Staged repair of a ruptured thoracoabdominal aortic aneurysm: a case report

BACKGROUND

A ruptured thoracoabdominal aortic aneurysm (rTAAA) represents a considerable challenge for surgeons. To date, endovascular procedures have not been able to completely replace open repair when debranching is required.

CASE PRESENTATION

A 73-year-old man was admitted to our hospital after complaining of left lateral abdominal pain. Enhanced computed tomography revealed a left retroperitoneal hematoma and a large, ruptured Crawford type IV TAAA. We first performed emergency resuscitative surgery to close the lacerated foramen. A graft replacement was performed 1 month after the initial surgery when the patient had stabilized. At 5 years postoperatively, neither occlusion nor anastomotic pseudoaneurysm was noted on computed tomography.

CONCLUSIONS

We provide an update on the perioperative management of patients undergoing open rTAAA repair. This procedure can be considered to ensure complete repair of an rTAAA.

Long-term results of etiology-based thoracic endovascular aortic repair: a single-center experience

The use of thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) and Stanford type B aortic dissection (TBAD) has been increasing; however, in terms of etiology, the differences of long term after TEVAR outcomes remain unexplored. Thus, we investigated etiology-specific long-term results of TEVAR for TAA and TBAD. A total of 421 TEVAR procedures were performed at our institution from July 2007 to December 2021; 249 TAA cases and 172 TBAD cases were included. Traumatic aortic dissection and aortic injury cases were excluded. The mean observation duration was 5.7 years. The overall 30-day mortality rate was 1.4% (n = 6), with 1.2% (n = 3) in the TAA group and 1.7% (n = 3) in the TBAD group. The overall incidence of postoperative stroke was 0.9% (n = 4), with 1.2% (n = 3) and 0.6% (n = 1) in the TAA and TBAD groups, respectively (p = 0.90). Paraplegia developed in 1.7% (n = 7) of patients, with 2.4% (n = 6) in the TAA group and 0.6% (n = 1) in the TBAD group. Freedom from aortic-related death was not significantly different between the two etiologies; however, thoracic reintervention was more common in the TBAD group (p = 0.003), with endoleak being the most common indication for reintervention. Additionally, retrograde type A aortic dissection occurred in four TBAD cases, while migration occurred in three TAA cases. The perioperative results of TEVAR for TAA and TBAD were satisfactory. The long-term results were unfavorable owing to the occurrence of etiology-specific and common complications. In terms of the high frequency of reintervention, the long-term complications associated with TEVAR are etiology specific.

Long-term results following off-pump coronary-artery bypass grafting in left ventricular dysfunction

Severe left ventricular (LV) dysfunction is an independent risk factor for early and long-term mortality after coronary-artery bypass grafting (CABG). Off-pump CABG (OPCAB) significantly reduces the early incidence of major complications in high-risk patients. Moreover, bilateral internal thoracic artery (BITA) grafting after CABG is associated with improved long-term outcomes. We aimed to evaluate the impact of multivessel OPCAB with BITA grafting for complete revascularization on postoperative and long-term outcomes in patients with low LV ejection fraction (EF). We included 121 patients with EF ≤ 30.0% who underwent isolated multivessel OPCAB (average LVEF, 24.8%) between April 2007 and December 2019. Sixty-six patients received BITA grafts, while 55 had single internal thoracic artery (SITA) grafts. We conducted multivariate analyses to examine the correlation between perioperative data and late mortality rate. The early mortality rate was 1.65%. After excluding in-hospital mortality cases, we performed long-term follow-up of 119 patients. Early postoperative echocardiography showed significant LVEF improvement in 89 (75.2%) patients. However, LVEF remained ≤ 30.0% in 30 (24.8%) patients. We recorded 15 and 30 cases of cardiac death and cardiac events, respectively, during the long-term follow-up period. Postoperative LVEF ≤ 30.0% (P < 0.01) and no use of BITA grafting (P = 0.03) were significant predictors of cardiac death and events; moreover, hemodialysis was a significant predictor of all-cause mortality rather than cardiac death. Multivessel OPCAB in patients with severe LV dysfunction was associated with acceptable in-hospital mortality and early postoperative improvement in LV function. Additionally, OPCAB with BITA grafting may provide long-term benefits with respect to cardiac death and events. However, the long-term benefits were significantly limited in patients without early postoperative improvement in LV function and patients with chronic hemodialysis.Clinical registration number: 5590 (14/5/2020 Tokyo Women's Medical University).

Systolic anterior motion due to morphology changes in constrictive pericarditis

Systolic anterior motion (SAM) can be caused by multifactorial mechanisms, including structural, morphological and functional factors. We report an unusual case of a 76-year-old woman presenting with SAM associated with constrictive pericarditis. Echocardiography showed no septal hypertrophy but SAM and left ventricular outflow tract obstruction and moderate mitral regurgitation. The restoration of diastolic function after complete pericardiectomy successfully eliminated it.

Fenestrated Fontan-like circulation under durable left-ventricular assist device support in fulminant myocarditis

Fulminant myocarditis is a fatal development from profound biventricular heart failure and often requires both right- and left-ventricular assistance to maintain hemodynamics, even at the risk of increased mortality and morbidity. Here, we present a 42-year-old female with profound biventricular failure due to fulminant myocarditis, resolved by an isolated durable left-ventricular assist device support under a fenestrated, Fontan-like circulation and managed low-pulmonary vascular resistance.

Structures on the ventricular side of the prosthetic valve in extremely late mitral paravalvular leak: a case report

Background

Mechanisms of paravalvular leak (PVL) after mitral valve replacement have not been fully delineated. Herein, we report a case of structures on the ventricular side of the mitral valve in a patient with an extremely late PVL.

Case summary

A 68-year-old female underwent aortic and mitral valve replacement with a mechanical valve 29 years ago. She was in good health for 28 years. However, exertional dyspnoea appeared 8 months ago. She was admitted to our hospital for congestive heart failure and haemolytic anaemia. Echocardiography showed severe regurgitation due to PVL of the mitral valve. The fluoroscopy showed that a circular calcification was found below the mitral prosthesis. The operation was performed through a median sternotomy. After the aortic cross-clamp, the aortic mechanical valve was removed. The ventricular side of the mitral valve was inspected with the endoscope through the aortic annulus before manoeuvers were performed in the mitral valve. A gap was seen between the prosthetic valve and annular tissue and subvalvular calcification. A bioprosthetic valve was placed with a modified collar-reinforcement technique using a xenopericardium strip. The postoperative course was uneventful. PVL and haemolysis completely disappeared.

Discussion

The ventricular side of the prosthetic valve could be observed before the mitral valve was removed. Not only the protruding circular calcification and displacement of the prosthetic valve to the atrial side but also the loss of adhesion and adhesive nature of the annular tissue played a definitive role in the late PVL occurrence and recurrence after percutaneous or surgical repair.

Completely detached mechanical aortic valve prosthesis stuck to the aortic arch in a patient with Behçet’s disease

Background

Although detachment of the implanted valve prosthesis was a well-known complication in patients with Behçet’s disease, complete detachment of an aortic bileaflet valve prosthesis has never been reported.

Case presentation

An 18-year-old boy with Behçet’s disease (HLA-A26 positive) who had previously undergone aortic valve replacement with an 18-mm ATS-Advanced Performance (ATS-AP) valve (ATS Medical, Inc., Minneapolis, MN) at the age of 12 years, presented sudden-onset general fatigue and was emergently transferred to the regional hospital. Chest X-ray showed displacement of the implanted mechanical valve. An echocardiogram revealed mobile valve prosthesis and severe aortic regurgitation. Just before leaving for our hospital for surgical treatment, a completely detached valve prosthesis was floating in the ascending aorta. On arrival, the valve prosthesis was stuck to the transverse arch. Emergent removal of the previous mechanical valve from the aortic arch and redo aortic valve replacement with a 24-mm ATS-AP valve were performed under total circulatory arrest. Infectious endocarditis was denied by histopathological examination. The patient was back to the intensive care unit with extracorporeal membrane oxygenation support, which was successfully decannulated 5 days later.

Conclusions

This was the first report of a patient with Behçet’s disease who encountered a complete detachment of implanted aortic valve prosthesis. The patient could be rescued by emergent surgery.

Reversal flow in the left anterior descending artery after internal thoracic artery grafting

Background

The flow capacity of the in situ internal thoracic artery (ITA) is not necessarily sufficient and can be a cause of hypoperfusion syndrome. We present a catastrophic case of in situ ITA grafting for an isolated left main trunk obstruction 13 years after the modified Bentall operation.

Case presentation

A 33-years-old woman had undergone the modified Bentall operation. Coronary angiography showed a critical stenosis in the left coronary artery. The patient underwent emergency off-pump coronary artery bypass graft with the left ITA to the left anterior descending artery (LAD). On the 7th day, the patient had severe dyspnoea and hypotension. Catheter angiography showed that the ITA was patent; however, blood flow from the in situ ITA was delayed, and reversal flow from the apex to the proximal LAD was found. The patient underwent implantation of a left ventricular assist device.

Conclusions

Concomitant aortocoronary bypass to the circumflex branch will minimise the risk of hypoperfusion, especially for young patients without atherosclerotic disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-02008-0.

Safety and arch complications after hemiarch versus total arch replacement with stented elephant trunk in acute type 1 dissection: Is a stent graft always beneficial?

OBJECTIVE

We aimed to determine the efficacy of total arch replacement with stented elephant trunk by comparing it with hemiarch replacement with and without open stent graft for acute aortic dissection type 1.

METHODS

We reviewed records of 177 patients who underwent hemiarch replacement (HAR group) (concomitant open stent, 125) and 98 patients who underwent total arch replacement (TAR group) (concomitant stented elephant trunk, 91) for acute type 1 dissection. Compared with the TAR group, the HAR group was older (68.1 vs 60.9 years; P < .01) and had more thrombosed false lumen (28.8% vs 4.1%, P < .01).

RESULTS

In-hospital death occurred for 7 patients in the HAR group and 1 patient in the TAR group (P = .17). More patients in the TAR group had a postoperative thrombosed false lumen, compared with the HAR group (68% vs 54%, P = .03). In patients with preoperative nonthrombosed false lumen in the HAR group, the rate of postoperative thrombosis was significantly lower than with versus without an open stent (31% vs 65%, P = .01). The rate of freedom from an aortic arch event in the TAR group at 5 years was significantly greater than that in the HAR group (100% vs 83.7%, P = .01).

CONCLUSIONS

Stented elephant trunk with TAR provided a high rate of false lumen thrombosis and a low incidence of arch events, whereas an open stent during HAR was not beneficial in terms of false lumen thrombosis and arch event prevention.

Validity of Ipsilateral Internal Mammary Coronary Artery Bypass Graft of Arteriovenous Fistula

BACKGROUND

In coronary artery bypass grafting (CABG) for haemodialysis patients, arteriovenous fistula can reduce blood flow from the internal mammary artery (IMA) graft. The purpose of this study was to delineate the rationale of ipsilateral IMA grafting to the arteriovenous fistula by assessing graft flow and patency.

METHOD

The clinical records of 139 haemodialysis patients who underwent off-pump CABG, including IMA grafting to the left anterior descending artery (LAD) between April 2007 and December 2018, were retrospectively reviewed. Clinical outcomes and transit-time flowmetry results of IMA to LAD bypass grafts during off-pump CABG and postoperative angiography were examined.

RESULTS

An ipsilateral IMA to the arteriovenous fistula (Ipsi-IMA) was used in 89 patients, and a contralateral IMA to the arteriovenous fistula (Contra-IMA) was used in 50 patients and no hospital deaths occurred. The mean graft flow and angiographic patency rate did not differ between the Ipsi-IMA and Contra-IMA groups. In patients with 51 to 90% stenosis of LAD, there was no significant difference in the mean graft flow. In comparison, in the patients with 91 to 100% stenosis of LAD, the mean graft flow in the Ipsi-IMA group was significantly lower than that in the Contra-IMA group (p=0.03). Kaplan-Meier analyses showed a 5-year survival rate of 57.6% for Ipsi-IMA and 64.8% for Contra-IMA (p=0.47).

CONCLUSIONS

In the revascularisation of the LAD, the graft patency rate of the Ipsi-IMA was not inferior to that of the Contra-IMA. However, when the LAD has 91 to 100% stenosis, a Contra-IMA to arteriovenous fistula may be beneficial in terms of sufficient flow capacity.

Development of an Automated Smartphone-Based Suture Evaluation System

OBJECTIVE

Quantification of skill level in surgical training is necessary for effective skill development. In this study, we report the development of a smartphone application that automatically and objectively evaluates training in stitching goldfish scoop poi, a fragile material currently used for practice by young surgeons in Japan.

METHODS

The application, named "e-Suture," enables the automatic evaluation of surgical technique quality by evaluating the gap between the mark printed on the poi and the insertion/extraction point of the needle (Accuracy), analyzing suture placement (Deflection), detecting tears in the poi material/tissue (Tears), and the time taken to perform the exercise (Time). The algorithm for scoring used a sigmoid function, and the coefficients were adjusted so that the scores of a sample of 20 cases ranged between 20 and 100 points.

RESULTS

The e-Suture prototype was completed. The e-Suture-derived ranking for 20 poi after training was significantly correlated with the mean of the rankings evaluated by 9 experts (correlation coefficient: 0.728; p = 0.000). We also tested which items the experts rated as the most important. The overall ratings obtained from the experts correlated with the e-Suture accuracy scoring results with a correlation coefficient of 0.836 (p = 0.000) for Accuracy, 0.31 (p = 0.173) for Deflection, and 0.518 (p = 0.019) for Tear.

CONCLUSION

The e-Suture application can easily and accurately quantify and evaluate the suturing skills of novie surgeons. Further studies should improve the accuracy of data to be analyzed by collecting more surgical data and applying it to other surgical techniques.

Surgical outcomes of bridge-to-bridge therapy with extracorporeal left ventricular assist device for acute myocardial infarction in cardiogenic shock

Background

Extracorporeal left ventricular assist device is often required for acute myocardial infarction patients in cardiogenic shock when temporary mechanical circulatory support fails to provide hemodynamic stabilization. This study aimed to evaluate the clinical outcomes of acute myocardial infarction patients in cardiogenic shock supported by an extracorporeal left ventricular assist device.

Methods

This retrospective study enrolled 13 acute myocardial infarction patients in cardiogenic shock treated with an extracorporeal left ventricular assist device from April 2011 to July 2020.

Results

Twelve (92.3%) and eleven (84.6%) patients were supported using venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pumping before implantation, respectively. The median duration from acute myocardial infarction to extracorporeal left ventricular assist device implantation was 7 (3.5–24.5) days. The overall in-hospital mortality rate was 30.8% (n = 4). Extracorporeal left ventricular assist device was explanted in one patient for cardiac recovery; eight (61.5%) patients were approved as heart transplant candidates in whom the extracorporeal left ventricular assist device was exchanged for a durable left ventricular assist device; two (15.4%) expired while waiting for a heart transplant, and two (15.4%) received a successful transplant. The 1- and 3-year overall survival rates after extracorporeal left ventricular assist device implantation were 68.3% and 49.9%, respectively.

Conclusions

The operative mortality after extracorporeal left ventricular assist device implantation in acute myocardial infarction patients in cardiogenic shock was favorable. Our strategy of early hemodynamic stabilization with extracorporeal left ventricular assist device implantation in these patients as a bridge-to-bridge therapy was effective in achieving better survival.

An unusual case of type IIIB endoleak after repeat thoracic endovascular aortic repair at acute-angled arch: A case of fabric tear by bare-metal stent

We report a case of an unusual case of type IIIB endoleaks after repeat thoracic endovascular aortic repair that was not visualized on computed tomography, first diagnosed during open conversion surgery, and successfully treated. A 69-year-old man had undergone repeat thoracic endovascular aortic repair for an enlarged thoracic aortic aneurysm six months before. His repeat computed tomography showed an acutely enlarged aneurysm, which had expanded from 80 to 96 mm in diameter, without any endoleaks. A type IIIB endoleak resulted from a small tear in fabric caused by a bare-metal stent of the previous endograft. The tip of the bare-metal of smaller outer endograft had penetrated a fabric portion of the inner larger endograft. The aneurysmal sac pressure was 58/46 mmHg, compared with a systemic pressure of 79/35 mmHg. The endografts were explanted and replaced with a vascular graft.

Infected aortic aneurysm caused by Streptococcus pyogenes: A case report

We reported the case with infected abdominal aortic aneurysm (AAA) caused by Streptococcus (S.) pyogenes. A seventy-seven-year-old man, who had the history of uncontrolled diabetes mellitus (DM), complained fever and abdominal pain. Abdominal computed tomography scan revealed the aneurysm above common iliac artery with false lumen. On admission, laboratory tests found marked elevation of inflammatory biomarkers. Thereby the infected AAA was suspected and blood culture was taken. The administration of meropenem (MEPM) and daptomycin (DAP) was started. Next day he underwent abdominal aortic replacement with prosthetic graft and debridement because of persistent abdominal pain and the enlargement of aneurysm. S. pyogenes in blood culture samples was identified by Matrix Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry. Same result was obtained from the tissue samples of the resected AAA. Then the diagnosis of infected AAA caused by S. pyogenes was made. Since isolated S. pyogenes showed the susceptibility to antibiotics tested including penicillin, antibiotics were changed to ampicillin (ABPC) for the de-escalation of antibiotics. He had kept the administration of ABPC for 4 weeks and transferred to another hospital for the further treatment of DM. The aneurysms by S. pyogenes are extremely rare, but we should note that S. pyogenes could induce the aneurysms.

Trapezoidal resection of an elongated anterior mitral leaflet and Alfieri stitch in hypertrophic cardiomyopathy

Background

In individuals with hypertrophic obstructive cardiomyopathy, elongated anterior mitral leaflets are commonly associated with systolic anterior motion. In patients with mild septal hypertrophy, a myectomy is considered insufficient to relieve systolic anterior motion and left ventricular outflow tract obstruction.

Case presentation

In the patient, who had relatively mild septal hypertrophy, the section of the anterior leaflet protruding into the left ventricular outflow tract was resected, concomitant with septal myectomy and the relocation of the papillary muscles. An edge-to-edge stitch was placed at the uppermost segment of the coaptation zone. Using these manoeuvres, systolic anterior motion, left ventricular outflow tract obstruction and mitral regurgitation were successfully resolved postoperatively.

Conclusions

We describe a surgical technique with an edge-to-edge suture for the resection of an elongated anterior mitral leaflet. In combination with septal myectomy and relocation of the papillary muscles, this technique is a simple and viable option, especially when septal hypertrophy is not severe.

Midterm results of mitral valve repair for atrial functional mitral regurgitation: a retrospective study

Background

Annular dilation by left atrial remodeling is considered the main cause of atrial function mitral regurgitation. Although acceptable outcomes have been obtained using mitral ring annuloplasty alone for atrial functional mitral regurgitation, data assessing outcomes of this procedure are limited. Therefore, we aimed to assess midterm outcomes of mitral valve repair in patients with atrial functional mitral regurgitation.

Methods

We retrospectively studied 40 patients (mean age: 69 ± 9 years) who had atrial fibrillation that persisted for > 1 year, preserved left ventricular ejection fraction of > 40%, and mitral valve repair for atrial functional mitral regurgitation. The mean clinical follow-up duration was 42 ± 24 months.

Results

Mitral ring annuloplasty was performed for all patients. Additional repair including anterior mitral leaflet neochordoplasty was performed for 22 patients. Concomitant procedures included maze procedure in 20 patients and tricuspid ring annuloplasty in 31 patients. Follow-up echocardiography showed significant decreases in left atrial dimensions and left ventricular end-diastolic dimensions. Recurrent mitral regurgitation due to ring detachment or leaflet tethering was observed in five patients and was seen more frequently among those with preoperative left ventricular dilatation. Three patients without tricuspid ring annuloplasty or sinus rhythm recovery by maze procedure developed significant tricuspid regurgitation. Five patients who underwent the maze procedure showed sinus rhythm recovery. Rates of freedom from re-admission for heart failure at 1 and 5 years after surgery were 95 and 86%, respectively.

Conclusions

Mitral valve repair is not sufficient to prevent recurrent atrial functional mitral regurgitation in patients with preoperative left ventricular dilatation. Tricuspid ring annuloplasty may be required for long-term prevention of significant tricuspid regurgitation.

Thoracic aortic mycotic aneurysm due to Staphylococcus argenteus: A case report

Staphylococcus argenteus was subdivided as a novel species from Staphylococcus aureus in 2014. We herein report a case of mycotic aneurysm caused by S. argenteus. A 59-year-old woman with diabetes and schizophrenia visited at the emergency room because of falling. Chest computed tomography revealed a left humerus fracture and a thoracic aortic aneurysm. With her elevated WBC count and CRP level, she was suspected to have a mycotic aneurysm. After being transferred to our hospital, vascular graft replacement surgery was performed. Isolates of blood cultures and surgical specimens were identified as S. argenteus by Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MAS MALDI Biotyper Ver. 8.0). Although S. argenteus lacks staphyloxanthin, a carotenoid pigment, it is coagulase positive. In addition to traditional and automated biochemical identification systems, even MALDI-TOF MAS may misidentify the organism as S. aureus depending on its version. S. argenteus should be considered when coagulase-negative Staphylococcus like colonies are obtained from samples of S. aureus infection. To our knowledge, this is the first case of aortic mycotic aneurysm caused by S. argenteus in Japan. Although S. argenteus is considered less virulent than Staphylococcus aureus, we should closely monitor the prevalence and the clinical impact of this pathogen on community-acquired infections and health care-associated infections.

Hemostatic Modification of the Bentall Procedure Using an Overlap Suture Technique

Bleeding from the proximal suture line after replacement of the aortic root can be very difficult to control. Such bleeding is an important predictor of morbidity and mortality. Here, we detail a reliable method that is simple to perform and effectively prevents surgical bleeding. We adopted a technique of overlapping the pledgeted interrupted U-stitches of the proximal sutures on the prosthetic graft, which can eliminate the bleeding from the proximal suture line.

The change in the mitral-septal angle after surgery for atrial functional mitral regurgitation

OBJECTIVE

The optimal surgical strategy for atrial functional mitral regurgitation remains uncertain. Preoperative mitral-septal angle ≤ 70° has been reported as a risk factor for an abnormal vortex pattern in mitral valve repair. This study aimed to elucidate the change in the mitral-septal angle after surgery for atrial functional mitral regurgitation and its effect on the mid-term outcomes.

METHODS

Forty patients underwent mitral valve repair for atrial functional mitral regurgitation. The mitral-septal angle was defined as the angle between the mitral annulus and the anteroseptal wall of the left ventricular mid-portion in the parasternal long-axis view on transthoracic echocardiography. All patients underwent mitral ring annuloplasty. Left atrial plication was performed in nine patients. The mean clinical follow-up period was 42 ± 24 months.

RESULTS

The ratio of left atrial volume to left ventricular end-systolic volume was negatively correlated with the preoperative mitral-septal angle. The postoperative mitral-septal angles were significantly smaller than the preoperative ones. The mitral-septal angle decreased with a decrease in the mitral annuloplasty ring size. Patients who underwent left atrial plication tended to show an increase in the mitral-septal angle postoperatively. There were no significant differences in mid-term morbidities, including heart failure, requiring re-hospitalization and mortalities between patients with postoperative MSA > 70° and those with postoperative MSA ≤ 70°.

CONCLUSIONS

Mitral ring annuloplasty negatively changed the mitral-septal angle, while left atrial plication may induce a positive change to the mitral-septal angle. An association between the mitral-septal angle and mid-term outcomes was not revealed in this study.

Effect of the Terminal Aortic Diameter on the Patency Rate of Iliac Limbs after Endovascular Aortic Repair

Objective: Endograft limb occlusion (ELO) is a complication of endovascular aneurysm repair (EVAR). In this study, we investigated the mechanism and anatomical features of ELO.

Materials and Methods: We retrospectively reviewed 227 consecutive patients with abdominal aortic aneurysm who underwent EVAR between 2007 and 2017. We then analyzed the preoperative risk factors and anatomical features of patients with ELO.

Results: A total of nine patients had ELO (4.0%). The diameter of the terminal aorta was significantly smaller in patients with ELO than in patients without ELO (18.0 mm vs. 22.3 mm, p=0.039). We measured the diameter of each limb near the terminal aorta. The smaller limb (SL) was occluded in all patients with occlusion. The difference between the larger limb (LL) and the SL (LL-SL) was significantly larger in patients with ELO than in patients without ELO (4.0 mm vs. 1.7 mm, p<0.001). The following were considered risk factors for ELO: younger age, narrow terminal aorta, severe calcification at the terminal aorta, and use of an Endurant device.

Conclusion: ELO occurs when the diameter of one side of the stent graft limb is small compared with the diameter of the other side owing to the narrow terminal aorta and calcification.

Recurrent mitral regurgitation after mitral valve repair for bileaflet lesions in the modern era

Background

Good mid-term durability of mitral valve repair of bileaflet lesions has been reported; however, patients may develop failure during follow-up. This study assessed late outcomes and mechanisms of failure associated with mitral valve repair of bileaflet lesions.

Methods

Fifty-six patients (mean age 67 ± 12 years) underwent mitral valve repair of bileaflet lesions due to degenerative disease in 2011–2018. Mitral annuloplasty was added to all procedures except for 1 patient with annular calcification. Mitral valve lesions were identified by surgical inspection. Mean clinical and echocardiography follow-up occurred at 2.7 ± 2.1 and 2.5 ± 1.9 years, respectively.

Results

Additional mitral valve repair techniques involved triangular resection (n = 15 patients), quadrangular resection with sliding plasty (n = 12), neochordoplasty (n = 52), and commissural plication (n = 26). Prolapse of ≥2 anterior and posterior leaflet scallops occurred in 22 (39%) and 30 (54%) patients, respectively. During follow-up, 10 (17.8%) patients developed moderate or severe mitral regurgitation. Whereas prolapse or tethering was observed early after neochordoplasty or quadrangular resection, recurrent regurgitation occurred late after commissural repair. Five-year freedom from recurrent moderate or severe mitral regurgitation rates was 71.1 ± 11.0%.

Conclusions

Seventeen percent of patients developed recurrent mitral regurgitation during follow-up. Repair failure in the early phase occurred owing to aggressive resection of the posterior mitral leaflet or maladjustment of the artificial neochordae. Recurrent mitral regurgitation might occur in the late phase even after acceptable commissural repair. A sequential approach may be useful to improve the quality of mitral valve repair in bileaflet lesions.

Comparison of the Efficacy of Transthoracic Cannulation into the Ascending Aorta Versus Femoral Artery Cannulation in Minimally Invasive Cardiac Surgery

Objective

To delineate the efficacy and safety of transthoracic cannulation to the ascending aorta through a right pleural cavity during minimally invasive cardiac surgery (MICS).

Methods

We retrospectively assessed the records of 104 patients who underwent MICS in our institution between December 2011 and December 2018. Procedures included mitral valve repair (88 patients), aortic valve replacement (8 patients), atrial septal defect closure (6 patients), and myxoma resection (2 patients). Aortic valve replacements were performed through the third intercostal space (ICS), whereas the other procedures were mainly performed through the fourth ICS. The femoral group comprised 60 patients in whom an artificial graft was anastomosed to the femoral artery and 4 who underwent cannulation into the femoral artery. The aorta group comprised 40 patients in whom transthoracic cannulation was performed through the second or third ICS, separate from the main skin incision.

Results

No mortality or critical complications were associated with cardiopulmonary bypass. Perfusion pressure measured at outflow of the artificial lung (224 ± 43 vs. 190 ± 42; P < 0.001) and pump pressure measured at the outflow of the pump (293 ± 50 vs. 255 ± 57; P < 0.001) were significantly higher in the femoral group than in the aorta group. The skin incision lengths were similar (56.9 ± 6.9 vs. 55.1 ± 6.0 mm; P = 0.107).

Conclusions

Transthoracic cannulation into the ascending aorta is reliable and can be safely performed. The possible risks associated with peripheral cannulation and retrograde perfusion can be avoided thereafter.

Early First-Generation Trifecta Valve Failure: A Case Series and a Review of the Literature

BACKGROUND

The Trifecta valve (Abbott, St Paul, MN) has excellent hemodynamic performance with acceptable rates of freedom from structural valve degeneration. However, some recent studies have reported early Trifecta valve failure. Here, we report a case series of seven Trifecta valve failures with a review of the literature.

METHODS

Of 107 implantations of Trifecta bioprostheses between 2012 and 2014, we encountered seven Trifecta valve failures (6.5%). Failure of a 19-mm Trifecta valve occurred in 1 patient, failure of a 21-mm Trifecta valve occurred in 5 patients, and failure of a 23-mm Trifecta valve occurred in 1 patient. The mean duration of valve durability was 51 ± 16 months. The mean effective orifice area index on the first echocardiogram after Trifecta valve implantation was 0.96 ± 0.26. The mode of presentation was prosthetic valve stenosis in 3 patients and severe aortic regurgitation in 4 patients.

RESULTS

Six patients underwent redo surgical aortic valve replacement. The common pathologic findings were circumferential pannus formation with noncoronary cusp tear and leaflet calcification. The rates of preoperative end-renal stage disease and postoperative prosthesis-patient mismatch were higher in patients with Trifecta valve failure. The incidence of early Trifecta valve failure was 3.1% at 48 months and 13.1% at 72 months.

CONCLUSIONS

In our experience, early Trifecta valve failure was caused by cusp tears or leaflet calcification. Patients with end-renal stage disease and prosthesis-patient mismatch should be closely followed. Some patients with cusp tears may require urgent surgery.

Superior trans-septal approach for minimally invasive mitral valve surgery via right small thoracotomy

Minimally invasive mitral valve surgery (MIMVS), despite its challenges, is not a rare procedure. However, MIMVS via a right small thoracotomy must be performed using long-shafted surgical instruments and thoracotomy instruments specialized for minimally invasive cardiac surgeries. We have performed 12 cases of MIMVS via right small thoracotomy using the superior trans-septal approach and secured a surgical visual field that easily allows a finger to reach the mitral valve annulus without using special instruments for minimally invasive cardiac surgery. We named this technique the "drawer-case technique." In conclusion, MIMVS via right thoracotomy using the superior trans-septal approach can be performed easily and safely, similar to mitral valve surgery performed via median sternotomy.

Early- and long-term results of thoracic endovascular aortic repair for blunt traumatic thoracic aortic injury: a single-centre experience

OBJECTIVES

Endovascular repair has been proposed as an alternative to classical surgical repair for the management of blunt traumatic thoracic aortic injury. However, the long-term outcomes of endovascular repair and the risks of left subclavian coverage remain unclear.

METHODS

From April 2001 to August 2018, 33 patients with blunt traumatic thoracic aortic injury underwent endovascular repair in our institution. A follow-up computed tomography and a clinical examination were performed before discharge and at 1 month, and yearly or every 2 years thereafter.

RESULTS

The mean age was 45 ± 19 years. The technical success rate was 100%. Complete coverage of the left subclavian artery (LSCA) was performed in 20 patients (60.6%). Among 20 patients with coverage of the LSCA, revascularization was performed in 1 patient. No in-hospital deaths occurred. The clinical follow-up rate was 97%, with a mean period of 7 years and a maximum of 18 years. The survival rates were 100% at 1 year, 95% at 5 years and 88.7% at 10 years after the event. Among the 5 patients (20%) who developed neurological complications, 1 who had undergone implantation of a 200-mm long stent graft and LSCA coverage without revascularization developed paraplegia during the long-term follow-up.

CONCLUSIONS

This study demonstrates that the endovascular treatment of blunt traumatic thoracic aortic injury is a safe and effective therapeutic method over a long-term follow-up period. LSCA coverage and long stent graft placement might be indications for revascularization to prevent spinal cord injury.

Distal Limited Open Stenting for Aortic Diverticulum in the Right Aortic Arch

An aortic diverticulum, including Kommerell's diverticulum, is an uncommon, congenital, aortic arch anomaly. Surgery for a diverticulum is challenging, and several surgical strategies have been reported. Here, we present the case of an asymptomatic 57-year-old man who was referred to our hospital. Computed tomography revealed right aortic arch and aortic diverticulum, and he underwent distal limited open stenting under hypothermic circulatory arrest with selective cerebral perfusion via median sternotomy. The postoperative course was uneventful. Thus, this report shows that our procedure is useful and safe for treating aortic diverticulum.

Intraoperative transit-time flowmetry in patients undergoing coronary surgery to determine relationships between graft flow and patency and prior coronary interventions and flow demand: a retrospective study

Background

The aim of this study was to delineate impacts of percutaneous coronary intervention (PCI), flow demand, and status of myocardium on graft flow.

Methods

We retrospectively assessed 736 individual coronary artery bypass grafts that had been created as the sole bypass graft for a vascular region in 405 patients. The grafts comprised 334 internal thoracic artery (ITA) to left anterior descending (LAD), 129 ITA and 65 saphenous vein grafts (SVG) to left circumflex (LCX), and 142 gastroepiploic artery (GEA) and 66 SVG to right coronary artery (RCA). Minimal luminal diameter, size of revascularized area, history of myocardial infarction, and PCI in the relevant area were examined to determine whether these factors are associated with flow insufficiency (FI), which was defined as ≤ 20 mL/min.

Results

FI developed in 123/736 grafts (16.7%) and correlated significantly with stenosis in the distal portion (23.0% vs. 12.8%, p = 0.0003). Prior myocardial infarction significantly correlated with FI in GEA–RCA (p = 0.002) and ITA–LCX grafts (p = 0.04). There was a history of PCI to the LAD (PCI group) in 54 ITA to LAD bypass grafts (16.2%), whereas the remaining 280 had no history of PCI to the LAD (no-PCI group). Graft flow was significantly greater in the no-PCI than in the PCI group (53 ± 29 vs. 42 ± 27; p = 0.006). The incidences of FI and graft failure were significantly higher in the PCI than the no-PCI group (22.2%, vs. 8.2%; p = 0.003; 9.2% vs. 1.8%; p = 0.003, respectively).

Conclusions

Prior PCI has a negative impact on graft flow. The influences of small revascularized area, myocardial infarction, and PCI are greater, necessitating consideration of factors associated with flow demand or microvasculature when planning revascularization.

Safety and Effectiveness of Tolvaptan Administration after Total Arch Replacement

BACKGROUND

Postoperative fluid overload in cardiovascular surgery is associated with increased mortality and morbidity. Recently, tolvaptan (TLV), a selective vasopressin V2 antagonist, has been used for perioperative fluid management. This study aimed to validate the safety and effectiveness of TLV administration after total arch replacement (TAR) using selective cerebral perfusion.

METHODS

From August 2016 to December 2016, 11 patients who had undergone TAR for thoracic aortic aneurysm were included in this study. In addition to the conventional diuretics furosemide (20 mg) and spironolactone (25 mg), TLV (7.5 mg) was administered orally.

RESULTS

TLV increased urine output 1-3 days after administration. Body weight was gradually and steadily reduced until discharge. Neither renal nor liver dysfunction was recognized during the TLV administration.

CONCLUSION

The concomitant use of TLV and conventional diuretics is safe and effective for fluid management after TAR using cardiopulmonary bypass, selective cerebral perfusion, and hypothermic circulatory arrest.

Midterm Results of 2-Stage Hybrid Arch Repair for Extensive Aortic Arch Aneurysms

BACKGROUND

This report evaluated the perioperative and midterm results of the 2-stage hybrid arch procedure. This procedure involves total arch replacement with an elephant trunk as the first stage and thoracic endovascular aortic repair as the second stage for patients with extended aortic arch pathology.

METHODS

Between April 2010 and April 2017, 55 consecutive patients (age, 74.2 ± 6.4 years) with extended aortic arch atherosclerotic pathology involving the aortic arch and descending aorta underwent first-stage total arch replacement with the elephant trunk procedure. The second stage was completed for 53 (96.4%) of the 55 patients. The mean duration between the 2 procedures was 2.4 ± 2.2 months. Postoperative follow-up was completed after a mean of 36.6 ± 24.9 months.

RESULTS

The in-hospital mortality rate for the first stage was 0%. Two patients died during the interval between surgeries. The in-hospital mortality rate for the second stage was 0%. Two (3.6%) of the 55 first-stage patients and none of the 53 second-stage patients experienced a postoperative stroke. No spinal cord dysfunction occurred during the first-stage and second-stage procedures. The 3- and 5-year survival rates were 88.2% and 67.0%, respectively. The 5-year thoracic aortic intervention-free rate was 95.5%.

CONCLUSIONS

Extended aortic arch aneurysms were repaired using a 2-stage hybrid arch repair. Perioperative mortality and midterm results were acceptable. Use of an elephant trunk provided a secure landing zone for thoracic endovascular aneurysm repair. This 2-stage hybrid procedure is an alternative approach to extended aortic arch pathology.

A Case of Upper Limb Arterial Embolization from Aortic Arch Intimal Sarcoma

We report a case with aortic intimal sarcoma who presented with left upper limb arterial embolization from tumor. A 79-year-old female patient presented with paleness and left upper limb paralysis. A transesophageal echocardiogram revealed a mobile and fragile mass attached in the aortic arch. Contrast-enhanced computed tomography showed a massive irregular tumor in the aortic arch with left common carotid and subclavian artery occlusion. Total arch replacement was performed, and tumor was resected en bloc. Although the postoperative course was uneventful, multiple metastasis to the limbs was observed. The patient died 6 months postoperatively.

Successful Thoracic Endovascular Aortic Repair using 2- and 3-Dimensional Fusion Imaging without Further Contrast Enhancement

We report a case of successful thoracic endovascular aortic repair using a 3-dimensional computed tomography (3D CT) roadmap for a patient with severe contrast media allergy. As 3D CT image data were previously obtained, we integrated the data with the fluoroscopic image three dimensionally and constructed a 3D CT roadmap. This method is anticipated to be effective in patients who require less contrast enhancement or radiological dose by examining the appropriate imaging protocol for the kinds, shapes, and positions of the benchmarks for fusion.

Two-stage Treatment Using Balloon Pulmonary Angioplasty and Pulmonary Endarterectomy in a Patient with Chronic Thromboembolic Pulmonary Hypertension

We performed a 2-stage procedure combining balloon pulmonary angioplasty and pulmonary endarterectomy for a high-risk chronic thromboembolic pulmonary hypertension patient with high pulmonary vascular resistance. First, balloon pulmonary angioplasty was performed for distal lesions to improve hemodynamics and decrease the surgical risk. Subsequently, pulmonary endarterectomy was performed for proximal lesions, and the hemodynamics and symptoms improved dramatically. Our strategy was therefore found to be useful for treating a high-risk chronic thromboembolic pulmonary hypertension patient.

Impact of the Clinical Frailty Scale on Outcomes After Transcatheter Aortic Valve Replacement

Background:

The semiquantitative Clinical Frailty Scale (CFS) is a simple tool to assess patients’ frailty and has been shown to correlate with mortality in elderly patients even when evaluated by nongeriatricians. The aim of the current study was to determine the prognostic value of CFS in patients who underwent transcatheter aortic valve replacement.

Methods:

We utilized the OCEAN (Optimized Catheter Valvular Intervention) Japanese multicenter registry to review data of 1215 patients who underwent transcatheter aortic valve replacement. Patients were categorized into 5 groups based on the CFS stages: CFS 1-3, CFS 4, CFS 5, CFS 6, and CFS ≥7. We subsequently evaluated the relationship between CFS grading and other indicators of frailty, including body mass index, serum albumin, gait speed, and mean hand grip. We also assessed differences in baseline characteristics, procedural outcomes, and early and midterm mortality among the 5 groups.

Results:

Patient distribution into the 5 CFS groups was as follows: 38.0% (CFS 1-3), 32.9% (CFS4), 15.1% (CFS 5), 10.0% (CFS 6), and 4.0% (CFS ≥7). The CFS grade showed significant correlation with body mass index (Spearman’s ρ=−0.077, P =0.007), albumin (ρ=−0.22, P <0.001), gait speed (ρ=−0.28, P <0.001), and grip strength (ρ=−0.26, P <0.001). Cumulative 1-year mortality increased with increasing CFS stage (7.2%, 8.6%. 15.7%, 16.9%, 44.1%, P <0.001). In a Cox regression multivariate analysis, the CFS (per 1 category increase) was an independent predictive factor of increased late cumulative mortality risk (hazard ratio, 1.28; 95% confidence interval, 1.10–1.49; P <0.001).

Conclusions:

In addition to reflecting the degree of frailty, the CFS was a useful marker for predicting late mortality in an elderly transcatheter aortic valve replacement cohort.

Impact of Subclinical Vascular Complications Detected by Systematic Postprocedural Multidetector Computed Tomography After Transcatheter Aortic Valve Implantation Using Balloon-Expandable Edwards SAPIEN XT Heart Valve

Complications after transcatheter aortic valve implantation (TAVI) remain an important issue. This study aimed to evaluate the impact of systematic postprocedural multidetector computed tomography (MDCT) to detect subclinical complications after TAVI. From October 2013 to August 2015, a total of 135 patients who underwent transfemoral TAVI (n = 116) or transapical TAVI (n = 19) with Sapien XT and MDCT preprocedure and postprocedure were enrolled. Postprocedural MDCT findings were compared with the preprocedural MDCT findings. Cardiovascular complications were observed in 25.9% of patients, including 6 cases (4.5%) with major complications. Of those, clinically apparent major complications were reported in 2 cases including rupture of the sinus of Valsalva and iliac rupture. The complications in the remaining 4 cases (3.0%) included aortic dissection, aortic intramural hematoma, and left ventricular apical pseudoaneurysm, which were totally asymptomatic and only detected by MDCT. The apical pseudoaneurysm required surgical repair. Minor complications were observed in 21.5% of patients, 50% of which were subclinical. Only 1 case with femoral pseudoaneurysm required an additional procedure. Noncardiovascular findings were detected in 27.4% of patients; the most frequent were pleural effusions and atelectasis, which were predominantly observed in those treated through a transapical approach. Contrast-induced acute kidney injury after postprocedural MDCT was reported in 1 patient whose clinical course was complicated by sepsis. In conclusion, postprocedural MDCT was useful in detecting important subclinical complications that may affect the clinical course without deterioration of renal function.

Incidence, Predictors, and Mid-Term Outcomes of Possible Leaflet Thrombosis After TAVR

OBJECTIVES

This study sought to clarify the incidence and predictors of hypoattenuated leaflet thickening (HALT) and mid-term outcomes after transcatheter aortic valve replacement.

BACKGROUND

HALT detected on multidetector computed tomography (MDCT) scanning raised concerns about possible subclinical leaflet thrombosis.

METHODS

We studied 70 of 100 consecutive patients from a single-center registry who underwent implantation with the Edwards SAPIEN-XT device. MDCT results, echocardiographic data, and laboratory findings obtained at the 6-month and 1-year follow-ups were analyzed.

RESULTS

Of 70 patients, MDCT scans revealed HALT in 1 patient (1.4%) at discharge, 7 (10.0%) at 6 months, and 10 (14.3%) at 1 year post-transcatheter aortic valve replacement cumulatively. The degree of leaflet immobility correlated with the HALT area on 4-dimensional MDCT (r = 0.68) on the basis of data from 10 patients. HALT was associated with male sex (70% vs. 25%; p = 0.008) and larger sinus of Valsalva (31.0 ± 2.0 mm vs. 28.6 ± 2.6 mm; p = 0.005). HALT was found in 3 of 49 patients with a 23-mm bioprosthesis and in 7 of 21 patients with a 26-mm bioprosthesis (6.1% vs. 33.3%; p = 0.006). D-dimer levels were significantly increased in the HALT group at the 6-month (2.3 μg/ml [interquartile range (IQR): 2.1 to 6.1 μg/ml] vs. 1.1 μg/ml [IQR: 0.8 to 2.2 μg/ml]; p = 0.002) and 1-year (2.7 μg/ml [IQR: 1.7 to 4.8 μg/ml] vs. 1.2 μg/ml [IQR: 0.9 to 2.1 μg/ml]; p = 0.006) follow-ups, despite no differences at discharge. The pressure gradient was decreased in the HALT group at the 1-year follow-up (8.3 ± 0.8 mm Hg vs. 11.1 ± 4.9 mm Hg; p = 0.005). After detecting HALT, additional anticoagulation therapy was not administered. Clinical outcomes, including all-cause mortality (0% vs. 1.7%; p = 1.00) and stroke (0% vs. 0%; p = 1.00), were similar between the groups.

CONCLUSIONS

HALT with reduced leaflet motion was not rare but usually subclinical. Valve hemodynamics and mid-term outcomes were uneventful even without additional anticoagulant therapy in our limited number of cases. Male sex, larger sinus and bioprosthesis size, and elevated D-dimer levels during follow-up were associated with this phenomenon.

Modified transiliac artery approach for transcatheter aortic valve implantation

We present a safe and effective method of transcatheter aortic valve implantation using an artificial graft anastomosed to the common iliac artery. A 10-mm woven polyethylene terephthalate graft is anastomosed to the common iliac artery. A guide wire and an expandable sheath are inserted through the graft, and bleeding from the puncture site is controlled by three tourniquets circled around the graft. Using this technique, we can bring the graft outside of the retroperitoneal space, allowing easy manipulation of the guide-wire and sheath, unimpeded by the constraints of the deep and narrow retroperitoneal space.

Heterotopic transplantation of a decellularized and recellularized whole porcine heart

OBJECTIVES

One of the final treatments for end-stage heart failure is heart transplantation. However, a shortage of donor hearts has created a long waiting list and limited benefits. Our ultimate goal is to create a whole beating heart fabricated on an organ scaffold for human heart transplantation. Here, we successfully performed the first transplantation using a decellularized whole porcine heart with mesenchymal stem cells.

METHODS

A porcine heart was harvested following cardiac arrest induced by a high-potassium solution and stored at -80°C for 24 h. The porcine heart was completely decellularized with 1% sodium dodecyl sulphate and 1% Triton X-100 under the control of perfusion pressure (100 mmHg) and maintained at 37°C. A decellularized whole-heart scaffold was sterilized with gamma irradiation. Cultured mesenchymal stem cells were collected and either infused into the ascending aorta or injected directly into the left ventricular wall. Finally, recellularized whole-heart scaffolds were transplanted into pigs under systemic anticoagulation treatment with heparin. Coronary artery angiography of the transplanted heart graft was performed.

RESULTS

In our decellularization method, all cellular components were removed, preserving the heart extracellular matrix. Heterotopic transplantations were successfully performed using a decellularized heart and a recellularized heart. The scaffolds were well perfused, without bleeding from the surface or anastomosis site. Coronary angiography revealed a patent coronary artery in both scaffolds. The transplanted decellularized heart was harvested on Day 3. Haematoxylin and eosin staining showed thrombosis in the coronary arteries and migrated inflammatory cells. Haematoxylin and eosin staining of the transplanted recellularized heart showed similar findings, with the exception of injected mesenchymal stem cells.

CONCLUSIONS

To the best of our knowledge, this is the first report of heterotopic transplantation of a decellularized whole porcine heart with mesenchymal stem cells. The scaffolds endured surgical procedures. We detected short-term coronary artery perfusion in the transplanted scaffolds by angiography. Future studies should analyse the histological features of transplanted decellularized scaffolds and optimize the system for recellularization to apply this unique technology clinically.

Hybrid Thoracic Endovascular Aortic Repair for Intercostal Patch Aneurysm after Thoracoabdominal Aortic Replacement

We report a case of hybrid thoracic endovascular aortic repair for intercostal patch aneurysm after thoracoabdominal aortic replacement. Eighteen years ago, a 63-year-old woman with Marfan syndrome had undergone thoracoabdominal aortic replacement with reimplantation of the intercostal artery in an island fashion. Follow-up computed tomography (CT) revealed a remaining intercostal patch aneurysm of diameter 60 mm 17 years after the last operation. Hybrid thoracic endovascular aortic repair for exclusion of this intercostal patch aneurysm was successfully performed, with visceral artery bypasses. Postoperative CT showed no anastomotic stenosis or endoleak.