Endovascular Aneurysm Repair Using Physician-Modified Fenestrated Endurant Contralateral Limb for Internal Iliac Artery Preservation.

CLINICAL IMPACT: We developed a novel Endovascular aortic repair technique for internal iliac artery preservation using a physician modified Endurant contralateral limb. This procedure was safe and reliable for preserving internal iliac artery flow in 24 patients with common and internal iliac artery aneurysms. We believe that our technique has the potential to expand the anatomic indications for internal iliac artery preserving procedures.

Successful Endovascular Repair of a Ruptured Common Iliac Artery Aneurysm Associated with an Ileal Pouch Neobladder Fistula.

A spontaneous fistula between a ruptured common iliac artery aneurysm and the ileal pouch neobladder is quite rare. We present the case of a 74-year-old man presenting with intense abdominal pain and massive hematuria. Computed tomography angiography revealed a ruptured common iliac artery aneurysm-ileal pouch neobladder fistula. His hemodynamics was unstable; emergent endovascular aortic repair was performed successfully. Infection and dysfunction of the neobladder were avoided owing to appropriate management.

Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in-hospital mortality and failure to be weaned from extracorporeal membrane oxygenation.

Postcardiotomy cardiogenic shock (PCCS) is a rare clinical entity associated with substantial morbidity and mortality. It is characterized by heart failure that results in an inability to be weaned from cardiopulmonary bypass (CPB). The aim of this study was to analyze the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with PCCS and to identify predictors of in-hospital mortality and failure to be weaned from ECMO. From January 2002 to August 2016, 3248 patients underwent cardiac surgery in our hospital. Of these, 29 patients (0.89%) required ECMO because of an inability to be weaned from cardiopulmonary bypass. The median duration of ECMO support was 144 h (340-52 h) (range 17-818 h). Sixteen patients (55.2%) were weaned from ECMO, and 6 (20.7%) survived to hospital discharge. The multivariate analysis revealed that reoperation [odds ratio (OR): 13.667, 95% confidence interval (CI): 0.999-187.056, p = 0.05] and ECMO support duration > 130 h (OR: 17.688, 95% CI: 1.324-236.233, p = 0.03) were independent predictors of failure to be weaned from ECMO. Temporarily being weaned from CPB > 15 min (OR: 0.027, 95% CI: 0.001-0.586, p = 0.02) was found to be a protective factor. The multivariate analysis revealed that CPB time > 270 min (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) and ECMO support duration > 60 h (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) were independent predictors of in-hospital mortality. ECMO is an acceptable technique for treating PCCS in patients undergoing cardiac surgery. Our data suggest a reevaluation of therapeutic strategies after 60 h and again after 130 h of ECMO support.

Correction to: Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in­hospital mortality and failure to be weaned from extracorporeal membrane oxygenation.

In the original publication of the article, author group affiliation was published incorrectly.

Potential utility of new surgical hemostatic film using Hydrofit®: a preliminary study.

We developed a surgical hemostatic film using Hydrofit® (Hydrofit® film). This film is prepared by reacting Hydrofit® with water in advance, and it can be used in the same way as an accessory silicone sheet. In addition, unlike the silicone sheet, there is no need to remove the Hydrofit® film from the body. In the present study, we describe the hemostatic effect of our new method using Hydrofit® film. We created a pulsatile flow circuit model using a ventricular assist device and a vascular graft. The circuit was filled with water, and the systolic pressure was adjusted to ≥ 130 mmHg. The artificial blood vessel was punctured by an 18-G needle. Operations to prevent water from leaking were attempted through either a conventional method using a silicone sheet or our new method using Hydrofit® film. In the 180-s trial, 14 attempts (93.3%) with the Hydrofit® film were successful. In the silicone sheet group, 13 attempts (86.7%) were successful before the silicone sheet was peeled off, and hemostasis was maintained in 10 (66.5%) cases after the silicone sheet was removed. After short-duration hemostasis for 60 s, good waterproofing was obtained in the Hydrofit® film group (success in 17 cases [85%]). In contrast, in the silicone sheet group, 10 attempts (50%) were successful before the silicone sheet was peeled off, and hemostasis was maintained in only 7 (35%) cases after the silicone sheet was removed. Hydrofit® film showed good hemostatic performance in the pulsatile flow circuit model.

[Pericardiocentesis and Pericardial Drainage].

Peicardiocentesis and surgical pericardial drainage are essential treatment and diagnostic modality for pericardial effusion. Though it theoretically is a simple therapeutic method, accurate diagnosis, correct decision, and safe procedure are not always easy. Thoracic and cardiovascular surgeons are required to have high level of expertise in pericardial drainage as surgeons who specialize this anatomical part of the body. The presence of pericardial effusion does not always require drainage. Accurate diagnosis is essential to determine correct indication. Echocardiography and computed tomography are useful tools for accurate diagnosis. The percutaneous drainage has become much safer in these 2 decades with the aid of imaging technology, especially echocardiography and fluoroscopy. Surgical pericardial window still has its role and is considered one of the standard treatment methods with minimal chance to require repeat procedure compared to percutaneous drainage.

[Adult Cor Triatriatum Found by Chance at the Onset of Myocardial Infarction].

Cor triatriatum sinister is a rare congenital heart disease in which the left atrium is divided into 2 chambers by a membrane, causing resistance to the blood flow to the left ventricle. The onset of symptoms depends upon the effective size of the orifice in the membrane and the associated heart disease. Our case is a 67-year-old woman with cor triatriatum found by chance at the onset of myocardial infarction. Coronary artery bypass surgery and excision of the membrane were successfully performed. Preoperative left ventricular dysfunction was improved after surgery. Imaging examinations such as enhanced computed tomography(CT) and magnetic resonance imaging(MRI) were useful for selecting surgical approach.

The oral administration of clarithromycin prevents the progression and rupture of aortic aneurysm.

OBJECTIVE: The pathogenesis of aortic aneurysm (AA) is associated with chronic inflammation in the aortic wall with increased levels of matrix metalloproteinases (MMPs). Clarithromycin (CAM) has been reported to suppresses MMP activity. In this study, we investigated whether CAM could prevent the formation and rupture of AA. METHODS: Male apolipoprotein E-deficient mice (28-30 weeks of age) were infused with angiotensin II for 28 days. CAM (100 mg/kg/d) or saline (as a control) was administered orally to the mice every day (CAM group, n = 13; control group, n = 13). After the administration period, the aortic diameter, elastin content, macrophage infiltration, MMP levels, and levels of inflammatory cytokines, including nuclear factor κB (NF-κB), were measured. RESULTS: The aortic diameter was significantly suppressed in the CAM group (P < .001). No rupture death was observed in the CAM group in contrast to five deaths (38%) in the control group (P < .01). CAM significantly suppressed the degradation of aortic elastin (56.3% vs 16.5%; P < .001) and decreased the infiltration of inflammatory macrophages (0.05 vs 0.16; P < .01). Compared with the controls, the enzymatic activity of MMP-2 and MMP-9 was significantly reduced in the CAM group (MMP-2, 0.15 vs 0.56 [P < .01]; MMP-9, 0.12 vs 0.60 [P < .01]), and the levels of interleukin 1ß (346.6 vs 1066.0; P < .05), interleukin 6 (128.4 vs 346.2; P < .05), and phosphorylation of NF-κB were also decreased (0.3 vs 2.0; P < .01). CONCLUSIONS: CAM suppressed the progression and rupture of AA through the suppression of inflammatory macrophage infiltration, a reduction in MMP-2 and MMP-9 activity, and the inhibition of elastin degradation associated with the suppression of NF-κB phosphorylation.

[Coronary Artery Bypass Surgery for the Patient with a History of Anaphylaxis due to Neuromuscular Blocking Agent ; Report of a Case].

We present herein a patient with rocuronium anaphylaxis, which had been identified using skin test, underwent conventional coronary artery bypass surgery without any neuromuscular blocking agent. Immobility was achieved with sedatives and analgesics.

Comparison of the Long-Term Outcomes of Mechanical and Bioprosthetic Aortic Valves　- A Propensity Score Analysis.

BACKGROUND: The aim of this study was to assess the long-term outcomes of aortic valve replacement (AVR) with either mechanical or bioprosthetic valves according to age at operation.Methods and Results:A total of 1,002 patients (527 mechanical valves and 475 bioprosthetic valves) undergoing first-time AVR were categorized according to age at operation: group Y, age <60 years; group M, age 60-69 years; and group O, age ≥70 years). Outcomes were compared on propensity score analysis (adjusted for 28 variables). Hazard ratio (HR) was calculated using the Cox regression model with adjustment for propensity score with bioprosthetic valve as a reference (HR=1). There were no significant differences in overall mortality between mechanical and bioprosthetic valves for all age groups. Valve-related mortality was significantly higher for mechanical valves in group O (HR, 2.53; P=0.02). Reoperation rate was significantly lower for mechanical valves in group Y (HR, 0.16; P<0.01) and group M (no events for mechanical valves). Although the rate of thromboembolic events was higher in mechanical valves in group Y (no events for tissue valves) and group M (HR, 9.05; P=0.03), there were no significant differences in bleeding events between all age groups. CONCLUSIONS: The type of prosthetic valve used in AVR does not significantly influence overall mortality.

Clinical outcomes and quality of life after surgery for dilated ascending aorta at the time of aortic valve replacement; wrapping versus graft replacement.

Wrapping and graft replacement are two optional procedures for the treatment of dilated ascending aorta at the time of aortic valve replacement (AVR). Wrapping is considered less invasive. The aim of this study was to compare the short- and long-term clinical outcomes as well as the long-term quality of life in patients undergoing these two procedures.This study enrolled 40 consecutive patients with dilated ascending aorta who had undergone either wrapping (WAA group, n=20) or replacement (RAA group, n=20) of the ascending aorta at the time of AVR. Short-term outcomes, long-term deaths, and aortic events were evaluated, as was quality of life using the SF-36 Short Form. Long-term maximal proximal aortic diameter was also obtained.There were no early deaths in either group. Pump time was shorter, and transfusion (55% vs. 95%, p=0.035) and postoperative atrial fibrillation (5% vs. 30%, p=0.036) rates were lower, in the WAA than in the RAA group. At a mean follow-up of 4.9 years, the overall 5 year survival rates in the WAA and RAA groups were 78.1% and 87.5%, respectively. There were no significant between group differences in SF-36 scores in any subcategory of this survey. Long-term maximal aortic diameter remained stable in both groups. Both surgical interventions for dilated ascending aorta at the time of AVR yield favorable and comparable results in patients with suitable anatomy. Furthermore, we found no differences in quality of life between these procedures.

[Management of Acute Type A Dissection Complicated with Acute Mesenteric Ischemia].

Acute mesenteric ischemia as malperfusion syndrome associated with acute aortic dissection is a difficult situation. The incidence is approximately 3~4% in acute type A dissection. Traditionally, most of these patients underwent immediate simple central aortic repair expecting that mesenteric artery obstruction and intestinal ischemia would be resolved by simple central aortic repair. However, short term mortality has been reported very high in this strategy. With the aid of rapidly progressing imaging techniques and newer endovascular repair techniques, results seem to be improving in recent years. Newer management strategy include aggressive and patient specific revascularization to the mesenteric arteries, delayed central aortic repair, and meticulous intensive care. Diagnosis and management of this condition require high level of expertise. Cardiac surgeons, vascular surgeons, interventional radiologists, gastroenterologists, general surgeons, anesthesiologists, intensivists must corporate to save these patients' lives. Since this is a relatively rare condition, scientific evidence is insufficient to make robust recommendations. Further studies are warranted.

[Effective Anticoagulation Therapy Prior to Surgical Excision of an Aortic Valve Papillary Fibroelastoma Diagnosed after a Transient Cerebral Ischemic Attack;Report of a Case].

Cardiac papillary fibroelastoma is reported to be the 2nd most common cardiac tumor following myxoma. Owing to the risk of embolism, early surgical excision is the treatment of choice. We report a case of effective anticoagulation therapy prior to surgical excision of an aortic valve papillary fibroelastoma. A 78-year-old man was admitted to our hospital because of transient cerebral ischemic attack. The symptom was relieved in a short period. Echocardiography revealed a tumor at the aortic valve. Cardiac computed tomography revealed a sea-anemone-like appearance of the tumor. Cardiac papillary fibroelastoma was suspected on close examination. The operation was postponed because of gingivitis that required draining. During 3 months awaiting the operation, he continued receiving anticoagulation therapy, which successfully prevented thromboembolism. Administration of anticoagulation therapy may be considered, unless early surgical excision can be performed.

[Total Arch Replacement Using Manufactured Frozen Elephant Trunk after Acute Type-A Dissection Repair].

The purpose of this study is to assess the result of total arch replacement(TAR) using manufactured frozen elephant trunk(FET) for chronic aortic dissection after initial repair including the effect of aortic remodeling by the FET. Between 2003 and 2015, we performed 11 TAR using manufactured FET. Initial repairs before were 9 ascending aortic replacements and 2 Bentall operations. The entry of residual dissection was located at arch in 7 and at distal anastomosis site in 4. There was no hospital death. The operative complication included 2 surgical site infection, 1 interstitial pneumonia and 1 paraplegia with almost full recovery. Postoperative computed tomography 2.1 months after operation showed distal end of the FET was located at aortic valve level in 7 and at pulmonary bifurcation level in 4. There was no entry in thoracic aorta. Thrombosis of descending aorta was achieved in 7 patients. Significant midterm aortic remodeling (increased diameter of true lumen and decreased diameter of false lumen) was achieved, although the total diameter of aorta was increased. TAR using manufactured FET after type-A dissection repair promoted entry closure and thrombosis of false lumen. It requires long-term observation to judge the effect for aortic remodeling.

The long-term results and changing patterns of biological valves at the mitral position in contemporary practice in Japan.

Mitral valve surgery has changed with the wide acceptance of mitral valve repair. The aim of this study is to obtain the long-term results of patients who underwent mitral valve replacement (MVR) using a biological prosthesis in contemporary practice in Japan. From January 1990 to December 2013, 76 patients underwent MVR using a biological prosthesis with or without concomitant surgery. Data were obtained by means of a questionnaire and a telephone interview. The mean follow-up period was 4.26 years. The etiologies of the patients included dilated cardiomyopathy (DCM) (n=20 [26.3%]), ischemic mitral regurgitation (n=7 [9.2%]). There is a trend towards decreasing number of rheumatic and degenerative disease and increasing number of DCM and ischemic mitral regurgitation. Three patients (3.9%) died in the perioperative period. The 5- and 10-year overall survival rates were 69.6% and 31.7%, respectively. The 5- and 10-year freedom from valve related death were 95.6% and 80.6 %, respectively. The linearized rates of valve-related complications were as follows: thromboembolism (0.63%/patient/year), bleeding (1.25%/patient/year). One patient underwent reoperation for structural degeneration 13 years after the first operation. The present study shows the long-term results of mitral valve replacement with bioproshtesis in a contemporary case series. The practice pattern is changing. The low rate of valve-related complication justify the current patient selection.

[Treatment Strategy for Acute Type B Aortic Dissection with End-organ Malperfusion].

Therapeutic strategies for treating Stanford type B dissection with endo-organ malperfusion remain controversial, and whether surgery or conservative treatment should be performed is a matter of ongoing debate. In this study, we examined the treatment strategies used in cases of malperfusion in which treatment was initiated conservatively at the onset of symptoms without superior mesenteric artery (SMA) or limb artery obstruction. A total of 16 patients had organ ischemia in this series. The obstructed branches were the SMA in 5 patients, the artery of Adamkiewicz in 2, the bilateral renal arteries in 3, the celiac artery in 3 and limb arteries in 3. The surgical procedure included bypass grafting in 2 patients with SMA obstruction and extra-anatomical bypass in 2 patients with limb artery obstruction. A total of 11 patients were treated without surgery. Three patients died, including 2 patients with SMA obstruction. The remaining patient who died had limb artery obstruction and did not undergo surgery. The results suggest that patients with acute type B aortic dissection with endo-organ malperfusion who develop SMA or limb artery obstruction require early surgery.

[Aortic Valve Replacement of Quadricuspid Valve with Regurgitation].

Congenital quadricuspid aortic valve is a very rare malformation. In most cases it has been found incidentally at aortic valve surgery or at autopsy. It frequently causes aortic regurgitation, which may become manifest in adulthood and require surgical treatment. We reported 4 cases of aortic regurgitation with quadricuspid aortic valve. In all cases, aortic valve replacement was preformed with prosthetic valve, and their postoperative courses were uneventful. Two were Hurwitz's classification type b, one was type a and the last patient was type c. Although quadricuspid aortic valve is a rare anomaly, its potential for severe valve failure in adulthood should be kept in mind.

Twenty-year outcome of aortic valve replacement with St. Jude Medical mechanical valves in Japanese patients.

BACKGROUND: Bioprostheses have become increasingly popular for aortic valve replacement (AVR) in recent years, but mechanical valves are still the standard choice, especially for younger patients. The aim of this study was to assess the very long-term outcomes in Japanese patients who underwent AVR with St. Jude Medical (SJM) mechanical valves. METHODS AND RESULTS: From 1991 to 2001, a total of 816 patients underwent AVR with SJM mechanical valves in 5 hospitals. Of these, 801 patients (mean age, 58.3±11.7 years) were analyzed in this study. There were 24 in-hospital deaths (3.0%). Mean follow-up duration was 11.6±6.7 years and the 10-year follow-up rate was 84.1%. Freedom from valve-related death at 5, 10, 15, and 20 years was 96.2%, 92.7%, 88.8%, and 86.6%, respectively. The linearized ratio of major bleeding events and thromboembolic events was 1.1% per patient-year and 1.0% per patient-year, respectively. Freedom from reoperation for the aortic prosthesis was 98.0% and 94.8% at 10 and 20 years, respectively. CONCLUSIONS: The SJM mechanical valve provided excellent long-term freedom from valve-related death and reoperation in patients undergoing AVR. Therefore, this valve should be recommended to younger patients who wish to avoid reoperation.

The number of cardiovascular surgeries in Japan may decrease after 2020.

The expected future number of cardiovascular operations is estimated based on the predicted Japanese population and the rate of cardiovascular surgery performance calculated from 16845 cases treated by the Nagoya University group of hospitals between 2001 and 2013. The population of <20-year-old individuals has decreased since 1990, while that of 20-64-year-old individuals has also decreased since 2000. The population of 65-79-year-old individuals is expected to peak in 2020, with only the population of ≥80-year-old individuals expected to increase until 2040. The performance rate of cardiovascular surgery per 100,000 population is low in the 20-64-year-old group and increases to reach a peak in the elderly population of 70-74-year-old individuals in valvular heart disease (55.5), ischemic heart disease (54.5) and thoracic aortic aneurysm (31.9) and decreases to about half those values in the ≥80-year-old age group. The number of cardiovascular operations (all types) per 100,000 was 40.6 in 2002, 42.1 in 2006 and 46.6 in 2010. The total number of expected cardiovascular operations is increasing slightly and will reach a peak in 2020 with an estimated 61,506 operations. It then decreases gradually to reach 55966 in 2035, on the premise that the cardiovascular surgery performance rate does not change from the present time. In order to maintain and expand to meet the medical needs of cardiovascular surgery, it is crucial that an effort be made to increase the cardiovascular surgery performance rate, especially in octogenarian patients.

Impact of the intraoperative use of fibrinogen concentrate for hypofibrinogenemia during thoracic aortic surgery.

Thoracic aortic surgery often causes massive bleeding due to coagulopathy. Hypofibrinogenemia is one of the major causative factors, but the utility of the intraoperative administration of fibrinogen concentrate has not yet been proven. The aim of this study was to estimate incidence of hypofibrinogenemia and to evaluate efficacy of using fibrinogen concentrate intraoperatively. The perioperative serum fibrinogen levels (SFL) had routinely been measured in consecutive 216 thoracic aortic surgeries performed from 2010 to 2012. Fibrinogen concentrate was principally used for hypofibrinogenemia (< 150 mg/dl of SFL) at cardiopulmonary bypass (CPB) termination. The patients who received fibrinogen concentrate (FIB group) were compared with the patients who did not received (non Fib group). There were 147 patients (68%) in FIB group at a dose of 5.5±3.5 g. The SFL were dramatically decreased with values of 164±71 mg/dl at CPB termination, compared to the preoperative SFL of 352±131 mg/dl. In the FIB group, the intraoperative and postoperative SFLs were 139±53 and 262±75 (mg/dl), respectively. Thus the SFL was recovered quickly by the administration. 110 cases (51%) showed hypofibrinogenemia at the termination of CPB. The predictors of hypofibrinogenemia were preoperative SFL < 250 mg/dl, emergency surgery and thracoabdominal aortic surgery. Hypofibrinogenemia frequently was observed at the termination of CPB during thoracic aortic surgery. Administering intraoperative fibrinogen concentrate appears to be a useful option to treat coagulopathy.