTATION: Herein, we present the case of a 79-year-old woman with a double left brachiocephalic vein who underwent cardiac surgical procedures. The normal left brachiocephalic vein was patent, and the accessory left brachiocephalic vein passed across the heart and aorta in front of the pericardium and drained into the superior vena cava. She underwent surgical ligation of the accessory left brachiocephalic vein, followed by an aortic valve replacement and coronary artery bypass grafting. Her postoperative recovery was uneventful, without any venous complications from the ligation of the accessory vein. The patient is doing well one year after the surgery. CONCLUSIONS: The presence of double left brachiocephalic veins should be recognized before cardiac surgery in order for us to avoid intraoperative technical issues concerning this venous anomaly and unpredictable intraoperative bleeding due to injury of the accessory left brachiocephalic vein.

Aortobifemoral Bypass Grafting with Reversed L-Shaped Technique for Endograft Infection.

Endograft infection after abdominal endovascular aortic repair is a rare but catastrophic complication associated with high perioperative mortality and postoperative recurrent infection. The optimal surgical treatment is still controversial, particularly regarding in situ or extra-anatomical revascularization. Herein, we describe a successful surgically treated case of a patient with an endograft infection complicated with abscess formation in the retroperitoneal space around the right common iliac artery. We performed an aortobifemoral bypass grafting using the reversed L-shaped technique by rerouting the right leg of the new prosthesis to avoid the infected area. The patient is doing well 1 year after surgery without recurrent infection. This technique was considered to be advantageous because revascularization could be performed remotely from the infected area.

Right-sided double valve replacement in an adult patient who underwent surgery for pulmonary stenosis in childhood: a case report.

BACKGROUND: Pulmonary regurgitation and the subsequent functional tricuspid regurgitation are frequently observed in adult patients who previously underwent pulmonary valvular operations. Pulmonary valve replacement, in combination with tricuspid annuloplasty, is frequently performed in adult patients. However, postoperative worsening or recurrence of tricuspid regurgitation is a major concern after pulmonary valve replacement with tricuspid annuloplasty. CASE PRESENTATION: Herein, we describe the case of a 56-year-old woman with severe pulmonary regurgitation and functional tricuspid regurgitation after congenital pulmonary stenosis surgery in childhood. Functional tricuspid regurgitation was due to tricuspid annular dilatation, marked right ventricle enlargement, and significant tethering. We performed a bioprosthetic double valve replacement, and the postoperative course was uneventful. The patient is doing well one year after the surgery without prosthetic valve dysfunction. CONCLUSIONS: When functional tricuspid regurgitation is severe and is associated with right ventricular dilatation and subsequent tethering, tricuspid valve replacement rather than annuloplasty should be considered.