[Coronary Artery Bypass Grafting for Coronary Aneurysms Causing Acute Myocardial Infarction;Report of a Case].

Coronary aneurysms are relatively rare. However, myocardial infarction associated with thrombus formation in the aneurysm and rupture of the aneurysm are clinical problems. There are no specific guidelines for the treatment of coronary aneurysms. Here, we report a case of a 47-year-old female with acute myocardial infarction. She had a history of collagen disease, which was suspected to be Kawasaki disease. She underwent thrombus aspiration supported by intra-aortic balloon pumping( IABP) because of acute thrombosis of coronary aneurysms, followed by coronary artery bypass grafting on 2 stages. The operative course was uneventful.

[Surgical Treatment for Postoperative Chylothorax after Aortic Arch Replacement via Median Sternotomy].

Postoperative chylothorax is known as a possible complication after thoracic surgery, but no treatment strategy has been established. We report a case of successful surgical treatment for postoperative chylothorax after redo aortic arch replacement via median sternotomy. A 48-year-old man, who had undergone redo aortic arch replacement for aortic pseudoaneurysm due to prosthetic vascular graft infection, developed postoperative chylothorax. Despite the conservative treatment with fasting and administration of octreotide for 4 days, there was no effect on reduction in drainage. Surgical repair was performed on postoperative day 13. About 3 hours before surgery, milk was administered from the nasogastric tube to make the drainage milky. After median re-sternotomy, a stump of the thoracic duct was clearly identified and exposed in the posterior mediastinum, and the thoracic duct was easily closed by clipping. There was no recurrence of chylothorax and oral intake was re-started on day 2. Early operation might be effective against postoperative chylothorax.

[Trial of the Profit Optimization of the Department of Cardiac Surgery in the Local National University Hospital].

In recent years economic sense is required in hospital management, the national university hospital is also no exception. We performed duty improvement efforts as well as the current state analysis in the department of cardiac surgery for the purpose of revenue optimization in our hospital. At result, we succeeded in the improvement of the medical index as well as medical profit and found the key of solution to the serious problem that national university hospital has.

[Vacuum-assisted Closure (VAC) Treatment for Sternal Infection in a Patient after Cardiovascular Surgery; Report of a Case].

One year ago, a 42-year-old woman underwent aortic root replacement because of a pseudoaneurysm that developed at the site of an anastomosis after ascending aortic replacement for acute aortic dissection. Six months later, she complained of fever and cough. A computed tomography revealed recurrence of the peudoaneurysm at the proximal anastomosis of the aortic root replacement. After emergency re-do aortic root replacement, she was admitted to intensive care unit (ICU) without sternal closure because of mediastinitis. The mediastinitis was managed by debridement and lavage drainage, followed by vacuum-assisted closure (VAC) treatment. The VAC treatment facilitated wound healing and active rehabilitation using a portable device. Finally, the wound was closed completely using a skin graft. VAC treatment is considered very useful in a case of post-sternotomy madiastinitis.

[Successful surgical treatment for acute type a aortic dissection in a patient with late pregnancy].

We report a case of successful surgical treatment for acute type A aortic dissection in a patient in late pregnancy. The patient was a 42-year-old woman who was pregnant for the 1st time. She was taken to hospital with a sudden onset of chest pain at 30 weeks' gestation. She was diagnosed with acute type A aortic dissection with annuloaortic ectasia (AAE) and aortic regurgitation, and was transferred to our hospital for further treatment. Emergency cesarean section and hysterectomy were performed, followed by modified Bentall operation on the next day. The postoperative course was uneventful for both the mother and the infant. Considering the severity of acute type A aortic dissection with AAE, aortic repair might have been performed as soon as possible after cesarean section.

[Early rehabilitation program in uncomplicated Stanford type B acute aortic dissection].

Between December 2009 and August 2011, 120 patients with uncomplicated Stanford type B acute aortic dissection( UBAD) received medical treatment. In October 2010, we initiated an early rehabilitation program for UBAD patients in an acute phase. This early rehabilitation program, which was aimed at enabling the patient to walk around the ward within 2 days, was conducted for 87 consecutive patients;the remaining 33 were subjected to the conventional rehabilitation program. Mortality was not significantly different between the 2 groups. The incidence of atelectasis, need for mechanical ventilation, and intensive care unit syndrome during medical treatment occurred in 48% (16/33), 15% ( 5/33), and 30% ( 10/33), respectively, of the conventional group and in 3.4% ( 3/87), 1.1% (1/87), and 3.4% ( 3/87), respectively, of the early rehabilitation group. The outer diameter of the aorta was dilated after 4 weeks' rehabilitation in smaller percentage of patients in the early rehabilitation group than the conventional one. Thus, the early rehabilitation program was more effective for patients with UBAD than the conventional one.

[Surgical treatment for prosthetic valve endocarditis after aortic root replacement].

Aorto-left ventricular continuity destruction due to prosthetic valve endocarditis is rare, but it is one of the fatal complications after aortic root operation. We report a case of surgical treatment for prosthetic valve endocarditis after aortic root replacement. A 47-year-old man, who had undergone aortic root replacement with a composite graft was transferred to our hospital with sudden chest pain and high fever. Enhanced computed tomography showed a large space with contrast enhancement suggesting perivalvular leakage around the artificial composite graft. Emergency operation including aortic root re-replacement and reconstruction of the left ventricular outflow tract was performed successfully. We focused on its technical aspect.

[Surgical treatment for traumatic injury of the ascending aorta and aortic arch; report of a case].

We herein report a rare case of surgical treatment for blunt traumatic injury of the ascending aorta and aortic arch. A 60-year-old male was crushed by an arm of a forklift while working. He suffered from multiple thoracic traumas, including injury of the ascending aorta and aortic arch, multiple fractures of the ribs and bilateral hemopneumothorax. An emergency surgery for aortic repair was performed because there were no other severe hemorrhagic compilations due to organ injures. There was a massive hematoma around the aortic arch, and the intimae of several parts of the distal ascending aorta and aortic arch were disrupted circumferentially. The aorta was replaced with a prosthetic graft from sinotubular junction to the aortic arch, between the left common carotid artery and the left subclavian artery. The patient's postoperative course was uneventful, and he was transferred to a rehabilitation facility on the 13th day after surgery.

Cardiopulmonary resuscitation at operating room entry in acute aortic dissection type A patients: is surgery contraindicated?

Background: This study aimed to compare the short-term outcomes of surgical treatment for acute type A aortic dissection between patients undergoing cardiopulmonary arrest at the time of entry into the operating room and patients who received successful preoperative cardiopulmonary resuscitation before entering the operating room or patients who had cardiopulmonary arrest on the operating room table after entering the operating room without cardiopulmonary arrest. In the present study, we focused on the circulatory status at the time of entering the operating room because it is economically and emotionally difficult to cease intervention once the patient has entered the operating room, where surgeons, anesthesiologists, nurses, and perfusionists are already present, all necessary materials are packed off and cardiopulmonary bypass have already been primed. Methods: Twenty (5.5%) of 362 patients who underwent surgical treatment for acute type A aortic dissection between January 2016 and March 2022 had preoperative cardiopulmonary arrest. To compare the early operative outcomes, the patients were divided into the spontaneous circulation group (n = 14, 70.0%) and the non-spontaneous circulation group (n = 6, 30.0%) based on the presence or absence of spontaneous circulation upon entering the operating room. The primary endpoint was postoperative 30-day mortality. The secondary endpoints included in-hospital complications and persistent neurological disorders. Results: Thirty-day mortality was 65% (n = 13/20) in the entire cohort; 50% (n = 7/14) in the spontaneous circulation group and 100% (n = 6/6) in the non-spontaneous circulation group. The major cardiopulmonary arrest causes were aortic rupture and cardiac tamponade (n = 16; 80.0%), followed by coronary malperfusion (n = 4; 20.0%). Seven patients (50.0%) survived in the spontaneous circulation group, and none survived in the non-spontaneous circulation group (P = .044). Five survivors walked unaided and were discharged home; the remaining two were comatose and paraplegic. Conclusions: The outcomes were extremely poor in patients with acute type A aortic dissection who had preoperative cardiopulmonary arrest and received ongoing cardiopulmonary resuscitation at entry into the operating room. Therefore, surgical treatment might be contraindicated in such patients.

Calcified amorphous tumor located on a severely calcified mitral annulus in a patient with normal renal function.

A calcified amorphous tumor (CAT) of the heart is a rare, nonneoplastic, intracavitary cardiac mass. Histological examination shows that it contains calcified and amorphous fibrous material with underlying chronic inflammation. Surgical excision is generally recommended to avoid future embolism. The risk of embolism has been reported to be especially high in mitral-annular-calcification-related CAT, which constitutes a subgroup of CAT that is often associated with end-stage renal disease. A case of a CAT attached to the anterior annulus of the mitral valve that was easily removed with a light touch of the forceps through aortotomy is reported.

The David Operation Offers Shorter Hemostasis Time Than the Bentall in Case of Acute Aortic Dissection Type A.

Background The aim of the present study was to compare the clinical outcome of the David operation and the Bentall operation in patients with Stanford type A acute aortic dissection (AADA) from the viewpoint of hemostasis. Methods Between April 2016 and April 2020, 235 patients underwent emergent surgery for AADA. Of them, 38 patients required aortic root replacement (ARR: The David operation 17, the Bentall operation 21). The mean age was 59.3±12.6 years. In the present series, the David operation was the first choice for relatively young people, and the Bentall operation was performed for relatively elderly patients and cases in which valve-sparing seemed impossible. Results Between the David and the Bentall group, the 30-day mortality rate did not differ significantly. However, hemostasis time (144.6±50.3 vs. 212.5±138.1 min, p=0.047), defined as the interval from the cessation of cardio-pulmonary bypass (CPB) to the end of the operation, and total operation time (477.8±85.7 vs. 578.3±173.6 min, p=0.027) were significantly shorter in the David group than in the Bentall group, and the amount of blood transfusion was less in the David group than in the Bentall group (red blood cells: 3.5±3.6 vs. 9.2±5.9 units, p=0.013; fresh frozen plasma: 4.1±4.7 vs 9.4±5.1 units, p=0.002; platelet concentrate: 33.2±11.3 vs 42.2±12.0 units, p=0.025). Conclusion David operation offers a shorter hemostasis time and consequently shorter operation time than the Bentall operation in the setting of AADA, probably due to double suture lines, despite its surgical complexity.

Tapentadol Safety and Patient Characteristics Associated with Treatment Discontinuation in Cancer Therapy: A Retrospective Multicentre Study in Japan.

INTRODUCTION: Tapentadol has analgesic effects comparable to those of conventional opioids and is associated with fewer side effects, including gastrointestinal symptoms, drowsiness, and dizziness, than other opioids. However, the safety of tapentadol in the Japanese population remains unclear; the present multicentre study aimed to examine the safety of tapentadol and the characteristics of patients likely to discontinue this treatment owing to adverse events. METHODS: The safety of tapentadol was assessed retrospectively in patients with any type of cancer treated between August 18, 2014 and October 31, 2019 across nine institutions in Japan. Patients were examined at baseline and at the time of opioid discontinuation. Multivariate analysis was performed to identify factors associated with tapentadol discontinuation owing to adverse events. RESULTS: A total of 906 patients were included in this study, and 685 (75.6%) cases were followed up until tapentadol cessation for any reason. Among patients who discontinued treatment, 119 (17.4%) did so because of adverse events. Among adverse events associated with difficulty in taking medication, nausea was the most common cause of treatment discontinuation (4.7%), followed by drowsiness (1.8%). Multivariate analysis showed that those who were prescribed tapentadol by a palliative care physician (odds ratio [OR] 2.60, 95% confidence interval [CI] 1.36-4.99, p = 0.004), patients switching to tapentadol due to side effects from previous opioids (OR 2.19, 95% CI 1.05-4.56, p = 0.037), and patients who did not use naldemedine (OR 5.06, 95% CI 2.47-10.37, p < 0.0001) had an increased risk of treatment discontinuation owing to adverse events. CONCLUSIONS: This study presents the safety profile of tapentadol and the characteristics of patients likely to discontinue this treatment owing to adverse events in the Japanese population. Prospective controlled trials are required to evaluate the safety of tapentadol and validate the present findings. TRIAL REGISTRATION NUMBER: UMIN 000044282 (University Hospital Medical Information Network).

Ventricular septal perforation followed by papillary muscle rupture with acute myocardial infarction: efficacy of venoarterial extracorporeal membrane oxygenation.

The occurrence of multiple mechanical complications after myocardial infarction in the same patient may be extremely rare, and the surgical strategy may be very complex because each mechanical complication can be extremely fatal. The case of a patient who underwent repair of a ventricular septal perforation by venoarterial extracorporeal membrane oxygenation (VA-ECMO), then mitral valve replacement and VA-ECMO for papillary muscle rupture 2 weeks after the ventricular septal perforation repair, is reported. Immediate preoperative stabilization with VA-ECMO may play a crucial role in treating multiple mechanical complications after myocardial infarction.

Total arch replacement with bilateral extra-anatomical axillary artery bypass and frozen elephant trunk technique for Kommerell's diverticulum.

A Kommerell's diverticulum is a rare congenital aortic arch anomaly associated with a high rate of aortic rupture or dissection. Therefore, surgical or endovascular repair should be considered early. A 64-year-old man was incidentally found to have an aortic arch anomaly, Kommerell's diverticulum, with a right aberrant subclavian artery and distal arch aneurysm. Hybrid total arch replacement with bilateral extra-anatomical axillary artery bypass and frozen elephant trunk technique was performed. This particular surgical approach would be a treatment option for any type of Kommerell's diverticulum.

Less invasive direct coronary artery bypass grafting using H graft for a patient with advanced prostatic cancer.

Minimally invasive direct coronary artery bypass grafting (MIDCAB) using an H graft was performed on a 74-year-old man with advanced prostatic cancer who needed coronary revascularization. Through a left anterior small thoracotomy, the left internal thoracic artery (LITA) and the left anterior descending artery (LAD) were cleared, and a short radial artery (RA) was placed in an end-to-side fashion between the LITA and LAD. The distal LITA was ligated to avoid potential steal phenomenon. A flow pattern through the RA graft evaluated by transit time flow measurements demonstrated good diastolic flow with a mean value of 37 mL/min. The total surgical duration was 80 min, and no blood products were required. A postoperative angiogram showed a widely patent H graft. The patient was relieved of chest pain and was discharged. The H graft procedure is a useful alternative technique to minimize the surgical trauma in limited situations such as a high-risk case.

Total arterial revascularization with composite skeletonized gastroepiploic artery graft in off-pump coronary artery bypass grafting.

BACKGROUND: Total arterial revascularization in coronary artery bypass grafting has recently become of great interest to many surgeons. At the same time, off-pump coronary bypass grafting has also become a popular procedure because of its low morbidity and mortality. Here we report our recent series of off-pump coronary bypass grafting performed with a grafting technique we developed by using the skeletonized gastroepiploic artery and the radial artery composite graft to achieve total arterial revascularization. METHODS: From September 2000 to April 2003, 98 patients underwent total arterial revascularization with the skeletonized gastroepiploic artery and radial artery composite graft on the beating heart. We used the gastroepiploic artery graft of choice in patients with a right coronary artery lesion. When multiple grafting was required in inferior, posterolateral, or lateral ventricular walls and the gastroepiploic artery graft was too short to cover these areas, we used the composite grafting technique. RESULTS: There were no in-hospital deaths and there was no severe morbidity among the study patients. Postoperative angiography showed graft occlusion at the anastomosis site between the gastroepiploic and radial arteries. The patency rate of the gastroepiploic arterial composite graft was 98.3% (118/120 distal anastomoses). CONCLUSIONS: A composite graft with the skeletonized gastroepiploic artery and the radial artery ensured sufficient caliber size and length for myocardial revascularization on inferior, posterolateral, and lateral ventricular walls. This composite graft can be used safely and effectively even in off-pump coronary bypass surgery with excellent early clinical and angiographic outcome in selected patients, although longer follow-up periods are necessary to draw definitive conclusions.

Skeletonized radial artery graft with the St. Jude Medical Symmetry Bypass System (aortic connector system).

BACKGROUND: We report our initial experience with an automatic anastomotic device using skeletonized radial artery in patients requiring off-pump coronary artery bypass grafting (CABG). METHODS: St. Jude Medical, Inc, Symmetry Bypass System (aortic connector system [ACS]) (St Jude Medical, St. Paul, MN) was used in ten patients. Ten consecutive patients who underwent off-pump CABG and who received at least one radial artery graft proximal anastomosis using the ACS were evaluated. The radial artery (RA) was harvested in a skeletonized fashion and applied to the ACS in the same manner as applying saphenous vein graft. The creation of the anastomosis lasted no longer than a few seconds. RESULTS: Our attempt to use the ACS for proximal anastomosis of the RA was successful in all ten patients. Mean operating time was 3.2 +/- 0.6 minutes and an average of 3.0 +/- 0.9 bypass grafts (range, 2 to 5 grafts) were performed. There was no postoperative fatal complication. Postoperative angiographic control showed that all grafts were widely patent including grafts other than the RA. During the mean postoperative follow-up of 10.3 +/- 2.9 months, there was no cardiac-related event in any patient. CONCLUSIONS: The St. Jude Medical Symmetry aortic connector system allows the construction of uniform and widely patent anastomoses in RA graft and does not require aortic side biting. Skeletonization of the RA is a safe and effective technique for applying ACS in off-pump CABG using multiple arterial grafts.

Skeletonization of gastroepiploic artery graft in off-pump coronary artery bypass grafting: early clinical and angiographic assessment.

BACKGROUND: Recently skeletonization has been recognized as an alternative to pedicle harvesting of the internal thoracic artery as a technique that increases the length and caliber size of the graft compared with pedicled internal thoracic artery grafts; however, this is not yet popular for harvesting the gastroepiploic artery (GEA). We report here our experience of skeletonized GEA grafting in off-pump coronary artery bypass grafting with early clinical and angiographic results. The purpose of this study was to evaluate skeletonization of GEA grafting in off-pump coronary artery bypass grafting with a large patient volume. METHODS: One hundred sixty-eight patients including 131 men and 37 women (mean age, 65 years; range, 45 to 87 years) underwent the skeletonized GEA grafting in off-pump coronary artery bypass grafting. These patients represent 41% (168 of 407 patients) of those who underwent off-pump coronary artery bypass grafting operations during the same period. We used the GEA graft of choice in patients with right coronary artery lesion. Skeletonization was performed in a unique manner we developed. RESULTS: There were no in-hospital deaths among the study patients. One patient had a perioperative myocardial infarction, which was considered a result of vasospasm of the GEA graft. None of the other patients had severe morbidity. The patency rate of the skeletonized GEA graft was 98.1% (151 of 154 distal anastomoses). CONCLUSIONS: This study suggests that skeletonization of the GEA graft can enlarge its caliber size and improve its flow capacity. In addition, the acceptable early clinical and angiographic outcome suggests that use of the skeletonized GEA graft in off-pump coronary artery bypass grafting surgery is safe and effective.

Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit?

BACKGROUND: The suitability of the radial artery after transradial catheterization as a bypass conduit has been of great concern to surgeons. METHODS: A total of 67 patients underwent isolated coronary artery bypass grafting using the radial artery: 22 patients received preoperative transradial catheterization (group 1) and 45 patients did not receive transradial catheterization (group 2). Those patients were retrospectively reviewed. RESULTS: Patient characteristics, operative procedures, and early clinical outcome were not different between groups. The stenosis-free graft patency rates in groups 1 and 2 were 88% (16 of 18 patients) and 90% (38 of 42 patients) in the left internal thoracic artery (p = 0.87); 77% (17 of 22 patients) and 98% (48 of 49 patients) in the radial artery (p = 0.017); and 87% (13 of 15 patients) and 84% (21 of 25 patients) in the saphenous vein (p = 0.42), respectively. Intimal hyperplasia of the radial artery was observed in 68% (11 of 16 patients) in group 1 and in 39% (14 of 34 patients) in group 2 (p = 0.046). CONCLUSIONS: Transradial catheterization reduced early graft patency and caused intimal hyperplasia, although it did not affect early clinical outcomes. We suggest that the use of the radial artery as a bypass conduit after transradial catheterization should be undertaken cautiously.

Flow simulation of the intracoronary shunt tube for off-pump coronary artery bypass.

INTRODUCTION: To simulate blood flow provided by the intracoronary shunt tube, and to clarify whether this method is actually suitable for Off-pump coronary artery bypass (OPCAB), we investigated the efficacy of the intracoronary shunt tube in a theoretical model on the basis of fluid dynamics. METHODS: Fluid dynamics analysis was performed to simulate flow decrease after attachment on an intracoronary shunt model. RESULTS: The flow ratio in the case of turbulent flow is in proportion to the ratio of the inner diameter to the third power, and that in the case of laminar flow is in proportion to the ratio of the inner diameter to the sixth power. When this analysis is applied to commercial shunt tubes, coronary flow was estimated as approximately 2-14% of pre-attachment flow in turbulent flow, and only less than 0.1% in laminar flow. CONCLUSIONS: This result suggests that use of intracoronary shunt tubes in OPCAB may rarely contribute to maintenance of coronary flow, and they should be used carefully, especially in a jeopardized coronary artery.