Thrombocytopenia Following Perceval Sutureless Aortic Valve Replacement in Asian Patients

BACKGROUND

This study analyzed the safety and performance of the Perceval valve for aortic valve replacement (AVR) in patients at 1 year after undergoing aortic stenosis (AS) treatment, and its effect on significant declines in the platelet count during the immediate postoperative period.Methods and Results: Data were collected retrospectively for the initial 121 patients (median age 77 years; 47.1% females) who underwent Perceval sutureless AVR between May 2019 and July 2022. Implantation was successful in all (100%), with median cross-clamp and CPB times of 59 and 100 min, respectively. Postoperative thrombocytopenia (platelet count <50×103/μL) was noted in 80 (66.1%) patients. Multivariate analysis showed advanced age (>80 years), preoperative low platelet count (<200×103/μL), and a sternotomy approach as significant risk factors for postoperative thrombocytopenia. One (0.8%) patient died within 30 days after the procedure. The 2-year site-reported event rate was 14% (n=17) for all-cause mortality, 0.8% (n=1) for cardiac mortality, 4.1% (n=5) for stroke, and 1.7% (n=2) for endocarditis and valve-related reoperation; there were no instances of paravalvular leakage or structural valve deterioration.

CONCLUSIONS

Thrombocytopenia was common after Perceval sutureless AVR, although its impact was not significant. Although Perceval sutureless AVR was found to be a safe and effective option, preoperative assessment of potential bleeding should be performed and the Perceval valve should not be used for patients with a high bleeding risk.

Late outcomes of the frozen elephant trunk technique for acute and chronic aortic dissection: the angle change of the FROZENIX by "spring-back" force

OBJECTIVES

To evaluate the outcomes of total arch replacement using the frozen elephant trunk technique with a FROZENIX^® J Graft for patients with either acute or chronic aortic dissection, and to evaluate the late-phase outcomes.

METHODS

Between January 2015 and December 2020, we used the frozen elephant trunk technique in 47 patients with acute aortic dissection and 12 patients with chronic aortic dissection. The primary endpoints were 30-day mortality, late aorta-related death and late aortic events. The secondary endpoints included early surgical complications and any aortic events (e.g. stent graft-induced new entry, frozen elephant trunk angle change).

RESULTS

In the acute group, there were no aorta-related deaths, although 13 patients (27.7%) experienced an aortic event; stent graft-induced new entry occurred in 6 patients (12.8%). In the chronic group, 1 patient (9.1%) experienced aorta-related death, and 9 (81.8%) experienced an aortic event; stent graft-induced new entry occurred in 4 patients (36.4%). During the late phase after surgery, there was a significant increase in the frozen elephant trunk angle in both groups. In the AAD group, both the FET angle and spring-back angle were significantly enlarged in the late phase. There were no significant differences between groups in the degree of angle change, the overall survival, or aortic event-free survival.

CONCLUSIONS

Total arch replacement using the frozen elephant trunk technique affords good early-stage results for both acute and chronic aortic dissection. During follow-up, careful monitoring for aortic events and appropriate therapeutic interventions are required. If surgeons are to use this device, they must have a thorough understanding of its spring back force and other features.

An elderly case of aortic stenosis associated with double-chambered right ventricle

Double-chambered right ventricle (DCRV) caused by right ventricular outflow tract obstruction, is a developmental cardiac anomaly in which the anomalous muscle bundles divide the right ventricular cavity into two chambers. Few cases with DCRV coexisting with severe aortic stenosis (AS) have been reported. Moreover, adult cases are extremely uncommon.We report an elderly case of a heavy DCRV with severe AS detected by transthoracic echocardiography and catheterization study. An 85-year-old woman with dyspnea on effort and right-sided heart failure was diagnosed with DCRV and severe AS by echocardiography. She underwent a resection of the anomalous muscle of the right ventricle and aortic valve replacement. Her symptoms disappeared postoperatively and was discharged home. At 2 years postoperatively, she was generally well without recurrence of DCRV. In conclusion, the case of DCRV with AS is rare and surgery is useful to relieve the heart failure symptoms and improve the prognosis of both young and adult patients.

Learning objective

Double-chambered right ventricle (DCRV) is uncommon in the older population; however, clinicians should consider DCRV in patients with right-sided heart failure as a differential diagnosis. The case of DCRV with aortic stenosis is rare, surgical treatment is particularly useful for these patients to relieve the heart failure symptoms and improve the prognosis in young and adult cases.

Comprehensive genetic screening for vascular Ehlers-Danlos syndrome through an amplification-based next-generation sequencing system

Vascular Ehlers-Danlos syndrome (vEDS) is a hereditary connective tissue disorder (HCTD) characterized by arterial dissection/aneurysm/rupture, sigmoid colon rupture, or uterine rupture. Diagnosis is confirmed by detecting heterozygous variants in COL3A1. This is the largest Asian case series and the first to apply an amplification-based next-generation sequencing through custom panels of causative genes for HCTDs, including a specific method of evaluating copy number variations. Among 429 patients with suspected HCTDs analyzed, 101 were suspected to have vEDS, and 33 of them (32.4%) were found to have COL3A1 variants. Two patients with a clinical diagnosis of Loeys-Dietz syndrome and/or familial thoracic aortic aneurysm and dissection were also found to have COL3A1 variants. Twenty cases (57.1%) had missense variants leading to glycine (Gly) substitutions in the triple helical domain, one (2.9%) had a missense variant leading to non-Gly substitution in this domain, eight (22.9%) had splice site alterations, three (8.6%) had nonsense variants, two (5.7%) had in-frame deletions, and one (2.9%) had a multi-exon deletion, including two deceased patients analyzed with formalin-fixed and paraffin-embedded samples. This is a clinically useful system to detect a wide spectrum of variants from various types of samples.

Sutureless Aortic Valve Replacement Through Lateral Mini-Thoracotomy - Feasibility and Effectiveness

BACKGROUND

Minimally invasive sutureless aortic valve replacement with the Perceval bioprosthetic heart valve (MISUAVR) is commonly performed through a right anterior thoracotomy (AT). However, a lateral thoracotomy (LT) may be superior as it does not require rib and right internal thoracic artery (RITA) cutting.Methods and Results: In total, 38 MISUAVRs performed from May 2019 to approximately August 2021 were retrospectively reviewed; 21 through LT (Group L), and 17 through AT (Group A). In Group L, the skin incision was made on the right anterior axillary line and third intercostal space, and in group A, on the right anterior chest and second or third intercostal space. All other surgical techniques were the same. Age, body surface area, EuroSCORE II, and ejection fraction were similar between the patients. Cardiopulmonary bypass (L: 82±19 vs. A: 93±28 min, P=0.19) and cross-clamp times (L: 57±13, vs. A: 64±23 min, P=0.19) were similar. Rib and/or RITA cutting were required in 94.6% of patients in group A and in none of group L (P<0.001). Surgical visualization score was better in group L (L: 1.19±0.40 vs. A: 1.94±0.69, P<0.01). Total amount of intraoperative bleeding was lower in group L (L: 623±141 vs. A: 838±316 mL, P<0.01). Duration of hospital stay was similar (P=0.30).

CONCLUSIONS

MISUAVR through LT has multiple advantages over AT.

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.

A right coronary artery aneurysm 16 years after surgical repair of anomalous origin of the right coronary artery from the pulmonary artery

Anomalous origin of the right coronary artery (RCA) from the pulmonary artery is a very rare congenital heart disease, and several reports have described long-term events after surgery. We report the case of a 46-year-old woman who underwent reimplantation of the RCA for anomalous origin of the right coronary artery from the pulmonary artery 16 years ago. An RCA aneurysm gradually developed and dilated over time, and we resected the aneurysm and also grafted the right gastroepiploic artery graft to the distal RCA. Careful long-term follow-up is required to avoid overlooking such a rare but life-threatening complication after surgical repair of anomalous origin of the right coronary artery from the pulmonary artery.

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.

Anterior tibial artery rupture treated using covered stent in a patient with vascular Ehlers-Danlos syndrome

Vascular Ehlers-Danlos syndrome (vEDS) is a rare degenerative connective tissue disease caused by a mutation of the COL3A1 gene that results in systemic vascular fragility. Arterial rupture is a potentially fatal serious complication that is the most commonly reported cause of death among patients with this disease, as ruptured vessels remain fragile even after surgical or endovascular reconstruction. Therefore, treatment for vascular complications in patients with vEDS remains controversial. Rupture or pseudoaneurysm of the infrapopliteal artery is extremely rare. We describe a 38-year-old woman with vEDS who presented with sudden widespread rupture of the anterior tibial artery. She was treated by endovascular reconstruction using covered stents. She has remained free of vascular events for two years after surgery, and the course has been uneventful. Endovascular reconstruction using covered stents might offer an alternative for relatively small ruptured arteries and avoid disturbing blood flow in the lower extremities of patients with vEDS. <Learning objective: Vascular Ehlers-Danlos syndrome (vEDS) causes systemic vascular fragility that results in arterial rupture. However, rupture of the arteries in the lower extremities is rare, and definitive treatment has not been established. Endovascular reconstruction with covered stents might offer an alternative treatment for ruptured arteries in the lower extremities of patients with vEDS.>.

[Treatment of Right Atrial Myxoma Complicated with Pulmonary Embolism;Report of a Case]

Myxomas are account for approximately half of primary cardiac tumors, 75% of which originate in the left atrium. We report a case of a right atrial myxoma complicated with bilateral pulmonary embolism. A 54-year-old woman was admitted to the hospital with a complaint of dyspnea. Echocardiography and computed tomography angiography showed a right atrial tumor and bilateral pulmonary embolism. We performed an emergency surgery to remove both the right atrial tumor and the pulmonary emboli. Histopathologically, the tumor was revealed to be myxoma. The postoperative course was uneventful. She is now doing well without any symptoms.

[Primary cardiac leiomyosarcoma originating from the left atrium]

Primary malignant cardiac tumors occur extremely rarely. Among these, leiomyosarcomas are exceptionally rare. We described a case of left atrial leiomyosarcoma in which surgical intervention was followed by adjuvant radiation therapy. A 74-year-old male was admitted for dyspnea. Chest X-ray showed severe pulmonary congestion. Echocardiography revealed large tumor in the left atrium. Emergency operation was performed. The tumor invaded the left atrial wall and the mitral valve, and the lesion was resected as extensively as possible. Postoperative pathologic examination confirmed leiomyosarcoma. He underwent adjuvant radiotherapy postoperatively. However, early local recurrence was recognized. He died due to sudden circulatory collapse in 8th postoperative month. As cardiac leiomyosarcomas have extremely poor prognosis, complete resection and effective postoperative adjuvant therapy are necessary.

[Total arch replacement using a new sheathless open stent-grafting technique]

Total arch replacement for extended distal arch aneurysm has been known to have a poor outcome because of a limited view on the distal side. An open stent-grafting technique has been employed in many institutions, but several complications have been reported. Specifically, embolism of the distal artery from aneurysm debris and injury to the aortic wall are serious complications. Therefore, we have developed and tested a new sheathless stent-grafting system. We use a small-sized sheath (12 Fr) as an inner cylinder and a stainless-steel Z-shaped stent (Gianturco:William Cook Europe A/S) in the distal part of the graft. This system is deployed by releasing 3-0 polypropylene suture after inserting the full-length graft. The major advantages of this system, compared with other devices, include flexibility, less invasiveness to the aortic wall and low potential for graft migration. This new system may be feasible and clinically effective in the surgical treatment of extended distal arch aneurysm.

[Long-term outcome of repair of prolapsing anterior mitral leaflet with artificial chordae replacement]

OBJECTIVE

We have performed a simple and uniform technique for reconstruction of artificial chordae in patients with anterior mitral prolapse since 1994. In this study, we investigated the long-term clinical and echocardiographic results of chordae replacement with Gore-Tex sutures for anterior mitral leaflet prolapse.

METHODS

A pair of Gore-Tex sutures is passed through a small autologous pericardium and tied on one side of the pericardium. Double-armed mattress stitches on the side without a knot are passed through the head of the papillary muscle and another small pericardium and then tied down. Using this simple technique, 2 pairs of artificial chordae are made. The length of the artificial chordae is determined during the leak test. Chordal replacement with this technique was performed in 30 patients (mean age, 59.3 years) with anterior mitral leaflet prolapse. Echocardiography was performed annually in these patients. Follow-up ranged from 0.2~16.2( 8.0±5.1) years.

RESULTS

There were no hospital deaths. Twenty-one patients had no mitral regurgitation( MR) and the others had trivial or mild MR. There were 2 reoperations and 4 cases with recurrent moderate MR in this series. Kaplan-Meier survival and freedom from reoperation at 15 years were 84% and 93%,respectively. Overall, freedom from recurrent moderate or severe MR at 15 years was 81%.

CONCLUSIONS

Our simple chordae replacement technique with Gore-Tex sutures for anterior mitral prolapse, results in good long-term durability. To avoid recurrence of regurgitation, intraoperative complete repair is essential.

[Aortic root reconstruction with Edwards Prima PLUS stentless valve]

We report successful treatment of 3 aortic root aneurysm cases with Edwards Prima PLUS stentless valve which has recently been approved in Japan. The patients were 69, 77, and 69 year-old male. All patients showed Sellers' IV degree aortic valve regurgitation. The aortic annulus diameters were 28, 23, and 26 mm, the Valsalva sinus diameters were 46, 53, and 57 mm, and the sino-tubular junction diameters were 32, 50, and 43 mm, respectively by echocardiographical measurement. Aortic root reconstructions with Edwards Prima PLUS stentless valve were chosen for all patients, considering the patient's age, pathological change of the aortic valve, and concomitant cardiovascular procedures. Only root reconstruction was performed in case 1. Ascending aortic replacement and single coronary artery bypass were added in case 2, and pulmonary vein isolation with radiofrequency ablation device and mitral ring annuloplasty were added in case 3. Total surgical duration was 218, 275, and 266 minutes, respectively and their postoperative courses were uneventful. This operation can be an appropriate choice for the selected patient with aortic root aneurysm.

[Modified infarction exclusion technique for surgical treatment of postinfarction ventricular septal rupture]

A ventricular septal rupture (VSR) is a fatal complication after an acute myocardial infarction. Surgical repair with an infarction exclusion technique (IET) has improved the surgical outcome for VSR. However, a residual shunt from the left ventricle to the right ventricle has been still one of the problems associated with this technique. We modified the IET so as to avoid the occurrence of the residual shunt In our modification, interrupted mattress sutures were placed transmurally to obtain a secure fixation of the pericardial patch. As for the interventricular septum, the VSR was enlarged to about 1.5 cm in diameter with a cavitron ultrasonic surgical aspirator to facilitate the placement of transmural sutures from the right ventricle to the left ventricle. We performed VSR repair with this modified IET in 3 patients, and have obtained beneficial results.

[Repair of postoperative residual shunt of postinfarction ventricular septal perforation: report of a case]

A 70 year-old man had the surgical repair of post-infarction ventricular septal perforation (VSP) with infarction exclusion technique. Five days after operation, residual shunt was observed by echocardiogram and he developed cardiac failure. Additional surgery for residual shunt was performed 1 month after 1st operation. The infracted myocardium was firm enough to closed directly, so the Xenomedica patch was sutured on the side of the perforated septum around VSP. The postoperative course was uneventful.

Primary malignant fibrous histiocytoma of the heart

We describe a case of a primary cardiac malignant fibrous histiocytoma in the left atrium of a 72-year-old man. Local recurrences appeared twice, at 2 and 14 months after initial tumor resection, and were managed surgically. The patient died of pancreatic metastasis 22 months after the initial diagnosis. The prognosis for MFH of the heart is poor despite aggressive surgical treatment.

Aneurysm of the Right Sinus of Valsalva After Aortic Valve Replacement in Takayasu Arteritis

We herein report a case with an aneurysm of the right sinus of Valsalva, which developed 14 years after an aortic valve replacement (AVR) for aortic regurgitation caused by Takayasu arteritis. The aortic wall around the right coronary artery ostium showed calcification, as a result, the modified Bentall procedure and coronary artery bypass to the right coronary artery were successfully performed. A pathological study of the resected aortic sinus wall showed a disruption of the elastic fibers in the media, granuloma formation, and a marked proliferation of the collagen fibers in the adventitia, and these findings were compatible with Takayasu arteritis. The development of an aneurysm of the sinus of Valsalva late after AVR indicates the necessity of a close and lifelong follow-up for patients with Takayasu arteritis, especially focusing on the aortic root morphology.

[Initial experience in endoscopic radial artery harvesting]

We report the initial experience of endoscopic radial artery (RA) harvesting (ERA) using Vasoview System. The expected advantages of ERA are superior cosmetic results and fewer wound complications to the conventional open technique. ERA was performed in 33 patients from September 2004 to September 2005. Preoperatively, Allen's test with Doppler imaging was performed in all patients. ERA was successfully performed within 50 minutes except in the first 3 patients (the mean time for harvest: 37 minutes). Direct injury of the RA occurred in 1 patient, but the RA could be used as a graft for coronary artery bypass grafting (CABG) by repairing with end-to-end anastomosis. Only 1 RA graft occluded as determined by the early postoperative angiography. Local dissection of the RA was observed in 2 patients, but no flow disturbance was observed. Delayed wound healing occurred in 1 aged patient. No significant nerve complications were encountered. ERA is easy to adopt and has greater cosmetic advantages.

A Safer Technique of Aortic Root Replacement After Aortic Valve Replacement

Aortic root replacement after aortic valve replacement (AVR) is often complicated by bleeding around the aortic root, which increases the risk of morbidity and mortality, making it a technically challenging procedure. We describe a new technique of aortic root replacement designed to minimize bleeding around the aortic root. This surgical technique focuses on safe dissection and exposure of the aortic root to avoid inadvertent entry into the right atrium or right ventricle; on modifying the proximal anastomosis of the graft to the aortic annulus; and on performing a coronary artery reimplantation that achieves complete hemostasis at the suture lines. We performed aortic root replacement after AVR in four patients over a 4-year period, without encountering any bleeding around the aortic root.

[Left ventricular pseudo-false aneurysm after a myocardial infarction; application of heart positioner]

We herein present the case of a pseudo-false aneurysm which developed in a patient after a myocardial infarction in the posterior left ventricular wall. A 71-year-old man experienced an acute myocardial infarction due to occlusion in the left circumflex artery. Five weeks after the myocardial infarction, echocardiography and magnetic resonance imaging (MRI) disclosed a pseudo-false aneurysm at the posterior left ventricular wall. A patch closure of the aneurysm and coronary artery bypass grafting (CABG) to both the left anterior descending artery and the left circumflex arteries were successfully performed. At surgery, the Starfish Heart Positioner, a commercially available device that is designed to lift the heart during off-pump CABG, was found to be very useful for exposing the posterior left ventricular wall by lifting and fixing the apex of the left ventricle.

Papillary fibroelastoma of the tricuspid valve

A 72-year-old male patient was admitted with chest oppression. Echocardiography disclosed a mobile tumor which was located on the atrial side of the tricuspid valve. Neither tricuspid obstruction nor regurgitation was observed. The mobility and the size, 20 mm in diameter, of the tumor indicated the need to perform surgical treatment. Through a right atriotomy, the tumor with multiple papillary fronds was found on the basal zone of the anterior leaflet. A resection of the tumor and tricuspid valvuloplasty with a partial annular reconstruction were performed. A pathological examination confirmed papillary fibroelastoma. He had an uneventful recovery, and postoperative echocardiography detected neither any residual tumor nor tricuspid regurgitation. In conclusion, it is reasonable to state that echocardiography is useful for detecting cardiac tumors, and a surgical resection is indicated for a mobile or large papillary fibroelastoma even when it is located on the right side of the heart.