How to anastomose a patch to avoid residual leak in the infarct exclusion method.

BACKGROUND AND AIM: Postinfarction ventricular septal defect is a potentially lethal complication of acute myocardial infarction for which surgical repair is mandatory. The infarct exclusion method has contributed to improving surgical outcomes, but a certain percentage of residual leakage continues to be reported. We considered possible mechanisms of residual leakage and modified the sewing method to overcome these mechanisms. METHOD: A bovine pericardial patch and a Teflon felt strip between the patch and endocardium to achieve good fit were used. The patch and felt were anchored with U stay sutures and reinforced with a running suture. RESULTS: Use of the modified method in seven cases showed improved outcomes. Only one patient had trivial leakage, compared to nine cases using the older method; six of nine patients had residual leaks, including three minor ones. CONCLUSIONS: Our method is a rational approach that effectively reduces residual leakage.

Thoracic endovascular aneurysm repair to treat recurrent lower limb ischemia secondary to occlusion of axillofemoral bypass.

INTRODUCTION: A case of malperfusion in which the patient presented with aortic dissection is presented. PRESENTATION OF CASE: A 69-year-old man with an acute aortic dissection (Stanford type B) had lower limb ischemia. Axillary-femoral bypass was performed, and his lower limb ischemia improved. Eight months after the onset of acute aortic dissection, he again had lower limb ischemia. Contrast-enhanced computed tomography showed axillary-femoral bypass occlusion and true lumen collapse, compressed by the increased false lumen pressure in the aorta. Thoracic endovascular aortic repair (TEVAR) was performed for entry closure. His lower limb ischemia was improved by TEVAR. DISCUSSION: One of the complications of type B aortic dissection is malperfusion. Endovascular therapy is a first step in treating the malperfusion of type B aortic dissection. It is important to seal the entry for the treatment of malperfusion. CONCLUSION: If there is an entry, it is important to seal it for the treatment of malperfusion.

A drainage catheter tangled around a closed left atrial appendage.

A 70-year-old man underwent cardiac surgery including left atrial appendage closure. A pigtail catheter was inserted into the pericardial sac because of delayed tamponade. Removal of the catheter was planned for 2 days after drain insertion. However, the resistance was high and pulsatile. The patient was transferred to the catheterization laboratory and a guide wire was inserted through the catheter, revealing the catheter route around the left atrial appendage. The wire was exchanged for a stiff wire to uncurl the catheter as much as possible, then the catheter was removed. The left atrial appendage does not usually represent an obstacle to catheter removal because it is soft and shrinkable. However, once the left atrial appendage becomes closed off, it can become hard, unshrinkable and an obstacle that might be caught by the drainage catheter.

A technique to prevent recurrence after the repair of pacemaker lead-induced tricuspid regurgitation.

This article describes how to repair pacemaker lead-induced tricuspid regurgitation without removing the pacing leads. Our technique can eliminate the lead contact with the tricuspid leaflets and the tricuspid apparatus and is effective in preventing recurrence.

A mycotic aortic aneurysm treated by thoracic endovascular aneurysm repair.

An 88-year-old man was admitted with general fatigue. Computed tomography (CT) showed a descending aortic aneurysm. The laboratory data indicated severe infection. Despite negative blood cultures, broad-spectrum intravenous antibiotic therapy was started. Though antibiotic therapy was continued for about 2 weeks, the aneurysm extended 20 mm. Thoracic endovascular aortic repair was performed, and antibiotic therapy was continued for 4 weeks after the procedure, followed by oral antibiotics for 1 year. CT showed regression of the aneurysm 15 months after reconstruction. Antibiotic therapy, preoperatively and postoperatively, is important for a mycotic aortic aneurysm.

Abnormal mobile structure in the aortic valve due to fibrous strand rupture.

Mobile abnormal structures in the aortic valve are difficult to diagnose in some cases. We describe a rare clinical case of fibrous strand rupture in a dialysis patient, which was surgically treated. Preoperative echocardiography showed a mobile structure attached to the noncoronary cusp, and intraoperative findings revealed rupture of the fibrous strand in this cusp. If aortic regurgitation without obvious cause is noted in cases of abnormal mobile structures, fibrous strand rupture could be a differential diagnosis.

Impact of glucose control on early vein graft failure after coronary artery bypass grafting: one-month angiographic results.

Objectives: To identify factors that determine early saphenous vein graft failure (VGF) within 1 month after coronary artery bypass grafting (CABG). Methods: Seven hundred forty-nine consecutive patients underwent primary isolated CABG with saphenous vein grafts at three Japanese centres from 1 January 2005 to 31 December 2014. According to angiographic findings within 1 month of CABG surgery, 63 patients (8.4%) developed early VGF. We examined the relationships between variables and early VGF by using multivariable logistic regression analysis. Results: The preoperative clinical characteristics were similar between patients with and without early VGF, except for median preoperative haemoglobin A1c levels, which were significantly higher among patients with early VGF (6.7 vs 6.4%, P = 0.046). Additionally, anastomosis to the vessel with chronic total obstruction was performed more frequently among patients with early VGF (22/63 [34.9%] vs 140/686 [20.4%], P = 0.007), and myocardial infarction during the hospital admission occurred more frequently among patients with early VGF (4/63 [6.3%] vs 2/686 [0.3%], P < 0.0001). Results of multivariable analysis showed that the preoperative haemoglobin A1c level was associated with early VGF (odds ratio per unit increase, 1.30; 95% confidence interval, 1.06-1.60; P = 0.013). Conclusions: An increased preoperative haemoglobin A1c level was strongly associated with early VGF after CABG. Thus, VGF happened more frequently in patients with poorly controlled diabetes mellitus.

Effect of dipeptidyl peptidase-4 inhibitor in patients undergoing bypass surgery.

OBJECTIVES: Patients with diabetes mellitus often have more complicated postoperative courses and worse outcomes after coronary artery bypass grafting than those without this condition. Dipeptidyl-peptidase-4 inhibitors are a new class of oral medication for treating type 2 diabetes mellitus. We investigated how these drugs influence the postoperative course after coronary artery bypass in patients with type 2 diabetes mellitus. METHODS: We retrospectively reviewed the clinical records of 177 patients with type 2 diabetes who has undergone coronary artery bypass surgery between 2009 and 2013; 107 were treated with dipeptidyl-peptidase-4 inhibitors postoperatively, and 70 who did not receive dipeptidyl-peptidase-4 inhibitors served as a control group. The rates of overall survival and major adverse cardiac and cerebrovascular events were compared between groups. RESULTS: Analysis of all-cause deaths showed that survival at 4 years was 92.8% and 83.6%, respectively, for the treated and control groups (p = 0.052). There was a lower incidence of major adverse cardiac and cerebrovascular events in the treated group (85.6% vs. 73.1%, p = 0.042). Cox regression analysis of the entire population revealed that dipeptidyl-peptidase-4 inhibitor use (hazard ratio 0.46, p = 0.048) and deep sternal wound infection (hazard ratio 11.89, p = 0.003) were independent predictors of major adverse cardiac and cerebrovascular events. CONCLUSIONS: Dipeptidyl-peptidase-4 inhibitors reduced the incidence of major adverse cardiac and cerebrovascular events and improved the long-term prognosis after coronary artery bypass in patients with type 2 diabetes mellitus.

Continuous postoperative insulin infusion reduces deep sternal wound infection in patients with diabetes undergoing coronary artery bypass grafting using bilateral internal mammary artery grafts: a propensity-matched analysis.

OBJECTIVES: Deep sternal wound infection (DSWI), especially in patients with diabetes mellitus (DM), is a major concern after coronary artery bypass grafting (CABG) with bilateral internal mammary artery (BIMA) grafts. We evaluated the risk of DSWI and other clinical outcomes between continuous insulin infusion therapy (CIT) and insulin sliding scale therapy (IST) in a cohort of DM patients who underwent CABG with BIMA. METHODS: The clinical records of DM patients who underwent isolated CABG with BIMA were retrospectively reviewed. The study population consisted of 95 patients who received CIT and 126 patients who received IST. Furthermore, a one-to-one matched analysis based on estimated propensity scores for patients who received CIT or IST yielded two groups comprising 58 patients each. The proportion of patients with DSWI, overall survival rates and major adverse cardiac events were compared between the two groups in the overall and the propensity-matching cohort. RESULTS: The prevalence of DSWI requiring debridement and closure was significantly reduced in the CIT group compared with that in the IST group [1/95 (1.1%) vs 9/126 (7.1%), P = 0.031]; these results were not attenuated even after propensity-matching analysis [0/58 (0%) vs 6/58 (10.3%), P = 0.031]. The mean preoperative glucose levels were similar between the two groups (157.5 ± 54.6 vs 176.1 ± ±70 mg/dl, P = 0.063), whereas the mean glucose values were significantly lower on the first and second operative days in the CIT group than in the IST group (132.9 ± 44.1 vs 197.8 ± 78.6 mg/dl, P < 0.0001; 153.5 ± 58.8 vs 199.6 ± 89.1 mg/dl, P < 0.0001, respectively). The glucose variability levels within 24 h postoperatively were significantly higher in the IST group (46.1 ± 19.4 vs 66.4 ± 26.8 mg/dl, P < 0.0001). The 30-day and 1-year survival rates were similar between the two groups (100 vs 99.2%, P = 0.384; 96.6 vs 94.4%, P = 0.454). No results were changed in the propensity-matching models. CONCLUSIONS: The CIT approach reduced the variability in glucose concentration and resulted in fewer instances of DSWI after CABG with BIMA grafts.

Early and mid-term results of isolated aortic valve replacement for aortic stenosis in octogenarians.

OBJECTIVE: As transcatheter aortic valve implantation (TAVI) may become a potential treatment for high-risk patients with aortic stenosis (AS), evaluation of outcomes after open aortic valve replacement (AVR) in elderly patients is warranted. We documented early and late outcomes after isolated AVR in octogenarians compared with younger age groups. METHODS: From January 2007 to December 2012, 136 patients underwent isolated AVR for AS (mean age 71.3 years, 39% males) and were classified into two groups (octogenarians and non-octogenarians). Twenty-four percent were aged 80 years or older. Forty-six percent of all patients were in New York Heart Association functional class III-IV. The estimated Society of Thoracic Surgeons and Japan operative mortalities were 3.4 and 2.5%, respectively. RESULT: The 30-day mortality was 0%. One in-hospital death occurred from low output syndrome and congestive heart failure in the non-octogenarian group. Postoperative morbidity was not statistically significant different between the age groups. All of the patients-with the exception of one case of in-hospital death and one patient who was transferred to another hospital-were discharged (postoperative length of stay, 16.4 days). The actuarial survival for 3 years by age group was 89.8% in octogenarians compared with 93.2% in non-octogenarians. CONCLUSION: Recent results show that isolated AVR for severe AS can be performed with a low operative mortality and morbidity regardless of age. TAVI may be an alternative for high-risk patients, but isolated AVR remains the standard intervention for AS even in increased age.

Usefulness of routine aortic valve calcium score measurement for risk stratification of aortic stenosis and coronary artery disease in patients scheduled cardiac multislice computed tomography.

OBJECTIVES: This study sought to investigate the clinical utility of aortic valve calcium score (AVCS) determined by using cardiac multislice computed tomography (MSCT). METHODS: Data of 1315 consecutive patients who underwent both conventional echocardiography and MSCT were reviewed. Degree of aortic stenosis (AS) was assessed according to mean pressure gradient (mPG) measured by echocardiography. Extent of coronary artery disease (CAD) derived by MSCT also was evaluated in 1173 patients who did not undergo prior coronary treatment. Both AVCS and coronary calcium score (CCS) were defined by Agatston units (AU) according to MSCT findings. RESULTS: A total of 613 of 1315 patients were defined as AVCS positive (mean, 100 AU [range, 31.0-380.0 AU]). AVCS showed significant correlations with mPG (Spearman's ρ = 0.81, p < 0.001), and CCS (ρ = 0.53, p < 0.001). Differential adequate cut-off values of AVCS were proved for predicting severe AS with mPG ≥ 40 mmHg (1596.5 AU; AUC, 0.88; sensitivity, 89.7%; specificity, 77.0%), and for predicting moderate AS with mPG ≥ 20 mmHg (886.5 AU; area under the curve [AUC], 0.91; sensitivity, 92.4%; specificity, 78.3%). Mean AVCS was higher with increased extent of CAD (none, 0 AU [range, 0-30 AU]; single vessel, 8.5 AU [range, 0-104 AU]; multivessel, 142 AU [range, 10-525 AU]; p < 0.001). The optimal cut-off value of AVCS for predicting multivessel disease was 49 AU (AUC, 0.77; sensitivity, 68.8%; specificity, 78.0%). CONCLUSIONS: AVCS might be a surrogate marker not only for AS grading but also for CAD progression. Therefore, routine AVCS assessment could be useful for risk stratification.