Surgical techniques using an attached patch for large left ventricular pseudoaneurysm after inferior acute myocardial infarction

We report a case of large left ventricular pseudoaneurysm after inferior acute myocardial infarction. Patch repair is commonly performed; however, only a few studies have described specific surgical techniques for left ventricular pseudoaneurysm repair of the inferior left ventricular wall. As an optimal repair technique for left ventricular pseudoaneurysm of the inferior left ventricular wall is lacking, we believe our technique is safe and effective in repairing this pathology.

Morphologic prognostic factor for thoracoabdominal aortic dilation after acute type A dissection repair

OBJECTIVES

Risk factors for late-term aortic dilation after acute type A aortic dissection repair have not been well examined. The goal of this study was to determine the relationship between the abdominal aortic true lumen location and thoraco-abdominal aortic dilation after surgical repair for acute type A aortic dissection.

METHODS

Patients who were preoperatively diagnosed with acute type A aortic dissection between April 2014 and July 2022 were included in this study. We evaluated the renal artery-level dissected aortic morphology and classified the study population into 2 groups: the ventral (those with the true lumen located on the ventral side) and the dorsal (other patients not assigned to the ventral group) groups, based on the location of the true lumen. Aortic dilation was defined as thoraco-abdominal aortic expansion ≥5 mm on 1-year postoperative computed tomography images.

RESULTS

We examined 49 surgical patients who were assigned to the ventral (n = 22) and dorsal (n = 27) groups. The number of patients with ≥5 mm thoraco-abdominal aortic dilation after the operation was significantly higher in the ventral group than in the dorsal group (90.9% vs 51.9%, P = 0.009). The multivariable logistic regression analysis showed that the ventral type was an independent prognostic factor for thoraco-abdominal aortic dilation after the operation (odds ratio, 6.01; 95% confidence interval, 1.56-23.77; P = 0.009).

CONCLUSIONS

The location of the true lumen of the abdominal aorta in acute type A aortic dissection may be a prognostic factor for thoraco-abdominal aortic dilation after surgical repair.

Appropriate sizing of the frozen elephant trunk: How to predict proximal descending aortic diameter prior to dissection?

OBJECTIVE

The predissection aortic diameter is the best reference for determining the size of the frozen elephant trunk in aortic dissection. We aimed to develop a new prediction method to estimate the predissection diameter of proximal descending aorta. Furthermore, we evaluated the accuracy of the estimated predissection proximal descending aortic diameters calculated using 3 prediction methods.

METHODS

A total of 39 patients with acute type A aortic dissection who underwent predissection computed tomography were included in derivation sets. We measured the aortic dimensions at 3 levels of the proximal descending aorta: 5, 10, and 15 cm from zone 2. We developed a new prediction method-postdissection aortic diameter divided by 1.13 (AoDNew factor)-and estimated the predissection aortic diameter using the new and previously proposed methods by Rylski (AoDRylski) and Yamauchi (EquationYamauchi). Furthermore, we validated the new prediction method using a validation dataset with 24 patients.

RESULTS

The rate of bias ≤2 mm was significantly greater with EquationYamauchi and AoDNew factor than with AoDRylski in the derivation group at each level of the proximal descending aorta (P < .001). In the validation group, the rate of bias ≤2 mm was significantly greater with EquationYamauchi and AoDNew factor than with AoDRylski at 10 cm and 15 cm from zone 2 (10 cm: P = .014, 15 cm: P < .001).

CONCLUSIONS

These results suggest that the new prediction method can be used as a simple and accurate estimation method for the predissection aortic diameter at the proximal descending aorta.

Comparison of bubble removal performances of five membrane oxygenators with and without a pre-filter

When employing minimal invasive extracorporeal circulation (MiECC), the removal of bubbles in the circuit is important to prevent air embolism. We investigated the bubble removal performance of the FHP oxygenator with a pre-filter and compared it with that of four oxygenators, including the Fusion oxygenator, Quadrox oxygenator, Inspire oxygenator, and FX oxygenator. A closed test circuit filled with an aqueous glycerin solution was used. Air injection (10 mL) was performed prior to the oxygenator, and the number and volume of the bubbles were measured at the inlet and outlet of each oxygenator. At the inlet of the five oxygenators, there were no significant differences in the total number of bubbles detected. At the outlet, bubbles were classified into two groups according to the bubble size: ≥100 μm and <100 μm. Tests were performed at pump flow rates of 4 and 5 L/min. For bubbles ≥100 μm, which are considered clinically detrimental, the FHP was the lowest number and volume of bubbles at both pump flow rates compared to the other oxygenators. Regarding the bubbles <100 μm, the number of bubbles was higher in the FHP than those in others; however, the volume of bubbles was significantly lower at 4 L/min and tended to be lower at 5 L/min. The use of the FHP with the pre-filter removed more bubbles ≥100 μm in the circuit than that by the other oxygenators.

Association between frailty and long-term outcomes among patients undergoing thoracic aortic surgery via median sternotomy

OBJECTIVE

Preoperative assessment of frailty is important for predicting postoperative outcomes. This study investigated the association between frailty and late outcomes among patients who underwent thoracic aortic surgery via median sternotomy.

METHODS

A total of 1010 patients underwent thoracic aortic surgery via median sternotomy between April 2008 and December 2016. Patients < 65 years of age, those who underwent urgent or emergent surgery, and those with incomplete data were excluded; as such, 374 patients were ultimately included in the present study. Frailty was evaluated using an index comprising history of dementia, body mass index < 18.5 kg/m², and hypoalbuminemia. A frailty score from 0 to 3 was determined by assigning 1 point for each criterion met. Frailty was defined as a score ≥ 1. Patients were categorized into of 2 groups: frail (n = 52) and non-frail (n = 322). The mean follow-up was 6.1 ± 3.1 years.

RESULTS

Overall in-hospital mortality did not differ between the frail and non-frail groups. However, the incidence of re-exploration for bleeding and discharge to a health care facility was higher in the frail group than in the non-frail group. Multivariable analysis revealed that preoperative frailty was an independent predictor of late mortality during follow-up [hazard ratio 3.71 (95% confidence interval 2.16-6.37); P < 0.001].

CONCLUSION

Preoperative frailty was associated with late mortality after thoracic aortic surgery. Assessment of preoperative frailty using a simple frailty index may be useful in the decision-making process for elderly patients.

Effects of antifouling compounds on the growth of macroalgae Undaria pinnatifida

Seaweeds are some of the principal primary producers of marine environments, and they are important ecological elements of coastal ecosystems. The effects of harmful chemicals on seaweeds may adversely affect coastal ecosystems, hence we aimed to develop a new phytotoxicity test using the gametophytes of a common temperate kelp species, Undaria pinnatifida (KU-1630), for the widely used antifouling chemical substances Cybutryne, Diuron, Cu2+, and Zn2+. Toxicity to gametophytes of U. pinnatifida was assessed by comparing the relative growth rate (RGR) at the logarithmic growth phase. Fragmentation method, initial algal biomass, photon irradiance, and adhesive period were investigated for developing optimal test conditions. Cybutryne exposure tests were performed with seven replicates and control, the RGR ranging from 0.17 to 0.19, while mean 7-day EC50 and no observed effect concentration (NOEC) were 5.1 μg/L and 1.8 μg/L, respectively. The 7-day EC50 for other antifoulants was 14 μg/L for Diuron, 17 μg/L for Cu2+, and 1500 μg/L for Zn2+. This test method demonstrated high sensitivity and reproducibility, and it may be added to the routine methods used for toxicity evaluation of hazardous chemicals.

Fenestrated and covered frozen elephant trunk technique for management of chronic aortic dissection

BACKGROUND

Reintervention for residual dissection after repaired type A aortic dissection remains challenging. When a frozen elephant trunk (FET) is used, the incidence of distal stent graft-induced new entry (d-SINE) is reportedly high in chronic dissection.

AIMS

We report a case of successful redo arch repair using fenestrated and covered FET techniques for chronic residual aortic dissection.

METHODS

After the arch was transected proximal to the left subclavian artery (LSCA), and a modified FET prosthesis, in which the distal edge of the FET was covered, was deployed. A fenestration was created in the FET on the LSCA aspect.

RESULTS

The postoperative course was uneventful.

DISCUSSION

The distal edge of the FET was covered to prevent d-SINE. Creation of a fenestration on the FET eliminates the need to reconstruct the LSCA.

CONCLUSION

The fenestrated FET technique simplifies redo arch repair and the covered FET technique can potentially prevent d-SINE.

Effects of a frozen elephant trunk on postoperative renal dysfunction in acute type A aortic dissection extending into the renal artery

BACKGROUND

We investigated the effects of frozen elephant trunk (FET) implantation on clinical outcomes in patients with acute type A aortic dissection (ATAAD) extending into the renal artery (RA).

METHODS

Between May 2016 and April 2021, 136 patients underwent surgery for ATAAD at our hospital. Patients who died within 7 days postoperatively and those without preoperative contrast-enhanced computed tomography (CT) data were excluded from the study. The remaining 125 patients were included in this study. A preoperative CT-documented RA abnormality was found in 53 patients. Clinical outcomes, including renal dysfunction and CT findings, were compared between 29 patients with and 24 patients without the FET prosthesis.

RESULTS

Among the 53 patients with RA abnormalities, origin of the RA from the false lumen was the most common type of abnormality. The percentage of men and rate of arch repair were higher, and the operation, cardiopulmonary bypass, and lower body hypothermic circulatory arrest times were longer in the FET than in the non-FET group. Early mortality rates were similar between groups. The incidence of postoperative acute kidney injury (AKI) was lower in the FET group (35% vs. 67%, p = 0.028). Multivariable analysis showed that FET implantation was associated with a low incidence of AKI (odds ratio: 0.28, 95% confidence interval: 0.08-0.96; p = 0.043). Among the 125 patients with or without RA abnormalities, no predictor of AKI was identified.

CONCLUSION

FET implantation protected against postoperative AKI in patients with ATAAD extension into the RA.

Predictive factors of distal stent graft-induced new entry after frozen elephant trunk procedure for aortic dissection

OBJECTIVES

The incidence rate of distal stent graft-induced new entry after frozen elephant trunk technique for aortic dissection remains controversial. The aim of this study was to investigate the incidence and seek the clinical and anatomical predictive factors.

METHODS

This study is a retrospective multicenter evaluation of complications including distal stent graft-induced new entry, aortic events, and re-intervention after the frozen elephant trunk procedure for aortic dissection.

RESULTS

Our cohort included total 177 consecutive patients who underwent the frozen elephant trunk procedure for acute and chronic aortic dissection at five centers in Japan from May 2014 to March 2021. The incidence rate of distal stent graft-induced new entry was 14.1% (25/177 patients). The cumulative incidence of d-SINE was 7.1%, 12.4%, 21.4% after 12, 36, and 60 months, respectively. Distal stent graft-induced new entry was not associated with mid-term survival rate. After competing risk regression analysis, onset time > 48 hours (subdistribution hazard ratio, 3.80; 95% confidence interval, 1.13-12.79; P=0.031) was detected as an independent predictor.

CONCLUSIONS

Awareness that there is a relatively higher incidence of distal stent graft-induced new entry after frozen elephant trunk procedures is important. Non-hyperacute phase was detected as an independent risk factor. Preemptive endovascular repair may be appropriate to protect new entry in high-risk patients.

Sutureless repair techniques for post-infarction left ventricular free wall rupture

Left ventricular free wall rupture after acute myocardial infarction is uncommon but lethal and is still associated with high mortality rates. This paper presents the surgical treatment options and clinical management for post-infarction left ventricular free wall rupture. Various types of techniques, specifically sutureless repair using TachoComb/TachoSil, and intraoperative video images are discussed. Currently, sutureless repair is the most recommended treatment option when possible. However, appropriate selection of the surgical procedure remains important.

Reconstruction of the left subclavian artery in arch repair: An end-to-side anastomosis technique

BACKGROUND

The left subclavian artery (LSCA) is deeply located and difficult to visualize in some cases of total arch replacement.

AIMS

We report an end-to-side anastomosis technique that enables safer and easier anatomical reconstruction of the LSCA.

MATERIALS AND METHODS

Under Hypothermic circulatory arrest, the origin of the LSCA was ligated and pulled caudally. With clamping the distal LSCA, a graft was anastomosed to the anterior wall of the LSCA and antegrade cerebral perfusion to the LSCA was ensured through the anastomosed graft. Thereafter, distal anastomosis was performed proximal to the LSCA.

RESULTS

The postoperative course was uneventful.

DISCUSSION

Our reconstruction technique provides excellent exposure of the LSCA by pulling the origin of the LSCA caudally. Hemostasis after reconstruction is feasible, as the anastomosis in the anterior wall of the LSCA is easily visualized.

CONCLUSION

The end-to-side anastomosis technique for LSCA reconstruction is a simple alternative in arch repair.

OUP accepted manuscript

Distal stent graft-induced new entry is not rare after frozen elephant trunk implantation. We report a case of covered frozen elephant trunk placement for prevention of distal stent graft-induced new entry. Coverage of the rigid distal stent edge using a graft reduces mechanical stress on the intima and radial force of the distal stent; therefore, this technique can potentially prevent distal stent graft-induced new entry.

Impact of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation

Negative impact of prosthesis-patient mismatch on long-term survival after valve replacement has been reported. However, the effect of prosthesis-patient mismatch after bioprosthetic mitral valve replacement has not yet been well examined. The purpose of this study was to investigate the effect of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation. A total of 181 patients underwent bioprosthetic mitral valve replacement between April 2008 and December 2016. After excluding patients with mitral stenosis and those with incomplete data, 128 patients were included in the study. Postoperative transthoracic echocardiography was performed before discharge for all patients and the effective orifice area of bioprosthetic mitral valve was calculated using the formula: 220/pressure half-time, and the effective orifice area index was calculated by the formula: effective orifice area/body surface area. Prosthesis-patient mismatch was defined as a postoperative effective orifice area index ≤ 1.2 cm²/m². The characteristics and outcomes were compared between the groups. There were 34 patients (26.6%) with prosthesis-patient mismatch and 94 patients (73.4%) without prosthesis-patient mismatch. There were no significant differences in the in-hospital mortality and morbidities. Multivariable analysis showed that prosthesis-patient mismatch was an independent predictor of late mortality (hazard ratio 3.38; 95% confidence interval 1.69-6.75; p = 0.001) and death from heart failure (hazard ratio 31.03, 95% confidence interval 4.49-214.40, p < 0.001). Prosthesis-patient mismatch at discharge after mitral valve replacement for mitral regurgitation was associated with long-term mortality and death from heart failure.

Long-term outcomes after aortic valve replacement using a 19-mm bioprosthesis

OBJECTIVES

Transcatheter aortic valve replacement is known to be associated with improved haemodynamics in patients with aortic stenosis and a small aortic annulus. However, limited benchmark data are available regarding the long-term outcomes in patients treated with surgical aortic valve replacement (SAVR). We investigated the long-term outcomes of SAVR using a 19-mm bioprosthesis.

METHODS

This study included consecutive patients who underwent SAVR using a 19-mm bioprosthesis at our hospital between 2008 and 2012.

RESULTS

In a total of 132 patients, moderate and severe prosthesis-patient mismatch occurred in 36 (27.3%) and 7 patients (5.3%), respectively. The median follow-up period was 7.7 years. The overall 5- and 10-year survival rates were 79.4% and 52.9%, respectively. The 5- and 10-year freedom from major adverse valve-related events rates were 89.6% and 74.2%, respectively. Neither moderate nor severe prosthesis-patient mismatch was associated with late mortality, major adverse valve-related events or heart failure. Follow-up echocardiographic data were obtained at a median interval of 4.8 years in 80% of patients who survived ≥6 months postoperatively. Follow-up echocardiographic data showed a significantly increased left ventricular ejection fraction, decreased mean transvalvular/transprosthetic pressure gradients and a decreased mean left ventricular mass. At follow-up, we observed moderate or severe haemodynamic structural valve deterioration in 17 patients; however, structural valve deterioration did not affect late survival or freedom from major adverse valve-related events rates, or heart failure.

CONCLUSIONS

SAVR using the 19-mm bioprosthesis was associated with satisfactory long-term clinical and haemodynamic outcomes.

Bail-Out Pull-Through Pull-Back Technique for Accidental Coverage of the Left Common Carotid Artery During Thoracic Endovascular Aortic Repair

PURPOSE

We describe a pull-through pull-back technique to revascularize the left common carotid artery (LCCA) that was unintentionally covered during thoracic endovascular aortic repair (TEVAR).

CASE REPORT

A 69-year-old man presented with back pain secondary to acute type B aortic dissection with an intimal tear in the proximal descending aorta. Serial computed tomography (CT) revealed an enlarged descending aorta and proximal progression of the aortic dissection. He underwent left carotid-subclavian artery bypass and TEVAR, 10 days after admission. The Valiant Navion stent graft without a bare stent was deployed proximally; however, the LCCA was unintentionally covered by the stent graft during this procedure. A pull-through form was created between the left axillary and femoral arteries using a 0.035-inch guide wire. The pull-through guide wire was gently pulled, and the greater curvature of the proximal end of the stent graft was displaced distally. Angiography confirmed restoration of antegrade blood flow into the LCCA. The patient's postoperative course was uneventful. Follow-up CT performed 6 months postoperatively confirmed preserved blood flow into the LCCA without endoleak nor stent migration.

CONCLUSION

The pull-through pull-back technique is a feasible troubleshooting strategy for accidental coverage of supra-aortic vessels during TEVAR.

Prevention of postoperative delirium after cardiovascular surgery: A team-based approach

OBJECTIVE

We investigated the efficacy of the Delirium Team Approach program for delirium prevention after cardiovascular surgery.

METHODS

We retrospectively investigated 256 patients who underwent cardiac or thoracic vascular surgery between May 2017 and May 2020. We compared the outcomes before and after implementation of the Delirium Team Approach program in December 2018. The program included the following components: (a) educational sessions for the medical team regarding delirium and its management, (b) review of preprinted physician orders for insomnia and agitation, and (c) routine screening for delirium. We investigated the early outcomes and effects of the Delirium Team Approach program on postoperative delirium.

RESULTS

The incidence of postoperative delirium significantly decreased from 53.3% to 37.0% after implementation of the Delirium Team Approach program (P = .008). Although no intergroup differences were observed in the rates of stroke and reexploration for bleeding, the length of intensive care unit stay and the overall length of postoperative hospital stay were shorter in the postintervention group. Hospital costs, excluding surgery, and the cost during intensive care unit stay were lower in the postintervention group. Multivariable analysis showed that the Delirium Team Approach program was associated with a reduction in postoperative delirium (odds ratio, 0.38; 95% confidence interval, 0.21-0.67; P = .001). Other predictors of delirium included age, dementia, chronic kidney disease, and intubation time. After risk adjustment using propensity score matching, the rate of postoperative delirium was lower in the postintervention group.

CONCLUSIONS

Implementation of the Delirium Team Approach program was associated with a lower incidence of postoperative delirium in patients who underwent cardiovascular surgery.

Clinical outcomes of a fenestrated frozen elephant trunk technique for acute type A aortic dissection

OBJECTIVES

We investigated the outcomes of a fenestrated frozen elephant trunk (FET) technique performed without reconstruction of one or more supra-aortic vessels for aortic repair in patients with acute type A aortic dissection.

METHODS

We investigated 22 patients who underwent the fenestrated FET technique for acute type A aortic dissection at our hospital between December 2017 and April 2020. The most common symptom was chest pain and/or back pain. Nine patients presented with malperfusion and 1 with cardiac arrest, preoperatively. A FET was deployed under hypothermic circulatory arrest and manually fenestrated under direct vision. Single fenestration was made in the FET in 15 patients, 2 fenestrations in 5 patients and a total fenestrated technique in 2 patients. Concomitant procedures were performed in 5 patients.

RESULTS

The cardiopulmonary bypass, aortic cross-clamp and hypothermic circulatory arrest times were 181 ± 49, 106 ± 43 and 37 ± 7 min, respectively. In-hospital mortality, stroke, or recurrent nerve injury did not occur in any patient. One patient developed paraparesis, which completely recovered at discharge. During the follow-up period (mean 18 ± 7 months), 1 patient died of heart failure. Fenestration site occlusion did not occur. Follow-up computed tomography (mean 12 ± 6 months postoperatively) revealed that the maximal aortic diameter remained unchanged at the levels of the distal end of the FET, the 10th thoracic vertebra and the coeliac artery; however, the aortic diameter was significantly reduced at the level of the pulmonary artery bifurcation.

CONCLUSIONS

The fenestrated FET technique is a simple, safe and effective procedure for selected patients with acute type A aortic dissection.

Preoperative sarcopenia is associated with late mortality after off-pump coronary artery bypass grafting

OBJECTIVES

We investigated the association between sarcopenia (a marker of frailty) and outcomes after coronary artery bypass grafting (CABG).

METHODS

This study included 304 patients who underwent elective isolated off-pump CABG at our hospital between October 2008 and August 2013. Psoas muscle area was measured on preoperative computed tomography scans. Sarcopenia was defined as the lowest sex-specific quartile of the psoas muscle area index (the psoas muscle area normalized for height). Patients were categorized into a sarcopenia group (76 patients) and a non-sarcopenia group (228 patients). Patients in the sarcopenia group were older and showed a lower body mass index, lower serum haemoglobin and albumin levels and lower prevalence of dyslipidaemia but higher prevalence of renal dysfunction and peripheral artery disease. The mean follow-up period was 4.5 ± 2.3 years.

RESULTS

The cut-off values for sarcopenia were psoas muscle area index 215 and 142 mm2/m2 in men and women, respectively. No intergroup difference was observed in the in-hospital mortality and morbidity rates. After risk adjustment using inverse probability weighting analysis, late mortality rates were significantly higher in the sarcopenia group than in the non-sarcopenia group (P = 0.022). Multivariable analysis showed that preoperative sarcopenia was an independent predictor of late mortality (hazard ratio 4.25, 95% confidence interval 2.18-8.28; P < 0.001). Preoperative sarcopenia was not associated with major adverse cardiac and cerebrovascular events during follow-up.

CONCLUSIONS

Preoperative sarcopenia (assessed by psoas muscle area index) was associated with late mortality after CABG and effectively predicts postoperative prognosis.

Long-Term Outcomes and Echocardiographic Data After Aortic Valve Replacement With a 17-mm Mechanical Valve

BACKGROUND

We investigated the long-term clinical and hemodynamic outcomes after aortic valve replacement (AVR) with a 17-mm mechanical valve.Methods and Results:Between January 2005 and December 2011, 80 patients with aortic stenosis underwent AVR with the 17-mm St. Jude Medical Regent prosthetic valve. Echocardiography was performed preoperatively, at discharge, and at follow-up, which was performed at least 2 years postoperatively (median interval, 7.3 years). Prosthesis-patient mismatch (PPM) was defined as an indexed effective orifice area <0.85 cm²/m²at discharge and occurred in 25 patients (31%). The median follow-up period was 8.7 years (100% complete). Overall in-hospital mortality was 2.5% (2 patients) with 27 late deaths (34%). The 5- and 10-year survival rates were 78.7% and 63.0%, respectively. Peripheral arterial disease and concomitant mitral valve repair were independent predictors of late mortality. The 5- and 10-year freedom from major adverse valve-related events (MAVRE) rates were 91.6% and 83.5%, respectively. PPM at discharge did not affect long-term survival, freedom from MAVRE, or freedom from heart failure. Echocardiographic data at follow-up revealed a significant reduction in the mean left ventricular mass index (LVMI). LVMI reduction observed at follow-up was similar between patients with and without PPM.

CONCLUSIONS

AVR with the 17-mm mechanical prosthesis had acceptable long-term clinical and hemodynamic outcomes. Significant reduction in LVMI was observed regardless of PPM.

Common carotid artery true lumen flow impairment in patients with type A aortic dissection

OBJECTIVES

Our aim was to evaluate clinical and neurological effects of common carotid artery (CCA) true lumen flow impairment or occlusion in patients with type A aortic dissection.

METHODS

Characteristics and imaging data of patients with dissected CCA secondary to acute type A aortic dissection from 3 institutions were analysed. We defined true lumen blood flow as unimpaired when the maximum true lumen diameter exceeded 50% of the complete CCA diameter, as impaired when the true lumen was compressed to ˃50% of the complete lumen, or as occluded.

RESULTS

Out of 440 patients, 207 presented unimpaired CCA flow, 172 impaired CCA flow and CCA occlusion was present in 61 patients. Preoperative shock (P = 0.045) or a neurological deficit (P < 0.001) were least common in patients with unimpaired CCA flow and most common in those with CCA occlusion. Non-cerebral, other-organ malperfusion was common in 37% of all patients, but the incidence was similar (P = 0.69). In patients with CCA occlusion, postoperative stroke (P < 0.001) and in-hospital mortality (0.011) were significantly higher, while the incidences were similar between patients with unimpaired and impaired CCA flow. Mixed-effects logistic regression models showed that CCA flow impairment (P = 0.23) or occlusion (P = 0.55) was not predictive for in-hospital mortality, but CCA occlusion was predictive for in-hospital stroke (odds ratio 2.166, P = 0.023).

CONCLUSIONS

Shock and non-cerebral, other-organ malperfusion are common in patients with CCA dissection. While there is a high risk for stroke in patients with CCA occlusion, CCA flow impairment and occlusion were not predictive for in-hospital mortality. Surgery should not be denied to patients with CCA flow impairment or occlusion.

Double-patch and glue repair of a postinfarction left ventricular pseudoaneurysm

An 85-year-old man with appetite loss, lightheadedness, and leg edema was referred to our institution. Computed tomography and transthoracic echocardiography revealed a left ventricular pseudoaneurysm with a maximal diameter of 80 mm and severe mitral regurgitation. Coronary angiography showed 90% stenosis and total occlusion of the left circumflex artery at segments 11 and 12, respectively. He was diagnosed with postinfarction left ventricular pseudoaneurysm and underwent patch repair using two bovine pericardium patches and biological glue, mitral valve replacement, and coronary artery bypass grafting. His postoperative course was uneventful.

Clinical outcome of acute thoracic aortic syndrome in nonagenarians

BACKGROUND

Decision-making regarding the operability of thoracic aortic disease in nonagenarian patients remains controversial because outcomes of open surgical repair of the thoracic aorta are unclear. We investigated the surgical and nonsurgical outcomes of acute thoracic aortic syndrome treatment in nonagenarians.

METHODS

After evaluating data in our institute from April 2016 to March 2020, we included 10 nonagenarians who needed surgical intervention on the thoracic aorta via a median sternotomy for acute thoracic aortic syndrome. The mean age of the cohort was 91.9 ± 2.1 years. Five patients underwent open surgical repair of the thoracic aorta (surgical group), and 5 refused surgery (nonsurgical group). All patients in the surgical group performed activities of daily living independently, with a mean clinical frailty scale of 3.2 ± 0.4. The surgical group included 4 patients with type A aortic dissection and one with a ruptured thoracic aortic aneurysm. Hemiarch replacement was performed in 3 patients and total arch replacement in 2. The mean follow-up period was 17.8 ± 5.1 months.

RESULTS

Hospital mortality rates were 0% in the surgical and 80% in the nonsurgical group. The mean length of hospitalization was 28.4 ± 6.7 days in the surgical group. The 1-year survival rates were 100% in the surgical group and 20% in the nonsurgical group.

CONCLUSION

Open surgical repair for acute thoracic aortic syndrome via median sternotomy is a reasonable treatment option even in nonagenarians. Involvement of family members is important for decision-making to devise the optimal treatment strategy (surgical vs. medical).

Minimized perfusion circuit for acute type A aortic dissection surgery

A minimized perfusion circuit (MPC) may reduce transfusion requirement and inflammatory response. Its use, however, has not been standardized for complicated cardiovascular surgery. We assessed outcomes of surgery for acute type A aortic dissection (ATAAD) performed with a MPC under circulatory arrest. The study involved 706 patients treated surgically for ATAAD (by hemiarch repair [n = 571] or total arch repair [n = 135]). Total arch repair was performed using selective antegrade cerebral perfusion. Our MPC, a semi-closed bypass system, incorporating a completely closed circuit and a level-sensing reservoir in the venous circuit, was used. Clinical variables, transfusion volume, and outcomes were investigated in patients who underwent hemiarch repair or total arch repair. The overall incidences of shock, organ ischemia, and coagulopathy (prothrombin time-international normalized ratio >1.5) were 26%, 35%, and 8%, respectively. Mean extracorporeal circulation (ECC) time was 149 minutes for the hemiarch repair group and 241 minutes for the total arch repair group, respectively. No patient required conversion to conventional ECC, and there were no complications related to the use of the MPC. The need for transfusion (98% vs. 91%, P = .017) and median transfusion volume (1970 vs. 1680 mL, P = .002) was increased in the total arch repair group. Neither in-hospital mortality (total arch; 12% vs. hemiarch; 7%, P = .11) nor 10-year survival (74.4% vs. 68.4%, P = .79) differed significantly. Outcomes of surgery for ATAAD performed with the MPC were acceptable. The possibility of transfusion and transfusion volume remains high during such surgery, despite the use of the MPC.

Contemporary outcomes of composite aortic root replacement in elderly patients

Figure 4.

OBJECTIVES

We investigated the clinical and haemodynamic outcomes in elderly patients undergoing composite aortic root replacement.

METHODS

Between 2005 and 2017, 135 patients underwent aortic root surgery at our hospital. Of these 135 patients, 47 patients aged ≥65 years were included in this study. Pathologies included aneurysms in 31, chronic aortic dissection in 6, acute aortic dissection in 4 and other causes in 6 patients. A bioprosthesis was used in 27 and a mechanical valve in 20 patients. The mean age was 71.0 ± 4.3 years. The mean follow-up period was 61 ± 35 months. Follow-up echocardiographic data (average 48 months after surgery) were collected in 35 patients (74%).

RESULTS

The in-hospital mortality rate was 2.1% (1 patient). Seven late deaths occurred during follow-up. The 1-, 5- and 8-year overall survival was 93.6%, 82.9% and 82.9%, respectively. Infective endocarditis, Marfan syndrome and diabetes were independent predictors of poorer survival. During the follow-up, thromboembolism occurred in 1 patient, major bleeding events in 5 patients, or proximal reoperation for prosthetic valve endocarditis in 1 patient. The type of valve, mechanical or biological valve, did not affect late mortality and morbidity. Follow-up echocardiography revealed significantly improved left ventricular ejection fraction compared with that at discharge.

CONCLUSIONS

Composite aortic root replacement provided satisfactory midterm outcomes in patients aged ≥65 years. Further studies with a longer follow-up are warranted to evaluate late valve-related events.

Preoperative neurological deficit in acute type A aortic dissection

OBJECTIVES

Our goal was to evaluate postoperative outcomes in patients with type A aortic dissection with preoperative neurological deficits independent of shock.

METHODS

Between 2002 and 2017, 150 of 1600 patients, operated on for aortic dissection type A in 3 centres, presented with preoperative new onset neurological deficits. Postoperative outcomes were classified using a modified Rankin Scale (mRS) as ‘no to moderate disability’ (mRS 0–3) or as ‘poor clinical outcome’ (mRS 4–6). Clinical and radiographic data were analysed.

RESULTS

Ninety-three patients (62%) had no to moderate disability and 57 (38%) had a poor clinical outcome. The in-hospital mortality rate was 18% (28 patients). Patients with poor clinical outcomes were significantly older (P = 0.01) and had a significantly higher incidence of hypertension (P = 0.04), history of stroke (P = 0.03) and common carotid artery occlusion (left common carotid artery: P = 0.01; right common carotid artery: P &lt; 0.01). One-third of all patients developed haemodynamic instability (P = 0.27). Cardiopulmonary bypass (P &lt; 0.01) and cross-clamp (P = 0.03) times were significantly longer in patients with poor clinical outcomes. Age (odds ratio 1.041; P = 0.02) and history of stroke (odds ratio 2.651; P = 0.03) were predictive of poor clinical outcome; coma was not. Haemorrhagic transformation occurred in 7 patients without any independent predictors.

CONCLUSIONS

Most patients with preoperative neurological deficit have no to moderate disability postoperatively but commonly develop preoperative haemodynamic instability. This study suggests that an immediate surgical approach may be reasonable in patients with preoperative neurological deficit or coma.

Ischaemic papillary muscle rupture without significant coronary artery lesion

Papillary muscle rupture is a rare but life-threatening complication of myocardial infarction (MI). Here, we describe a case of papillary muscle rupture caused by a microscopic MI. A 76-year-old woman was referred to our institution, where she developed cardiac arrest upon admission. Severe mitral regurgitation was noted without significant coronary artery lesions. Emergency surgery was performed, and posteromedial papillary muscle rupture was observed. Postoperatively, cardiac magnetic resonance imaging revealed a microscopic MI of the posteromedial papillary muscle.

Peripheral administration of κ-opioid receptor antagonist stimulates gonadotropin-releasing hormone pulse generator activity in ovariectomized, estrogen-treated female goats

Pulsatile gonadotropin-releasing hormone (GnRH) secretion is indispensable for reproduction in mammals. Kisspeptin neurons in the hypothalamic arcuate nucleus (ARC), referred to as KNDy neurons because of the coexpression of neurokinin B and dynorphin A, are considered as components of the GnRH pulse generator that produces rhythmic GnRH secretion. The present study aimed to investigate if peripheral administration of PF-4455242, a κ-opioid receptor (KOR, a dynorphin A receptor) antagonist, facilitates pulsatile luteinizing hormone (LH) secretion and GnRH pulse generator activity in estrogen-treated ovariectomized Shiba goats to determine the possibility of using KOR antagonists to artificially control ovarian activities. PF-4455242 was intravenously infused for 4 h (1 or 10 μmol/kg body weight/4 h) or as a single subcutaneous injection (1 or 10 μmol/kg body weight). In a separate experiment, the same KOR antagonist (10 μmol/kg body weight/4 h) was intravenously infused during the recording of multiple unit activity (MUA) in the ARC that reflects the activity of the GnRH pulse generator to test the effects of KOR antagonist administration on GnRH pulse generator activity. Intravenous infusion and single subcutaneous injection of the KOR antagonist significantly increased the frequency of LH pulses compared with controls. Intravenous infusion of KOR antagonist also significantly increased the frequency of episodic bursts in the MUA. The present study demonstrates that peripherally administered KOR antagonist stimulates pulsatile LH secretion by acting on the GnRH pulse generator, and peripheral administration of PF-4455242 can be used to facilitate pulsatile LH secretion, which in turn facilitates ovarian activities in farm animals.

Incidence of postoperative atrial fibrillation in transdermal β-blocker patch users is lower than that in oral β-blocker users after cardiac and/or thoracic aortic surgery

OBJECTIVE

Postoperative atrial fibrillation (POAF) after open heart surgery is associated with a high risk of mortality and morbidity. Although oral β-blockers are usually recommended to prevent POAF, the efficacy of a transdermal β-blocker patch in preventing POAF is unclear. We compared the incidence of POAF between users of oral and transdermal bisoprolol.

METHODS

We investigated 108 patients who underwent cardiac and/or thoracic aortic surgery between April 2016 and February 2018. We compared perioperative clinical and hemodynamic variables between 49 patients treated with a transdermal bisoprolol patch and 59 patients treated with an oral bisoprolol fumarate.

RESULTS

POAF occurred in 24% of patients in the transdermal and in 46% of patients in the oral bisoprolol groups (p = 0.027). No intergroup difference was observed in in-hospital mortality, perioperative blood pressures and heart rates, and other morbidities. Multivariable logistic regression analysis revealed that the use of transdermal bisoprolol was independently associated with a lower rate of POAF (odds ratio 0.21, 95% confidence interval 0.05-0.84, p = 0.027).

CONCLUSIONS

A transdermal bisoprolol patch is an effective and safe β-blocker drug delivery system. The incidence of POAF in this group was lower than that in users of oral bisoprolol.

Preoperative frailty is associated with progression of postoperative cardiac rehabilitation in patients undergoing cardiovascular surgery

OBJECTIVE

Preoperative frailty affects the progression of cardiac rehabilitation (CR) after cardiovascular surgery. Different frailty assessment measures are available. However, it remains unclear which tool most likely predicts the progress of CR. Our aim was to evaluate preoperative frailty using different methods and to identify the predictors in the progress of postoperative CR.

METHODS

Eighty-nine patients underwent elective cardiovascular surgery at our institution between May 2016 and April 2018. Mortality cases and patients without evaluation of preoperative frailty were excluded. This study included the remaining 78 patients. We divided the patients into two groups: 47 patients who achieved 100 m walking within 7 days after surgery (successful CR group) and 31 patients who achieved 100 m walking later than 8 days after surgery (delayed CR group). Preoperative frailty was assessed using the Kaigo-Yobo Check-List, Cardiovascular Health Study, Short Physical Performance Battery, and Clinical Frailty Scale.

RESULTS

The prevalence of frailty defined by these four measures was higher in the delayed CR group. The delayed CR group had lower nutritional status, serum hemoglobin level, serum albumin level, and psoas muscle index. Multivariable analysis demonstrated the Kaigo-Yobo Check-List score as an independent predictor for delayed CR (odds ratio 1.53, 95% confidence interval 1.18-1.98, p = 0.001) and Clinical Frailty Scale as an independent predictor for discharge to a health care facility (odds ratio 3.70, 95% confidence interval 1.30-10.51, p = 0.014).

CONCLUSIONS

Among the various tools for assessing frailty, the Kaigo-Yobo Check-List was most likely to predict the progress of postoperative CR after elective cardiovascular surgery.

Postinfarction right ventricular wall dissection with left-to-right shunting

Ventricular septal rupture is an uncommon fatal complication of acute myocardial infarction. In rare cases, the rupture can extend into the right ventricular free wall and cause intramyocardial dissection. We describe the case of a patient who developed postinfarction right ventricular free wall dissection with left-to-right shunting and successfully underwent patch repair.

Sutureless repair for postinfarction left ventricular free wall rupture

OBJECTIVE

Left ventricular free wall rupture is a catastrophic complication of acute myocardial infarction. Sutureless repair has been reported to be an effective surgical procedure for left ventricular free wall rupture. However, the outcomes of sutureless repair remain unclear.

METHODS

Between January 2001 and December 2016, 42 patients were treated for left ventricular free wall rupture at Jichi Medical University. Of them, 35 consecutive patients undergoing sutureless repair using the TachoComb (CSL Behring, Tokyo, Japan) or TachoSil (Nycomed, Zurich, Switzerland) patches were included in this study. No patient required cardiopulmonary bypass. The oozing type of left ventricular free wall rupture was observed in 33 patients (94%), and the blow-out type was observed in 2 patients (6%). The rupture sites were the anterior wall in 16 patients (46%), the posterior-lateral wall in 11 patients (31%), and the inferior wall in 8 patients (23%).

RESULTS

The in-hospital mortality rate was 17% (6 patients). Re-rupture after sutureless repair occurred in 17% (6 patients). Of them, 4 cases (67%) of re-rupture occurred within 24 hours after surgery. The 2 patients with blow-out type left ventricular free wall rupture experienced re-rupture. Three patients required mitral valve surgery after sutureless repair during the admission. The overall survivals at 1, 5, and 10 years were 71.4%, 68.6%, and 62.9%, respectively. Multivariable analysis revealed that re-rupture was an independent predictor for decreased survival (hazard ratio, 58.6; 95% confidence interval, 4.9-701.6; P = .001). Postoperative pseudoaneurysm formation was not detected during the follow-up.

CONCLUSIONS

Sutureless repair using TachoComb/TachoSil patches can be a viable treatment option for left ventricular free wall rupture. Care should be taken when applying this technique in cases of the blow-out type left ventricular free wall rupture.

Effect of attention bias modification on event-related potentials in patients with irritable bowel syndrome: A preliminary brain function and psycho-behavioral study

BACKGROUND

Attention bias modification normalizes electroencephalographic abnormalities in alpha and beta power percentages related to attention in patients with irritable bowel syndrome (IBS). Yet, it is unknown whether ABM contributes to the normalization of event-related potentials (ERP) in these patients. We hypothesized that ERP related to attention deficit would be normalized after ABM implementation in individuals with IBS.

METHODS

Thirteen patients with IBS and 10 control subjects completed a 2-month intervention that included five ABM sessions. Each session included 128 trials, resulting in a total of 640 trials during the study period. Event-related potentials were measured at the first and fifth sessions. As per the international 10-20 system for electroencephalographic electrode placement, right parietal P4 was evaluated to measure the attention component of facial expression processing.

KEY RESULTS

A group comparison of P100 latency at P4 revealed that latencies were significantly different between groups in session 1 (IBS vs control, 108 ± 8 vs 97 ± 14; t = -2.51, P = .0203). This difference was absent in session 5 (94 ± 11 vs 93 ± 11, respectively; t = -0.397, P = .6954, r = .09), indicating an effect of ABM in the IBS group.

CONCLUSIONS AND INFERENCES

Attention bias modification may have clinical utility for normalizing brain function and specifically attentional abnormalities in patients with IBS.

Gene expression profiling of acute type A aortic dissection combined with in vitro assessment

OBJECTIVES

The mechanisms underlying aortic dissection remain to be fully elucidated. We aimed to identify key molecules driving dissection through gene expression profiling achieved by microarray analysis and subsequent in vitro experiments using human aortic endothelial cells (HAECs) and aortic vascular smooth muscle cells (AoSMCs).

METHODS

Total RNA, including microRNA (miRNA), was isolated from the intima-media layer of dissected ascending aorta obtained intraoperatively from acute type A aortic dissection (ATAAD) patients without familial thoracic aortic disease (n = 8) and that of non-dissected ascending aorta obtained from transplant donors (n = 9). Gene expression profiling was performed with mRNA and miRNA microarrays, and results were confirmed by quantitative polymerase chain reaction (qPCR). Target genes and miRNA were identified by gene ontology analysis and a literature search. To reproduce the in silico results, HAECs and AoSMCs were stimulated in vitro by upstream cytokines, and expression of target genes was assessed by qPCR.

RESULTS

Microarray analysis revealed 1536 genes (3.6%, 1536/42 545 probes) and 41 miRNAs (3.0%, 41/1368 probes) that were differentially expressed in the ATAAD group (versus donor group). The top 15 related pathways included regulation of inflammatory response, growth factor activity and extracellular matrix. Gene ontology analysis identified JAK2 (regulation of inflammatory response), PDGFA, TGFB1, VEGFA (growth factor activity) and TIMP3, TIMP4, SERPINE1 (extracellular matrix) as the target genes and miR-21-5p, a TIMP3 repressor, as target miRNA that interacts with the target genes. Validation qPCR confirmed the altered expression of all 7 target genes and miR-21-5p in dissected aorta specimens (all genes, P < 0.05). Ingenuity pathway analysis showed TNF-α and TGF-β to be upstream cytokines for the target genes. In vitro experiments showed these cytokines inhibit TIMP3 expression (P < 0.05) and enhance VEGFA expression (P < 0.01) in AoSMCs but not HAECs. miR-21-5p expression increases in AoSMCs under TNF-α and TGF-β stimulation (fold change: 1.36; P = 0.011).

CONCLUSIONS

Results of our novel approach, integrating in vitro assessment into gene expression profiling, implicated chronic inflammation characterized by MMP-TIMP dysregulation, increased VEGFA expression, and TGF-β signalling in the development of dissection. Further investigation may reveal novel diagnostic biomarkers and uncover the mechanism(s) underlying ATAAD.

Early and mid-term outcomes of endovascular and open surgical repair of non-dissected aortic arch aneurysm†

OBJECTIVES

With the introduction of endovascular stent graft technology, a variety of surgical options are available for patients with aortic aneurysms. We sought to evaluate early-term and mid-term outcomes of patients undergoing endovascular and open surgical repair for non-dissected aortic arch aneurysm.

METHODS

Overall, 200 patients underwent treatment for isolated non-dissected aortic arch aneurysm between January 2008 and February 2016: 133 patients had open surgery and 67, endovascular repair. Early-term and mid-term outcomes were compared.

RESULTS

Seventy percent ( n  = 47) needing endovascular repair underwent fenestrated stent graft and 30% ( n  = 20) underwent the debranched technique. Patients in the open surgery group were younger (71 vs 75 years, P  < 0.001) and had a lower prevalence of ischaemic heart disease (11% vs 35%, P  < 0.001). Intensive care unit stay (1 vs 3 days, P  < 0.001), hospital stay (11 vs 17 days, P  < 0.001) and surgical time (208 vs 390 min, P  < 0.001) were lower in the endovascular repair group than in the open surgery group. There were 3 in-hospital deaths each in the open surgery and endovascular groups (2% vs 5%, respectively, P  = 0.40). Mid-term survival ( P  < 0.001) and freedom from reintervention ( P  = 0.009) were better in the open surgery than in the endovascular repair group. No aneurysm-related deaths were observed. The propensity-matched comparison ( n  = 58) demonstrated that survival was better in the open surgery group ( P  = 0.011); no significant difference was seen in the reintervention rate ( P  = 0.28).

CONCLUSIONS

Close follow-up for re-intervention may reduce the risk for aneurysm-related deaths and provide acceptable outcomes in patients undergoing endovascular repair.