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We report the case of a 76-year-old woman with an incomplete atrioventricular septal defect and severe congestive heart failure who underwent surgical repair. Surgical intervention involved mitral valve repair and patch closure of the ostium primum defect, resulting in a favorable postoperative course. Successful outcomes support surgery as a reasonable treatment option owing to its significant improvement in postoperative quality of life, even in elderly patients with left atrioventricular valve degeneration.

DOI： 10.1093/jscr/rjae187

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The leukemoid reaction (LR) is reported to be caused by severe stress conditions such as infection, malignancies, intoxication, severe hemorrhage, or acute hemolysis; this condition is attributed to a very severe prognosis. Some reports have suggested that the LR was associated with a systemic stress response. A 36-year-old man who required mechanical circulatory support (MCS), including veno-arterial extracorporeal membrane oxygenation and Impella 5.5 due to severe heart failure, was transferred to our hospital. He showed a markedly elevated WBC count and died of multiple organ failure. The autopsy revealed the possibility that leukocytosis might have been due to an LR; however, the cause of the cardiac failure was unknown. To the best of our knowledge, this study is the first to report a rare case of LR in a patient with severe heart failure requiring MCS.

DOI： 10.7759/cureus.54603

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Language：Japanese   Publishing type：Research paper (scientific journal)  

BACKGROUND: This study investigates short-term outcomes following surgical interventions for atrial fibrillation (Af), including the Cox-maze Ⅳ procedure (maze procedure) and pulmonary vein isolation (PVI), performed concurrently with other cardiac surgeries. Additionally, we aim to determine the indications for surgical intervention for Af. METHOD: We retrospectively studied a total of 1,580 patients, out of which 274 had preoperative Af, that underwent cardiac surgery between January 2015 and April 2023. Patients who underwent emergency surgery, died in the hospital postoperatively, or received pacemaker implantation were excluded. Patients were first divided into two groups:the intervention group (n=135, 53.6%) and the non-intervention group( n=117, 46.4%), further categorized by whether they were in sinus rhythm at discharge. The intervention group was then subdivided into the maze procedure group( n=54), and the PVI group (n=76). RESULTS: Within the maze procedure group, significant differences were observed between the sinus rhythm and non-sinus rhythm groups in terms of age, preoperative Af duration, and aortic valve intervention status. In the PVI group, patients with persistent Af, longer preoperative Af duration, and larger left atrium diameter( LAD) were less likely to return to sinus rhythm. Smaller LAD was also a significant factor for returning to sinus rhythm in the non-intervention group. Multivariate analysis for all patients revealed that an LAD smaller than 50 mm was the strongest predictor for returning to sinus rhythm post operation( p<0.01). CONCLUSION: For patients with persistent Af, the maze procedure is favored over PVI as a surgical intervention. When LAD exceeds 50 mm, the likelihood of returning to sinus rhythm is diminished.

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INTRODUCTION: The minimally invasive cardiac surgery off-pump coronary artery bypass (MICSOPCAB) is technically difficult; therefore, previous studies have indicated that MICSOPCAB should be contraindicated in patients with impaired left ventricular (LV) function. In this study, we investigated the feasibility of MICSOPCAB in patients with impaired LV function. METHODS: The 226 patients underwent MICSOPCAB between August 2017 and September 2022. Our study defined impaired LV function as ejection fraction (EF) in echocardiography 40% or less. The patients were divided into Low EF group (n = 39) and Normal EF group (n = 187). RESULTS: The Low EF group was in a more critical preoperative condition than Normal EF group (41.0% in the Low EF group vs. 14.4% in the Normal EF group; p < 0.001). For preoperative transthoracic echocardiography, LV end-diastolic diameter (5.5 ± 0.9 cm in the Low EF group vs. 5.0 ± 0.8 cm in the Normal EF group; p < 0.001) and LV end-systolic diameter (4.4 ± 1.0 cm in the Low EF group vs. 3.4 ± 1.0 cm in the Normal EF group; p < 0.001) were significantly larger in the Low EF group. No differences were found in the operative time (180 [160-240] min in the Low EF group vs. 205 [165-253] min in the Normal EF group; p = 0.231) and the median number of distal anastomoses (2 [1-2] in the Low EF group vs. 2 [1-3] in the Normal EF group; p = 0.073). Intensive care unit stay was longer in the Low EF group than in the Normal EF group (2 [1-2] in the Low EF group vs. 1 [1-2] in the Normal EF group; p = 0.010). Perioperative transfusion was more common in the Low EF group than in the Normal EF group (69.7% vs. 49.2%; p = 0.023). There were no differences in major complications, hospital stay, and 30-day mortality. The Kaplan-Meier curve showed no significant difference in postoperative major adverse cardiac or cerebrovascular events rates between the two groups (p = 0.185). CONCLUSION: In this study, MICSOPCAB can be performed in patients with low EF having short- and mid-term outcomes similar to patients with normal EF. Therefore, low EF should not be contraindicated in MICSOPCAB.

DOI： 10.3389/fsurg.2024.1324343

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The frozen elephant trunk (FET) is an effective method for making the distal anastomosis more proximal and facilitating aortic remodeling in acute aortic dissection. However, misdeployment of FET to the false lumen has been reported in several cases. Such cases are usually treated with bail-out thoracic endovascular aortic repair (TEVAR) through the femoral artery or additional FET under direct vision to redirect the blood flow to the true lumen. We encountered a case of misdeployment of FET into the false lumen during open aortic surgery for the treatment of Stanford type A acute aortic dissection. After reconstruction of the aorta and all arch vessels, we performed antegrade bail-out TEVAR through a side branch of the four-arm Dacron graft as main access using a pull-through technique through the right femoral artery, which was perfused from the true lumen. This technique, which uses a Dacron graft branch for stent graft access, enabled us to confirm the true lumen because the distal anastomotic site was definitely the true lumen, and we were also able to avoid access difficulties at the iliac artery.

DOI： 10.1055/s-0042-1747672

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Although total arch replacement would be performed in a patient with acute type A aortic dissection and concomitant aortic aneurysm in the distal aortic arch, total arch replacement may be too invasive in elderly patients with significant morbidities. A 92-year-old female with acute type II DeBakey aortic dissection and concomitant distal aortic arch aneurysm was successfully treated with hemi-arch replacement followed by thoracic endovascular aortic repair. Hybrid two-stage repair of DeBakey type II aortic dissection complicated by distal arch aneurysm using thoracic endovascular aortic repair after hemi-arch replacement may be effective.

DOI： 10.1093/jscr/rjad648

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Cases that are inoperable owing to poor preoperative conditions are sometimes encountered. However, there are some cases that are led to radical treatment by performing bridge therapy. Here, we presented a case of a patient with complex cardiac disease in an inoperable state who underwent bridging therapy that led to successful surgical treatment. A 73-year-old male who received hemodialysis treatment and had severe aortic valve stenosis and coronary artery disease planned surgical treatment. However, he was deemed inoperable owing to his low cardiac function and hemodynamic instability. Therefore, to escape from a fatal condition, we first performed balloon aortic valvuloplasty and percutaneous coronary intervention as palliative procedures. Subsequently, his cardiac function and hemodynamic stability remarkably improved; therefore, after 1 month, we performed a successful radical surgical treatment. Even in inoperable patients, bridging therapy leading to radical treatment is possible.

DOI： 10.59958/hsf.5779

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Acute coronary syndrome with cardiogenic shock is a life-threatening condition, but with planned staged treatment combined with coronary revascularization and mechanical circulatory supports its management is increasingly possible. Here, we present our successful life-saving case. A 76-year-old male patient was diagnosed with ST-elevation myocardial infarction with cardiogenic shock due to severe stenosis of the left main coronary artery based on the severe triple vessel disease. We initially introduced Impella CP and performed a percutaneous coronary intervention without stenting on the patient. We maintained hemodynamics with Impella CP and performed coronary artery bypass grafting after a week. Intraoperatively, Impella CP was left to function as a left ventricular vent. The patient required upgrading to Impella 5.5 plus veno-arterial extracorporeal membrane oxygenation postoperatively, but his condition gradually improved, all mechanical circulatory supports could be weaned off, and he eventually survived.

DOI： 10.1093/jscr/rjad631

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BACKGROUND: Post-implant right heart failure (RHF) has been recognized as a crucial prognostic factor in patients receiving left ventricular assist devices (LVADs), and its management has long attracted attention from cardiologists and surgeons. CASE PRESENTATION: This report described an 18-year-old female with acutely deteriorating heart failure due to dilated cardiomyopathy who underwent paracorporeal pulsatile-flow LVAD and developed early post-implant RHF. At postoperative day (POD) six, she was almost asymptomatic at rest on 2.5 mg/kg/min of dobutamine; however, the echocardiogram, performed as part of the daily postoperative care, revealed a severely enlarged right ventricle with a decompressed left ventricle, implying the development of post-implant RHF. Bolus infusion of saline and reduction of pump flow (6.0 L/min to 3.0 L/min) led to normalization of both ventricular shapes in 30 s, suggesting that RHF could be managed without surgical interventions. Milrinone was started on POD six, followed by sildenafil administration on POD seven. Fluid balance was strictly adjusted under the close observation of daily echocardiograms. Milrinone and dobutamine were discontinued on PODs 18 and 21, respectively. The patient was listed for a heart transplant on POD 40. Despite reduced right ventricular function (right ventricular stroke work index of 182.34 mmHg*ml/m- 2, body surface area 1.5 m2), she was successfully converted to implantable LVAD on POD 44 with no recurrence of post-implant RHF thereafter for four years. CONCLUSIONS: In post-implant RHF management, early detection, together with proper and prompt medical management, is crucial to avoiding any surgical intervention. Close observation of daily echocardiograms might be helpful in detecting subclinical RHF and is useful for post-implant medical management.

DOI： 10.1186/s13019-023-02368-1

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Low cardiac output syndrome (LOS) is a condition that causes low perfusion and perfusion failure of the entire body's tissues due to a decline in heart contractile strength, posing a significant challenge in cardiothoracic surgical perioperative management. Appropriate myocardial protection is crucial to prevent ischemia-reperfusion injury during open-heart surgery and prevent LOS. The integrated myocardial protection method, proposed by Buckberg et al., is one technique employed for this purpose. In the treatment of LOS, interventions are made in the parameters of stroke volume and heart rate, structural abnormalities are excluded and dealt with, and mechanical assistance is utilized when necessary. With the aging and increasing severity of surgical patients, the risk of postoperative LOS is on the rise. Therefore, the application of appropriate myocardial protection and treatment methods leads to improved prognosis. It's worth noting that ensuring optimal myocardial protection during surgery and the correct application of medication and devices for intervention can significantly improve patient outcomes. With the rise in high-risk surgical cases due to aging and an increase in severe conditions, the importance of these interventions cannot be overstated.

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DOI： 10.1016/j.atssr.2023.08.001

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Driveline infection (DLI) is treated by local irrigation via driveline exit site (DLES) and surgical debridement is considered in patients with deep DLI. We describe three cases of deeply progressed superficial DLI that were considered to require surgical debridement but could be treated with a unique catheter cleaning method using intravenous indwelling catheter, a cotton swab with 10% silver nitrate solution and a monofilament nylon thread. Case 1 was a 60-y-old man with ischemic cardiomyopathy with left ventricular assist device implantation 2 y before. Daily bedside debridement with 10% silver nitrate solution was performed via the DLES. Case 2 was a 43-y-old man with ischemic cardiomyopathy who had recurrent DLI with methicillin-resistant Staphylococcus aureus, and case 3 was a 49-y-old woman with hypertrophic cardiomyopathy, who also showed improvement in their DLI with Pseudomonas aeruginosa. These cleaning methods may be useful for the deeply progressed superficial DLI.

DOI： 10.1093/jscr/rjad443

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For patients with cardiogenic shock, delaying surgery with mechanical circulatory support is reported to yield better outcomes than emergency surgery. We report on an 82-year-old man diagnosed with vertebral osteomyelitis with concomitant infective endocarditis. Chest radiographs revealed a growing abscess, which resulted in an aorto-right ventricular fistula. Providing Impella support allowed for hemodynamic stabilization prior to surgery. The patient had an uneventful postoperative course and reported to be well in a follow-up 1 year later. Impella support can be used as a bridge to surgery for repairing fistulous tract formation in patients in cardiogenic shock.

DOI： 10.59958/hsf.5519

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Minimally invasive direct coronary artery bypass is preferred due to its less invasive nature; however, it carries the risk of graft failure owing to inherent technical challenges. We present a case where minimally invasive direct coronary artery bypass grafting was performed and graft failure was detected via coronary angiography 3 days post-operation. Successful percutaneous coronary intervention was subsequently performed on the failed graft itself to salvage myocardial cellular damage. Consequently, the combination of minimally invasive direct coronary artery bypass and percutaneous coronary intervention, both less-invasive revascularization approaches, effectively achieved the primary treatment objective.

DOI： 10.1093/jscr/rjad420

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Authorship：Lead author   Language：Japanese   Publishing type：Research paper (other academic)  

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DOI： 10.1016/j.amjmed.2023.01.041

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Superior mesenteric artery (SMA) aneurysms (SMAAs) are rare and account for approximately 7% of all visceral artery aneurysms. If the anatomical complexity permits and the patency of organ perfusion is allowed, then an endovascular approach is the first choice for minimally invasive procedures. We report the case of a 92-year-old female with a giant SMAA and challenging anatomy, including a short proximal sealing zone from the origin of the SMA and a short distal sealing zone from the hepatic artery bifurcation. In view of her advanced age, she was treated endovascularly with covered stents. Reintervention was required to correct a postoperative endoleak; however, a favorable outcome was achieved with endovascular therapy.

DOI： 10.5758/vsi.230020

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Neuron-specific enolase (NSE) is one of the biomarkers used as an indicator of brain disorder, but since it is also found in blood cell components, there is a concern that a spurious increase in NSE may occur after cardiovascular surgery, where cardiopulmonary bypass (CPB) causes hemolysis. In the present study, we investigated the relationship between the degree of hemolysis and NSE after cardiovascular surgery and the usefulness of immediate postoperative NSE values in the diagnosis of brain disorder. A retrospective study of 198 patients who underwent surgery with CPB in the period from May 2019 to May 2021 was conducted. Postoperative NSE levels and Free hemoglobin (F-Hb) levels were compared in both groups. In addition, to verify the relationship between hemolysis and NSE, we examined the correlation between F-Hb levels and NSE levels. We also examined whether different surgical procedures could produce an association between hemolysis and NSE. Among 198 patients, 20 had postoperative stroke (Group S) and 178 had no postoperative stroke (Group U). There was no significant difference in postoperative NSE levels and F-Hb levels between Group S and Group U (p = 0.264, p = 0.064 respectively). F-Hb and NSE were weakly correlated (r = 0.29. p < 0.01). In conclusion, NSE level immediately after cardiac surgery with CPB is modified by hemolysis rather than brain injury, therefore it would be unreliable as a biomarker of brain disorder.

DOI： 10.1007/s10047-023-01398-9

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Minimally invasive mitral valve surgery (MIMVS) is widespread and has become a standard procedure in cardiac surgery [Chitwood 1997; Carpentier 1996]. Therefore, MIMVS is a common procedure for patients with degenerative disease [Raanani 2010; Iribarne 2010] as well. However, the safety of MIMVS in patients with rheumatic heart disease (RHD) has not thoroughly been investigated, due to the low prevalence of RHD in developed countries, where MIMVS is standardized [Miceli 2015]. Here, we investigated the safety of MIMVS for patients with RHD at Lampang Hospital in Thailand.

DOI： 10.1532/hsf.5391

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Second-time coronary artery bypass grafting is sometimes technically challenging due to severe adhesion of the heart, difficulty of identifying target coronary arteries, advanced sclerosis of the ascending aorta and limited availability of graft vessels. Here we report a patient, in whom a coronary-to-coronary bypass grafting from the native right coronary artery to the left anterior descending artery using a free right internal mammary artery was used as a graft conduit.

DOI： 10.1093/jscr/rjad136

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DOI： 10.1016/j.xjtc.2022.11.018

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Language：English   Publisher：(一社)日本循環器学会  

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With an incidence of 3 in 100 million, giant coronary artery aneurysm (CAA) with coronary artery fistula (CAF) is a very rare condition. To prevent rupture, giant CAA with CAF should be swiftly treated. We present a Jehovah's Witness patient with giant CAA and coronary-pulmonary artery fistula. We resected the giant CAA in one piece, while ligating the CAF, without allogeneic blood transfusion. Due to rarity of these conditions, many thoracic surgeons lack direct experience in its surgical procedures. Herein, we share footage of this surgery as an example of how to safely resect CAA with minimal bleeding.

DOI： 10.1055/s-0042-1757877

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OBJECTIVE: This study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection. SUBJECTS: From April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta. METHODS: Of the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed. RESULTS: The duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p < 0.01). The overall operative mortality rate was 10.3% in the proximal repair group and 14.7% in the extended repair group (p = 0.379). The mean follow-up period was 31.1 ± 26.7 months in the proximal repair group and 35.3 ± 26.8 months in the extended repair group. During follow-up, the cumulative survival and freedom from reintervention rates at 5 years were 66.4% and 92.9% in the proximal repair group, and 76.1% and 72.6% in the extended repair group, respectively (p = 0.515 and p = 0.134). CONCLUSIONS: No significant differences were found in the rates of long-term cumulative survival and freedom from aortic reintervention between the two surgical strategies. These findings suggest limited aortic resection achieves acceptable patient outcomes.

DOI： 10.3389/fsurg.2023.1081167

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INTRODUCTION: During stent grafting, managing the internal iliac artery (IIA) becomes a significant issue when an abdominal aortic aneurysm (AAA) is complicated by bilateral common iliac artery (CIA) aneurysms. The iliac branch system (IBS) has a defined length; therefore, the CIA should be sufficiently long. However, situations arise where the IBS must be used even in patients with a short CIA. A case of contralateral CIA occlusion due to deviation of the proximal iliac branched component of the IBS is reported. REPORT: A 73 year old man underwent stent grafting with inferior mesenteric artery coil embolisation and IBS for a 70 mm AAA and >30 mm bilateral CIA aneurysm. As standard procedure, the right iliac branched component and the internal iliac component were used. After removing the guidewire used for deploying the internal iliac component, the left 12 Fr Dryseal and guidewire were pulled down. The proximal end of the right iliac branched component deviated over the left CIA origin, resulting in CIA occlusion. As a solution, a 12 Fr Dryseal was inserted with a dilator and guidewire in the 16 Fr Dryseal from the left side, following which the tip of the 12 Fr Dryseal dilator was used to push the iliac branched component to create a gap. The guidewire was successfully inserted, and the surgery was subsequently completed as planned. The post-operative course of the patient was uneventful. CONCLUSION: When deploying an iliac branched component in cases where the CIA is shorter than the length of the component, it is crucial to place the contralateral guidewire into the aorta before pulling down the contralateral sheath. The iliac branched component may follow the pull through wire and occlude the contralateral CIA. Furthermore, if the element occludes the contralateral CIA, it can be managed using this method.

DOI： 10.1016/j.ejvsvf.2023.05.017

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Recently, endovascular aortic aneurysm repair (EVAR) is the most common surgery for abdominal aortic aneurysm (AAA). However, iliac limb complications of EVAR often cause problems in patients with high iliac tortuosity. There is no difference of rate of iliac limb complication among EVAR devices, such as Excluder, Endurant, and Zenith in high iliac tortuosity. But there has been not reported about AFX. We studied AFX iliac extension as it is the only stent graft with an endoskeletal framework. This study aimed to evaluate the AFX iliac extension patency in a case in vitro and to use it in seven cases of AAA with high iliac tortuosity. The silicon tube inserted in the AFX iliac extension was flexed at 30, 60, 90, and 120 degrees, and the lumen of the iliac extension was monitored using an underwater camera in the circulatory system. During the experiment, the Iwaki Bellows Pump (IWAKI CO., LTD., Tokyo, Japan) produced a pulsating flow. We used this in seven patients with AAA high iliac tortuosity cases between November 2018 and May 2019. If the silicon tube inserted in the AFX iliac extension was flexed at 60 and 120 degrees, the stent protruded into the lumen. However, the graft was dilated at all degrees. All seven patients with AFX iliac extension had no complications and a patent iliac artery. The AFX iliac extension can reduce iliac limb complications in cases of high iliac tortuosity.

DOI： 10.1055/s-0041-1729736

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DOI： 10.1016/j.xjtc.2022.09.011

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DOI： 10.1016/j.xjtc.2022.09.010

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Hypothermic circulatory arrest (HCA) is an essential procedure during aortic surgery to protect organs; however, hypothermia is believed to cause coagulopathy, which is a major fatal complication. This study aimed to clarify the impact of hypothermia on coagulation by eliminating clinical biases in vitro. In the hypothermic storage study, blood samples from five healthy volunteers were stored at 37 ℃ (group N) for 3 h or at 20 ℃ for 2 h, followed by 1 h of rewarming at 37 ℃ (group H). Thromboelastography was performed before and after 3 h of storage. In the mock circulation loop (MCL) study, blood samples were placed in the MCL and (a) maintained at 37 ℃ for 4 h (group N, n = 5), or (b) cooled to 20 ℃ to simulate HCA with a 0.1 L/min flow rate for 3 h and then rewarmed to 37 ℃ (group H, n = 5). The total MCL duration was 4 h, and the flow rate was maintained at 1 L/min, except during HCA. Blood samples collected 15 min after the beginning and end of MCL were subjected to standard laboratory tests and rotational thromboelastometry analyses. Hypothermia had no impact on coagulation in both the hypothermic storage and MCL studies. MCL significantly decreased the platelet counts and clot elasticity in the INTEM and EXTEM assays; however, there was no effect on fibrinogen contribution measured by FIBTEM. Hypothermia does not cause irreversible coagulopathy in vitro; however, MCL decreases coagulation due to the deterioration of platelets.

DOI： 10.1007/s10047-022-01324-5

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BACKGROUND: No study has examined the association of the calcification of abdominal artery orifices with nonocclusive mesenteric ischemia (NOMI) in dialysis patients undergoing cardiac surgery. Thus, this study aimed to determine whether calcification of abdominal blood vessel orifices in hemodialysis patients may be a risk factor for NOMI and examine the long-term survival of dialysis patients after undergoing cardiac surgery. METHODS: From April 2014 to September 2020, 100 dialysis patients underwent cardiac surgery at our hospital. The calcification of the celiac artery (CA) and superior mesenteric artery (SMA) was evaluated by computed tomography, and the degree of orifice stenosis was graded as follows: patent, 0; partial occlusion, 1; and complete occlusion, 2. RESULTS: Eight patients experienced NOMI, and all of them died. SMA calcification scores were not significantly different between the NOMI and non-NOMI groups (1.38±0.52 vs. 1.13±0.69; P = 0.247). However, the average CA orifice calcification score was significantly greater in the NOMI group than in the non-NOMI group (1.63±0.52 vs. 1.15±0.65; P = 0.039), and the SMA+CA orifice calcification scores were significantly different between the groups (3.00±0.76 vs. [non-NOMI] 2.25±1.18; P = 0.028). In all patients, the 30-day and in-hospital mortality rates were 13% and 18%, respectively. All patients were completely followed up with a mean follow-up period of 604±585 days. Kaplan-Meier survival curves showed that patients with SMA and CA calcification tended to have a shorter overall survival than patients without calcification; however, no significant difference was noted. CONCLUSIONS: The calcification of CA and/or SMA orifices was associated with postoperative NOMI and poor long-term survival among dialysis patients undergoing cardiac surgery.

DOI： 10.1532/hsf.4859

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BACKGROUND: To avoid lead failure and pocket infection in neonates and infants requiring pacemakers, we used the axillary approach of placing the generator in the axilla and the leads in the intrathoracic space. We describe the technical details of the axillary approach and evaluate the efficacy of this method. METHODS: We assessed 21 patients (7 male) weighing 8 kg or less who underwent epicardial pacemaker implantation with the axillary approach between 2004 and 2018. The axillary approach entails (1) positioning the pacemaker generator in the axilla to avoid local skin and pocket complications due to tissue compression by the generator, and (2) making a double loop in the pleural space to reduce stress on the pacemaker leads caused by somatic growth. This approach can be combined with median sternotomy for simultaneous intracardiac repair. RESULTS: The patients' median age at pacemaker implantation was 6 months; 16 patients (76%) were aged less than 12 months. The median body weight was 4.5 kg (interquartile range, 3 to 7). In all 5 patients requiring simultaneous cardiac repair, a median sternotomy was performed to access the heart. Sixteen patients required only pacemaker implantation: left thoracotomy was performed in 10 patients, right thoracotomy in 5, and subxiphoid approach in 1. The 5-year and 10-year freedom from pacemaker-related adverse events was 89.4% and 79.5%, respectively. CONCLUSIONS: The axillary approach using intrathoracic double-loop routing of leads to position the generator in the axilla for pacemaker implantation can be a valuable alternative for neonates/infants weighing 8 kg or less with or without complex congenital heart disease.

DOI： 10.1016/j.athoracsur.2021.06.079

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BACKGROUND: It remains unclear whether the Rho-kinase (ROCK) inhibition in combination with mechanical circulatory support (MCS) had a synergic protective effect on myocardial ischemia (MI)/reperfusion injury in therapeutic strategies for acute myocardial infarction (AMI). We report the results of an approach using a rat model consisting of a miniaturized cardiopulmonary bypass (CPB) and AMI. METHODS: A total of 25 male Wistar rats were randomized into 5 groups: (1) Sham: a suture was passed under the left anterior descending artery (LAD) creating no MI. A vehicle solution (0.9% saline) was injected intraperitoneally. (2) Myocardial ischemia (MI) + vehicle (MI + V): LAD was ligated for 30 min and reperfused for 120 min, followed by administration of vehicle solution. (3) MI + fasudil (MI + F): the work sequence of group 2, but the selective ROCK inhibitor fasudil (10 mg/kg) was administered instead. (4) MI + V + CPB: CPB was initiated 15 min after the ligation of the LAD to the end of the reperfusion, in addition to the work sequence in group 2. (5) In the MI + F + CPB group, the work sequence of group 4, but with fasudil administration (10 mg/kg). RESULTS: Measurements of cardiac function through conductance catheter indicated that the drop of + dP/dt after reperfusion was moderately limited in MI + F + CPB (vs. MI + V, dP/dt p = 0.22). The preload recruitable stroke work was moderately improved in the MI + F + CPB (p = 0.23) compared with the corresponding control animals (MI + V). Phosphorylated protein kinase B expression in the MI + V + CPB and MI + F + CPB was higher than that in MI + V (p = 0.33). CONCLUSION: Therefore, fasudil administration with MCS resulted in a moderately better left ventricular performance.

DOI： 10.1177/02184923221114457

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Vascular tissue engineering has shown promising results in "healthy" animal models. However, studies on the efficacy of artificial grafts under "pathological conditions" are limited. Therefore, in this study, we aimed to characterize the performance of polyvinyl alcohol (PVA)-coated poly-ε-caprolactone (PCL) grafts (PVA-PCL grafts) under diabetic conditions. To this end, PCL grafts were produced via electrospinning and coated with the hydrophilic PVA polymer, while a diabetic rat model (DM) was established via streptozotocin injection. Thereafter, the performance of the graft in the infrarenal abdominal aorta of the rats was evaluated in vivo. Thus, we observed that the healthy group showed CD31 positive/αSM positive cells in the graft lumen. Further, the patency rate of the PVA-PCL graft was 100% at 2 weeks (n = 7), while all the DM rats (n = 8) showed occluded grafts. However, the treatment of DM rats with neutral protamine Hagedorn insulin (tDM) significantly improved the patency rate (100%; n = 5). Furthermore, the intimal coverage rate corresponding to the tDM group was comparable to that of the healthy group at 2 weeks (tDM vs. healthy: 16.1% vs. 14.7%, p = 0.931). Therefore, the present study demonstrated that the performance of the PVA-PCL grafts was impaired in DM rats; however, insulin treatment reversed this impairment. These findings highlighted the importance of using a model that more closely resembles the cases that are encountered in clinical practice to achieve a clinically applicable vascular graft with a small diameter.

DOI： 10.1039/d2bm00531j

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Postoperative atrial fibrillation is a poor prognostic factor associated with increased mortality rates. Patients experiencing significant pericardial effusion develop postoperative atrial fibrillation; however, little is explored about the association between postoperative atrial fibrillation and post-cardiotomy pericardial effusion. This retrospective, single-center study included adult patients who underwent cardiovascular surgery via median sternotomy from January 2016 to December 2019. Patients who underwent routine postoperative computed tomography at 7 ± 3 days after surgery (n = 294) were included. Pericardial effusion was measured at the thickest point. Patients were classified into those with (n = 127) and without (n = 167) postoperative atrial fibrillation. The association of pericardial effusion with other factors was evaluated. A possible confounder-adjusted logistic regression analysis after multiple imputation was performed to obtain odds ratios for postoperative atrial fibrillation using previously published risk factors. Age, intraoperative bleeding volume, and pericardial effusion size were all significantly higher in the group with postoperative atrial fibrillation. Multivariate logistic regression after multiple imputation revealed that age, intraoperative bleeding volume, and postoperative pericardial effusion were significantly associated with postoperative atrial fibrillation. Our findings suggest that post-cardiotomy pericardial effusion is associated with postoperative atrial fibrillation. However, the causality remains unknown, making further studies mandatory.

DOI： 10.1007/s10554-022-02560-9

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The best treatment for ventricular functional mitral regurgitation still remains unclear. Papillary muscle tugging approximation (PMTA) is a technique known to preserve function of the sub-valvular apparatus, keeping it functionally in synch with the left ventricle systolic and diastolic dynamics. Herein, we present a case of mitral valve replacement with PMTA in a patient with severely impaired left ventricular function 14 years post initial mitral valve repair, which significantly improved during a course of 4 years after the reoperation without any complications.

DOI： 10.1093/jscr/rjac339

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BACKGROUND: Anesthetic management of thoracic aortic aneurysms (TAAs) is sometimes difficult due to fatal complications, including hypovolemic shock secondary to aneurysm rupture. We report the successful management of an impending rupture of a TAA with associated esophageal stenosis and compression of the pulmonary artery and left bronchi. CASE PRESENTATION: An 83-year-old woman, diagnosed with an impending rupture of the ascending TAA, was scheduled to undergo emergency total aortic arch replacement. Computed tomography showed esophageal stenosis with significant amounts of food residues in the thoracic esophagus and compression of the pulmonary artery and bronchi. We performed awake intubation and superior laryngeal nerve block with light sedation to prevent aspiration and aneurysmal rupture, respectively. General anesthesia was induced immediately after the intubation. No intraoperative complications occurred. CONCLUSIONS: Performing awake intubation with a superior laryngeal nerve block and sedation may prevent aspiration of food residues and hemodynamic changes that may lead to rupture.

DOI： 10.1186/s40981-022-00534-3

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OBJECTIVE: To identify whether preoperative magnetic resonance imaging findings of the brain can predict postoperative delirium in patients who undergo arch replacement for aneurysms. METHODS: Overall, 193 patients who underwent aortic replacement for the first time at a single institution between April 2014 and September 2020 were enrolled in this retrospective study. After we excluded patients with acute aortic dissection, no preoperative magnetic resonance imaging findings of the brain, and postoperative cerebral infarction, 50 patients were included and divided into 2 groups, according to their confusion scale results: postoperative delirium (group D) and nonpostoperative delirium (group ND). Preoperative magnetic resonance imaging findings of the brain were classified into lacunar stroke, periventricular hyperintensity, and deep subcortical white matter hyperintensity groups; the latter 2 groups were further classified based on the Fazekas scale, grade 0 to 3. RESULTS: There were 23 patients (46%) in group D and 27 (54%) in group ND. The mean age was significantly greater in group D than in group ND (75 vs 70 years; P = .007). The mean operative time was significantly longer in group D than in group ND (447 vs 384 minutes; P = .024). As for preoperative magnetic resonance imaging findings of the brain, there were significantly more lacunar stroke cases in group D than in group ND (P = .027). In multivariable logistic regression with stepwise selection, high-grade periventricular hyperintensity was significantly related to postoperative delirium (odds ratio, 9.38; 95% confidence interval, 1.55-56.56; P = .015). CONCLUSIONS: Silent cerebral ischemia detected by preoperative magnetic resonance imaging of the brain was a significant risk factor for postoperative delirium.

DOI： 10.1016/j.xjon.2022.02.026

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Triplex (Terumo Corp, Tokyo, Japan) is a relatively new vascular protheses with a non-biodegradable coating material. We experienced two cases of graft elongation in Triplex grafts post-operatively. In one of the cases, the graft elongation led to occlusion of the left subclavian artery. In the other case, the graft elongation resulted in a pseudoaneurysm of the ascending aorta. A unique feature of Triplex grafts is that they may reduce post-operative inflammation reaction; however, they could also invite a limited adhesion formation with the surrounding tissue, which contribute to prostheses elongation, due to a lack of prostheses stability and fixation. A careful observation based on the feature of implanted protheses is required.

DOI： 10.1093/jscr/rjac255

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BACKGROUND: Off-pump coronary artery bypass grafting has not been standardized in Southeastern Asian countries because it is technically demanding. However, this method could be suitable for economically disadvantaged institutions because it saves cost on the heart-lung machine. We summarized our results to assess the validity of our early introduction of this method. METHODS: We reviewed the data from 750 patients who underwent off-pump coronary artery bypass grafting at our institution. Before the introduction of off-pump coronary artery bypass grafting, experts from Japan were enlisted to teach our surgeons technicalities of the procedure. The primary outcome was in-hospital mortality, and secondary outcomes included any major adverse cardiac or cerebrovascular event. RESULTS: The in-hospital mortality rate was 1.5%. The rates of survival and freedom from major adverse cardiac or cerebrovascular event 3 years after the operation were 92.5% ± 1.8% and 90.7% ± 2.2%, respectively. In the multivariable analysis, the independent risk factors for major adverse cardiac or cerebrovascular event were chronic obstructive pulmonary disease (adjusted hazard ratio = 2.35, 95% confidence interval = 1.35-4.10, P = .003) and renal insufficiency (adjusted hazard ratio = 2.70, 95% confidence interval = 1.52-4.80, P = .001), whereas risk factors for in-hospital death were pump conversion (relative risk = 17.4, 95% confidence interval = 1.63-4.41, P < .001). CONCLUSION: Successful introduction of off-pump coronary artery bypass grafting provided a favorable outcome almost equal to that in high-volume centers in developed countries.

DOI： 10.1016/j.sopen.2022.01.002

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OBJECTIVE: To evaluate the effectiveness of the 5-minute test (FMT), developed to record the amount of pericardial bleeding in patients undergoing general cardiac surgery, and determine the relationship between this test and postcardiotomy bleeding. METHODS: The medical records of 573 patients who underwent adult cardiac surgery between January 2016 and December 2019 were reviewed retrospectively. Patients were divided into 2 groups: the FMT group included patients who underwent general cardiac surgery between January 2018 and December 2019 (n = 278), and the control group included patients who underwent general cardiac surgery between January 2016 and December 2017 (n = 295). The postcardiotomy reexploration rate due to intrapericardial bleeding or cardiac tamponade within 1 week after surgery and the amount of bleeding until 2 days after surgery were compared. The FMT procedure involved counting the amount of bleeding by packing 4 to 6 surgical gauze sheets for 5 minutes. Sternal closure was performed when the amount of blood measured by the FMT was <100 g. RESULTS: Compared with the control group, the FMT group had a significantly lower incidence of postcardiotomy reexploration (1.5% vs 5.7%; P = .007) and a reduced amount of bleeding after cardiac surgery (median, 1165 mL [interquartile range (IQR), 756.2-1743.8 mL] versus 1440 mL [IQR, 825.0-2130.0 mL]; P = .005). There was a significant positive correlation between the FMT gauze sheet weight and postcardiotomy bleeding (r = 0.322; P < .001). CONCLUSIONS: The FMT is an objective and effective tool for estimating postoperative bleeding during cardiac surgery that can prevent postcardiotomy reexploration and reduce the amount of postcardiotomy bleeding.

DOI： 10.1016/j.xjtc.2021.08.049

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DOI： 10.1016/j.xjtc.2022.01.015

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Either the Bentall-De Bono operation or the valve-sparing aortic root replacement is commonly chosen for aortic root management. However, if the preoperative condition is poor, a simpler technique is preferred; therefore, we performed hemi-root replacement with diagonal resection of the aortic root preserving the left coronary sinus of Valsalva. Because reimplantation of the left coronary artery is not required, this technique may shorten operative time and reduce coronary malperfusion, a condition characterized by reduced transit flow time and reduced cardiac contractility.

DOI： 10.1093/jscr/rjac129

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The proper surgical strategy for retrograde type A aortic dissection (RTAD) is still controversial, and some studies have reported the efficacy of frozen elephant trunk and thoracic endovascular aortic repair (TEVAR). A 68-year-old man was diagnosed with acute type A aortic dissection using enhanced computed tomography. The false lumen at the arch and ascending aorta was thrombosed, and the primary entry was placed in the descending aorta. In addition, there were malperfusions of the right renal artery and both iliac arteries. We performed TEVAR using the right femoral artery combined with the petticoat technique. At 11 days postoperatively, we observed rapid aortic remodeling at the arch and ascending aorta. The patient was discharged uneventfully after 14 days. We believe that TEVAR for RTAD is effective in appropriate patients. However, the accumulation of the number of cases and accurate strategies for patient selection are in demand.

DOI： 10.1093/jscr/rjac050

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BACKGROUND: It still remains unclear the depth of influence of left ventricular dysfunction on the recovery of patients' physical conditions in the early and midterm period following off-pump coronary artery bypass grafting (OPCAB). METHODS: From April 2011 to May 2018, 851 patients underwent OPCAB in our center. All were grouped into two groups: Those whose ejection fraction (EF) was under 35% were defined as the Low EF group (N = 158) and those who maintained EF over 35% were defined as the Faired EF group (N = 693). Preoperatively, there was significant difference in NYHA class (P < 0.001), CCS class (P = 0.038), level of creatinine (P < 0.001), and rate of establishment of IABP (P < 0.001). RESULTS: Regarding all-cause death in the early postoperative period, low EF was a not a risk factor in patients (P = 0.52) or in the matched cohort (P = 0.398); however, in the midterm, it was a significant risk factor in patients (HR 2.07, P = 0.016) and in the matched cohort (HR 2.72, P = 0.029). Overall survival at 5 years in the Low EF group was significantly inferior to that of the Faired EF group in all (67.4±4.1% and 86.1±2.9%, P = 0.001) and in the matched cohort (66.5±6.4% vs. 86.5±4.5%, P = 0.008). CONCLUSION: OPCAB seems beneficial for patients with LV dysfunction considering the early outcome, however, low EF is a significant risk factor for overall death in the midterm period.

DOI： 10.1532/hsf.4311

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OBJECTIVES: The aims of the present study were to evaluate and compare the safety and feasibility, including hospitalization, intensive care unit (ICU) stay, frequency of conversion to general anesthesia (GA), pH, PaCO2, and PaO2, of selected patients who underwent minimally invasive mitral valve surgery (MIMVS) via a right minithoracotomy under conscious sedation (CS) to avoid GA. The authors also aimed to evaluate the perioperative management of spontaneous breathing. DESIGN: A retrospective, observational study. SETTING: Single-center. PARTICIPANTS: This study enrolled 101 patients who underwent MIMVS under CS or GA. INTERVENTIONS: The patients who underwent MIMVS were managed under CS or GA according to indication criteria. MEASUREMENTS AND MAIN RESULTS: ICU stay (p = 0.010), postoperative time until first fluid intake (p < 0.0001), and duration of mechanical ventilation (p = 0.004) were shorter in the CS group than in the GA group. No patients converted to GA from CS. PaCO2 during cardiopulmonary bypass (CPB) in the CS group was significantly lower than that in the GA group. However, PaCO2 at the termination of CPB in the CS group was significantly higher than that in the GA group. CONCLUSIONS: In the CS group, advanced-age patients with comorbidities underwent mitral surgery without postoperative complications. The authors' findings suggested that MIMVS under CS could be a potentially less-invasive method, providing a quicker recovery than MIMVS under GA.

DOI： 10.1053/j.jvca.2021.07.005

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Background and objective Postcardiotomy cardiogenic shock (PCS) is one of the most critical conditions observed in cardiac surgery. Recently, the early initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been recommended for PCS patients to ensure end-organ perfusion, especially in high-volume centers. In this study, we investigated the effectiveness of earlier initiation of VA-ECMO for PCS in low-volume centers. Methods We retrospectively assessed patients admitted in two of our related facilities from April 2014 to March 2019. The patients who underwent VA-ECMO during peri- or post-cardiac surgery (within 48 hours) were included. We divided the patients into two groups according to the timing of VA-ECMO initiation. In the early initiation of VA-ECMO group, the "early ECMO group," VA-ECMO was initiated when patients needed high-dose inotropic support with high-dose catecholamines, such as epinephrine, without waiting for PCS recovery. In the late initiation of VA-ECMO group, the "late ECMO group," VA-ECMO was delayed until PCS was not controlled with high-dose catecholamines, with the intent of avoiding severe bleeding complications. Results A total of 30 patients were included in the analysis (early ECMO group/late ECMO group: 19/11 patients). Thirty-day mortality in the entire cohort was 60% (n=18), and there was no significant difference between the two groups (early ECMO group/late ECMO group: 64%/55%, p=0.712). Thirteen and six patients died without being weaned off in the early ECMO (43%) and late ECMO groups (55%), respectively; there was no significant difference between the two groups (p=0.696). The median duration of ECMO support was five days (IQR: 1.5-6.5). Conclusions The early initiation of ECMO did not contribute to patients' 30-day outcomes in low-volume centers. To improve outcomes of ECMO therapy in patients with PCS, centralization of low-volume centers may be required.

DOI： 10.7759/cureus.22474

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BACKGROUND: The objective of this study was to develop a method to evaluate the effects of an aortic dissection on hemodynamic parameters by conducting a comparison with that of a healthy (nondissected) aorta. Open-source software will be implemented, no proprietary software/application will be used to ensure accessorily and repeatability, in all the data analysis and processing. Computed tomography (CT) images of aortic dissection are used for the model geometry segmentation. Boundary conditions from literature are implemented to computational fluid dynamics (CFD) to analyze the hemodynamic parameters. METHODS: A numerical simulation model was created by obtaining accurate 3-dimensional geometries of aortae from CT images. In this study, CT images of 8 cases of aortic dissection (Stanford type-A and type-B) and 3 cases of healthy aortae are used for the actual aorta model geometry segmentation. These models were exported into an open-source CFD software, OpenFOAM, where a simplified pulsating flow was simulated by controlling the flow pressure. Ten cycles of the pulsatile flow (0.50 sec/cycle) conditions, totaling 5 sec, were calculated. RESULTS: The pressure distribution, wall shear stress (WSS) and flow velocity streamlines within the aorta and the false lumen were calculated and visualized. It was found that the flow velocity and WSS had a high correlation in high WSS areas of the intermittent layer between the true and false lumen. Most of the Stanford type-A dissections in the study showed high WSS, over 38 Pa, at the systole phase. This indicates that the arterial walls in type-A dissections are more likely to be damaged with pulsatile flow. CONCLUSIONS: Using CFD to estimate localized high WSS areas may help in deciding to treat a type-A or B dissection with a stent graft to prevent a potential rupture.

DOI： 10.1016/j.avsg.2021.08.007

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A calcified amorphous tumor (CAT) of the heart is a rare, nonneoplastic, intracavitary cardiac mass. Histological examination shows that it contains calcified and amorphous fibrous material with underlying chronic inflammation. Surgical excision is generally recommended to avoid future embolism. The risk of embolism has been reported to be especially high in mitral-annular-calcification-related CAT, which constitutes a subgroup of CAT that is often associated with end-stage renal disease. A case of a CAT attached to the anterior annulus of the mitral valve that was easily removed with a light touch of the forceps through aortotomy is reported.

DOI： 10.1093/jscr/rjab608

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Background The aim of the present study was to compare the clinical outcome of the David operation and the Bentall operation in patients with Stanford type A acute aortic dissection (AADA) from the viewpoint of hemostasis. Methods Between April 2016 and April 2020, 235 patients underwent emergent surgery for AADA. Of them, 38 patients required aortic root replacement (ARR: The David operation 17, the Bentall operation 21). The mean age was 59.3±12.6 years. In the present series, the David operation was the first choice for relatively young people, and the Bentall operation was performed for relatively elderly patients and cases in which valve-sparing seemed impossible. Results Between the David and the Bentall group, the 30-day mortality rate did not differ significantly. However, hemostasis time (144.6±50.3 vs. 212.5±138.1 min, p=0.047), defined as the interval from the cessation of cardio-pulmonary bypass (CPB) to the end of the operation, and total operation time (477.8±85.7 vs. 578.3±173.6 min, p=0.027) were significantly shorter in the David group than in the Bentall group, and the amount of blood transfusion was less in the David group than in the Bentall group (red blood cells: 3.5±3.6 vs. 9.2±5.9 units, p=0.013; fresh frozen plasma: 4.1±4.7 vs 9.4±5.1 units, p=0.002; platelet concentrate: 33.2±11.3 vs 42.2±12.0 units, p=0.025). Conclusion David operation offers a shorter hemostasis time and consequently shorter operation time than the Bentall operation in the setting of AADA, probably due to double suture lines, despite its surgical complexity.

DOI： 10.7759/cureus.21747

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PURPOSE: We aimed to identify the risk factors of critical bleeding and investigate the safety of recombinant activated factor VII (rFVIIa) in aortic surgery under hypothermic circulatory arrest (HCA). PATIENTS AND METHODS: The present single-center retrospective study compared the baseline characteristics of 144 patients who underwent aortic surgery under HCA at our institute. Among the total cohort of 144 patients, 42 received rFVIIa (rFVIIa group), while the remaining 102 patients did not (non-rFVIIa group). Perioperative bleeding and transfusions, postoperative 30-day mortality, and adverse events (AEs) were analyzed in 29 propensity score-matched pairs. RESULTS: Before surgery, the rFVIIa group demonstrated a greater number of shocks (p=0.019), higher JapanSCORE II mortality rate (p=0.033), low platelet count (p=0.015) and fibrinogen (p<0.001) level, prolonged activated partial thromboplastin time (aPTT) (p=0.005) and prothrombin time international normalized ratio (PT-INR) (p=0.006), and longer aortic cross clamp time (p=0.049). Postoperative bleeding, transfusion, 30-day mortality, and AEs were comparable between the groups both in the entire-unmatched cohort and propensity score matching cohort. CONCLUSION: Preoperative shock, higher JapanSCORE II mortality rates, low platelet and fibrinogen levels, prolonged aPTT and PT-INR, and longer aortic clamping time might be risk factors for excessive bleeding and indicate the need for rFVIIa treatment. The present study suggests that rFVIIa can be safely used to address critical and continuous bleeding in spite of adequate transfusion and supplementation of other coagulation factors in aortic surgery under HCA, without an increase in 30-day mortality and AEs.

DOI： 10.2147/TCRM.S352609

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OBJECTIVE: Secure proximal anastomosis is an essential part of surgical treatment for acute aortic dissection type A (AADA). This study aimed to investigate the effectiveness of the modified turn-up technique for proximal anastomosis in AADA and compare this technique with other techniques. METHODS: We divided 57 patients who underwent ascending aorta replacement for AADA into the modified turn-up technique group (group A: 36 patients) and the other technique group (group B: 21 patients). Intraoperative and postoperative course data were compared between groups A and B. In group A, we also compared early-career surgeons (practicing for <10 years after graduation) and aged surgeons (practicing for ≥10 years after graduation). RESULTS: Preoperative patient characteristics did not differ between groups. There was a tendency toward shorter operation time in group A than in group B without statistical significance (p = 0.12), and the length of intensive care unit stay was significantly shorter (p < 0.01); the occurrence of cerebral infarction was lower (p < 0.01) in group A than in group B, whereas mortality and major complications other than the cerebral infarction rate did not differ between the groups. In group A, 13 patients were operated on by early-career surgeons, while 23 patients were operated on by surgeons with more than 10 years of experience. Aortic clamp time and circulatory arrest time were significantly longer in patients operated on by early-career surgeons, but outcomes were comparable. CONCLUSIONS: The modified turn-up technique was comparable to other techniques. Even for less skilled surgeons (e.g., early-career surgeons), the use of this technique may lead to stable outcomes.

DOI： 10.3389/fsurg.2022.917686

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The low patency of synthetic vascular grafts hinders their practical applicability. Polyvinyl alcohol (PVA) is a non-toxic, highly hydrophilic polymer; thus, we created a PVA-coated polycaprolactone (PCL) nanofiber vascular graft (PVA-PCL graft). In this study, we examine whether PVA could improve the hydrophilicity of PCL grafts and evaluate its in vivo performance using a rat aorta implantation model. A PCL graft with an inner diameter of 1 mm is created using electrospinning (control). The PCL nanofibers are coated with PVA, resulting in a PVA-PCL graft. Mechanical property tests demonstrate that the PVA coating significantly increases the stiffness and resilience of the PCL graft. The PVA-PCL surface exhibits a much smaller sessile drop contact angle when compared with that of the control, indicating that the PVA coating has hydrophilic properties. Additionally, the PVA-PCL graft shows significantly less platelet adsorption than the control. The proposed PVA-PCL graft is implanted into the rat's abdominal aorta, and its in vivo performance is tested at 8 weeks. The patency rate is 83.3% (10/12). The histological analysis demonstrates autologous cell engraftment on and inside the scaffold, as well as CD31/α-smooth muscle positive neointima regeneration on the graft lumen. Thus, the PVA-PCL grafts exhibit biocompatibility in the rat model, which suggests that the PVA coating is a promising approach for functionalizing PCL.

DOI： 10.3389/fcvm.2022.946899

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PURPOSE: The effect of chronic limb threatening ischemia (CLTI) on advanced cardiac disease, which requires surgical treatment, has rarely been reported. The purpose of this study was to review the outcomes of cardiac surgery in patients with CLTI and determine the risk factors, with a particular focus on the severity of CLTI. PATIENTS: The baseline characteristics and outcomes of 33 patients who were treated for CLTI and underwent cardiac surgery were retrospectively analyzed. The states of CLTI were evaluated based on the Wound, Ischemia, and foot Infection (WIfI) classification system, and 33 patients were divided into the low-WIfI group (stages 1-2, n = 13) and high-WIfI group (stages 3-4, n = 20). RESULTS: The in-hospital mortality rate was 0% in low-WIfI group and 35% in high-WIfI group (p = 0.027). Postoperative complications, particularly severe infections, occurred more frequently among high-WIfI group than low-WIfI group (70.0% vs. 23.1%, p < 0.01). Multivariable analysis identified foot infection grade as a WIfI classification factor and lower albumin levels as factors significantly associated with postoperative complications. The 1-year and 2-year survival rates were 84.6% and 67.7% in low-WIfI group and 45% and 28.1% in high-WIfI group, respectively (p = 0.011). CONCLUSIONS: Cardiac surgery in patients with high WIfI stage was an extremely high-risk procedure. In such patients, lowering the WIfI stage by lower extremity revascularization and/or debridement of diseased parts prior to cardiac surgery can be considered.

DOI： 10.3389/fsurg.2022.892309

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Immunoglobulin G4-related disease (IgG4-RD) can affect various organs, including the cardiovascular system. In this study, we described the case of a 72-year-old man with periaortitis both in the ascending and terminal aorta related to IgG4-RD. He presented with swelling in the left leg. Computed tomography (CT) showed increased wall thickness of the ascending aorta and retroperitoneal fibrosis, which, in turn, caused deep vein thrombosis. Using positron emission tomography-computed tomography, the patient was diagnosed with IgG4-RD in the aorta. Although it was difficult to distinguish intramural hematoma (IMH) from IgG4-related periaortitis, treatment with steroids has dramatically improved his periaortitis. IgG4-related periaortitis should be differentiated from IMH due to their similar morphologies.

DOI： 10.3400/avd.cr.21-00024

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If multiple treatments are performed within a short time, when something occurs, it is difficult to identify its cause. Here, we present a case of thoracic endovascular aortic repair (TEVAR) for acute aortic dissection (AAD) after multiple treatments. A 76-year-old woman underwent minimally invasive aortic valve replacement, transcatheter lumbar artery embolism and retroperitoneal tumor resection within a short period of time. After a series of procedures, the patient experienced sudden back pain, and computed tomography revealed an AAD Type B. Her back pain persisted; therefore, we performed TEVAR, and the post-operative course was uneventful. In this case, the relationship between AAD and treatment before AAD was unclear, but AAD should considered when performing treatments that may cause AAD.

DOI： 10.1093/jscr/rjab559

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Authorship：Corresponding author   Language：Japanese   Publishing type：Research paper (scientific journal)  

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BACKGROUND: Coagulopathy and following massive bleeding are complications of cardiovascular surgery, particularly occurring after procedures requiring prolonged cardiopulmonary bypass (CPB). Reliable and rapid tests for coagulopathy are desirable for guiding transfusion. Measuring multiple coagulation parameters may prove useful. The purpose of this study is to determine the laboratory parameters predicting massive bleeding. METHODS: In a prospectively collected cohort of 48 patients undergoing cardiovascular surgery, markers of coagulation and fibrinolysis were measured using automated analyzer and their correlations with bleeding volume were determined. RESULTS: Operation time was 318 (107-654) min. CPB time was 181 (58-501) min. Bleeding volume during surgery was 2269 (174-10,607) ml. Number of transfusion units during surgery were packed red blood cells 12 (0-30) units, fresh frozen plasma 12 (0-44) units, platelets 20 (0-60) units and intraoperative autologous blood collection 669 (0-4439) ml. Post-surgery activities of coagulation factors II (FII), FV, FVII, FVIII, FIX, FX, FXI and FXII were decreased. Values of fibrinogen, antithrombin, α2 plasmin inhibitor (α2PI) and FXIII were also decreased. Values of thrombin-antithrombin complex (TAT) were increased. Values of FII, FIX, FXI and α2PI before surgery were negatively correlated with bleeding volume (FII, r = - 0.506: FIX, r = - 0.504: FXI, r = - 0.580; α2PI, r = - 0.418). Level of FIX after surgery was negatively correlated with bleeding volume (r = - 0.445) and level of TAT after surgery was positively correlated with bleeding volume (r = 0.443). CONCLUSIONS: These results suggest that several clinical and routine laboratory parameters of coagulation were individually associated with bleeding volume during cardiovascular surgery. Determining the patterns of coagulopathy may potentially help guide transfusion during cardiovascular surgery.

DOI： 10.1186/s12959-021-00324-4

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BACKGROUND: Achieving external access to and manual occlusion of the left atrial appendage (LAA) during minimally invasive mitral valve surgery (MIMVS) through a small right thoracotomy is difficult. Occlusion of the LAA using an epicardial closure device seems quite useful compared to other surgical techniques. METHODS: Fourteen patients with atrial fibrillation underwent MIMVS with concomitant surgical occlusion of the LAA using double-layered endocardial closure stitches (n=6, endocardial suture group) or the AtriClip Pro closure device (n=8, AtriClip group) at our institution. The primary safety endpoint was any device-related adverse event, and the primary efficacy endpoint was successful complete occlusion of blood flow into the LAA as assessed by transthoracic echocardiography at hospital discharge. The primary efficacy endpoint for stroke reduction was the occurrence of ischemic or hemorrhagic neurologic events. RESULTS: All patients underwent LAA occlusion as scheduled. The cardiopulmonary bypass and aortic cross-clamp times in the endocardial suture group and the AtriClip group were 202±39 and 128±41 minutes, and 213±53 and 136±44 minutes, respectively (p=0.68, p=0.73). No patients in either group experienced any device-related serious adverse events, incomplete LAA occlusion, early postoperative stroke, or neurologic complication. CONCLUSION: Epicardial LAA occlusion using the AtriClip Pro during MIMVS in patients with mitral valve disease and atrial fibrillation is a simple, safe, and effective adjunctive procedure.

DOI： 10.5090/jcs.21.048

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An 81-year-old man was transferred to our hospital for a ruptured infected descending aortic aneurysm. An emergency thoracic endovascular aortic repair was performed, but a computed tomography scan 7 days later revealed an aortoesophageal fistula. The establishment of extracorporeal circulation using the femoral artery and utilization of the omentum was considered difficult. We performed bilateral axillofemoral bypass followed by descending aortic resection and esophagectomy. However, the patient's circulatory insufficiency worsened, and he died on the 18th postoperative day. In the treatment of aortoesophageal fistula, bilateral axillofemoral bypass is not recommended as an alternative to descending aortic replacement.

DOI： 10.1093/jscr/rjab356

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DOI： 10.1016/j.xjtc.2021.03.030

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Surgical treatment is challenging in pediatric patients with left ventricular outflow tract (LVOT) stenosis (LVOTS). We herein present the case of a 2-year-old male patient with porencephaly who was diagnosed with LVOTS accompanied by moderate mitral valve regurgitation (MR) with systolic anterior motion (SAM). Edge-to-edge mitral valve reconstruction and myectomy of the abnormal cardiac muscle were performed, with an uneventful postoperative course. LVOT myectomy and edge-to-edge mitral valve repair may be considered as a safe and acceptable approach with good clinical outcomes in pediatric patients with LVOTS accompanied by MR with SAM.

DOI： 10.1093/jscr/rjab240

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BACKGROUND: The aim of the present study was to validate safety of total arch replacement (TAR) using a novel frozen elephant trunk device, operated by trainees as surgical education. METHODS: Sixty-four patients including 19 patients (29.6%) with acute aortic dissection type A (AADA) underwent TAR in our institute between April 2014 and March 2019 were retrospectively analyzed. Twenty-nine patients were operated by trainees (group T) and 35 patients were operated by attending surgeons (group A). RESULTS: Patient characteristics did not differ between groups. Operative time (409.4 ± 87.8 vs. 468.6 ± 129.6 minutes, p = 0.034), cardiopulmonary bypass time (177.7 ± 50.4 vs. 222.9 ± 596.7 minutes, p = 0.019), and hypothermic circulatory arrest time (39.5 ± 13.4 vs. 54.5 ± 18.5 minutes, p = 0.001) were significantly shorter in group A than in group T, but aortic clamping time did not differ between groups (115.3 ± 55.7 vs. 114.2 ± 35.0 minutes, p = 0.924) because the rate of concomitant surgery was higher in group A (37.1 vs. 10.3%, p = 0.014). Thirty-day mortality was 3.1% in the entire cohort. Although operation time was longer in group T, there were no significant difference in postoperative results between the groups, and the experience levels of the main operator were not independent predictors for in-hospital mortality + major postoperative complications. There was no difference in late death and aortic events between groups. CONCLUSIONS: The present study demonstrated that TAR can be safely performed by trainees, and suggests TAR as a possible and safe educational operation.

DOI： 10.1055/s-0040-1713354

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Here, we report our unique "non-pledget commissural suture technique" to avoid complete atrioventricular block during surgical aortic valve replacement, whereby all commissural stiches are made in a figure-of-eight fashion without a pledget. Then, standard stiches in a non-everting fashion are made using pledget sutures and a prosthetic valve is implanted at the supra-annular position. Among 152 evaluated patients, only five patients experienced complications, including three left bundle branch blocks, one postoperative pacemaker implantation, and one moderate paravalvular leak. Based on the high success rate, our technique may be a reasonable alternative for surgical aortic valve replacement.

DOI： 10.1007/s11748-021-01605-5

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Pulmonary valve stenosis and regurgitation can occur in the distant stages after intracardiac repair of tetralogy of Fallot (TOF). Aortic regurgitation (AR) can also occur, although it is rare in postoperative patients. However, there are few reports of simultaneous replacement of the pulmonary and aortic valves in young patients after intracardiac repair of TOF, and there are no clear guidelines for selecting a valve prosthesis in such patients. We report a case of severe pulmonary valve stenosis and regurgitation with severe AR 38 years after the TOF operation, in which urgent double valve replacement and right ventricular outflow tract patching were performed with a mechanical valve in the aortic valve position and a bioprosthetic valve in the pulmonary valve position, with a successful outcome.

DOI： 10.1093/jscr/rjab170

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The extraction of a pacemaker (PM) lead may cause tricuspid regurgitation; however, in cases of device infection, surgical intervention or immediate PM system replacement is undesirable in the short term to prevent reinfection. We describe a case where Micra leadless PM was used as a bridge procedure to ensure an adequate period for antibacterial therapy and later replaced with a permanent PM system in the setting of PM pocket infection.

DOI： 10.1093/jscr/rjab094

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The isolation technique is a useful adjunct that prevents atherosclerotic embolism in the brain when the aneurysm is filled with a massive hematoma or 'shaggy aorta'. But the technique is not widespread because of the difficulty in performing the cannulation. We modified this technique by simplifying the cannulation procedure using a puncture method with aortic root cannulas.

DOI： 10.1093/jscr/rjab082

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Coronary artery fistula (CAF) is a relatively rare congenital abnormality of the coronary arteries; typically, patients who undergo surgery for CAFs are relatively young because it is a congenital disease. Here we present a case of an aneurysmal coronary-to-pulmonary artery fistula rupture in a 96-year-old female. Considering her extreme high age and missing preoperative diagnostics, only local hemostasis without anatomical repair was performed but the patient is still doing well 1 year after the operation.

DOI： 10.1007/s11748-020-01488-y

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BACKGROUND: In adult patients with primary or recurrent coarctation of the aorta (CoA), extra-anatomic bypass grafting (EABG) has been widely used as a surgical treatment option. However, there have been few reports on pseudoaneurysms (PAs) of the distal anastomotic sites after extra-anatomic bypass for CoA. CASE PRESENTATION: A 51-year-old man with hemoptysis was transferred to our hospital. Twenty years ago, he had undergone EABG from the ascending to the descending aorta (ascending-to-descending EABG) for CoA with right aortic arch. Eight years ago, he underwent thoracic endovascular aortic repair (TEVAR) for the ruptured PA on the distal anastomotic site of the EABG. Contrast-enhanced computed tomography scans revealed recurrent ruptured PA on the distal anastomotic site of the EABG. Therefore, we decided to replace the descending aorta, followed by end-to-side anastomosis of the EABG to the replaced descending aorta. However, due to massive adhesion of the lung to the EABG and PA, we performed transection of the descending aorta to decompress the PA. The postoperative course was uneventful, and the patient is doing well 5 months after surgery. CONCLUSIONS: Aortic transection between the CoA and the distal anastomosis site may be a useful additional procedure in patients previously treated with TEVAR for PAs in the distal anastomosis site after EABG.

DOI： 10.1186/s40792-021-01136-4

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BACKGROUND: Although minimally invasive mitral valve surgery (MIMVS) has become the first choice for primary mitral regurgitation (MR) in recent years, clinical evidence in this field is yet limited. The main focus of this study was the analysis of preoperative (Pre), postoperative (Post), and 1-year follow-up (Fu) data in our series of MIMVS to identify factors that have an impact on the left ventricular ejection fraction (LVEF) evolution after MIMVS. METHODS: We reviewed the perioperative and 1-year follow-up data from 436 patients with primary MR (338 isolated MIMVS und 98 MIMVS combined with tricuspid valve repair) to analyze patients' baseline characteristics, the change of LV size, the postoperative evolution of LVEF and its factors, and the clinical outcomes. RESULTS: The overall mean value of ejection fraction (EF) slightly decreased at 1-year follow-up (mean change of LVEF: -2.63 ± 9.00%). A significant correlation was observed for preoperative EF (PreEF) und EF evolution, the higher PreEF the more pronounced decreased EF evolution (in all 436 patients; r = -.54, p < .001, in isolated MIMVS; r = -.54, p < .001, in combined MIMVS; r = -.53, p < .001). Statistically significant differences for negative EF evolution were evident in patients with mild or greater tricuspid valve regurgitation (TR) (in all patients; p < .05, odds ratio [OR] = 1.64, in isolated MIMVS; p < .01, OR = 1.93, respectively). Overall clinical outcome in New York Heart Association classification at 1 year was remarkably improved. CONCLUSIONS: Our results suggest an excellent clinical outcome at 1 year, although mean LVEF slightly declined over time. TR could be a predictor of worsened follow-up LVEF in patients undergoing MIMVS.

DOI： 10.1111/jocs.15256

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In transaortic (TAo) trasncatheter aortic valve implantation (TAVI), direct transmission of forces to the stenotic aortic valve is possible. Therefore, the need of balloon aortic valvoplasty in TAo-TAVI may be very limited regarding the deliverability of TAVI prosthesis. However, if the TAVI prosthesis becomes undeliverable, it becomes seriously problematic. Herein, we present a case of TAo-TAVI in which the TAVI prosthesis was undeliverable, and it was forcefully pushed together with the introducer system into the aortic valve as a bailout technique.

DOI： 10.1093/jscr/rjab001

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An anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart disease. Among the variants, an anomalous origin of the left anterior descending coronary artery from the pulmonary artery (ALADPA) is extremely rare. Here, we report a case of ALADPA in an adult that was treated with coronary artery bypass grafting using the left internal thoracic artery.

DOI： 10.1055/s-0040-1721470

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Transcatheter aortic valve replacement has become a popular choice for cases with severe aortic stenosis. However, when severe mitral regurgitation is comorbid in high-risk patients with severe aortic stenosis, therapeutic options must be weighed for each case. Here we present a very frail 88-year-old patient with severe aortic stenosis and severe mitral valve regurgitation who underwent a successful awake minimally invasive mitral valve repair after transcatheter aortic valve replacement.

DOI： 10.1055/s-0040-1718774

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BACKGROUNDS: Minimally invasive mitral valve surgery (MIMVS) in patients with a small body presents surgeons with a technically difficult surgical maneuver. We hypothesized that physique might negatively influence the safety and technical complexity of MIMVS. METHODS: One hundred and twenty-one patients underwent MIMVS in our institution between May 2014 and April 2020. These patients were categorized into two groups. The first group was the small physique group (n = 20) consisting of patients with a stature <150 cm. The second group was the normal physique group (n = 101) consisting of patients with a stature >150 cm. The primary endpoint was freedom from death and major adverse cardiovascular and cerebrovascular events (MACCE). The secondary endpoint was freedom from moderate or severe mitral regurgitation. RESULTS: Cardiopulmonary bypass time (130 ± 29 vs. 156 ± 55 min, p = 0.02) and aortic cross-clamp time (75 ± 27 vs. 95 ± 39 min, p = 0.03) were significantly shorter in the small physique group. Both in the early and midterm periods, there was no significant difference in the mortality (early, 5.0 vs. 1.0%, p = 0.30. midterm, 5.0 vs. 1.0%, p = 0.09), MACCE (early, 5.0 vs. 6.9%, p = 0.65. midterm, 5.0 vs. 5.9%, p = 0.93) and the residual MR (early, 0 vs. 1.0%, p = 0.66. midterm, 5.0 vs. 4.9%, p = 0.93) between the two groups. CONCLUSIONS: Small physique is not a hurdle for MIMVS in terms of the safety of the operation.

DOI： 10.3389/fsurg.2021.746302

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The article "Hypothermic circulatory arrest induced coagulopathy: rotational thromboelastometry analysis", written by Hayato Ise, Hiroto Kitahara, Kyohei Oyama, Keiya Takahashi, Hirotsugu Kanda, Satoshi Fujii, Takayuki Kunisawa, Hiroyuki Kamiya, was originally published electronically on the publisher's internet portal on 7 June 2020 without open access.

DOI： 10.1007/s11748-020-01416-0

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Secondary aortoenteric fistula or erosion (SAEFE), an abnormal connection between the aorta and gastrointestinal tract, is a rare but critical complication after abdominal aortic aneurysm repair. Most SAEFEs occur between the aorta or proximal graft anastomosis and the duodenum, and occurrence between the iliac graft and small intestine is rare. Standard SAEFE management involves graft removal and extra-anatomical bypass. However, this is extremely invasive and has a high mortality rate. We encountered a rare case of SAEFE with no sign of infection, which was successfully treated by ligating the iliac graft to reduce mechanical pulsatile stress and bleeding following the retroperitoneal approach.

DOI： 10.3400/avd.cr.20-00094

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The Polycomb repressive complex 2 (PRC2) is a multicomponent histone H3K27 methyltransferase complex, best known for silencing the Hox genes during embryonic development. The Polycomb-like proteins PHF1, MTF2, and PHF19 are critical components of PRC2 by stimulating its catalytic activity in embryonic stem cells. The Tudor domains of PHF1/19 have been previously shown to be readers of H3K36me3 in vitro. However, some other studies suggest that PHF1 and PHF19 co-localize with the H3K27me3 mark but not H3K36me3 in cells. Here, we provide further evidence that PHF1 co-localizes with H3t in testis and its Tudor domain preferentially binds to H3tK27me3 over canonical H3K27me3 in vitro. Our complex structures of the Tudor domains of PHF1 and PHF19 with H3tK27me3 shed light on the molecular basis for preferential recognition of H3tK27me3 by PHF1 and PHF19 over canonical H3K27me3, implicating that H3tK27me3 might be a physiological ligand of PHF1/19.

DOI： 10.7554/eLife.58675

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A myxoma is one of the most common tumors in cardiac surgery, with most of them originating from the left or right atrial walls and causing embolic complications. An 84-year-old woman was referred to our institution after echocardiography showed an interatrial septum tumor that was presumed to be a thrombus; however, postoperative pathological examination revealed it to be a cardiac myxoma. This atypical myxoma was covered with a solid capsule containing connective tissue and substantial calcifications, which had made it difficult to establish a diagnosis of myxoma.

DOI： 10.1093/jscr/rjaa333

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Unloading of the left ventricle (LV) is essential for the treatment of LV free-wall rupture (LVFWR), and it is well-known that the LV can be optimally unloaded with the Impella system. However, there has been no report on applying the Impella system for the treatment of LVFWR. Here, we report a patient with FWR after massive myocardial infarction who was successfully treated with non-suture repair via median sternotomy and implantation of Impella CP (Abiomed, Danvers, MA).

DOI： 10.1093/jscr/rjaa263

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OBJECTIVES: Hypothermic circulatory arrest (HCA) has been considered to cause coagulopathy during cardiac surgery. However, coagulopathy associated with HCA has not been understood clearly in details. The objective of this study is to analyze the details of coagulopathy related to HCA in cardiac surgery by using rotational thromboelastometry (ROTEM). METHODS: We retrospectively analyzed 38 patients who underwent elective cardiac surgery (HCA group = 12, non-HCA group = 26) in our hospital. Blood samples were collected before and after cardiopulmonary bypass (CPB). Standard laboratory tests (SLTs) and ROTEM were performed. We performed four ROTEM assays (EXTEM, INTEM, HEPTEM and FIBTEM) and analyzed the following ROTEM parameters: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF) and maximum clot elasticity (MCE). The amount of perioperative bleeding, intraoperative transfusion and perioperative data were compared between the HCA and non-HCA group. RESULTS: Operation time and hemostatic time were significantly longer in the HCA group, whereas CPB time had no difference between the groups. The amount of perioperative bleeding and intraoperative transfusion were much higher in the HCA group. SLTs showed no difference between the groups both after anesthesia induction and after protamine reversal. In ROTEM analysis, MCE contributed by platelet was reduced in the HCA group, whereas MCE contributed by fibrinogen had no difference. CONCLUSION: Our study confirmed that the amount of perioperative bleeding and intraoperative transfusion were significantly higher in the HCA group. ROTEM analysis would indicate that clot firmness contributed by platelet component is reduced by HCA in cardiac surgery.

DOI： 10.1007/s11748-020-01399-y

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BACKGROUND: Pulmonary vein stenosis or occlusion is a rare but one of the most devastating complications after catheter ablation for cardiac arrhythmias, and surgical repair is an option in severe cases. The sutureless technique, which avoids direct suture of vessel walls, was initially described for congenital pulmonary vein stenosis and has been widely performed due to its good restenosis-free rate. CASE PRESENTATION: A 52-year-old male developed left pulmonary vein occlusion after catheter ablation for atrial fibrillation. The surgical repair with sutureless technique using the left atrial appendage was performed without any complications. Postoperative computed tomography demonstrated the revascularization of the pulmonary vein. CONCLUSIONS: The sutureless technique using the left atrial appendage is significantly reasonable particularly in case of left pulmonary vein stenosis or occlusion after catheter ablation for atrial fibrillation since it reduces the risks of restenosis and thromboembolism.

DOI： 10.1186/s40792-020-00930-w

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Delayed cardiac tamponade (DCT) can be a fatal complication after cardiac surgery, but its early diagnosis and/or prediction is sometimes difficult. This study aimed to confirm the efficacy of postoperative computed tomography (CT) as routine examination compared with transthoracic echocardiography (TTE) for predicting DCT after cardiac surgery. This study was a retrospective single-center analysis of 485 consecutive patients undergoing cardiac surgery from January 2016 to July 2018 in our department. Among them, 237 patients were enrolled in this analysis after application of the exclusion criteria: minimally invasive surgery via small thoracotomy, death in the acute phase, and no CT 7 ± 3 days after surgery. Pericardial effusion (PE) was measured at the thickest part using CT and TTE. DCT was found in nine enrolled patients (3.8%). The mean PE on CT was 7.7 ± 5.5 mm in the no event group and 23.4 ± 5.7 mm in the DCT group (p = 0.026), whereas the mean PE on TTE was 6.2 ± 4.5 mm in the no event group and 10.8 ± 4.4 mm in the DCT group (p = 0.170). On multivariate analysis, PE greater than 20 mm on CT (Odds ratio, 13.93; 95% confidence interval 2.57-75.46; p = 0.002) was a significant predictor of DCT. The present study suggested that postoperative CT examination is superior to TTE for predicting DCT. If PE is less than 20 mm on CT, it could be treated conservatively; otherwise, preventive/therapeutic intervention should be considered.

DOI： 10.1007/s10554-020-01820-w

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The occurrence of multiple mechanical complications after myocardial infarction in the same patient may be extremely rare, and the surgical strategy may be very complex because each mechanical complication can be extremely fatal. The case of a patient who underwent repair of a ventricular septal perforation by venoarterial extracorporeal membrane oxygenation (VA-ECMO), then mitral valve replacement and VA-ECMO for papillary muscle rupture 2 weeks after the ventricular septal perforation repair, is reported. Immediate preoperative stabilization with VA-ECMO may play a crucial role in treating multiple mechanical complications after myocardial infarction.

DOI： 10.1093/jscr/rjaa188

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BACKGROUND: This study aimed to evaluate the significance of serum neuron-specific enolase (NSE) level as a predictor of neurologic injury in thoracic aortic surgery. METHODS: We neurologically assessed 60 consecutive patients who underwent thoracic aortic surgery for thoracic aortic aneurysm (n = 26) and aortic dissection (n = 34). Using moderate hypothermic circulatory arrest with antegrade cerebral perfusion, total arch replacement and hemiarch replacement were performed in 37 and 23 patients, respectively. Serum NSE levels in venous blood samples drawn before surgery and at 1 day after surgery were measured. Severity of neurologic injury was categorized as either uncomplicated (n = 48), temporary neurologic dysfunction (TND, n = 5), or permanent neurologic dysfunction (PND, n = 7). The extent of stroke was estimated on computed tomography or magnetic resonance imaging. RESULTS: The NSE level significantly differed among the three groups (PND > TND > uncomplicated) on the first postoperative day. Receiver-operating characteristic curve analysis showed that the cutoff value of NSE level was 34.14 ng/mL for neurologic injury (sensitivity, 0.769; specificity, 0.851) and 43.56 ng/mL for PND (sensitivity, 1.000; specificity, 0.963). The NSE level significantly correlated with the extent of stroke (r = 0.61, p < 0.001). CONCLUSION: Serum NSE level is a significant predictor of adverse neurologic outcomes and extent of stroke after thoracic aortic surgery.

DOI： 10.1055/s-0038-1677511

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A coronary artery fistula (CAF) is an abnormal connection between a coronary artery and a cardiac chamber or a great vessel. CAF draining into the main pulmonary artery, called coronary-to-pulmonary artery fistula (CPAF), is one of the common variations of CAF. Although there is no definitive surgical indication of CPAF, it is treated concomitantly during other cardiac surgeries. Here, we present the case of a patient who underwent surgical closure of multiple CPAFs and coronary artery bypass grafting under cardiopulmonary bypass.

DOI： 10.1007/s11748-019-01118-2

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BACKGROUND: The aim of this study is to evaluate severe mitral regurgitation caused by so called atrial leaflet "pseudoprolapse" and verify the effect of simple annular stabilization. METHODS: One-hundred-twenty-two patients underwent surgery for severe mitral regurgitation at our institute between January 2015 to July 2018. Of those, 32 cases diagnosed as anterior leaflet prolapse that underwent mitral repair were analyzed. Ten cases with pseudoprolapse, which is defined as anterior leaflet prolapse without dropping into the left atrium beyond the annular line causing eccentric regurgitation flow directed to the posterior atrium, were classified as the Pseudoprolapse Group. The other 22 cases had obvious anterior leaflet prolapse dropping into the left atrium; these cases were classified as the True Prolapse Group. We compared clinical findings between the 2 groups and reviewed pseudoprolapse cases. RESULTS: Patients in the Pseudoprolapse Group had lower ejection fraction and lower regurgitation volume than those in the True Prolapse Group. A2 lesion as main inflow of regurgitation was more included in the Pseudoprolapse Group. All but one patient in the Pseudoprolapse Group received only simple annuloplasty, and all patients in the True Prolapse Group received leaflet repair and annuloplasty. In both groups, mid-term regurgitation grade and the reoperation rate were satisfactory. In the Pseudoprolapse Group, 6 cases were clarified as atrial functional mitral regurgitation, and 4 cases were considered to have focal posterior leaflet tethering. CONCLUSIONS: Pseudoprolapse cases could be characterized by low ejection fraction, low regurgitation volume, and A2 prolapse. For most cases with pseudoprolapse, simple annuloplasty may be enough, however further study is needed.

DOI： 10.1532/hsf.2895

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Inferior mesenteric artery (IMA) aneurysm is a rare occurrence, accounting for 1% of all visceral artery aneurysms and is often found incidentally. Surgical resection and endovascular intervention have been first-line treatments because IMA aneurysms have a relatively high risk of life-threatening rupture. Herein, we report the case of a 57-year-old man having a large IMA aneurysm with an arteriovenous fistula that was treated conservatively. The IMA aneurysm was incidentally found using computed tomography (CT) and was connected to the splenic vein through the abnormally dilated tortuous vessels of an arteriovenous fistula. Surgical resection was planned initially; however, preoperative follow-up CT revealed that the aneurysm had shrunk with the growth of an intraluminal thrombus. Subsequently, the condition was conservatively managed with serial CT follow-up. Two years after the first visit, the aneurysm had shrunk and been completely replaced with a thrombus.

DOI： 10.1016/j.avsg.2019.10.067

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DOI： 10.1053/j.jvca.2019.10.056

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Ventricular septal rupture (VSR) is a serious and fatal mechanical complication after acute myocardial infarction. Emergent or urgent, surgical/transcatheter intervention is necessary to treat VSR, though the outcome is not favorable. We performed temporary pulmonary artery banding (PAB) in an 85-year-old man who presented with chest pain to adjust the shunt flow through the VSR, which prevented further pulmonary edema and delayed the timing of surgical repair. There has been no report showing successful PAB performed for VSR after myocardial infarction.

DOI： 10.1093/jscr/rjaa010

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We experienced two cases of postoperative iatrogenic aorto-right atrial fistula (ARAF) after tricuspid valve repair (TVR) using minimally invasive cardiac surgery (MICS) technique. In both the cases, the flow of ARAF passed through the sinus of Valsalva near the noncoronary cusp (NCC)/right coronary cusp (RCC) commissure or NCC to right atrium. The quality of the fine needle used in the MICS technique may be inferior to that used in conventional surgery; ARAF after TVR could be a unique pitfall with the MICS technique.

DOI： 10.1055/s-0040-1718552

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DOI： 10.1016/j.jtcvs.2019.06.064

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Hemoptysis after thoracic endovascular/open aortic repair is relatively rare but a well-known complication, and normally diagnosed with aortobronchial fistula (ABF). Here, we present a patient who suffered from recurrent massive hemoptyses even after multiple thoracic endovascular aortic repairs (TEVARs), where hemoptysis was ultimately controlled by pneumonectomy. In this case, the bleeding source was not the aorta but the lung parenchyma itself, indicating the importance of raising awareness that the cause of massive hemoptysis after TEVAR may not always be an ABF.

DOI： 10.1177/1179547620939078

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INTRODUCTION: To facilitate safe anastomosis of a vascular prosthesis onto the proximal ascending aorta without side clamping, a clampless anastomotic device with large diameter aortic puncher was developed. REPORT: First, a vascular prosthesis is anastomosed onto the aorta without making a hole, then the aortic wall within the prosthesis is punched out using the device. DISCUSSION: After further refinement of the present device, endovascular surgery with debranching could be performed more safely and quickly.

DOI： 10.1016/j.ejvsvf.2020.02.003

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Cardiovascular disease is the most common cause of death in the world. In severe cases, replacement or revascularization using vascular grafts are the treatment options. While several synthetic vascular grafts are clinically used with common approval for medium to large-caliber vessels, autologous vascular grafts are the only options clinically approved for small-caliber revascularizations. Autologous grafts have, however, some limitations in quantity and quality, and cause an invasiveness to patients when harvested. Therefore, the development of small-caliber synthetic vascular grafts (<5 mm) has been urged. Since small-caliber synthetic grafts made from the same materials as middle and large-caliber grafts have poor patency rates due to thrombus formation and intimal hyperplasia within the graft, newly innovative methodologies with vascular tissue engineering such as electrospinning, decellularization, lyophilization, and 3D printing, and novel polymers have been developed. This review article represents topics on the methodologies used in the development of scaffold-based vascular grafts and the polymers used in vitro and in vivo.

DOI： 10.3389/fcvm.2020.592361

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OBJECTIVES: Mitral valve repair is the preferred method used to address mitral valve regurgitation, whereas transcatheter mitral valve repair is recommended for high-risk patients. We evaluated the risk-predictive value of the age-adjusted Charlson comorbidity index (aa-CCI) in the setting of minimally invasive mitral valve surgery. METHODS: The perioperative course and 1-year follow-up of 537 patients who underwent isolated or combined minimally invasive mitral valve surgery were evaluated for 1-year mortality as the primary end point and other adverse events. The predictive values of the EuroSCORE II and STS score were compared to that of the aa-CCI by a comparative analysis of receiver operating characteristic curves. Restricted cubic splines were applied to find optimal aa-CCI cut-off values for the increased likelihood of experiencing the predefined adverse end points. Consequently, the perioperative course and postoperative outcome of the aa-CCI ≥8 patients and the remainder of the sample were analysed. RESULTS: The predictive value of the aa-CCI does not significantly differ from those of the EuroSCORE II or STS score. Patients with an aa-CCI ≥8 were identified as a subgroup with a significant increase of mortality and other adverse events. CONCLUSIONS: The aa-CCI displays a suitable predictive ability for patients undergoing minimally invasive mitral valve surgery. In particular, multimorbid or frail patients may benefit from the extension of the objectively assessed parameters, in addition to the STS score or EuroSCORE II. Patients with an aa-CCI ≥8 have a very high surgical risk and should receive very careful attention.

DOI： 10.1093/ejcts/ezz240

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DOI： 10.1016/j.jclinane.2019.01.025

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OBJECTIVE: To investigate whether minimally invasive mitral valve repair (MIMVR) can be transferred from a high-volume center into a very small volume center and to clarify how many cases are necessary for maintenance of this program, early outcomes of MIMVR in Asahikawa Medical University were compared with those results in patients operated by a single surgeon in Duesseldorf University Hospital. METHODS: Sixty-five patients who underwent MIMVR in Asahikawa Medical University (group A) between May 2014 and July 2018 and 134 patients who underwent MIMVR in Duesseldorf University Hospital (group D) between September 2009 and January 2014 by a surgeon who started MIMVS later in Asahikawa were retrospectively analyzed. RESULTS: In group D, there were more patients with ischemic mitral valve regurgitation and with annular calcification than in group A. Survival rate at 6 months and 1 year was 98.5% and 98.5% in group A and 92.9% and 91.3% in group D, respectively. EuroSCORE II was significantly higher in patients dead within 30 days and within the first year. CONCLUSIONS: The present study demonstrated that MIMVR programs can be transferred with acceptable early results into very low volume centers, if the team is developed by surgeons who are well trained and experienced in MIMVR. Moreover, the present study suggested that case number for maintenance of acceptable results may be obviously less than the previous recognition that this kind of specialized surgery could be maintained with at least 50 cases annually. However, meticulous preparations for surgery are essential for satisfactory surgical outcomes.

DOI： 10.1007/s11748-019-01065-y

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A Kommerell's diverticulum is a rare congenital aortic arch anomaly associated with a high rate of aortic rupture or dissection. Therefore, surgical or endovascular repair should be considered early. A 64-year-old man was incidentally found to have an aortic arch anomaly, Kommerell's diverticulum, with a right aberrant subclavian artery and distal arch aneurysm. Hybrid total arch replacement with bilateral extra-anatomical axillary artery bypass and frozen elephant trunk technique was performed. This particular surgical approach would be a treatment option for any type of Kommerell's diverticulum.

DOI： 10.1093/jscr/rjz211

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DOI： 10.1016/j.athoracsur.2019.01.051

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A 39-year-old man with severe mitral regurgitation was referred to our institution for surgical evaluation. During preoperative workup, a coronary-pulmonary artery fistula was incidentally found by computed tomography. After multidisciplinary cardiac team discussion, the decision was made to proceed with coronary-pulmonary artery fistula ligation and mitral valve repair through a mini-thoracotomy approach. Cardiopulmonary bypass was initiated with femoral vessels. A mini-thoracotomy was made in the fourth intercostal space. First, mitral valve repair with posterior leaflet folding and ring annuloplasty was done. The coronary-pulmonary artery fistula was running on the roof of the left atrium and was ligated with metal clips under thoracoscopic vision. Postoperative computed tomography showed no residual fistula.

DOI： 10.1177/1556984519836868

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The first case of late thoracic wall bleeding after minimally invasive mitral valve repair treated by endovascular therapy is reported. A 55-year-old woman underwent mitral valve repair and tricuspid annuloplasty through a mini-thoracotomy approach. Her postoperative course was uneventful until she had anemia one week after the surgery. Contrast-enhanced computed tomography showed right hemothorax due to bleeding from a branch of the right lateral thoracic artery. Endovascular coil embolization and gelatin sponge injection were performed. The patient was discharged without any complications on postoperative day 20.

DOI： 10.1093/jscr/rjz187

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BACKGROUND: The cerebroprotective effect of retrograde cerebral perfusion (RCP) and selective antegrade cerebral perfusion (SCP) still remains controversial. Laser speckle flowgraphy has shown much promise for novel perioperative neuromonitoring by assessing blood flow of the optic nerve head. This study aimed to evaluate the cerebral microcirculation in humans using laser speckle flowgraphy during simple circulatory arrest, RCP, and SCP under moderate hypothermia and to investigate whether RCP under moderate hypothermia is a reliable method of cerebral protection. METHODS: A total of 23 consecutive patients who underwent a scheduled aortic arch or hemiarch surgical procedure on thoracic aorta aneurysm were enrolled. The laser speckle flowgraphy measurement that calculates mean blur ratio, a parameter of cerebral circulation, was obtained 6 times: after induction of anesthesia, baseline (T1), after initiation of cardiopulmonary bypass with cardiac arrest (T2), simple circulatory arrest (T3), RCP (T4), SCP (T5), and after the termination of cardiopulmonary bypass (T6). RESULTS: Both mean blur ratios of simple circulatory arrest and RCP were significantly decreased compared with baseline. In contrast, no significant differences were observed between simple circulatory arrest and RCP. The mean blur ratio of SCP was significantly increased compared with both simple circulatory arrest and RCP. CONCLUSIONS: In conclusion, no significant difference was observed in the cerebral circulation between RCP and simple circulatory arrest without adjunctive strategy under moderate hypothermia. In contrast, the cerebral circulation during SCP was significantly higher than simple circulatory arrest and RCP. These results suggest that cerebral microcirculation may not be adequate during RCP compared with SCP under moderate hypothermia.

DOI： 10.1016/j.athoracsur.2018.11.067

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The case of a patient with pacemaker-induced cardiomyopathy in whom left ventricular (LV) function was dramatically improved after switching the ventricular pacing site from the right ventricular apex to the LV free wall via a left mini thoracotomy due to pacemaker-associated infective endocarditis (PAIE) is presented. Our experience suggests that a surgically implanted epicardial LV lead on the LV lateral wall can be a good alternative pacing site that preserves LV function, especially in patients with PAIE.

DOI： 10.1093/jscr/rjz155

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Herein, we report the case of a 49-year-old man with a potentially fatal allergy to propofol and remifentanil who underwent awake minimally invasive mitral valve surgery with cardiopulmonary bypass using thoracic epidural anesthesia, without the need for endotracheal general anesthesia. The aim was the management of spontaneous respiration during cardiopulmonary bypass surgery in an awake patient.

DOI： 10.1016/j.athoracsur.2018.07.090

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Pulmonary artery sarcoma is a rare and highly malignant neoplasm. Early diagnosis and a multidisciplinary approach including surgical treatment and optimal medical therapy could prolong survival. Since the clinical symptoms and imaging findings of pulmonary artery sarcoma mimic pulmonary embolism, definitive diagnosis and surgical intervention are often delayed. In this report, a case of pulmonary artery sarcoma that was initially misdiagnosed as pulmonary embolism is presented.

DOI： 10.1093/jscr/rjz078

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Minimally invasive cardiac surgery has recently become widespread because it has few disadvantages. However, lung hernia has been reported as a rare complication of minimally invasive cardiac surgery (MICS), and normally requiring additional surgical procedures. We describe herein a case of manual repositioning of lung hernia after MICS.

DOI： 10.1093/jscr/rjz056

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Brachiocephalic artery dissection complicated by acute type A aortic dissection occasionally causes cerebral malperfusion. Although immediate central aortic repair has been the standard treatment for aortic dissection, dissection in supra-aortic vessels frequently remains after the surgery. The residual brachiocephalic artery dissection is reported to be associated with late neurological events. Therefore, additional intervention for brachiocephalic artery dissection during central aortic repair should be considered in selected cases. In this report, we describe two cases requiring open brachiocephalic artery stenting simultaneous with central aortic repair. There were no neurological or stent induced complications at latest follow-up.

DOI： 10.1093/jscr/rjz018

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DOI： 10.1053/j.jvca.2018.10.001

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An emergency thoracic endovascular aortic repair (TEVAR) with zone 2 landing without revascularization of the left subclavian artery was performed due to the impending rupture of a distal arch aneurysm in an old patient presenting hemoptysis. Two months later, the patient had recurrent massive hemoptyses and continued after additional zone 0 TEVAR. The lung parenchyma was considered to be the bleeding source and transcatheter pulmonary artery embolization was performed, and the episodes of massive hemoptysis appeared to have ceased. However, the patient died of sudden recurrent massive hemoptysis 40 days later. Inflammation and/or infection of the lung parenchyma adjunct to the aortic aneurysm could be cause of fatal hemoptysis, and aggressive therapy such as lung resection should be considered in such patients.

DOI： 10.1177/1179547619896577

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Background: Although, in theory, valve-sparing aortic root replacement (David procedure) is an ideal surgical option for acute aortic dissection type A (AADA) it is usually not regarded as the first-choice treatment due to the emergency setting and the relative complexity of the procedure. Here, we report the results of a consecutive, single-surgeon series of 45 AADA patients with the David procedure as first-choice treatment strategy. Methods and Results: Between September 2009 and July 2013 a total of 49 patients with AADA were consecutively operated by the same surgeon at our institution. The David procedure was the treatment of choice for the proximal aorta unless aortic valve pathology or critical preoperative patient status advocated against it. Median follow-up was 5.0 years (CI95%, 4.0-6.0). Out of the 45 patients included in this study the David procedure was performed in 28 patients (62.2%), while in 17 patients (37.8%) an alternative surgical strategy had to be pursued. Although X-clamping (168.5 ± 41.7 vs. 110.3 ± 51.1 min; p = 0.001), cardiopulmonary bypass (CPB) (245.0 ± 62.4 vs. 211.8 ± 123 min; p = 0.029) and total operation time (383.8 ± 88.5 vs. 312.8 ± 144.8; p = 0.047) were significantly longer in the David-group as compared to the non-David group, there was no difference in major complication rate as well as 30-day (17.9 vs. 23.5%; p = 0.645) and 5-year mortality (28.6 vs. 35.3%) between groups. Conclusions: This small series indicates that the David procedure may be safe and feasible as a primary surgical treatment strategy for AADA.

DOI： 10.3389/fsurg.2019.00046

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A 79-year-old woman visited a hospital with coronary vasospastic angina and supraventricular tachycardia. Periodic inspection of echocardiography suggested a right atrial tumor which was not pointed out 6 months ago, but magnetic resonance imaging suggested a valve aneurysm. These findings were contradictory. We preoperatively diagnosed a cardiac tumor because of its new onset and mobility. Tumor resection and valve repair was planned in consideration of the risk of embolism. As a result, we finally diagnosed tricuspid valve aneurysm from the intraoperative findings and histopathological findings. We assumed that valve aneurysm was formed in the healing process of subclinical infective endocarditis. It was inferred that preoperative diagnosis of valve aneurysm is very difficult.

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Extracorporeal life support (ECLS) is used for the treatment of severe cardiogenic shock. However, pulmonary congestion can progress to a severe problem with ECLS therapy. We report our experience with the Impella system for severe pulmonary congestion with ECLS therapy. We used the Impella system for two patients, which led to successful unloading of the left ventricle. Impella implantation during ECLS support appears to be a promising concept. However, more evidence is required for further evaluation.

DOI： 10.1093/jscr/rjy302

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Since its introduction in Japan in 1980, the extracorporeal left ventricular assist device has been used as a bridge to the recovery of cardiac function or to heart transplantation by many institutions. In this case report, we describe a 23-year-old female with peripartum cardiomyopathy. She had a persistently low cardiac index despite intensive care with intravenous inotropes, intra-aortic balloon pumping and extracorporeal membrane oxygenation; thus, we implanted an extracorporeal left ventricular assist device. Thereafter, her cardiac function gradually improved; the device was removed 2 months after the implantation. She currently has good heart function.

DOI： 10.1093/jscr/rjy285

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A 79-year-old man with a heavy smoking history presented with threatened lower limbs due to acute exacerbation of peripheral artery disease (PAD). He underwent emergent distal bypass surgery for the right leg and external iliac stenting for the left leg. Fatal coronary artery spasm (CAS) with ST segment changes on electrocardiography was observed 28 h after the procedures, resulting in cardiac arrest. Coronary angiography showed widespread CAS with improvement after intra-arterial nitroglycerin infusion. We should keep in mind that CAS may occur more frequently than expected in PAD patients, especially those who have not stopped smoking prior to revascularization.

DOI： 10.3400/avd.cr.18-00050

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Minimally invasive cardiac surgery (MICS) with high quality thoracoscopy has been widespread. MICS has been very well established for mitral valve repair because of its anatomical condition. For aortic valve surgery and coronary artery surgery, MICS has not been so widespread in comparison to mitral valve surgery, but there has yet room for further development. Here we review current status of thoracoscopy for MICS.

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DOI： 10.1053/j.jvca.2017.10.007

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Ductus arteriosus aneurysm (DAA) is rare in adults, but often involves life-threatening complications. Open repair is common, but is invasive and relatively dangerous. With the continued development of endovascular devices, we can now choose endovascular repair for DAA. However, endovascular repair for infected lesion is controversial. We report a successful case of thoracic endovascular aortic repair with perioperative antibiotic therapy for infected DAA in a 59-year-old man.

DOI： 10.1093/jscr/rjy229

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We report a case of total arch replacement in a patient who suffered repeated cerebral infarctions due to unstable plaque simultaneously in the innominate and left subclavian arteries.

DOI： 10.1093/jscr/rjy172

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BACKGROUND: Though several cases of upper gastrointestinal tract injury caused by transesophageal echocardiography (TEE) have been reported, gastric perforation is very rare. Herein, we report the case of TEE-associated gastric perforation that was successfully treated conservatively. CASE PRESENTATION: An 82-year-old man underwent mitral valve repair. Postoperative esophagogastroduodenoscopy and computed tomography revealed gastric perforation. Surgical treatment was initially considered, but conservative management was selected to avoid increasing operative stress, to minimize the need for total gastrectomy (including the lower esophagus), and to minimize the risk of a potential intraperitoneal infection spreading to the thoracic cavity. CONCLUSION: Conservative management of gastric perforation can be successful even when the perforation is recognized later than 12 h following the event, provided that there are no abdominal symptoms and no signs of peritoneal effusion or sepsis. Our experience suggests that conservative management is a feasible option for treating TEE-associated gastric perforation in appropriately selected cases.

DOI： 10.1186/s40981-018-0189-7

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Ischemic stroke is uncommon in pediatric populations and is sometimes caused by cardiac myxoma. In such cases, neurological deficits initially present in ischemic stroke due to emboli or thrombi of the myxoma. Echocardiography is helpful to diagnose myxoma in a timely manner and allows urgent surgical resection of the myxoma. We report a successful case of myxoma in a 7-year-old boy who initially presented with left-sided hemiparesis.

DOI： 10.1186/s40792-017-0411-2

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BACKGROUND: Cardiac redo surgery, especially after a full sternotomy, is considered a high-risk procedure. Minimally invasive mitral valve surgery (MIMVS) is a potential therapeutic approach. However, current developments in interventional cardiology necessitate additional discussion regarding the therapy of choice in high-risk patients. In this context, it is necessary to clarify the perioperative and postoperative risks induced by the factor previous sternotomy in the setting of MIMVS. Thus, we present a comparative study analyzing the outcome of MIMVS after previous sternotomy vs. primary operation. METHODS: We identified 19 patients who received isolated or combined mitral valve (MV) surgery via the MIMVS approach after previous full sternotomy (PS group) and compared the results to those of a group of 357 patients who received primary MIMVS (non-PS group). After a propensity score analysis, groups of n = 15 and n = 131, respectively, were subjected to a comparative evaluation. A 1-year follow-up analysis of functional cardiac parameters and clinical symptoms was performed, accompanied by a Kaplan-Meier analysis. RESULTS: Except for the rate of realized MV reconstructions (PS group: 53.8% vs. non-PS group: 85.5%; p = 0.011), no significant differences were to be noted within the intraoperative and early postoperative course. However, patients in the PS group experienced an increased intensive care unit stay length (PS group: 2 days, 95% CI, 1-8 vs. non-PS group: 1 day, 95% CI, 1-2; p = 0.072). The follow-up examinations revealed excellent functional and clinical outcomes for both groups. The Kaplan-Meier analysis displayed no significant difference regarding the postoperative mortality (p = 0.929) related to the patients at risk. CONCLUSION: A previous sternotomy remains a risk factor for MIMVS and demands special attention in the early postoperative period. Nevertheless, the early- and late-term results concerning the functional and clinical outcomes suggest that the MIMVS procedure is satisfactory, even after a full sternotomy.

DOI： 10.3389/fsurg.2018.00005

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Background Minimally invasive cardiac surgery via right lateral minithoracotomy is a well-described approach. However, reports on isolated tricuspid valve surgery (TVS) in this technique are rare. Therefore, we like to give a contribution by reporting our experience. Methods We retrospectively reviewed 25 tricuspid valve operations via right lateral minithoracotomy with femoral cannulation between August 2009 and September 2013 (18 repairs, 7 replacements, and 72% repair rate). Three patients (12%) presented for a re-do operation, and nine patients (36%) suffered from active endocarditis at admission. All patients underwent TVS as single valve procedure. Ten patients received additional procedures such as removal of infected leads, resection of atrial tumors, or closure of atrial septal defects. An annuloplasty ring was inserted in 12 cases. We investigated the short-term morbidity and mortality with regard to the surgical procedure. Results Repair rate was 72%. Thirty-day and 1-year mortality were 4 and 20%, respectively. The only patient with early mortality received the surgical procedure on the tricuspid valve as fourth cardiac-related surgery and postoperative mortality was due to intracranial air embolism. Perioperative morbidity included reoperation for bleeding (8%) and stroke (4%). No disturbance of wound healing occurred. Durations of intensive care unit stay and hospital stay were 2.3 ± 2.4 and 17.4 ± 13.1 days, respectively. Endocarditis-caused surgery did not reveal any significant difference in the intra- or perioperative course compared with other indications. Conclusion Minimally invasive TVS via right lateral minithoracotomy is feasible with good results. Even in a cohort of patients suffering from elevated rate of active endocarditis, a high repair rate can be achieved.

DOI： 10.1055/s-0035-1546428

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We report a rare case of papillary muscle rupture due to myocardial infarction during left ventricular assist device support. A 69-year-old woman with cardiogenic shock due to acute myocardial infarction requiring venoarterial extracorporeal membrane oxygenation support was transferred for further surgical intervention. Six days after the event, extracorporeal membrane oxygenation was decannulated, and an extracorporeal left ventricular assist device was implanted. On postoperative day 11, she suffered from sudden onset hypoxia due to pulmonary edema. Transesophageal echocardiography showed new onset severe mitral regurgitation. No further surgical intervention was performed according to the family's wishes, and she passed away on the 22nd postoperative day. Autopsy findings revealed papillary muscle rupture. Although the left ventricle is unloaded by the left ventricular assist device, papillary muscle rupture should be recognized as a possible complication after myocardial infarction.

DOI： 10.1007/s10047-017-0951-z

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Laser speckle flowgraphy (LSFG) is an ophthalmologic equipment that qualitatively detects the blood flow of the optic nerve head, which is known to be related with cerebral microcirculation. LSFG can also measure the mean blur rate, which quantitatively calculates the blood flow. We aimed to assess the utility of LSFG in the evaluation of cerebral perfusion during aortic surgery under hypothermic circulatory arrest with retrograde and antegrade cerebral perfusion. Two patients underwent total arch replacement for aneurysm. The blood flow of the optic nerve head was monitored with LSFG and the mean blur rate value was measured during the surgery. The LSFG could detect the blood flow quantitatively in the optic nerve head during both retrograde and antegrade cerebral perfusion; and the value was correlated with rSO2 value.

DOI： 10.1007/s11748-016-0727-z

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DOI： 10.1053/j.jvca.2017.04.030

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OBJECTIVES: Laser speckle flowgraphy (LSFG) is a novel modality to assess blood flow of the optic nerve head (ONH), which is reported to be a surrogate marker of cerebral microcirculation. We conducted LSFG measurements during minimally invasive cardiac surgery with retrograde femoral arterial perfusion and evaluated its feasibility and usability as a neuromonitor. METHODS: We prospectively enrolled 7 patients who underwent mitral valve repair through a right minithoracotomy with retrograde femoral arterial perfusion. LSFG was used to analyse the ONH blood flow based on examinations of the mean blur rate (MBR). The MBR was measured after the induction of anaesthesia (time 1); after the initiation of cardiopulmonary bypass (time 2); during cardiac arrest (time 3) and after the termination of cardiopulmonary bypass (time 4). RESULTS: All procedures were performed successfully, and there were no neurovascular complications or deaths. LSFG measurements were easily and uneventfully conducted without any related complications. The MBR was 11.2 ± 2.3 at time 1, 11.1 ± 1.8 at time 2, 11.3 ± 1.7 at time 3 and 13.6 ± 3.5 at time 4. Statistically, the MBR at time 4 was significantly higher than those at all other times ( P  < 0.05). CONCLUSIONS: LSFG measurements were safely conducted during minimally invasive cardiac surgery and assessed ONH blood flow quantitatively. We consider this modality to be easy to manipulate and less operator dependent, resulting in good reproducibility. The results are well visualized and compared quantitatively. Our result suggests that LSFG might be an accurate neuromonitor. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov : 15102-2.

DOI： 10.1093/icvts/ivx046

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DOI： 10.1053/j.jvca.2016.09.012

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Background The aim of the study was to assess the value of post-operative cardiac troponin T-levels, measured with a new highly sensitive assay (hs-cTnT), as a suitable parameter to predict patients' outcome after cardiac surgery. With the introduction of the new hs-cTnT assay the correlation between measured levels and the post-operative patient's outcome remains to be evaluated. Methods Patients undergoing coronary artery bypass grafting (n = 213) were included. Perioperative measurements of hs-cTnT and CK-MB were correlated to parameters of clinical outcome and further explored. Patients with an uneventful course were compared with those with post-operative complications, including need of repeat revascularization (RR) or death (RR/death), cardiogenic shock (CS) or death (CS/death) and a combination of all (RR/CS/death). Results Significant results were observed in patients after isolated CABG, where CS/death and RR/CS/death patients had higher post-operative hs-cTnT levels (P < 0.01). Moreover, multivariate analysis of the CABG-group revealed that acute renal failure (OR =14.7, 95% CI =2.7-79.1, P < 0.001), early post-operative hs-cTnT levels higher than the upper quintile (> 1,476.8 pg/ml) (OR =8.1, 95% CI =3.0-22.2, P < 0.001) and unstable angina pectoris (OR =2.4, 95% CI =1.1-5.7, P < 0.05) were the most powerful independent predictors of post-operative complications. Upon discriminant analysis the application of hs-cTnT almost doubled the sensitivity of the outcome prediction. Conclusions The new hs-cTnT assay is a useful diagnostic tool that may significantly enhance the prediction of adverse events after CABG. In our study a hs-cTnT-value >1,476.8 pg/ml proved to be a reliable marker for ongoing post-operative complications.

DOI： 10.1080/00015385.2017.1304693

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An 83-year-old man with arch aneurysm underwent total arch replacement with frozen elephant trunk and extra-anatomical left subclavian artery bypass. One year later, he felt dizziness associated with head rotation. The hypoplastic left vertebral artery was occluded by a thrombus extending from the left subclavian artery ligation site, and the dynamic stenosis of right vertebral artery by head rotation induced dizziness. He was diagnosed with Bow Hunter syndrome. Vertebral artery hypoplasia represents a possible cause of this rare complication. To the best of our knowledge, this is the first report describing Bow Hunter syndrome after total arch replacement.

DOI： 10.1093/icvts/ivw445

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In recent years economic sense is required in hospital management, the national university hospital is also no exception. We performed duty improvement efforts as well as the current state analysis in the department of cardiac surgery for the purpose of revenue optimization in our hospital. At result, we succeeded in the improvement of the medical index as well as medical profit and found the key of solution to the serious problem that national university hospital has.

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Authorship：Lead author   Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1007/s11748-017-0767-z

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BACKGROUND: Patients requiring an intra-aortic balloon pump (IABP) after cardiac surgery are critically ill and need a prolonged ICU stay. Considering limited health care resources, the early identification of patients with an extremely poor prognosis is important as a solid base for the decision whether further aggressive continuation or cessation of the therapy is recommendable. METHODS: From 2001 to 2007, 552 patients with low-output syndrome after open-heart surgery and IABP implantation in OR or within 24 h thereafter on ICU were retrospectively analyzed. RESULTS: The overall mortality at 30 and 180-day were 31 and 40 %, respectively. According to multivariate analyses, following factors were used to generate an IABP score: female gender, age ≥70 years, simultaneous coronary and valve surgery, aortic cross-clamp time >120 min., need of norepinephrin more than 0.4 µg kg(-1) min(-1), postoperative dialysis, and maximal serum creatinine kinase >3000 mg mL(-1). The 30-day mortality continuously increased along the score (10.1 % for score = 0, n = 98; 11.8 % for score = 1, n = 144; 27.5 % for score = 2, n = 153; 40.4 % score = 3, n = 89; 65.2 % for score = 4, n = 46; 77.8 % for score = 5, n = 27) and reached 100 % for all patients with a score of 6 (n = 4). CONCLUSIONS: Prediction of 30 days mortality was possible with our scoring system based on multivariate analysis, and patients with scores of 4 or greater had remarkably worse early and late survival.

DOI： 10.1007/s11748-016-0679-3

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DOI： 10.1093/ejcts/ezw112

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We report on the unique clinical course of a 44-year-old male HIV-positive heart transplant recipient, who was bridged by mechanical circulatory support (MCS). The patient was admitted with acute ischemic heart failure due to severe myocardial infarction. After emergency coronary artery bypass grafting and nine days of extracorporeal life support, we implanted a left ventricular assist device. As HIV infection was effectively treated and other contraindications were not present, we decided to perform a heart transplantation (HTX). At the current time, 34 months after unremarkable HTX, rejection or opportunistic infections have not occurred.

DOI： 10.1111/jocs.12787

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Invasive fungal infection after solid-organ transplantation is known as a severe complication and carries with it a high risk of infection-related mortality. Among patients after heart transplant Aspergillus species most often cause atypical pneumonia. The incidence of invasive aspergillosis after heart transplant has been reported from 3% to 14%. It is the opportunistic pathogen with the highest mortality, ranging from 50% to 80%. Prompt antifungal therapy is crucial, but rapid diagnostic procedures with sufficient sensitivity and specificity are lacking at the moment. We present a rare case of a patient with massive metastasizing invasive aspergillosis within 1 month after heart transplant, undetected before death.

DOI： 10.6002/ect.2014.0115

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The first description of aortic valve replacement (AVR) as minimally invasive cardiac surgery (MICS) was given by Rao et al. in 1993. Recently, the number of MICS-AVR has increased and this procedure has been established as the routine standard operative technique in some institutes. MICS-AVR can be performed with two different approaches. One is an upper partial sternotomy and the other is a right small anterior minithoracotomy. MICS-AVR via upper partial sternotomy can be performed without any special instruments and the technical hurdles are relatively few, but the cosmetic benefit is limited. MICS-AVR via right anterior minithoracotomy offers maximal cosmetic benefit, but the technical hurdles are fairly high. For MICS-AVR, longer aortic clamping time and cardiopulmonary bypass time are needed, but this disadvantage can be overcome with sutureless aortic valve repair, and therefore this procedure may become a standard open surgical procedure in the era of transcatheter aortic valve implantation.

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OBJECTIVES: According to demographic changes in the industrialized world, the average age of patients referred to cardiac surgery is increasing. These patients typically display numerous comorbidities, associated with increased perioperative risk. Therefore, the indication for a catheter-based therapy is progressively extended, including interventions on the mitral valve (MV). In this context, we evaluated a contemporary series of octogenarians undergoing minimally invasive MV surgery at our institution using right lateral minithoracotomy to elucidate the preoperative risk profile and the postoperative course in this particular cohort. METHODS: Between October 2009 and October 2014, 34 patients aged 80 years and older (82.5 ± 2.0) undergoing minimally invasive MV surgery were identified with a subgroup of 15 patients (44.1%) receiving concomitant surgery on the tricuspid valve (TV). We analysed the preoperative profile, perioperative course and functional outcome. RESULTS: Preoperative comorbidities included insulin-dependent diabetes mellitus (17.6%), COPD (17.6%), active endocarditis (2.9%) and previous neurological events (2.9%). The mean left ventricular ejection fraction was 59.7 ± 6.9%. Mean European System for Cardiac Outcome Risk Evaluation II was 5.2 ± 5.3%. The repair rate of all treated MVs and TVs in isolated and combined procedures was 81.6% (73.5% for MV and 100.0% for TV surgery). Postoperatively, 4 patients (11.8%) required new-onset intermittent haemodialysis. Prolonged ventilation (>12 h) was necessary in 9 patients (26.5%). The 30-day mortality rate was 5.9%. CONCLUSIONS: Minimally invasive right lateral MV surgery in octogenarians results in favourable outcomes. Therefore, MV surgery represents a valid option in this cohort, providing established and durable concepts of valve reconstruction.

DOI： 10.1093/icvts/ivv323

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Here we describe a patient with a fulminant pulmonary embolism, who has been successfully treated with an extracorporeal life support system and simultaneous systemic thrombolytic therapy after 1 h of cardiopulmonary resuscitation.

DOI： 10.1007/s11748-013-0338-x

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OBJECTIVES: Temporary right ventricular assist devices (RVADs) may be required to support patients with perioperative refractory right ventricular failure (RVF). We report on our experience using a different technique of RVAD implantation that does not necessitate resternotomy at the time of RVAD removal. METHODS: Patients with perioperative RVF who underwent temporary RVAD implantation between January 2010 and February 2014 were reviewed. A dacron graft was attached to the pulmonary artery and passed through a subxiphoid exit, where the RVAD outflow cannula was inserted. The inflow cannula was percutaneously cannulated in the femoral vein, and the sternum was primarily closed. On the day of RVAD explantation, the outflow graft of the RVAD was pulled and ligated, and the insertion site was secondarily closed. The RVAD inflow cannula was removed, and direct pressure was applied. RESULTS: Twenty-one patients (age 58 ± 14 years) were supported. Seventeen patients (81%) had RVF after left ventricular assist device implantation, and 4 patients developed postcardiotomy RVF. The median duration of RVAD support was 9 days (range: 2-88 days). Eleven patients (52%) were successfully weaned from the RVAD. Two patients were bridged to transplantation. Eight patients died on left ventricular assist device and/or RVAD support. The survival rates to discharge or heart transplantation, and to 1-year, were 62% and 52%, respectively. CONCLUSIONS: No technical issues were encountered in this large series of RVAD implantations using the described technique for various forms of postoperative RVF. Extended support duration and reduction of resternotomy risks may be the main advantages of this technique compared with conventional RVAD implantation methods.

DOI： 10.1016/j.jtcvs.2014.10.104

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Veno-arterial extracorporeal membrane oxygenation (ECMO) may be implanted using peripheral ECMO (pECMO) or central ECMO (cECMO) cannulation techniques. The aim of this study was to compare the outcome between these two cannulation techniques. A retrospective study was performed at Düsseldorf University Hospital from October 2009 through June 2011. Inclusion criteria were patients with veno-arterial ECMO support ≥24 h. Various pre- and postimplantation variables were investigated including postimplantation hemodynamic and ECMO parameters, oxygenation/ventilation parameters at 3, 6, 12, 24, 48, 72 h, as well as renal and liver function tests at first and third postoperative days following implantation. Outcome data of patients receiving pECMO were compared with those who received cECMO. The inclusion criteria were met by 37 patients (25 pECMO and 12 cECMO). There were no significant differences in baseline characteristics between these two groups except for younger age in pECMO patients (P=0.005). All postimplantation variables were comparable between the two groups except for higher PO2 and lower PCO2 values at the 3rd hour postimplantation in patients with pECMO (P=0.007 and 0.01, respectively). Eleven (44%) of the pECMO patients required re-exploration for bleeding versus 100% of patients with cECMO (P=0.01). Ischemic leg complication was observed in four pECMO and three cECMO patients. Thirty-day mortality in patients with pECMO and cECMO was 60% versus 67%, respectively (P=1.00). In this study, no particular oxygenation/ventilation, hemodymanic, or end-organ function advantage was observed with either cannulation technique. However, more bleeding and resternotomy complications were observed in cECMO patients.

DOI： 10.1111/aor.12245

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BACKGROUND AND AIM OF THE STUDY: The benefit of valve-sparing aortic root replacement compared to conventional aortic root replacement surgery remains unclear. METHODS: Between February 2009 and November 2010, a total of 112 patients underwent aortic root surgery at the Department of Cardiovascular and Thoracic Surgery, Heinrich-Heine-University, Dusseldorf, Germany. The valve-sparing technique was used when leaflets were grossly normal. In cases where the valve could not be saved, a prosthetic or biological substitute was used for the aortic root, according to existing guidelines. The patients were allocated to three groups: (i) valve-sparing aortic root replacement group using the David technique (VSR-David; n = 47); (ii) valve-replacing aortic root surgery with a prosthetic conduit using the Bentall-Kuchucus technique (VRR-Prosthetic; n = 31); and (iii) valve-replacing aortic root surgery with a biological stentless valve with the full root technique (VRR-Bio; n = 34). RESULTS: Intraoperative data revealed that, in the VSR-David group, the cardiopulmonary bypass and cross-clamp times were significantly longer (207 +/- 68 min and 140 +/- 38 min respectively; both p = 0.001). The VRR-Prosthetic patients were at highest risk (mean EuroSCORE 15.9%) compared to the VSR-David and VRR-Bio groups (10.8% and 10.4%, respectively). Postoperative analysis showed that patients in the VRR-Bio group had the lowest number of perioperative heart failures (p = 0.004). The perioperative 30-day mortality was significantly higher in the VRR-Prosthetic group (22.6%; p = 0.004). Transaortic flow velocities were significantly lower in the VSR-David group, followed by the VRR-Bio group and VRR-Prosthetic group (1.66 +/- 0.54, 1.98 +/- 0.45, and 2.29 +/- 0.39 m/s, respectively; p = 0.012). The univariate and multivariate analyses of perioperative risk factors showed that only open distal anastomosis was strongly associated with negative results, but not the valve-sparing technique. CONCLUSION: Aortic valve-sparing root replacement must be considered as an excellent alternative for young patients requiring aortic root replacement when a biological valve is clinically indicated. For patients aged >65 years, or with a decreased life expectancy, the full root technique with a stentless valve should be used, given its technical simplicity and excellent postoperative results.

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BACKGROUND: The aims of this study are (1) to investigate the occurrence rate of postoperative complications in patients ≥ 80 years old after cardiac surgery and (2) to elucidate the impact of the most common postoperative complications on mortality. METHODS: Between January 1998 and December 2007, 649 patients aged over 80 years received isolated first-time coronary artery bypass graft (CABG), isolated aortic valve replacement (AVR) or a combination of both in our institute. Prospectively entered patient data were analyzed with respect to major complications and outcome parameters. RESULTS: Acute renal failure (55.0% vs. 7.5%, p = 0.0001), low cardiac out-put syndrome (43.1% vs. 8.8%, p = 0.0001), sepsis (52.0% vs. 10.3%, p = 0.0001), prolonged respiratory failure with tracheotomy (29.0% vs. 11.0%, p = 0.002), re-thoracotomy due to bleeding (26.9% vs. 10.6%, p = 0.0001), and postoperative laparotomy (30.8% vs. 11.5%, p = 0.033) had a significant impact on mortality. A multivariate analysis revealed that advanced age (OR 1.130, 95%CI; 1.017-1.256, p = 0.023), low output syndrome (OR 5.094, 95%CI; 1.1635-15.871, p = 0.005), renal failure (OR 8.128, 95%CI; 3.347-19.742, p = 0.0001) and sepsis (OR 4.975, 95%CI; 1.420-17.426, p = 0.012) as independent risk factors. CONCLUSIONS: The present study demonstrates that among major complications, low output syndrome, renal failure requiring renal replacement therapy and sepsis, dramatically impaired the postoperative course patients aged over 80 years undergoing CABG, AVR or combined CABG and AVR.

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BACKGROUND: The purpose of this study is to examine the influence of the prosthesis type on early mortality and long-term survival after re-replacement of aortic valve prosthesis, especially in patients over 60 years old. METHODS: Late outcome of 223 patients who underwent a reoperation on the aortic valve and received a mechanical (mechanical group) or biological (biological group) heart valve prosthesis at a single institution were analyzed for survival and major valve-related complications, including structural valve deterioration, thromboembolism, hemorrhage, further reoperation, and valve-related mortality. RESULTS: Preoperative New York Heart Association class IV (P = 0.001), emergency procedure (P = 0.002), and endocarditis (P = 0.025) were significant risk factors for 30-day mortality rates, which were 8.4 % and 12.5 %, respectively (mechanical versus biological group, P = 0.361). A subanalysis of elective patients revealed a low risk of 30-day mortality of 2.4 % and 1.8 %, respectively. Event-free survival was comparable at 5 years (73.9% ± 3.6% versus 70.5% ± 6.5%, mechanical versus biological group) and 10 year (49.7% ± 5.0% versus 35.3% ± 9.8%, mechanical versus biological group). In a propensity-matched subanalysis, survival and event-free survival were comparable at 5 and 10 years in both groups. CONCLUSION: The type of aortic valve prosthesis did not affect early outcome and late survival in patients who underwent valve replacement, and therefore, the current strategy favoring a biological aortic valve prosthesis for patients aged over 60 years in first-time operations could also be applied in re-replacement.

DOI： 10.1532/HSF98.20111167

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In the last decade, cardiovascular tissue engineering has made great progress developing new strategies for regenerative medicine applications. However, while tissue engineered heart valves are already entering the clinical routine, tissue engineered myocardial substitutes are still restrained to experimental approaches. In contrast to the heart valves, tissue engineered myocardium cannot be repopulated in vivo because of its biological complexity, requiring elaborate cultivation conditions ex vivo. Although new promising approaches-like the whole-heart decellularization concept-have entered the myocardial tissue engineering field, bioreactor technology needed for the generation of functional myocardial tissue still lags behind in the sense of user-friendly, flexible and low cost systems. Here, we present a novel customizable modular bioreactor system that can be used for whole-heart cultivation. Out of a commercially obtainable original equipment manufacturer platform we constructed a modular bioreactor system specifically aimed at the cultivation of decellularized whole-hearts through perfusion and controlled 3D biomechanical stimulation with a simple but highly flexible operation platform based on LabVIEW. The modular setup not only allows a wide range of variance regarding medium conditioning under controlled 3D myocardial stretching but can also easily be upgraded for e.g. electrophysiological monitoring or stimulation, allowing for a tailor-made low-cost myocardial bioreactor system.

DOI： 10.1007/s10047-013-0705-5

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Decellularization is a promising option to diminish immune and inflammatory response against donor grafts. In order to accelerate the autologous in vivo recellularization of aortic conduits for an enhanced biocompatibility, we tested fibronectin surface coating in a standardized rat implantation model. Detergent-decellularized rat aortic conduits (n = 36) were surface-coated with covalently Alexa488-labeled fibronectin (50 μg/ml, 24 h) and implanted into the systemic circulation of Wistar rats for up to 8 weeks (group FN; n = 18). Uncoated implants served as controls (group C; n = 18). Fibronectin-bound fluorescence on both surfaces of the aortic conduits was persistent for at least 8 weeks. Cellular repopulation was examined by histology and immunofluorescence (n = 24). Luminal endothelialization was significantly accelerated in group FN (p = 0.006 after 8 weeks), however, local myofibroblast hyperplasia with significantly increased ratio of intima-to-media thickness occurred (p = 0.0002 after 8 weeks). Originating from the adventitial surface, alpha-smooth muscle actin and desmin positive cell invasion into the media of fibronectin-coated conduits was significantly increased as compared to group C (p < 0.0001). In these medial areas, in situ zymography revealed enhanced matrix metalloproteinase activity. In both groups, inflammatory cell markers (CD3 and CD68) and signs of thrombosis proved negative. With regard to several markers of cell adhesion, inflammation and calcification, quantitative real-time PCR (n = 12) revealed no significant inter-group differences. Fibronectin surface coating of decellularized cardiovascular implants proved feasible and persistent for at least 8 weeks in the systemic circulation. Biofunctional protein coating accelerated the autologous in vivo endothelialization and induced a significantly increased medial recellularization. Therefore, this strategy may contribute to the improvement of current clinically applied bioprostheses.

DOI： 10.1016/j.biomaterials.2013.04.037

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BACKGROUND: The objective of this study was to describe a small animal aortic conduit model that could analyze long-term conduit valve (CV) function by echocardiography. METHODS AND RESULTS: Recipient Wistar rats (200-250g, n=20) underwent aortic leaflet injury of their native aortic valve under echocardiographic control. After 2 weeks, U-shaped decellularized CVs obtained from other rats were implanted onto the abdominal aorta. Implanted CVs were analyzed via pulsed-wave echocardiography at day 0, 4 and 12 weeks. CV stenosis was assessed as systolic flow velocity (post-pre CV)/flow velocity in the ascending aorta. CV regurgitation was assessed as the ratio of the amount of reversed diastolic flow to forward systolic flow in post-pre CV. The endpoint was set at 12 weeks. Three rats died immediately after aortic valve injury and all surviving rats received CV implantation (n=17, 85%). The survival rate after conduit implantation was 100% at 4 weeks and 88% (15/17) at 12 weeks. Regarding the CV function at 0, 4 and 12 weeks, the average observed value of CV stenosis was 3.8±7.9%, 3.1±4.1% and 14±10% (P<0.01), respectively. The average value of CV regurgitation was 0%, 12±27% and 52±43%, respectively (P<0.001). CONCLUSIONS: By using this model, the degeneration of implanted CV could be assessed not only qualitatively, but also quantitatively.

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PURPOSE: Splenic abscess formation is a serious complication in the setting of active endocarditis, and splenectomy is recommended. However, the optimal timing for splenectomy is yet undetermined. The purpose of this study was to evaluate the role of a one-stage splenectomy and valve surgery for active endocarditis. METHODS: Among 202 consecutive endocarditis patients, 18 had splenic lesions on preoperative abdominal screening, who underwent cardiac surgery and splenectomy as a one-stage procedure (group A) and were compared to patients with unremarkable abdominal screening (group B, n = 184) undergoing sole cardiac surgery. RESULTS: No difference was observed regarding preoperative characteristics (age, gender, New York Heart Association [NYHA] grade, diabetes, coronary artery disease, redo surgery, adiposity, smoking), intubation time, and prolonged ventilation. There were 23 early postoperative deaths in group B (12.5%) vs. none in group A. At 180 days, survival was significantly higher for patients in group A (94.4%) vs. group B (67.9%, p = 0.016), although this difference did not reach statistical significance (log-rank test, p = 0.073). Multivariate Cox proportional hazards regression revealed age above 50 years (hazard ratio [HR] 3.327, 95% confidence interval [CI] 1.279-8.650) and NYHA class above III (NYHA III or IV: HR 3.117, 95% CI 1.119-8.683, p = 0.030; NYHA IV: HR 3.678, 95% CI 1.984-6.817, p < 0.001) as independent risk factors for mortality at 180 days. A trend towards a protective factor was observed for simultaneous splenectomy (HR = 0.171, 95% CI 0.023-1.255). CONCLUSION: Simultaneous valve surgery and splenectomy is an approach for active endocarditis complicated by splenic lesions with a low 180-day mortality. Despite the expected risk elevation by septic lesions and the additive trauma of a laparotomy, patients with simultaneous splenectomy had a favourable outcome regarding early mortality and mortality at 6 months.

DOI： 10.1007/s00423-012-0931-y

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OBJECTIVES: Sternal dehiscence and mediastinitis are rare but serious complications following cardiac surgery. The aim of this study was to investigate the influence of the number of sternal wires used for chest closure on sternal complications. METHODS: From May 2003 to April 2007, 4714 adult patients received cardiac surgery in our institute. X-ray images of all patients were reviewed and the used wires were counted. Patients who received another material or longitudinal wiring technique according to Robicsek for chest closure were excluded from this analysis; thus 4466 patients were included into the final analysis. Figure-of-eight wiring was counted as two wires. RESULTS: Sternal complications occurred in 2.4%, and hospital mortality with or without sternal complications were 2.8 and 2.7%, respectively (P = 0.60). Mean numbers of sternal wires were 7.8 in both patient groups with or without sternal complications (P = 0.79). Multivariate analysis revealed diabetes mellitus [odds ratio (OR) 1.54, 95% CI 1.01-2.34, P = 0.04], chronic obstructive pulmonary disease (OR 1.85, 95% CI 1.12-2.79, P = 0.01) and renal insufficiency (OR 1.70, 95% CI 1.11-2.59, P = 0.001) as significant risk factors for sternal complications. In high-risk patients, the use of less than eight wires was significantly associated with postoperative sternal complications. CONCLUSIONS: Particularly in high-risk patients, careful haemostasis should be done and eight or more wires should be used to avoid sternal complications.

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BACKGROUND: Numerous limitations of aortic valve grafts currently used in pediatric patients cause the need for alternative prostheses. For the purpose of in vivo evaluation of novel engineered aortic conduit grafts, we aimed at downsizing a previously described model to create a growing rodent model. MATERIALS AND METHODS: U-shaped aortic conduits were sutured to the infrarenal aorta of young Wistar rats (70-80 g, n = 10) in an end-to-side manner. Functional assessment was performed by Doppler sonography and high resolution rodent MRI. Histology and immunohistochemistry followed after 8 wk. RESULTS: Postoperative recovery rate was 80%. Conforming to clinical observations, postoperative MRI (d 5) and Doppler sonography (wk 8) revealed unimpaired conduit perfusion. Explanted implants were luminally completely covered by an endothelial cell layer with local hyperplasia and accumulation of α-smooth muscle actin (+) cells. Moreover microcalcification of the decellularized scaffolds was observed. CONCLUSIONS: Our downsized model of aortic conduit transplantation enables overall characterization with detailed analysis of maturation of engineered aortic grafts in a growing organism.

DOI： 10.1016/j.jss.2011.10.009

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Postoperative bleeding is the most common complication following the implantation of ventricular assist devices. This is a case report of a HeartWare HVAD patient with intractable bleeding following chest tube insertion necessitating massive blood transfusion and multiple thoracotomies. Anticoagulation and antiplatelet therapy were discontinued and intravenous NovoSeven was administered as last resort. Bleeding ceased immediately and no pump-related issues were observed. However, thrombus formation in the right atrium and superior vena cava was detected.

DOI： 10.1111/j.1525-1594.2012.01473.x

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OBJECTIVES: Considering the expanding technology of catheter-based aortic valve implantation, high-risk patients who would not be suitable for conventional aortic valve replacement (AVR) should be identified. METHODS: From 1997 to April 2007, 190 patients aged from 80 and 89 years old received isolated AVR. Patients between 80 and 84 years old were categorized as the early octogenarians (n = 148) and patients between 85 and 89 years old were categorized as the late octogenarians (n = 42). RESULTS: Thirty days mortality in the early and late octogenarians were 6 and 21%, respectively (p = 0.003). The additive and logistic EuroSCORE were 8.0 ± 2.4 and 8.8 ± 1.8 in the early octogenarians and 13.2 ± 11.8 and 14.6 ± 8.7 in the late octogenarians. Multivariate analysis revealed the late octogenarians (OR 6.7, 95%CL 1.8-24.4, p = 0.004) and poor left ventricular function (OR 8.0, 95%CL 1.2-53.5, p = 0.032) as significant risk factors for 30 days mortality. Early octogenarians showed 1-year, 3-year, 5-year, and 8-year survival of 82.4, 67.6, 54.7, and 33%, respectively. Late octogenarians showed 1-year, 3-year, 5-year, and 8-year survivals of 69.0, 66.2, 41.6, 22.3%, respectively. CONCLUSIONS: Mortality after AVR in the late octogenarians was very high, and was underestimated by EuroSCORE in this patients group. In late octogenarians, catheter-based aortic valve implantation despite relative low EuroSCORE level could be considered as a reasonable alternative.

DOI： 10.1055/s-0032-1304544

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The enhancement of valvular interstitial cell (VIC) calcification by transforming growth factor-β1 (TGF-β1) and the endothelial inducing effect of vascular endothelial growth factor (VEGF) have been demonstrated. Here we report the modulating properties of extracellular matrix (ECM) modification on VIC calcification in the presence of TGF-β1 and VEGF. Ovine aortic VICs cultured on collagen, fibronectin, laminin, or uncoated surfaces were exposed to TGF-β1, VEGF, or left untreated. VEGF significantly inhibited the formation of calcific nodules independent of ECM Protein coating (p < 0.05). TGF-β1 exposition resulted in the formation of calcific nodules on collagen, laminin, and uncoated control surfaces. In contrast, fibronectin coating resulted in significantly reduced nodule formation despite TGF-β1 administration. Further, we showed a marked increase of apoptotic and dead cells in calcific nodules. Overall, our data demonstrate that, an additive protective effect on VICs can be achieved by providing specific growth factors or a specific ECM environment. Here, VEGF administration inhibited calcification and apoptosis, particularly in combination with fibronectin coating. This combination appears to be a promising tool for modification of heart valve scaffolds for tissue engineering purposes and preclinical trials.

DOI： 10.1089/ten.TEA.2010.0304

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OBJECTIVE: Successful animal and clinical implantation of decellularised heart valves has been performed in the pulmonary position. Comparable results have not yet been achieved for the aortic position with the high haemodynamic demands of the systemic circulation and the challenging implantation procedure. METHODS: Allogenic aortic valves (n=10) were decellularised using detergents (decellularised aortic valves (dAoVs)). Five prostheses were analysed for decellularisation quality and scaffold preservation. Five valves were orthotopically implanted in juvenile sheep in a subcoronary technique. After 5 months, echocardiography, immunohistology, histology, electron microscopy and western blot (WB) were used for analysis. RESULTS: All animals survived the follow-up with increased body weight (38.8 ± 2.8kg vs 56.0 ± 2.6kg, p<0.001). After implantation, three dAoVs showed negligible and two others minor insufficiency (I), which remained unchanged at explantation. Effective orifice area increased slightly (1.1 ± 0.2cm(2) vs 1.6 ± 0.3cm(2), p=0.051). Explanted dAoVs (n=4) showed excellent macroscopy with minor soft-tissue nodules observed at the free cusp margins of only one dAoV. No valve showed any signs of thrombosis or calcification. On microscopic evaluation, the cusp architecture was preserved with an almost complete endothelial repopulation as confirmed by vimentin(+)/von Willebrand factor (vWF(+))-staining, WB of endothelial markers (eNOS/vWF) and scanning electron microscopy (SEM). Partial interstitial reseeding with vimentin(+)/alpha-smooth muscle (αsm(+))-cells was noted. Quantitative measurement of collagen-IV, collagen-I, laminin and elastin (WB) demonstrated preserved scaffold composition as compared to native tissue. CONCLUSION: The dAoVs showed excellent functional outcome at 5 months in a subcoronary model of juvenile sheep. Advanced endothelial and nascent interstitial repopulation, with preserved structural integrity under the high-shear-stress milieu of the aortic valve, encourage further long-term studies.

DOI： 10.1016/j.ejcts.2010.03.024

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The effect of antiplatelet therapy (APT) on postoperative bleeding, transfusion needs and re-exploration remains unclear. This study examines the influence of APT, as well as antiplatelet mono- and combined therapy, on haemorrhage and transfusion requirements in patients undergoing coronary artery bypass on cardiopulmonary bypass (CPB). Six hundred and fifty patients were reviewed retrospectively, 325 patients received APT within seven days and 325 control patients. APT group had two subgroups: clopidogrel (CLO) group: n=48 patients received CLO as mono-therapy; combined group: n=277 patients received both CLO and aspirin (ASS). The mediastinal drainage at 12 h was control group: 505 ml+/-445 ml and APT group: 802 ml+/-720 ml, P<0.001. APT group (vs. control group) received significantly more units of blood (3.9+/-4.2 vs. 1.9+/-2.6; P<0.001), platelet units (1.0+/-1.4 vs. 0.1+/-0.3; P<0.001), and fresh frozen plasma (FFP) units (2.9+/-3.9 vs. 0.9+/-2.2; P<0.001), respectively. Combined and mono-therapy groups had no significant differences in bleeding and blood transfusion. Considerations should be given to delaying elective coronary surgery for patients received APT for seven days.

DOI： 10.1510/icvts.2009.211805

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BACKGROUND: The site of cannulation for repair of ascending aortic dissection remains controversial. We present our experience with ascending aortic cannulation for acute aortic dissection type A. METHODS AND RESULTS: From January 1988 to September 2007, we operated on 242 patients for acute aortic dissection type A. Medical records of 235 patients who received ascending aortic cannulation or femoral cannulation were retrospectively reviewed. Long-term follow-up was complete in 97% of patients. Cannulation was accomplished in 82 patients through the ascending aorta and in 153 patients through the femoral artery. Preoperative patient characteristics were almost comparable between groups. Similarly, there were no differences in preoperative patient characteristics and intraoperative parameters including operation time, bypass time, cross-clamp time, hypothermic circulatory arrest time, and percentage of total arch replacement. The 30-day mortality rate was 14% in the aortic group and 23% in the femoral group (P=0.07), and incidence of stroke was 4.9% in the aortic group and 4.5% in the femoral group (P=0.86). During follow-up (mean, 5.5 years), survival at 5 years and 10 years was 65% and 41% in the aortic group and 64% and 46% in the femoral group, respectively (P=0.97). CONCLUSIONS: The cannulation site should be chosen according to the patient's pathology and status, and the present study suggests that ascending cannulation in patients with acute aortic dissection type A can be a safe alternative, offering acceptable early and long-term outcomes.

DOI： 10.1161/CIRCULATIONAHA.108.844480

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DOI： 10.1016/j.jtcvs.2008.10.006

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INTRODUCTION: The purposes of this study are to identify a patient cohort that would benefit from the use of mechanical circulatory support (MCS) in the presence of the Eurotransplant high-urgency (HU) program. METHODS: Sixty-five patients (heart transplantation (HTx) group, 77%) underwent heart transplantation and 17 patients (D group, 20%) died while on the HU waiting list. These 82 patients were included in this retrospective study. RESULTS: The mean waiting time on HU list was 18.3+/-17.7 days in HTx group and 12.5+/-9.4 days in D group (p=0.075). The average weekly allocation rate from the active HU list was 27.7%, and the mean weekly waiting-list mortality was 12.1%. The use of intra-aortic balloon pumping (p=0.005), mechanical ventilation (p=0.007), higher dose of dobutamine (0.005), lower serum level of sodium (p=0.046), and higher serum level of C reactive protein (CRP) (0.040) at the registration of HU listing were associated with waiting-time mortality, and the serum creatinine level more than 1.5mg/dl (p=0.007, odds ratio; 14.5, 95% CI; 2.1-102.0) and the serum CRP level more than 10mg/l (p=0.026, odds ratio; 6.3, 95%CI; 1.2-31.4) were identified as significant predictors. CONCLUSION: It would be appropriate that a patient who would not be able to tolerate one or two weeks waiting time to be considered as a candidate for MCS implantation in the presence of the HU program. The patient selection criteria for MCS implantation should include not only hemodynamic parameters, but also the aspect of a beginning multi-organ failure.

DOI： 10.1016/j.ejcts.2008.05.059

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More than a decade after the first reports on successful three-dimensional cardiac cell culture for experimental and potential therapeutic application, the interest and experimental efforts in the field of myocardial tissue engineering continues to grow. The hope that tissue cultures may one day act as graft substitute for malfunctioning myocardium continues to drive current scientific activity. Against this background interest seem to have progressively shifted towards the aim of engineering single tissue components. Accordingly, elements of the extracellular matrix (ECM) have gained increasing attention as potentially crucial mediators in developing and maintaining the characteristics of three-dimensional cardiac cell cultures. The ECM is now no longer regarded as merely a scaffold for developing tissue, a concept that is widely acknowledged in modern tissue engineering. The understanding of the role of precursor and stem cells has highlighted new complicated aspects of cell proliferation and differentiation and ECM proves to play an important role in providing essential signals to influence major intracellular pathways such as proliferation, differentiation and cell metabolism. Furthermore, progress in biochemical engineering has provided the perspective of application of synthetic ECM-linked molecules with bioactive potential. With the advent and continuous refinement of cell removal techniques, a new class of native acellular ECM has emerged with some striking advantages. The presently available ECM materials aim to closely resemble the in vivo microenvironment by acting as an active component of the developing tissue construct. It is therefore not surprising that most of the focus in myocardial tissue engineering has been on cell-matrix interaction, for both naturally derived and synthetic ECM. This article provides a review of established models of myocardial tissue engineering with respect to the employed ECM materials including current frontiers in material development.

DOI： 10.1016/j.ejcts.2008.03.062

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We developed a coronary active perfusion system (synchronized arterial flow ensuring system [SAFE-System]) to prevent myocardial ischemia during distal anastomosis in off-pump coronary artery bypass grafting (CABG). The purpose of this study was to identify the relationship between the flow rate of the SAFE-System and myocardial function. Studies were performed on pigs, which were divided into five groups: external shunt perfusion group (group A, n = 6); 0.1 mL/beat flow rate for the SAFE-System group (group B, n = 6); 0.2 mL/beat flow rate group (group C, n = 6); 0.3 mL/beat flow rate group (group D, n = 6); and 0.4 mL/beat flow rate group (group E, n = 6). Regional myocardial blood flow and left ventricular function were monitored for 30 min. The regional myocardial blood flow in group A was severely decreased (P < 0.001), and was significantly lower than in the other groups (P < 0.001). The slope of the end-systolic pressure-volume relationship, and the slope of the preload recruitable stroke work relationship in groups A, D, and E were lower than in groups B and C. As compared with the use of a passive external shunt, a coronary active perfusion system provides adequate myocardial blood flow and hemodynamics. It was possible to maintain left ventricular function when using 0.1 or 0.2 mL/beat flow rate. The use of a coronary active perfusion system appears to make the off-pump CABG procedure safer and may increase the application of off-pump bypass grafting.

DOI： 10.1111/j.1525-1594.2008.00579.x

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Patients with extensive aortic aneurysms involving the ascending aorta, aortic arch, and the descending aorta are still considered to be a challenge for many cardiovascular surgeons. The introduction of the elephant trunk technique by Borst et al. in 1983 has greatly facilitated surgery on this kind of pathology and this technique has been recognized as a standard modality for treatment of extended aortic aneurysms. As a next step, the frozen elephant trunk technique has been introduced in some institutes in the late 1990s. With this technique, surgery is performed through a median sternotomy, and an endovascular stent-graft is placed into the descending aorta in an antegrade fashion through the opened aortic arch. Then the ascending aorta and the aortic arch are replaced conventionally. The frozen elephant trunk technique enables one-stage repair of extended aortic aneurysms in a certain patient cohort with similar operative mortality as with the conventional elephant trunk technique, in which a second-stage operation is a prerequisite. Although the surgical strategy should be adjusted specifically to each patient's individual pathology, the frozen elephant trunk technique may become the next standard treatment for extended aortic aneurysm instead of its conventional variant.

DOI： 10.1016/j.ejcts.2008.02.030

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OBJECTIVE: This study was undertaken to identify preoperative and intraoperative risk factors influencing outcome after operations requiring hypothermic circulatory arrest with selective antegrade cerebral perfusion in a single center. METHODS: Between November 1999 and March 2006, a total of 501 consecutive patients (median age 64 years, range 20-86 years, 320 male) underwent aortic arch surgery with moderate hypothermic circulatory arrest (25 degrees C +/- 2 degrees C) and additional selective antegrade cerebral perfusion (14 degrees C) at our institution for various indications (256 aneurysms, 153 acute and 23 chronic type A aortic dissections, 66 other). Of these, 181 were emergency operations. Statistical analysis was carried out to determine risk factors for 30-day mortality as well as for temporary and permanent neurologic dysfunction. RESULTS: Overall mortality was 11.6%. Permanent neurologic dysfunction occurred in 48 patients (9.6%); temporary neurologic dysfunction was detected in 67 patients (13.4%). Multivariate analysis revealed age (P = .001, odds ratio 1.08), reoperation (P = .006, odds ratio 3.58), femoral arterial cannulation (P = .004, odds ratio 2.87), and cardiopulmonary bypass duration (P < .001, odds ratio 1.009) as risk factors for mortality. Permanent neurologic dysfunction was associated with preoperative renal insufficiency (P = .029, odds ratio 2.79) and operation time (P < .001, odds ratio 1.005), whereas temporary neurologic dysfunction occurred in patients with coronary artery disease (P = .04, odds ratio 2.29), emergency surgery (P = .001, odds ratio 4.09), and increasing hypothermic circulatory arrest duration (P = .01, odds ratio 1.015). CONCLUSION: Moderate hypothermic circulatory arrest in combination with cold selective antegrade cerebral perfusion is an adequate tool for neuroprotection during aortic surgery. Nevertheless, the safety of this technique is limited for patients with long intraoperative durations, advanced age, and multiple comorbidities. This technique, which avoids profound core temperatures, has become an alternative to simple deep hypothermic circulatory arrest.

DOI： 10.1016/j.jtcvs.2007.07.067

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OBJECTIVE: In human patients the influence of skeletonized internal thoracic artery harvesting on the sternal microcirculation in the perioperative phase has not been well investigated. METHODS: Twenty-four consecutive male patients who were scheduled for isolated coronary artery bypass grafting were prospectively randomized into 2 groups. The left internal thoracic artery was harvested by using the skeletonized technique in group 1, and it was harvested with a pedicle in group 2. Superficial (2 mm) and deep (8 mm) tissue oxygen saturation and blood flow were measured presternally and retrosternally in the upper, middle, and lower sternal parts with a novel laser Doppler flowmetric and remission spectroscopic system (Oxygen-to-See; LEA Medizintechnik, Giessen, Germany). RESULTS: Presternal tissue oxygen saturation deteriorated at the upper and middle sternum, and presternal blood flow deteriorated at all measurement points after internal thoracic artery harvesting in both groups. Skeletonization had no advantage in maintaining presternal microcirculation. Retrosternal microcirculation also deteriorated at all measurement points after internal thoracic artery harvesting in both groups. However, the deterioration of the retrosternal microcirculation was significantly less in group 1 at the middle and lower sternum; values of oxygen saturation to the baseline were 86% +/- 3.8% versus 60% +/- 4.3% (P = .001) at 2-mm depth and 82% +/- 4.2% versus 61% +/- 6.1% (P = .009) at 8-mm depth at the middle sternum and 95% +/- 3.2% versus 78% +/- 1.3% (P = .001) at 2-mm depth and 94% +/- 2.2% versus 78% +/- 4.6% (P = .004) at 8-mm depth at the lower sternum in groups 1 and 2, respectively. CONCLUSION: The damage of the tissue microcirculation in the middle and lower retrosternal area is significantly less after internal thoracic artery skeletonization compared with that after the pedicled internal thoracic artery harvesting technique.

DOI： 10.1016/j.jtcvs.2007.09.004

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The minimized extracorporeal circulation system (MECC) is being used to reduce priming volume and blood/polymer contact during cardiac procedures. In this study, we evaluated the efficacy and potential advantages of the system in coronary artery bypass graft (CABG) patients. We included two groups of patients destined for CABG in a prospective, randomized study: Group A was operated on the usual pump (n = 30) while Group B was operated using the MECC (n = 50). Pre-operative demographics, intra-operative times and values as well as a series of post-operative outcome data (blood loss, transfusion requirements, ventilation time, ICU and hospital stay) were recorded. CK, CK-MB, troponin-T, IL-6 and IL-8 were measured. Pre-operative and post-operative lung function were assessed. In the MECC-operated group, patients developed less post-operative troponin-T (0.2 ± 0.3 vs. 0.5 ± 0.5 ng/mL, p = 0.031) and less IL-8 (13.8 ± 5 vs. 22.5 ± 0.5 μg/L, p = 0.05). While blood loss was comparable in both groups, packed red blood cells and fresh frozen plasma were given less frequently in the MECC group (p = 0.015 resp. 0.022). The one-tailed Student's t-test revealed shorter bypass time in the MECC group (74 ± 17 vs. 82 ± 24 min). There was no difference in ventilation and ICU-time (patients were not treated in a fast-track fashion). The FEV1 was better in the MECC group (relative values: 70.1 ± 18.2% vs. 61.1 ± 12.3%, p = 0.02). Utilization of the MECC may cause less cytokine (IL-8) liberation, owing to less blood/ tubing contact, as well as less red blood cell and fresh frozen plasma demand. It may also be the circuit in patients with chronic obstructive pulmonary disease (COPD). © 2008 SAGE Publications.

DOI： 10.1177/0267659108097880

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The safety of total arterial revascularization with a left internal thoracic artery-radial artery T-graft was evaluated in patients with at least two-vessel coronary artery disease and aortic valve stenosis requiring concomitant aortic valve replacement. From June 2001 to January 2005, 18 patients underwent aortic valve replacement and total arterial revascularization, while 101 had aortic valve replacement and conventional grafting. By matching age, sex, left ventricular ejection fraction, and number of distal anastomoses, 1:2 matched groups were generated: 15 patients with a left internal thoracic-radial artery T-graft, and 30 with left internal thoracic artery and additional vein grafts. Aortic cross clamp and cardiopulmonary bypass times were similar in both groups. There were no significant differences in postoperative data between the groups. Early mortality was 0% in the T-graft group and 2% in those with conventional grafts. Follow-up ranged from 2 to 50 months. Event-free survival was 100% in the T-graft group and 90% in the conventional graft group. Total arterial grafting with a left internal thoracic-radial artery T-graft can be performed in selected patients with aortic valve stenosis requiring simultaneous aortic valve replacement.

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BACKGROUND: The aim of this study is to evaluate the safety of proximal arch repair using only moderate hypothermic circulatory arrest (HCA) at a temperature of 25 degrees C to 28 degrees C without any adjunctive cerebral protection in comparison with those with moderate HCA and selective cerebral perfusion. METHODS: Thirty patients who underwent proximal arch repair using moderate HCA without selective cerebral perfusion (SCP) were retrospectively examined and defined as the SCP (-) group. As a control group, 31 patients who underwent moderate HCA and SCP within 10 minutes were included in this study and defined as the SCP (+) group. RESULTS: Mean circulatory arrest time was 9.4 +/- 0.8 minutes and 7.5 +/- 1.8 minutes (p = 0.0001) and mean nasopharyngeal temperature at the induction of the circulatory arrest was 26.0 +/- 1.2 degrees C and 26.8 +/- 1.3 degrees C (p = 0.014) in the SCP (+) group and SCP (-) group, respectively. Operative mortality was 3.2% in the SCP (+) group and 3.3% in the SCP (-), and neurologic complications were found in three (9.7%) patients in the SCP (+) group and two (6.7%) patients in the SCP (-) group (p = 0.69). CONCLUSIONS: It was possible to perform proximal arch replacement in selected patients using moderate HCA without any adjunctive cerebral protection with excellent results, and no advantage of the use of SCP was found in patients who required short HCA for proximal arch replacement.

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BACKGROUND: We assessed the outcome in patients with Marfan syndrome operated on exclusively with the aortic valve-sparing reimplantation technique for aortic root aneurysms during more than a decade. METHODS: Between July 1993 and April 2005, the aortic valve-sparing reimplantation technique (David I) was used in 325 patients. In 59 patients with clinical evidence of Marfan syndrome, procedures were done for aortic root aneurysm (n = 55) or aortic dissection type A (n = 4). Their mean age was 30 +/- 12 years (range, 9 to 62 years), and 37 (63%) were male. Additional procedures were arch replacement in 4 patients, coronary artery bypass grafting in 1, mitral valve surgery in 9, and closure of atrial septal defect in 3. Mean follow-up was 54 +/- 37 months (range, 0 to 139 months). RESULTS: No patient died during the first 30 days postoperatively. Mean bypass time was 163 +/- 34 minutes (range, 99 to 248 minutes), and mean aortic cross clamp time was 126 +/- 28 minutes (range, 78 to 202 minutes). Four patients (6.8%) required rethoracotomy for postoperative bleeding. Five late deaths (8.5%) occurred during follow-up. Reoperation of the reconstructed valve was required in 7 patients. Freedom from reoperation was 88% +/- 5% at 5 years and 80% +/- 9% at 10 years. Mean grade of aortic insufficiency was 1.81 preoperatively compared with 0.20 early postoperatively (p < 0.001). At last investigation, the mean grade of aortic insufficiency increased slightly to 0.22 (p = 0.16). Anticoagulation was not required in 67% of patients. One thromboembolic complication and four instances of minor bleeding were documented. All patients were in New York Heart Association functional class I (86%) or II at last contact. CONCLUSIONS: Excellent early outcome, favorable long-term results, and acceptable durability of the reimplanted valve should encourage use of this technique in patients with Marfan syndrome.

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OBJECTIVE: There is no common guideline on what temperature should be achieved at the lower body circulatory arrest followed by the initiation of selective cerebral perfusion. METHODS: Between October 1999 and August 2005, a total of 377 patients underwent repair of the aortic arch with selective cerebral perfusion and hypothermic circulatory arrest at 20 degrees C to 28 degrees C and were divided into two groups: (1) 125 patients with deep lower body circulatory arrest at 20 degrees C to 24.9 degrees C (deep lower body circulatory arrest group) and (2) 252 patients with moderate lower body circulatory arrest at 25 degrees C to 28 degrees C (moderate lower body circulatory arrest group). To compensate for the differences in patient characteristics, we used a propensity score matching analysis, and comparable patients, 92 patients from each group, were identified for final analysis. RESULTS: There were no significant differences in mortality or morbidity between deep and moderate lower body circulatory arrest, in either the entire study cohort or the propensity-matched cohort. C-reactive protein level 1 day after the operation approached but fell short of significance (108.4 +/- 47.7 mg/L in deep lower body circulatory arrest group and 95.8 +/- 44.2 mg/L in moderate lower body circulatory arrest group, P = .07). The mean temperatures at the initiation of lower body circulatory arrest were 24.1 degrees C +/- 2.2 degrees C in patients who underwent reexploration for bleeding and 24.9 degrees C +/- 1.8 degrees C in patients who did not (P = .025); the difference also reached statistical significance in multivariate analysis (P = .046, odds ratio 0.796). CONCLUSIONS: Our results suggest that moderate lower body circulatory arrest can be safely performed for aortic arch repair. In fact, postoperative inflammatory response tended to be lower in patients with moderate lower body circulatory arrest than those with deep lower body circulatory arrest, and deep lower body circulatory arrest was a strong risk factor for reexploration for bleeding.

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Objective: To confirm the quality of total arterial CABG carried out using the left internal thoracic artery (LITA) and a radial artery (RA) T-graft and distal anastomoses immediately in the OR, we developed a new technique using intraoperative graft angiography. Methods: A 5-Fr sheath is inserted in the proximal radial artery stump, through which a catheter for LITA angiography is later introduced. From July 2004 to March 2005, 23 patients underwent total arterial CABG with the T-graft and intraoperative graft angiography. Results: On-pump CABG was performed in 22 patients and off-pump CABG in 1 patient. Mean procedure time for the angiography was 13.7 ± 7.3 minutes, and mean fluoroscopy time was 6.2 ± 4.6 minutes. In two patients, the RA-marginal artery side-to-side anastomosis was stenosed and had to be revised as demonstrated by graft angiography. In one patient, the RA was kinked and in another, there was a kinking of the LITA. In both cases, kinking was corrected. The remaining anastomoses were seen to have unobstructed flow with no evidence of stenosis. Conclusions: Intraoperative graft angiography can be performed in patients undergoing total arterial CABG. This concept of intraoperative cooperation between an interventional cardiologist and surgeons could significantly improve the operative outcome in CABG surgery. © Georg Thieme Verlag KG Stuttgart.

DOI： 10.1055/s-2007-965386

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A compact cardiopulmonary bypass (CPB) utilized by closed circuit system with minimized priming volume can be a solution to reduce adverse effects of CPB, and the Resting Heart System (RHS; Medtronic, Inc, Minneapolis, MN, USA) is the newest one on the market. We performed CABG with RHS in 10 patients, and report here our preliminary experiences with RHS in comparison with conventional CPB. Twenty patients who underwent isolated CABG were randomized into two groups; RHS group (n=10) with the use of RHS and Conventional group (n=10) with the use of a conventional CPB. There were no significant differences of preoperative patient characteristics in both groups. The mean number of grafts was 2.7+/-0.6 and 2.7+/-0.8 (P=0.38), the mean aortic clamp was 32+/-11 and 35+/-11 min (P=0.35), and CPB times were 68+/-25 and 72+/-24 min (P=0.82) in RHS and Conventional group, respectively. All patients but one had no complications and survived in both groups. One patient in RHS group died suddenly on the 5th postoperative day after uneventful postoperative course. Postoperative leukocyte count at 6 h after the operation and value of the C-reactive protein were 11200+/-2310 and 13300+/-3990/mm(3) (P=0.10) and 44.4+/-9.7 and 65.3+/-18.5 mg/l (P=0.045) in RHS and Conventional group, respectively. CABG operations could be safely performed using the RHS with a comfort level similar to standard CPB.

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OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) has been used as initial, biventricular circulatory support for patients with severe postcardiotomy cardiogenic shock (PCS). Due to its aggressiveness and limited weaning quote, concerns have been raised about maintenance of ECMO support regarding duration. However, it is frequently hazardous for physicians to make an individualized decision, whether and when discontinuation of ECMO support should be considered. We tried to find measurable values during ECMO support that could predict the patient mortality on ECMO support. METHODS: During a 9-year period, 32 patients (mean age 55.4+/-11.9; ranging from 30 to 75 years) with ECMO support for postcardiotomy cardiogenic shock were included in this study. RESULTS: Eighteen patients died without weaning (group I, 56.25%), while 14 patients could be weaned off the ECMO support (group II, 43.75%). In the group II, six patients (18.75%) died later in the postoperative course and eight patients (25%) survived to be discharged from hospital. The overall survival of all 32 patients at 30 days was 31.25% (n=10). At a follow-up period of 3.88+/-1.58 years, the overall survival rate was 12.5% (n=4). Mean duration of ECMO support was 2.7+/-1.7 days. The following variables were significantly different between the two groups: blood lactate level and the level of MB isoenzyme of creatine kinase (CK-MB) 48 h after ECMO initiation (p<0.01, p=0.001) as well as the CK-MB relative index as the ratio of CK-MB to total CK (p<0.001). Logistic regression identified that only the CK-MB relative index 48 h after ECMO initiation was associated with mortality on ECMO support (p=0.011, odds ratio=1.219, 95% confidence interval: 1.046-1.421). CONCLUSION: For adult non-transplantation patients with postcardiotomy cardiogenic shock, the CK-MB relative index 48 h after ECMO initiation can be a predictor of mortality on ECMO support. This might be a useful tool for considering a patient either for discontinuation of ECMO support or further treatment.

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OBJECTIVE: To investigate whether deep (<20 degrees C) hypothermia is necessary in patients undergoing pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. METHODS: Between January 2004 and February 2005, 30 patients (New York Heart Association (NYHA) class III or IV) were randomly assigned to increasing (1 degrees C) levels of moderate (28-32 degrees C) hypothermic cardiopulmonary bypass (CPB), each study group including six patients. Primary study endpoint was adverse neurological outcome. Overall preoperative total pulmonary vascular resistance was 1110+/-192 dynes cm(-5). RESULTS: Mean CPB and cross-clamp times, and core temperature at the time of circulatory arrests were 129+/-39 min and 92+/-24 min, and 30.1+/-1.5 degrees C, respectively. Circulatory arrest was induced 2+/-0.7 times and its mean total duration was 10.3+/-5.2 min (range, 2-19 min). Postoperatively, three patients (10%) belonging to the 31 degrees C (n=1) and 32 degrees C (n=2) groups suffered from temporary neurological dysfunction. Postoperative mechanical ventilatory support and ICU stay were 26.3+/-18.9 h and 6.6+/-8.5 days, respectively, and uninfluenced by degree of hypothermia. There were no lung reperfusion injuries or any other major complications. All patients had a significant hemodynamic improvement. CONCLUSION: Results suggest that pulmonary endarterectomy can be safely performed with moderate hypothermia and short periods of circulatory arrests without the need of profound hypothermia.

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BACKGROUND: Here we report our surgical experiences with aberrant right subclavian artery (ARSA) aneurysm in 8 patients. METHODS: Eight patients underwent surgical treatment for ARSA aneurysm between March 1994 and June 2005. The age of these patients ranged from 20 to 75 years. The mean size of the ARSA aneurysm was 3.3 cm, ranging from 2 to 5 cm. The ARSA aneurysm was completely resected through a left posterolateral thoracotomy after reconstruction of the right subclavian artery through the supraclavicular approach in 4 patients (group 1). The ARSA aneurysm was excluded through a left posterolateral thoracotomy without revascularization of the right subclavian artery in 2 patients (group 2). The distal site of the ARSA aneurysm was closed followed by revascularization through a median sternotomy, and the ARSA aneurysm was left as a blind sack in 2 patients (group 3). RESULTS: None of the patients in group 1 or 3 had any postoperative complications. In group 2, 1 had a steal syndrome caused by the exclusion of the ARSA aneurysm, and the other died of sepsis 2 months after the operation. CONCLUSIONS: Complete anatomical repair of the ARSA aneurysm could be performed through the combination of the supraclavicular approach and the left posterolateral thoracotomy, with excellent results. Exclusion of the ARSA aneurysm without revascularization resulted in a suboptimal outcome. Surgical results of simple closure of the ARSA followed by revascularization were uneventful, but the ARSA aneurysm was left as a blind sack.

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We hereby present our experiences with arterial cannulation through the aneurysm in patients with thoracoabdominal aortic aneurysm. This can be a good option for thoracoabdominal aortic aneurysm repair in patients with diseased peripheral arteries.

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The optimal technique for preservation of a retainable aortic valve is yet to be defined. We present a new facilitated procedure allowing for reimplantation of the complete aortic root in selected patients with acute type A aortic dissection or ascending aortic aneurysm.

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BACKGROUND: This study quantified the number of intraoperative microemboli in patients undergoing aortic arch surgery using selective cerebral perfusion (SCP) in comparison with those in patients undergoing ascending aortic replacement without circulatory arrest and SCP. METHODS: A transcranial Doppler monitoring of the medial cerebral artery was performed in 15 patients undergoing proximal arch replacement with SCP (SCP group) and 15 patients undergoing replacement of the ascending aorta (control group). RESULTS: There was no significant difference in the high-intensity transient signal counts between the SCP group and the control group at any phase. In the SCP group, 4.8% of microemboli occurred during cross-clamping, and only 0.6% occurred during SCP. In the control group, 4.6% occurred during cross-clamping. Most microemboli occurred after removing the cross-clamps in both groups; 92.2% in the SCP group and 92.1% in the control group. CONCLUSIONS: The present study demonstrated that outbreak frequency of microemboli during SCP was very low, and thus implies that the risk of embolic event that may be caused by SCP is very low.

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BACKGROUND: The conditions at the injection site are important in cell transplantation for severe ischemic heart disease. The omentum is both a well-vascularized tissue and a source of angiogenic factors. We examined the effectiveness of autologous bone marrow-derived mononuclear cells (BM-MNCs) with or without omentopexy in a large animal model. METHODS: Myocardial infarction was generated in the lateral wall by ligation of coronary artery branches in miniswine. Animals received BM-MNC injection with or without omentopexy. Controls received saline only. Three weeks after surgery, regional myocardial blood flow and contractility were measured, and density of arterioles was evaluated immunohistologically. Angiography and postmortem examinations were performed to determine collateral communication. RESULTS: Regional myocardial contractility was significantly improved by BM-MNC transplantation both with and without omentopexy (0.29 +/- 0.02 vs 0.11 +/- 0.03, p < 0.01, 0.30 +/- 0.02 vs 0.12 +/- 0.01, p < 0.01, respectively). Relative regional myocardial blood flow in the combined omentopexy group was significantly higher than the controls both at rest (1.05 +/- 0.11 vs 0.57 +/- 0.07, p < 0.01) and under stress (1.09 +/- 0.08 vs 0.40 +/- 0.10, p < 0.01). The number of arterioles (< 50 microm) in both groups were higher than the controls (88.1 +/- 5.00 vs 38.1 +/- 8.99, p < 0.01 and 109.2 +/- 9.91 vs 38.1 +/- 8.99, p < 0.01, respectively). The number of large arterioles (> 50 microm) in the combined omentopexy group was significantly higher than in both BM-MNC alone (26.9 +/- 2.4 vs 17.6 +/- 1.8, p = 0.011) and controls (26.9 +/- 2.4 vs 10.0 +/- 1.3, p < 0.01). Collateral communication between the omentum and myocardium was demonstrated by angiography and postmortem injection. CONCLUSIONS: The BM-MNC transplantation may attenuate cardiac contractile dysfunction, and omentopexy may enhance angiogenesis induced by BM-MNC transplantation.

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INTRODUCTION: We have been using only moderate hypothermic circulatory arrest (HCA) for patients with ascending aortic aneurysms extending into the proximal aortic arch if the distal anastomoses seem to be simple and easy. The aim of this study is to evaluate the early and midterm results of the use of moderate HCA without any adjunctive cerebral protection in such patients. METHODS: Between October 2000 and March 2005, 23 patients with an age range of 39 to 77 years (mean, 59.7 +/- 12.2 years) received surgical repair of the ascending aorta extending into the proximal aortic arch using HCA without any adjunctive cerebral protection. Mean circulatory arrest time was 7.5 +/- 2.0 minutes (range, 2-13 minutes), and mean core temperature at induction of the circulatory arrest was 26.7 +/- 1.4 degrees C (range, 24-30 degrees C). RESULTS: Operative mortality was 4.3% (1/23) due to unknown cause after successful extubation. Temporary neurological dysfunction was observed in only 1 patient (4.3%), and no persistent neurologic event was observed in any of the patients. One patient died 3 months after the operation due to a mediastinitis. No other cardiac or neurologic event was observed in the 21 surviving patients. CONCLUSION: Our results suggest that moderate HCA at 26 degrees C to 28 degrees C without any adjunctive cerebral protection within 10 minutes is safe in selected patients.

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PURPOSE: We developed a synchronized, arterial-flow, ensuring system to perform coronary anastomoses safely without any ischemia-related event. DESCRIPTION: Arterial blood is removed from the femoral artery. The resulting blood passes a switching valve and is pumped out to a syringe pump. This pump controller provides pulsatile arterial blood flow synchronized with the diastolic phase on an electrocardiogram. The arterial blood is perfused to the coronary artery through a fine flexible cannula during anastomosis. EVALUATION: From February 1999, 524 consecutive patients were operated on using the synchronized arterial flow ensuring system. Mean duration for each anastomosis was 7.6 +/- 3.3 minutes (range, 4 to 20 min). There were no intraoperative fatal arrhythmias, ventricular arrhythmias, or short-run or hemodynamic deterioration during anastomoses. No hospital death was observed, and postoperative myocardial infarction occurred in 2 patients (0.4%). Postoperative angiography showed a 98.1% patency rate. CONCLUSIONS: The early clinical and angiographical results for off-pump CABG with the synchronized arterial flow ensuring system were excellent without mortality. We believe that off-pump CABG can be more safely performed using the synchronized arterial flow ensuring system based on our favorable results.

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A novel skeletonization technique using the scissors-type harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH, USA) is presented. This "samurai technique," which uses the harmonic scalpel by frequently turning over the scissors, facilitates the handling of the gastroepiploic artery, enlarges the caliber size, and allows easy skeletonization without any vessel injury.

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BACKGROUND: We developed a new instant regional myocardial blood flow (RMBF) monitor utilizing the thermal diffusion method in which the RMBF value is presented as the value inversely proportional to the thermocouple voltage output (1/V). The purposes of this study were (1) to validate the accuracy of RMBF measurement by the instant RMBF monitor in comparison with the colored microsphere method for calibration; (2) to investigate influences of it on the RMBF; and (3) to assess changes in RMBF caused by the shunt tube insertion. METHODS: Twenty pigs were used for this study: 4 for comparison between the instant RMBF meter and the colored microsphere method, 4 for validation of reproducibility, and 6 for measurement of RMBF during shunt tube. RESULTS: The relation between RMBF values obtained by the colored microsphere method and 1/V values by instant RMBF monitor was colored microsphere = 140,992 (1/V)--231 in epicardial layer (R2 = 0.819) and colored microsphere = 111,381 (1/V)--165 in endocardial layer (R2 = 0.693). The correlation coefficient and R2 values between RMBF values measured by both methods were 0.985 and 0.839 in epicardial layer, and 0.963 and 0.679 in endocardial layer, respectively. The RMBF at each layer did not change after the attachment of the monitor. Fifteen minutes after shunt tube insertion, RMBF measured by the colored microsphere method decreased to 31.1% (p = 0.0001) and 33.7% (p = 0.0001) in epicardium and endocardium, respectively, and no difference was observed from the value measured by the instant RMBF monitor. CONCLUSIONS: This instant RMBF monitor can provide instantaneous and continuous information of RMBF without requiring tissue examination.

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BACKGROUND: Recently skeletonization has been recognized as an alternative to pedicle harvesting of the internal thoracic artery as a technique that increases the length and caliber size of the graft compared with pedicled internal thoracic artery grafts; however, this is not yet popular for harvesting the gastroepiploic artery (GEA). We report here our experience of skeletonized GEA grafting in off-pump coronary artery bypass grafting with early clinical and angiographic results. The purpose of this study was to evaluate skeletonization of GEA grafting in off-pump coronary artery bypass grafting with a large patient volume. METHODS: One hundred sixty-eight patients including 131 men and 37 women (mean age, 65 years; range, 45 to 87 years) underwent the skeletonized GEA grafting in off-pump coronary artery bypass grafting. These patients represent 41% (168 of 407 patients) of those who underwent off-pump coronary artery bypass grafting operations during the same period. We used the GEA graft of choice in patients with right coronary artery lesion. Skeletonization was performed in a unique manner we developed. RESULTS: There were no in-hospital deaths among the study patients. One patient had a perioperative myocardial infarction, which was considered a result of vasospasm of the GEA graft. None of the other patients had severe morbidity. The patency rate of the skeletonized GEA graft was 98.1% (151 of 154 distal anastomoses). CONCLUSIONS: This study suggests that skeletonization of the GEA graft can enlarge its caliber size and improve its flow capacity. In addition, the acceptable early clinical and angiographic outcome suggests that use of the skeletonized GEA graft in off-pump coronary artery bypass grafting surgery is safe and effective.

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BACKGROUND: We report our initial experience with an automatic anastomotic device using skeletonized radial artery in patients requiring off-pump coronary artery bypass grafting (CABG). METHODS: St. Jude Medical, Inc, Symmetry Bypass System (aortic connector system [ACS]) (St Jude Medical, St. Paul, MN) was used in ten patients. Ten consecutive patients who underwent off-pump CABG and who received at least one radial artery graft proximal anastomosis using the ACS were evaluated. The radial artery (RA) was harvested in a skeletonized fashion and applied to the ACS in the same manner as applying saphenous vein graft. The creation of the anastomosis lasted no longer than a few seconds. RESULTS: Our attempt to use the ACS for proximal anastomosis of the RA was successful in all ten patients. Mean operating time was 3.2 +/- 0.6 minutes and an average of 3.0 +/- 0.9 bypass grafts (range, 2 to 5 grafts) were performed. There was no postoperative fatal complication. Postoperative angiographic control showed that all grafts were widely patent including grafts other than the RA. During the mean postoperative follow-up of 10.3 +/- 2.9 months, there was no cardiac-related event in any patient. CONCLUSIONS: The St. Jude Medical Symmetry aortic connector system allows the construction of uniform and widely patent anastomoses in RA graft and does not require aortic side biting. Skeletonization of the RA is a safe and effective technique for applying ACS in off-pump CABG using multiple arterial grafts.

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BACKGROUND: Total arterial revascularization in coronary artery bypass grafting has recently become of great interest to many surgeons. At the same time, off-pump coronary bypass grafting has also become a popular procedure because of its low morbidity and mortality. Here we report our recent series of off-pump coronary bypass grafting performed with a grafting technique we developed by using the skeletonized gastroepiploic artery and the radial artery composite graft to achieve total arterial revascularization. METHODS: From September 2000 to April 2003, 98 patients underwent total arterial revascularization with the skeletonized gastroepiploic artery and radial artery composite graft on the beating heart. We used the gastroepiploic artery graft of choice in patients with a right coronary artery lesion. When multiple grafting was required in inferior, posterolateral, or lateral ventricular walls and the gastroepiploic artery graft was too short to cover these areas, we used the composite grafting technique. RESULTS: There were no in-hospital deaths and there was no severe morbidity among the study patients. Postoperative angiography showed graft occlusion at the anastomosis site between the gastroepiploic and radial arteries. The patency rate of the gastroepiploic arterial composite graft was 98.3% (118/120 distal anastomoses). CONCLUSIONS: A composite graft with the skeletonized gastroepiploic artery and the radial artery ensured sufficient caliber size and length for myocardial revascularization on inferior, posterolateral, and lateral ventricular walls. This composite graft can be used safely and effectively even in off-pump coronary bypass surgery with excellent early clinical and angiographic outcome in selected patients, although longer follow-up periods are necessary to draw definitive conclusions.

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We report here our initial experience in angiography of gastroepiploic artery (GEA) grafts via a brachial approach using the Yumiko catheter regarding technical aspect. Good-quality GEA angiography was obtained in 12 (86%) of 14 patients using our technique. GEA graft angiography can be performed using the Yumiko catheter via a brachial approach. This technique may be less stressful for patients receiving coronary catheterization, including GEA graft angiography.

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The aim of this study was to compare early and late graft patency in patients with and without previous successful PTCA. Of the 70 patients who received both early and late follow-up angiography, 13 patients who had received successful PTCA at the left anterior descending coronary artery (LAD) before CABG (group I) and 31 patients who had not received preoperative PTCA in any vessel (group II) were retrospectively reviewed. There were no significant differences in patient characteristics including major coronary risk factors. The mean duration between the operation and control angiography was 35+/-23 months in group I and 36+/-19 months in group II (P=0.90). Occlusions of the LITA graft were observed in four patients of group I and in four patients of group II. Cumulative patencies of the LITA graft were 54% in group I and 83% in group II (P=0.12). The late patency rate of the LITA graft bypassed to the LAD in patients that received previous successful PTCA in the coronary artery tended to be lower than in patients without previous PTCA. This result should be confirmed by further prospective studies.

PubMed

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BACKGROUND: The suitability of the radial artery after transradial catheterization as a bypass conduit has been of great concern to surgeons. METHODS: A total of 67 patients underwent isolated coronary artery bypass grafting using the radial artery: 22 patients received preoperative transradial catheterization (group 1) and 45 patients did not receive transradial catheterization (group 2). Those patients were retrospectively reviewed. RESULTS: Patient characteristics, operative procedures, and early clinical outcome were not different between groups. The stenosis-free graft patency rates in groups 1 and 2 were 88% (16 of 18 patients) and 90% (38 of 42 patients) in the left internal thoracic artery (p = 0.87); 77% (17 of 22 patients) and 98% (48 of 49 patients) in the radial artery (p = 0.017); and 87% (13 of 15 patients) and 84% (21 of 25 patients) in the saphenous vein (p = 0.42), respectively. Intimal hyperplasia of the radial artery was observed in 68% (11 of 16 patients) in group 1 and in 39% (14 of 34 patients) in group 2 (p = 0.046). CONCLUSIONS: Transradial catheterization reduced early graft patency and caused intimal hyperplasia, although it did not affect early clinical outcomes. We suggest that the use of the radial artery as a bypass conduit after transradial catheterization should be undertaken cautiously.

PubMed

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A skeletonized arterial graft holder, designed for use during off-pump coronary artery bypass grafting, is described. This new holder is atraumatic and holds a skeletonized arterial graft securely during anastomosis. It helps the operator to make the first several stitches avoiding graft injuries, and the use of this instrument facilitates the use of skeletonized arterial grafts for coronary artery bypass grafting.

PubMed

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INTRODUCTION: To simulate blood flow provided by the intracoronary shunt tube, and to clarify whether this method is actually suitable for Off-pump coronary artery bypass (OPCAB), we investigated the efficacy of the intracoronary shunt tube in a theoretical model on the basis of fluid dynamics. METHODS: Fluid dynamics analysis was performed to simulate flow decrease after attachment on an intracoronary shunt model. RESULTS: The flow ratio in the case of turbulent flow is in proportion to the ratio of the inner diameter to the third power, and that in the case of laminar flow is in proportion to the ratio of the inner diameter to the sixth power. When this analysis is applied to commercial shunt tubes, coronary flow was estimated as approximately 2-14% of pre-attachment flow in turbulent flow, and only less than 0.1% in laminar flow. CONCLUSIONS: This result suggests that use of intracoronary shunt tubes in OPCAB may rarely contribute to maintenance of coronary flow, and they should be used carefully, especially in a jeopardized coronary artery.

PubMed

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We developed a coronary active perfusion system (CAPS) to avoid myocardial ischemia during off-pump coronary artery bypass (OPCAB). The purpose of this study was to determine the optimal timing of CAPS perfusion, and to investigate any adverse effects when it is driven within the systolic phase. Twenty-four pigs were divided into four groups: (A) systolic, (B) early-diastolic, (C) middle-diastolic, and (D) late-diastolic perfusion. Myocardial blood flow (MBF), hemodynamic and mechanical data were measured during 30 minutes of CAPS perfusion. MBF in group A was lower than in the other groups (p<0.001), but no significant differences were observed among groups B to D. End-systolic pressure-volume relation (Mw) and preload recruitable stroke work relation (Ees) in group A was lower than in groups B to D (p<0.01 and p<0.05, respectively), but no significant differences were observed among groups B to D. CAPS could maintain regional MBF and left ventricular function if it was driven only within the diastolic phase and required no strict adjustment, but CAPS has an adverse effect when it is driven in the systolic phase.

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PubMed

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Good long-term results with the bioprosthetic valves for patients 70 years old and older have been reported. However, because the average lifespan is increasing, we aimed to clarify whether patients older than 70 may still be candidates for valve re-replacement. Seventy-one patients 70 years old and older, who received a total of 81 bioprosthetic valve replacements during 73 procedures between 1988 and 2000, were reviewed. There were 8 hospital and 7 late deaths. Ten-year actual survival after valve replacement was 73.5%, and 82.8% when hospital deaths were excluded. During the follow-up period, 2 patients received mitral valve re-replacement. Ten years of freedom from reoperation were found in 66.7% for all valves and in 50.0% for mitral valves. The average lifespan in Japan is currently 77.64 years for men and 84.62 years for women; therefore, valve degeneration in patients who receive bioprosthesis replacement in their early 70s should be anticipated.

PubMed

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OBJECTIVES: To avoid myocardial ischemia in off-pump coronary artery bypass, we developed a coronary active perfusion system (CAPS). The purposes of this study were to investigate the changes in myocardial blood flow and tissue oxygenation during CAPS perfusion, and to validate the ventricular arrhythmias and hemodynamic deterioration preventing the effect. METHODS: Sixteen pigs were divided into a CAPS perfusion group (group C) and a simple coronary occlusion group (group O). The left anterior descending coronary artery was snared in both groups and 30 min of CAPS perfusion was performed in group C. RESULTS: Ventricular arrhythmias were not observed in group C, but occurred in seven out of eight pigs in group O (P=0.003). None of the hemodynamic variables changed in group C, but they deteriorated in group O. Myocardial blood flow, saturation, and hemoglobin plus myoglobin concentration were maintained with a baseline level in group C, but decreased significantly in group O (P<0.001). CONCLUSION: CAPS is a reliable method to avoid myocardial ischemia during coronary occlusion and it may be useful for off-pump coronary artery bypass

PubMed

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OBJECTIVES: There has been no method which can measure regional myocardial blood flow in real-time and continuously. The purpose of this study was to validate myocardial blood flow measurement using a thermal diffusion method. For this purpose, myocardial blood flow measurement was performed using the thermal diffusion method and the electrolytic hydrogen clearance method. METHODS: Seven pigs were used for this study, six were for comparison between the thermal diffusion and electrolytic hydrogen clearance methods, and one was for demonstration of myocardial blood flow measurement using the thermal diffusion method on a beating heart coronary artery bypass model with ischemic preconditioning. RESULTS: A good correlation was found between myocardial blood flow values obtained by the electrolytic hydrogen clearance method and 1/V values obtained by a thermal diffusion probe, the correlation coefficient was 0.841 (P<0.001). During the beating heart coronary artery bypass, the regional myocardial blood flow was recorded in real-time and continuously. CONCLUSIONS: This study demonstrated measurement of regional myocardial blood flow using the thermal diffusion method for the first time and simultaneous measurement using the electrolytic hydrogen clearance method for calibration. It provided a real-time and continuous myocardial blood flow measurement and has a potential to contribute to progress in beating-heart surgery.

PubMed

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Authorship：Lead author   Language：English   Publishing type：Research paper (scientific journal)  

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To avoid myocardial ischemia during off-pump coronary artery bypass, we developed a coronary active perfusion system (CAPS) that perfuses arterial blood to the coronary artery at the diastolic phase of the cardiac cycle by a syringe pump system. We report herein the details and compare CAPS with a passive shunt circuit from the femoral artery (FA shunt), regarding the physiology of the coronary artery. Six pigs were used for this study. After CAPS or FA shunt perfusion was established, coronary flow and coronary pressure were measured. The coronary flows in the native coronary artery, FA shunt perfusion, and CAPS perfusion with syringe pump stroke volume settings ranging from 0.1 to 0.4 ml were 27.2+/-3.0, 4.1+/-1.5, 12.7+/-1.2, 24.8+/-1.9, 33.3+/-1.6, and 42.2+/-1.9 ml/min, respectively. Mean coronary pressures under FA shunt perfusion and CAPS perfusion with stroke settings from 0.1 to 0.4 ml were 23.7+/-4.6, 48.8+/-5.0, 61.3+/-7.5, 70.8+/-5.4, and 82.3+/-5.2 mm Hg, respectively. CAPS had an advantage over the FA shunt regarding coronary flow with safe coronary pressure. Using CAPS, an off-pump coronary artery bypass can be performed safely without myocardial ischemia.

PubMed

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BACKGROUND AND AIM OF THE STUDY: A congenital coronary artery fistula (CAF) is a relatively rare congenital anomaly and is defined as an abnormal direct communication between any coronary artery and any of the cardiac chambers. This article reviews our experience over the past 27 years, as well as other literature, and discusses the surgical indications and methods relating to CAF. METHODS: From 1973, 25 patients aged from 2 to 69 years underwent surgical treatment for congenital CAF. Seventeen patients were diagnosed as isolated CAF. All patients under 19 years of age with isolated CAF were asymptomatic. Twenty fistulas originated from the left coronary artery and 9 from the right. The pulmonary artery was the most dominant drainage site. Four patients among the isolated CAF cases were surgically treated without a cardiopulmonary bypass. RESULTS: All patients were discharged from hospital without any perioperative complications. Postoperative coronary angiography was done on all patients with only one slightly residual CAF flow. The average follow-up time was 9.6 years and all patients were asymptomatic and doing well. CONCLUSIONS: Definitive surgical correction is safe and effective, with good results. Therefore, it should be considered even in asymptomatic patients because of the risk of future complications.

PubMed

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OBJECTIVES: We sought to test the effectiveness of ultra-short-acting cardioselective beta-blockade, landiolol hydrochloride, for warm heart surgery. METHODS: The isolated perfused rat heart preparation was used. After preischemic measurement of cardiac function, 3 min of coronary infusion of crystalloid cardioplegic solution (37 degrees C) with landiolol hydrochloride of various concentrations (1, 2.5, 5, and 10 mmol/l) or without it (control group) was performed, followed by 30 min of warm ischemic arrest. Finally, postischemic function was measured. RESULTS: The percentage recoveries of heart rate in hearts receiving 0, 1, 2.5, 5, and 10 mmol/l landiolol hydrochloride were 89.4+/-3.4%, 90.9+/-1.7%, 89.6+/-1.8%, 83.4+/-3.3%, and 74.3+/-1.9% (P<0.05 vs. 0, 1, and 2.5 mmol/l groups), respectively. The percentage recoveries of aortic flow were 55.6+/-3.1%, 62.8+/-3.3%, 75.0+/-4.2% (P<0.05 vs. 0 and 10 mmol/l groups), 65.3+/-5.3%, and 51.6+/-4.0%, respectively. Similar recovery profiles were observed with the first derivative of the rise in aortic pressure, stroke volume and stroke work. The total amount of coronary effluent in the hearts receiving 5 or 10 mmol/l was lower than in the other groups. CONCLUSIONS: Landiolol hydrochloride has the potential to enhance postischemic cardiac function after the warm cardioplegic arrest. The optimal concentration for maximum postischemic functional recovery was 2.5 mmol/l, and recoveries of aortic flow and heart rate decreased in hearts receiving 5 mmol/l or more.

PubMed

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To examine the clinical features of primary cardiac tumors, 34 patients who underwent surgical treatment from 1973 to 2000 at the Kanazawa University Hospital were analyzed and the literature was reviewed. The 34 patients were divided into 3 categories: (i) myxomas; (ii) benign non-myxomas; and (iii) malignant tumors. Twenty-three patients (70%) were diagnosed with myxomas, including 22 left atrial myxomas and 1 right atrial myxoma. Seven patients (18%) were diagnosed with benign non-myxoma tumors, including 3 hemangiomas, 1 fibroma, 1 rhabdomyoma, 1 pheochromocytoma, and 1 lipoma. Four patients (12%) were diagnosed with malignant tumors, including 2 angiosarcomas, 1 rhabdomyosarcoma, and 1 malignant fibrous histiocytoma. Among the myxoma patients, in-hospital mortality was 9% (2/23), late mortality was 10% (2/21), and no recurrent myxomas have been identified. Among benign non-myxoma patients there were no perioperative deaths; however, 1 patient died 11 years after surgery, with no linked cause. No recurrent tumors have been identified. Among malignant tumor patients, 1 patient died the day following surgery and the rest died within 14 months. Early and late results of surgery were acceptable for those patients with benign tumors, while the prognosis for patients with malignant tumors was very poor.

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Authorship：Lead author   Language：Japanese   Publishing type：Research paper (scientific journal)  

左主幹部単独病変に対するバイパス術の際のバイパス本数と左内胸動脈グラフトの開存率の検討

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Methylenetetrahydrofolate reductase (MTHFR) is a critical enzyme in the folate cycle. Reduced MTHFR activity induces DNA hypomethylation and stability, which may protect the tumor suppressor gene p16INK4. We examined the association between MTHFR polymorphism and expression of p16INK4. The frequency of the MTHFR genotypes were 21 Ala/Ala, 29 Ala/Aal, and 7 Val/Val. Expression of p16INK4 was 26.2 +/- 26.8% in the Val/Val genotype and 11.2 +/- 16.6% in the other genotypes (p=0.46) as examined by immunostaining, and excluding four specimens that were overstained. These results suggest that folate metabolism can affect carcinogenesis through the expression of p16INK4.

PubMed

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Authorship：Lead author   Language：Japanese   Publishing type：Research paper (scientific journal)  

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Language：Japanese   Book type：Scholarly book

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Language：Japanese   Book type：Scholarly book

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Language：Japanese   Book type：Scholarly book

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Language：Japanese   Book type：Scholarly book

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Language：Japanese   Book type：Scholarly book

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Language：Japanese   Book type：Scholarly book

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Language：English   Book type：Scholarly book

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Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：(株)南江堂  

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2023&ichushi_jid=J00349&link_issn=&doc_id=20230926100004&doc_link_id=issn%3D0021-5252%26volume%3D76%26issue%3D10%26spage%3D751&url=http%3A%2F%2Fwww.pieronline.jp%2Fopenurl%3Fissn%3D0021-5252%26volume%3D76%26issue%3D10%26spage%3D751&type=PierOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00005_2.gif

Language：Japanese   Publisher：(株)北隆館  

哺乳動物の心臓は再生不可能な臓器と長らく考えられてきた。しかし,過去十数年間の研究でこのパラダイムは変化し,現在では哺乳動物の心臓は自己再生し,心筋細胞は一生を通じて新規に合成されるものと理解されている。このことから,内在的に存在する心筋細胞の分裂制御機構を理解することで,心臓再生の新たな方法を開発できる可能性がある。本稿では,心筋細胞の分裂と心臓再生における最近の知見をまとめ,筆者らが明らかにした,ヘテロクロマチンによる心筋細胞の分裂抑制機構について紹介する。(著者抄録)

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Language：Japanese   Publisher：(一社)日本体外循環技術医学会編集委員会  

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Language：Japanese   Publisher：(株)日本医事新報社  

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Language：Japanese   Publisher：(株)メディカ出版  

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Language：Japanese   Publisher：北海道外科学会  

症例は19歳男性,フットサルのサークル活動中に意識消失し,心肺停止となった。ただちに心肺蘇生が行われ,自動体外式除細動器(AED)で計2回除細動を行ったところ自己心拍が再開した。AEDの初期波形は心室細動であった。冠動脈コンピュータ断層撮影では右冠動脈(RCA)が左冠動脈洞より起始し,上行大動脈と肺動脈の間を走行しており,右冠動脈左冠動脈洞起始症と診断され手術を実施する方針となった。術式は右内胸動脈-RCAの冠動脈バイパス術(CABG)及びRCA根部離断を行った。術後経過は良好であり,術後11日目に独歩退院となった。術後約1年経過した現在,自制内ではあるが運動は再開できており,経過は良好である。冠動脈起始異常症の術式選択に関する一定のガイドラインは存在せず,またその解剖学的多様性から,術式は多岐にわたる。本症例のように,左右冠動脈起始部が近接している場合,CABG+異常起始冠動脈根部離断術は有効な選択肢となり得る。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2023&ichushi_jid=J01375&link_issn=&doc_id=20230731050010&doc_link_id=%2Fdc7hksrg%2F2023%2F006801%2F011%2F0042-0045%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdc7hksrg%2F2023%2F006801%2F011%2F0042-0045%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(公社)日本整形外科学会  

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Language：English   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：(一社)日本病理学会  

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Language：Japanese   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：(一社)日本人工臓器学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本人工臓器学会  

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Language：Japanese   Publisher：The Japanese Society for Cardiovascular Surgery  

DOI： 10.4326/jjcvs.51.m4

CiNii Research

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Language：English   Publisher：(一社)日本心血管インターベンション治療学会  

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Language：Japanese   Publisher：[札幌] : 北海道外科学会  

CiNii Books

CiNii Research

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Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：北海道外科学会  

大動脈弁置換術後に発生する左室-右房瘻の報告は多くないが、発生すると急性心不全をはじめ様々な病態を生じる。われわれは、感染性心内膜炎に対する大動脈弁置換術後15年目に人工弁感染を呈し再手術を施行、その後程なくして左室-右房瘻をきたした一例を経験したので報告する。51歳男性で主訴は息切れであった。当科紹介の1ヵ月半前に、大動脈弁置換術を施行されていた。退院後、息切れがひどくなり前医で精査した結果、左室-右房瘻を認めた為、当科で再手術(本人にとって3回目の心臓手術)となった。術中所見では、卵円窩上縁と三尖弁の間に直径約1cmの瘻孔を認め、これが大動脈と左室流出路の2ヶ所に通じていた。人工弁を摘除すると無冠尖の右冠尖寄りの弁輪が欠損しており、その部位に仮性瘤があり右房に開口している所見が得られた。手術は大動脈基部置換術を施行した。術後経過は良好で、術後9日目に自宅退院となった。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2022&ichushi_jid=J01375&link_issn=&doc_id=20220721160012&doc_link_id=%2Fdc7hksrg%2F2022%2F006701%2F013%2F0068-0071%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdc7hksrg%2F2022%2F006701%2F013%2F0068-0071%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：北海道外科学会  

[はじめに]当院で体外循環式心肺蘇生法(Extracorporeal cardiopulmonary resuscitation;ECPR)を施行した症例を検討した。[方法]2014年4月から2019年12月までに当院でECPRを施行した42例を後方視的に検討した。院内心停止(in-hospital cardiac arrest;IHCA)群と院外心停止(out-of hospital cardiac arrest;OHCA)群に分類し、各集団内において生存群と死亡群を比較した。[結果]28日以内死亡率はIHCA群で11例中8例(72.7%)、OHCA群で31例中28例(90.3%)であり、OHCA群での死亡率は高かったが統計学上の有意差には至らなかった。IHCA群において生存群と死亡群間には、心停止の原因、心電図上の初期波形や胸骨圧迫時間など、全ての項目で有意差を認めなかった。OHCA群においては、生存群の全例で初期波形がショック適応波形であり、死亡群と比較して有意差を認めた(p<0.05)。[結語]当院におけるECPR施行症例について検討した。IHCA群では統計学的有意差を得た項目は認めなかったが、OHCA群では心電図上の初期波形で有意差を得られた。本研究ではECPRの症例数が少なく統計学的検定力が弱いこと、ECPR適応症例の選定にバイアスが生じている可能性があり、今後もさらなるデータの蓄積、検討が必要と考えられる。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2022&ichushi_jid=J01375&link_issn=&doc_id=20220721160009&doc_link_id=%2Fdc7hksrg%2F2022%2F006701%2F010%2F0052-0056%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdc7hksrg%2F2022%2F006701%2F010%2F0052-0056%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：北海道外科学会  

[はじめに]心原性ショックに対する治療法として、長期間留置が可能であることと早期離床を重視して、当院ではImpella5.0を心臓外科が主導し積極的に使用しており、その短期成績を報告する。[対象・方法]2019年8月から2021年4月までの期間に当院でImpellaを導入した18例(5.0:10名、CP:5名、2.5:3名)を対象とした。[結果]患者背景はImpella5.0挿入症例でICU入室時の乳酸値の値(5.0:12.1±15.0mg/dL、CP/2.5:7.25±21.8mg/dL、p=0.01)が高く見られたが、溶血、出血、感染、位置異常などの合併症割合はデバイス間で有意差はみられなかった。Impella5.0において、平均留置期間(5.0:11.1±6.8日、CP/2.5:5.0±5.7日、p=0.06)は長くなる傾向にあったが有意差は見られなかった。Impellaからの離脱(5.0:70%(n=7)、CP/2.5:62.5%(n=5)、p=0.74)、ICU滞在日数(5.0:25.0±13.0日、CP/2.5:16.9±19.7日、p=0.33)、病院滞在日数(5.0:47.2±32.9日、CP/2.5:34.0±47.3日、p=0.52)、30日死亡率(5.0:20.0%(n=2)、CP/2.5:50.0%(n=4)、p=0.18)、全死亡率(5.0:40%(n=4)、CP/2.5:62.5%(n=5)、p=0.34)は同程度であった。[結語]心原性ショック患者に対するImpella5.0のbridge to recoveryを目的とした長期使用は有用である可能性が示唆される。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2022&ichushi_jid=J01375&link_issn=&doc_id=20220721160008&doc_link_id=%2Fdc7hksrg%2F2022%2F006701%2F009%2F0046-0051%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdc7hksrg%2F2022%2F006701%2F009%2F0046-0051%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：北海道外科学会  

【はじめに】冠動脈インターベンション(PCI)の技術発達に伴い、冠動脈バイパス手術(CABG)を修練医が執刀経験する機会は少なくなった。このような状況で、計画的かつ安全に修練医がCABGを執刀する為に我々が行っている取り組みを紹介する。【対象・方法】対象は2015年9月から2021年9月にかけて、当科で施行した166例(うち緊急62例:37.3%)のCABG、90例は修練医が、76例は指導医が執刀した。修練医は、初回執刀前に最低50例のdry-labトレーニングを行った。執刀医と患者選択はJapan SCORE II(Expected mortality、6.7+±9.2%)を参照し決定した。第一次エンドポイントを30日死亡とした。【結果】修練医群と指導医群の成績比較では、人工心肺時間(143±41vs.110±44min、p<0.001)、大動脈遮断時間(98±35vs.76±38、p=0.006)で有意差を認めた。しかし、全グラフト開存率(97.8vs.97.4%、p=0.86)や30日死亡率(2.2vs.2.6%、p=0.41)では有意差を認めなかった。【結語】十分なdry-lab trainingと慎重な患者選択、適切な指導医の指導下であれば修練医によるCABGも満足すべき結果を得られる。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2022&ichushi_jid=J01375&link_issn=&doc_id=20220721160003&doc_link_id=%2Fdc7hksrg%2F2022%2F006701%2F004%2F0016-0021%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdc7hksrg%2F2022%2F006701%2F004%2F0016-0021%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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Language：Japanese   Publisher：The Japan Society of Mechanical Engineers  

Currently, biomechanical simulations of blood vessels and organs are widely used in medical research, and it is expected to realize rapid and accurate medical diagnosis by personalized biological simulations for each individual using high-speed and high-precision 3D modeling of the body internal geometry by Multi Detector-row Computed Tomography (MDCT) and Magnetic Resonance Imaging (MRI). In particular, biomechanical simulation approach using Open Source Software (OSS) has been developed for use in the medical field, and recently, its application to more challenging multiphysics simulation has been studied. However, OSS has many issues such as assurance of accuracy and validity of the analysis, the computation time and stability of Fluid-Structure Interaction (FSI), and the lack of analysis functions for complex phenomena. In particular, blood flow simulation using OpenFOAM, a fluid analysis OSS, has issues in the representation of blood pressure changes caused by pulsation and body movement, and the stability of coupled analysis in conjunction with other structural analysis software. In this study, we added the Windkessel model, which is one of the models for expressing blood pressure changes, to OpenFOAM and developed a two-way coupled multi-physics simulation approach using OpenFOAM and CalculiX. As an example of personalized biomechanical simulation, we applied the method to simulate blood flow in the thoracic aorta and evaluated its effectiveness.

DOI： 10.1299/jsmecmd.2022.35.15-05

CiNii Research

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Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：[札幌] : 北海道外科学会  

CiNii Books

CiNii Research

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Other Link： http://id.ndl.go.jp/bib/031902360

Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：東京 : ダイヤモンド社  

CiNii Books

CiNii Research

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Other Link： https://ndlsearch.ndl.go.jp/books/R000000004-I031704522

Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本人工臓器学会  

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Language：Japanese   Publisher：(一社)日本脈管学会  

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Language：Japanese   Publisher：(一社)日本脈管学会  

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Language：Japanese   Publisher：北海道外科学会  

【はじめに】大動脈弁狭窄症(AS)の治療法には、従来の大動脈弁置換術(sAVR)と経カテーテル的大動脈弁留置術(TAVI)に加えて、Sutureless valveを用いたAVR(SUAVR)がある。われわれは2020年9月から主に70歳代、もしくは複合手術症例に対しSutureless valveを使用し、3ヵ月間で導入期7症例を経験したため報告する。【対象・方法】2020年9月からの3ヵ月間に当科で施行したSUAVR7例(男性2名:女性5名、平均年齢76歳)を対象とした。単独手術が5例、冠動脈バイパス術(CABG)併施手術が2例であった。【結果】5例を胸骨正中切開で、2例を右前胸部小開胸で手術を施行した。術後の経胸壁心臓超音波検査(TTE)では全症例でASの改善を認めた。PVLはごくtrivialを2例、mildを1例に認めた。ペースメーカ植込が必要な症例や院内死亡例は認めなかった。ごく軽度の新規脳梗塞を1例に認めた。【結語】さらなる高齢化により高リスク症例が増加すると予測される今後において、SUAVRは有効な選択肢になり得る。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2021&ichushi_jid=J01375&link_issn=&doc_id=20210727190004&doc_link_id=%2Fdc7hksrg%2F2021%2F006601%2F005%2F0026-0031%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdc7hksrg%2F2021%2F006601%2F005%2F0026-0031%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：[札幌] : 北海道外科学会  

CiNii Books

CiNii Research

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Other Link： http://id.ndl.go.jp/bib/031229192

Language：Japanese   Publisher：北海道外科学会  

症例は70歳代男性。大動脈弁狭窄症に対し、7年前に生体弁(19mm)を用いた大動脈弁置換術を施行した。術後より人工弁位の加速血流を認めていたが、経過中に人工弁狭窄の増悪を認め、労作時の息切れが出現・増悪した為に再手術の方針となった。人工弁を摘出後、Valsalva洞へSOLO SMART弁23mmを縫着した。術後経過は良好であり、大動脈弁狭窄の所見も認めず術後19日目に独歩退院となった。ステントレス弁であるSOLO SMART弁はステント弁と比べて血行動態的に有利であり、再手術症例では人工弁摘出後の脆弱で不整な弁輪への縫着を回避しより大きなサイズが縫着可能である。高齢化に伴い、今後、経カテーテル的大動脈弁留置術が施行不能である19mm生体弁機能不全を来す症例が一定数現れてくるものと予想され、そのような症例に対してSOLO SMART弁は有効な選択肢となり得る。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2020&ichushi_jid=J01375&link_issn=&doc_id=20210115020015&doc_link_id=%2Fdc7hksrg%2F2020%2F006502%2F016%2F0179-0181%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdc7hksrg%2F2020%2F006502%2F016%2F0179-0181%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：北海道外科学会  

症例は70歳代女性、胸腹部大動脈瘤破裂で前医より緊急搬送された。クラウド型遠隔医療システムを用いて、前医にて撮像されたCTを転送し、患者到着前から治療戦略を決定することで迅速に手術を行うことができた。CTでは並列に起始する腹腔動脈(CA)、上腸間膜動脈(SMA)を巻き込み、腎動脈直上に及ぶ最大径78mmの大動脈瘤とその周囲への造影剤の漏出を認めた。大動脈造影にてCAより中枢側に破裂孔を認め、ステントグラフト(SG)をCA・SMA直上の瘤内に留置した。退院直前のCTにて瘤径の拡大を認めたため術後67日に胸腹部人工血管置換術を行った。術後肺炎を契機に敗血症を発症しSG挿入術から265日後に死亡した。手術前・周術期死亡率の高い本疾患において、クラウド型遠隔医療システムを用いることで迅速にSG挿入術を行い、破裂孔閉鎖を行うことができた。次の治療につなぐことが出来た点において胸腹部大動脈瘤破裂治療の選択肢になりうると考えられる。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2020&ichushi_jid=J01375&link_issn=&doc_id=20210115020012&doc_link_id=%2Fdc7hksrg%2F2020%2F006502%2F013%2F0164-0168%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdc7hksrg%2F2020%2F006502%2F013%2F0164-0168%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(一社)日本人工臓器学会  

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Language：Japanese   Publisher：(一社)日本人工臓器学会  

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Language：Japanese   Publisher：(一社)日本脈管学会  

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Language：Japanese   Publisher：(一社)日本脈管学会  

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Language：Japanese   Publisher：(一社)日本人工臓器学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本人工臓器学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本胸部外科学会  

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Language：Japanese   Publisher：(一社)日本外科学会  

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Language：Japanese   Publisher：(一社)日本脈管学会  

今回われわれは12年前に胸部下行大動脈置換術が施行された74歳女性における残存解離性胸腹部大動脈瘤切迫破裂に対し,胸部ステントグラフト内挿術(TEVAR)にてEntry閉鎖を行った後に追加TEVARおよび腹部ステントグラフト内挿術(EVAR)にてRe-entry閉鎖を行い良好な結果を得た。開胸手術が困難な遺残解離性大動脈瘤切迫破裂に対する治療法としては血管内治療は有用な一つの選択肢と考えられた。しかし,長期成績が不明なため注意深い経過観察が必要である。(著者抄録)

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Language：Japanese   Publisher：北海道外科学会  

41歳男性。ファロー四徴症などに対して4度の手術の既往がある。肺動脈弁位人工弁機能不全と肺動脈狭窄による右心不全が進行したため手術適応とした。両下腿には高度なリンパ浮腫・うっ血性潰瘍と陰嚢水腫が見られた。4度にわたる手術で胸骨下の癒着が高度と予想したことと、実際にも過去の手術で胸骨切開時に大動脈を損傷していることから、胸骨切開前に人工心肺を開始することとした。しかし両鼠径部の腫脹が高度のため大腿動静脈へのアプローチは困難と考えた。そこで右内経静脈経由右房脱血、左鎖骨下動脈送血で体外循環を開始した後、胸骨を切開した。その際、大動脈を損傷したが、循環動態の悪化をきたすことなく手術を継続できた。高度の癒着のため大動脈遮断を回避し、systemic hyperkalemiaを併用した低体温心室細動下、に予定通りre-Rastelli手術を完遂できた。先天性心疾患に対する小児期手術の成績が向上したことに伴い成人期での再手術例が増加している。胸骨切開時や癒着剥離時の大血管損傷を回避すること、万が一損傷した場合の対処法などの戦略をあらかじめ立てておく必要がある。胸骨切開前の人工心肺開始と低体温併用systemic hyperkalemiaによりre-Rastelli手術を完遂できたので報告する。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2020&ichushi_jid=J01375&link_issn=&doc_id=20200703090015&doc_link_id=%2Fdc7hksrg%2F2020%2F006501%2F016%2F0069-0073%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdc7hksrg%2F2020%2F006501%2F016%2F0069-0073%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：Japanese   Publisher：(NPO)日本心臓血管外科学会  

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Language：English   Publisher：(NPO)日本血管外科学会  

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Language：English   Publisher：(NPO)日本血管外科学会  

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Language：Japanese   Publisher：北海道外科学会  

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Language：Japanese   Publisher：(株)日本臨床社  

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Language：Japanese   Publisher：(一社)日本脈管学会  

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Language：Japanese   Publisher：日本臨床外科学会  

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