The comparison of the clinical outcomes and costs between surgical aortic valve replacement and transcatheter aortic valve implantation based on the Japanese Diagnosis Procedure Combination database.

PURPOSE: We evaluated the clinical outcomes and costs of surgical aortic valve replacement (SAVR) and transfemoral transcatheter aortic valve implantation (TAVI) for aortic stenosis using the Japanese Diagnosis Procedure Combination (DPC) database. METHODS: Using our extraction protocol, we retrospectively analyzed summary tables in the DPC database from 2016 to 2019, which were provided by the Ministry of Health, Labor and Welfare. A total of 27,278 patients were available (SAVR, n = 12,534; TAVI, n = 14,744). RESULTS: The TAVI group was older than the SAVR group (SAVR vs. TAVI: 74.6 vs. 84.5 years; P < 0.01), with a lower in-hospital mortality (1.0 vs. 0.6%; P < 0.01) and a shorter hospital stay (26.9 vs. 20.3 days; P < 0.01). TAVI conferred more total medical service reimbursement points than SAVR (493,944 vs. 605,241 points; P < 0.01), especially materials points (147,830 vs. 434,609 points; P < 0.01). Total insurance claims for TAVI were approximately 1 million yen higher than those for SAVR. Regarding the details of costs, only the operation cost was higher, while other costs were lower with TAVI than with SAVR. CONCLUSION: Our analysis revealed that both SAVR and TAVI showed acceptable clinical outcomes. TAVI was associated with higher total insurance claims than SAVR. If the material cost of TAVI operations can be reduced, greater cost-effectiveness can be expected.

Early results of expanding the anatomical indications for using a Gore Iliac branch endoprosthesis to treat aortoiliac and iliac aneurysms.

PURPOSE: To assess the safety and anatomical suitability of using a Gore Iliac Branch Endoprosthesis (IBE) in aortoiliac and iliac aneurysm repair. METHODS: Between 2017 and 2020, 20 patients underwent endovascular aneurysm repair (EVAR) with a Gore IBE device (bilateral IBE, n = 1) after expanding the instructions for use (IFU) criteria. We evaluated the early clinical outcomes and suitability of the IFU criteria, retrospectively. RESULTS: Six patients (30%) met all the IFU criteria. Anatomical suitability according to the IFU criteria for the collective total of 21 IBE limbs was confirmed for 10 (47.6%) proximal common iliac arteries, 21 (100%) external iliac arteries, 18 (85.7%) internal iliac arteries, and in the length from the lowest renal artery to the iliac bifurcation in 15 (71.8%) patients. Assisted primary technical success was achieved in all patients with various bail-out techniques. One patient (5%) required a bare-stent insertion 7 days after EVAR for severe stenosis in the ipsilateral limb caused by a small terminal aorta. There was no case of occlusion of an iliac branch component device. CONCLUSIONS: Gore IBEs were implanted safely and effectively with various bail-out techniques to repair aortoiliac and iliac aneurysms in our Japanese patients with a low rate of inclusion IFU criteria.

[Repeated Heart Failure after Transcatheter Aortic Valve Implantation Using Self-expandable Bioprosthetic Valve:Report of a Case].

The patient was an 81-year-old man. Transcatheter aortic valve implantation( TAVI) was performed for severe aortic stenosis using Evolut R. The patient moved to intensive care unit without an adverse event after the operation. But repeated acute heart failure occurred several times during hospital stay. Mitral regurgitation (MR) was worsened from mild at baseline to moderate or more by transthoracic echocardiography. Various factors that worsened MR after TAVI have been reported, and treatment strategy for severe aortic stenosis patients with MR should be carefully developed.

Acute Dissection of the Middle Colic Artery Immediately after Endovascular Abdominal Aortic Aneurysm Repair: A Case Report.

A 78-year-old man underwent endovascular abdominal aortic aneurysm repair (EVAR) for a true aortic aneurysm. He developed sudden abdominal pain 4 hr after EVAR. Angiography revealed a dissected aneurysm of the middle colic artery (MCA). Despite conservative treatment, follow-up computed tomography revealed an expanded aneurysm of the MCA. We therefore performed coil embolization of the dissected MCA to prevent a rupture of the aneurysm. There has never been a reported case of acute dissection of the MCA immediately after EVAR that was not caused by catheters. In this report, we discuss the possible underlying mechanisms and the optimal therapeutic strategy for this rare complication.

[Incidentally detected bronchial artery aneurysm with combined operation for mitral regurgitation;report of a case].

A 77-year-old woman was admitted to the hospital for heart failure with orthopnea. Echocardiography revealed massive mitral regurgitation. During preoperative cardiac catheterization, an aneurysm was indentified incidentally just below the tracheal carina. Three dimensional computed tomography showed three bronchial artery aneurysms behind the pulmonary artery and the left atrium. The proximal aneurysm was the largest and was 22 mm in diameter. It was resected by retracting the ascending aorta to the left, the superior vana cava to the right and right pulmonary artery cranially under cardiopulmonary bypass, and mitral valve plasty was performed. We believed that resection of the proximal aneurysm would cause thrombotic occlusion of the other 2 aneurysms. Bronchial artery aneurysm is a rare entity that is observed in fewer than 1% of those who undergo selective bronchial arteriography. In addition, because bronchial artery aneurysm is a potentially life-threatening lesion, it should be treated promptly when diagnosed.

Clinical experience with the RELAY NBS PLUS stent-graft for aortic arch pathology.

PURPOSE: To assess the safety, efficacy and performance of the RELAY NBS PLUS stent-graft in patients with aortic arch pathology. METHODS: From July 2010 to December 2011, the RELAY NBS PLUS was used to treat 13 patients (eight males; mean age 59.8 years, range 29-78 years) suffering from aortic arch pathology. The distribution of the proximal landing zone was Zone 0 in one case, Zone 1 in three cases and Zone 2 in nine cases. Bypass of the cervical branches was performed in 11 patients. RESULTS: The surgery-related mortality within 30 days and postoperative morbidity were 0%. Postoperative computed tomography at discharge confirmed 100% clinical success without any endoleaks. The mean radius of the inner curve in the aortic arch was 16.2 mm (range 5.8-25.7 mm). We detected two bird-beak configurations with a severely angulated aortic arch with a radius of the inner curve <15 mm. At the mid-term follow-up (mean 22.1 months; range 13.8-28.2 months), all patients were alive without aorta- or device-related complications. CONCLUSIONS: RELAY NBS PLUS stent-grafts can be safely and effectively implanted with controlled deployment to satisfactorily repair aortic arch pathology, even in the cases considered to present with an unfavorable anatomy for the first generation commercially available stent-graft devices. These encouraging outcomes will need to be confirmed in a larger series with a longer follow-up.

Sex-Related Differences Between Patients Undergoing Surgery for Acute Type A Aortic Dissection.

Introduction This study aimed to evaluate the sex-specific characteristics and surgical outcomes in patients with acute type A aortic dissection (ATAAD). Materials and methods We reviewed the surgical records of patients who underwent ATAAD repair at our institution between 2004 and 2020 (n=213). Results Of the 213 patients, 100 (46.9%) were male, and 113 (53.1%) were female. Males were younger than females (62.5 vs. 72.9 years, p<0.0001). Females had more nonspecific symptoms (p=0.04), more frequently developed ATAAD before noon (45.0% vs. 53.1%, p=0.01), and had a significantly longer time from onset to surgery (425.1 vs. 595.8 min, p=0.03). The ascending aorta was replaced more frequently in females than in males (54.5% vs. 72.8%, p<0.01). No significant difference was observed in the in-hospital mortality rate between males and females (9.0% vs. 10.6%, p=0.69). The multivariable logistic analysis demonstrated that being male was not an independent predictor of operative mortality (OR, 0.96; 95% CI, 0.18-5.21; p=0.96). At 10 years, males had significantly better long-term survival rates in the unadjusted cohort than females (79.4% vs. 55.9%, p=0.02). Conclusions Male sex was not an independent predictor of early death in patients with ATAAD after surgery, although significant differences were noted in terms of age, onset time, chief complaint, imaging findings, and surgical procedures. A sex-based management strategy involving specific differences should be considered to improve outcomes.

Thoracic endovascular aortic repair of an ascending aortic pseudoaneurysm.

A 74-year-old man with a history of two thoracic aortic repairs, including a modified Bentall procedure using a mechanical valve and total arch replacement, was referred to our hospital with the development of hoarseness. Computed tomography revealed an anastomotic pseudoaneurysm between the prosthetic grafts in the ascending aorta. Two aortic cuffs for abdominal aorta were deployed through the left axillary artery using a transcatheter aortic valve replacement guidewire placed at the supra-aortic mechanical valve during ventricular rapid pacing and were successfully covered with an inlet to the pseudoaneurysm on postoperative computed tomography. The postoperative course was favorable.

How to select the optimal size of frozen elephant trunk in total arch replacement for type A acute aortic dissection.

BACKGROUND: Total arch replacement (TAR) with a frozen elephant trunk (FET) is a common technique for acute aortic dissection, but there is no consensus on the optimal size of the FET. METHODS: Forty-four patients who underwent TAR with FET for acute aortic dissection at our hospital since 2014 were included. The aortic diameter obtained from FET was measured on postoperative computed tomography (CT) and the estimated oversizing ratio was calculated. We investigated the relationship between the estimated oversizing ratio and postoperative outcomes. We also measured the maximum true lumen diameter, circumference of the true lumen, and total aortic diameter at the same level as the FET end on preoperative CT and examined the correlation with the aortic diameter obtained from FET. RESULTS: The average estimated oversizing ratio was 109%. Early postoperative CT showed complete thrombosis of the false lumen in 41 (93.2%) patients. No distal stent graft-induced new entry occurred during follow-up. The correlation coefficients between the three measurements and aortic diameter obtained from FET were 0.64 (maximum true lumen diameter), 0.76 (true lumen diameter calculated from circumference), and 0.72 (total aortic diameter), respectively. CONCLUSIONS: The aortic diameter obtained from FET on postoperative CT was strongly correlated with the true lumen diameter calculated from the circumference and total aortic diameter on preoperative CT. It is reasonable to select a size of approximately 130% of the true lumen diameter calculated from the circumference or 80% to 85% of the total aortic diameter.

Acute type A aortic dissection with a tear in the posterior wall of the ascending aorta early after off-pump coronary artery bypass grafting.

The patient was a 68-year-old man who underwent triple-vessel OPCAB uneventfully with aortic proximal anastomosis at one site using the saphenous vein with a mechanical device, not a side clamp, with mild traction of the ascending aorta by aortic taping. On postoperative day 7, computed tomography revealed extremely localized AAD with a tear on the posterior wall of the ascending aorta. Emergent ascending aortic replacement was successfully performed. Surprisingly, the tear extended laterally along the traction site of the tape. To our knowledge, this is the first report of AAD early after OPCAB originating at a location other than the sites of proximal anastomosis or side clamping. Proximal anastomosis with a mechanical device to the towed aorta may indirectly or directly injure the intima of the posterior wall, causing this complication. Manipulating the aorta under abnormal pressure should be avoided.

Partial aortic root remodeling with an adventitial inversion technique for an acute type a aortic dissection.

This case report describes a partial aortic root remodeling, which applied a valve-sparing technique, with an adventitial inversion technique for an acute type A aortic dissection with intimal tear extending into the noncoronary sinus of Valsalva. Postoperative computed tomography at six months showed no dissection or pseudoaneurysm in the aortic root.

Predictors of short-term thrombocytopenia after transcatheter aortic valve implantation: a retrospective study at a single Japanese center.

OBJECTIVE: Thrombocytopenia is common after transcatheter aortic valve implantation (TAVI) and is associated with mortality and major complications, although the underlying mechanisms are unclear. This retrospective single-center study aimed to identify factors associated with the decrease in platelet count (DPC) after TAVI in Japanese patients. Patients with severe aortic valve stenosis who underwent transfemoral TAVI between March 2014 and August 2019 were grouped according to DPC values of < 50% or ≥ 50% (DPC = 100% × [baseline platelet count-nadir platelet count]/[baseline platelet count]). Multivariable logistic regression analysis was performed to identify factors associated with a DPC of ≥ 50%. RESULTS: Among the 131 patients who underwent transfemoral TAVI, 74 patients (56%) had a DPC of ≥ 50%, and 57 patients (44%) had a DPC of < 50%. Significant risk factors for a DPC of ≥ 50% were older age, lower body mass index (BMI), and use of balloon-expandable valves (BEV). The multivariable analysis revealed that a DPC of ≥ 50% was independently predicted by low BMI (adjusted odds ratio: 0.884, 95% confidence interval: 0.785-0.997; P = 0.039) and BEV use (adjusted odds ratio: 3.014, 95% confidence interval: 1.003-9.056; P = 0.045). Platelet count monitoring after TAVI, especially when using BEV devices, is essential for Japanese patients with low BMI.

Placement of a Zenith® Dissection Endovascular System in the Descending Thoracic Aorta Can Hamper Further Surgical Aortic Operations.

INTRODUCTION: The efficacy of endovascular treatment for complicated Stanford type B acute aortic dissection is being established. However, aortic events sometimes occur, and some cases require surgical intervention. REPORT: A 52 year old man underwent ascending aorta replacement for Stanford type A acute aortic dissection in August 2016. Post-operative computed tomography (CT) showed residual dissection from the aortic arch to the right common iliac artery and a large re-entry in the right common iliac artery (RCIA). Two months after the operation, CT revealed enlargement of the false lumen of the thoracic aorta and the thoracic aortic diameter. Aiming to reduce the false lumen and remodel the aorta, a three stage operation was performed, as described below. Four months after the dissection, total aortic arch replacement and a frozen elephant trunk insertion were performed as the first stage. Subsequently, as a second stage operation, thoracic endovascular repair (TEVAR) was performed using a Zenith® Dissection Endovascular System (Cook Japan Co., Ltd, Tokyo, Japan), with the aim of expanding the true aortic lumen. The implanted devices were a stent graft for the proximal part and two bare stents for the middle and distal part. As a third stage operation, abdominal aortic endovascular treatment was performed with the purpose of closing the re-entry from the RCIA. However, two years after the three stage operation, CT showed that the thoracic aorta was over 60 mm in diameter. Graft replacement of the thoraco-abdominal aorta was performed. The bare stents were expected to be easily removable from the aorta, but unexpectedly, they were strongly attached to the intima, which made it extremely difficult to perform surgical and aortic operations. DISCUSSION: Surgical operations for the aorta can become more difficult after bare stent placement in the aorta.

Mitral valve stenosis caused by abnormal pannus extension over the prosthetic ring and leaflets after Duran ring mitral annuloplasty.

We treated a 61-year-old woman with mitral stenosis caused by pannus formation after Duran ring annuloplasty. Pannus overgrowth on the ring with extension onto both leaflets narrowed the mitral orifice and severely restricted the mobility of the valve leaflets. Mitral valve replacement with a St. Jude Medical mechanical heart valve prosthesis was successfully performed, and the postoperative course was uneventful. Patients undergoing Duran ring annuloplasty should be followed up with the consideration of possible mitral stenosis caused by pannus extension, as the cause for pannus formation remains unclear.

Early and mid-term outcomes of total arch replacement with the frozen elephant trunk technique for type A acute aortic dissection.

OBJECTIVES: The aim of this study was to evaluate the outcomes of the frozen elephant trunk (FET) technique, using the J Graft FROZENIX for Stanford type A acute aortic dissection, in comparison with the unfrozen elephant trunk technique. METHODS: Between January 2010 and August 2018, we performed total arch replacement for Stanford type A acute aortic dissection in our hospital. Thirty patients were treated by the elephant trunk procedure (ET group), and 20 patients were treated by the FET procedure (FET group). To evaluate aortic remodelling, we measured the area of the aorta, the true lumen and the false lumen at 12 months of follow-up. RESULTS: Preoperative characteristics and operation time were not significantly different between the 2 groups. The quantity of blood transfused was much greater in the ET group than in the FET group. Resection or closure of the most proximal entry tear was obtained in 73.3% (22 out of 30 patients) in the ET group and 100% (20 out of 20 patients) in the FET group (P = 0.015). There was no case that had recurrent nerve palsy or paraplegia in the FET group. Stent graft-induced new entry occurred in 3 cases (15.8%) in the FET group. There were no significant differences between the 2 groups in aortic area, true lumen area or false lumen area. CONCLUSIONS: Total arch replacement with the FET technique in Stanford type A acute aortic dissection carries a risk of distinct complications; however, with thorough advance planning, it should be possible to safely institute this treatment. Further randomization, with a comparison of each technique, is required to provide clear conclusions whether the FET is useful for acute Stanford type A aortic dissection.

Adult-onset primary Ewing's sarcoma of the right atrium: a case report.

BACKGROUND: Primary cardiac tumors, which are only detected in 0.001-0.03% of autopsies, are rare. Only 25% of primary cardiac tumors are malignant, of which 95% are sarcomas. Ewing's sarcoma, one of the Ewing's sarcoma of family tumors, is thought to be derived from neural crest cells. While Ewing's sarcoma usually presents in the bone of children, Ewing's sarcoma of cardiac origin is rare, with only a few reports described in the literature. The prognosis is unpredictable because of the scarcity and unestablished treatment. We herein report an extremely rare case of primary cardiac Ewing's sarcoma in the right atrium of a 64-year-old man. CASE PRESENTATION: The patient is a 64-year-old Japanese male who was referred to our hospital to treat a floating mass of the right atrium (RA). Although the patient was asymptomatic, we performed an operation to urgently resect the floating mass on the next day of admission due to the risk of pulmonary embolism. The operation was performed under cardiopulmonary bypass and cardiac arrest. We resected the tumor with at least 1.5 cm of the RA wall as a margin. The postoperative pathological diagnosis of the mass was compatible with a primitive neuroectodermal tumor (PNET, a form of Ewing's sarcoma). The cells were positive for CD56, CD99, and Vimentin and negative for S-100 and Desmin. Although no malignant cells were observed in the margin of the resected RA wall and the sarcoma was completely resected, he was transferred to another hospital to receive adjuvant postoperative chemotherapy to improve the prognosis by preventing subclinical micrometastasis. CONCLUSIONS: We experienced an extremely rare case of primary cardiac Ewing's sarcoma in the right atrium of a 64-year-old man, which was successfully resected under cardiac arrest. Although the sarcoma was completely resected, postoperative chemotherapy and long-term follow-up are recommended for patients with primary cardiac sarcoma because of the high rates of metastasis and recurrence.

Aortic valve replacement and tricuspid valve annuloplasty via a left thoracotomy in an adult with left pulmonary agenesis.

We report a case of a 66-year-old man who was diagnosed with severe aortic regurgitation, moderate tricuspid regurgitation and chronic atrial fibrillation. Preoperative computed tomography showed left lung agenesis. We performed aortic valve replacement, tricuspid valve annuloplasty and right pulmonary vein isolation via a left thoracotomy. This approach provided an adequate field of view.

Influence of preoperative serum creatinine level and intraoperative volume of contrast medium on the risk of acute kidney injury after transfemoral transcatheter aortic valve implantation: a retrospective observational study.

OBJECTIVE: This study aimed to determine if contrast medium volume (CMV) is a risk factor for acute kidney injury (AKI) during transcatheter aortic valve implantation (TAVI) via a transfemoral approach performed without major complications. All TAVI procedures performed at our institution between March 2014 and March 2018 were retrospectively reviewed. AKI was diagnosed using the Acute Kidney Injury Network classification based on the Valve Academic Research Consortium-2 definition. Procedures performed via a transapical approach and those in which circulatory dynamics failed intraoperatively were excluded. RESULTS: Eighty-one (96.4%) of 100 patients scheduled for TAVI were enrolled; seven (8.6%) developed AKI and 74 (91.4%) did not. The serum creatinine (SCr) level was significantly higher (p < 0.05) and the estimated glomerular filtration rate was significantly lower in the AKI group (p < 0.05). The CMV was significantly higher in the AKI group (103 ml vs 84 ml, p < 0.05), as was the CMV × SCr/BW value (3.34 vs 1.49, p < 0.01). The area under the curve for CMV × SCr/BW was 0.9228 and the cut-off value was 2.99. The CMV, SCr, and estimated glomerular filtration rate affect the likelihood of AKI after transfemoral TAVI and a CMV × SCr/BW value > 2.99 accurately predicts AKI.

Transapical thoracic endovascular aortic repair in aortic arch aneurysm through a pre-existent bioprosthetic aortic valve.

An 80-year-old man had undergone Y-graft replacement for ruptured abdominal aortic aneurysm followed by bioprosthetic aortic valve replacement. Follow-up computed tomography revealed a 65-mm aneurysm at the distal aortic arch. We selected endovascular surgery because of the patient's high-risk condition, and the extreme curvature of the 8-mm artificial blood vessels led us to adopt a transapical approach. No signs of deterioration of the bioprosthesis were noted, and the patient's hemodynamic condition remained stable during surgery. Transapical thoracic endovascular aortic repair through a pre-existent aortic bioprosthesis is an efficient alternative approach for treating aortic aneurysm, even after bioprosthetic aortic valve replacement.