Akihito Matsushita

Preoperative evaluation of patients with liver cirrhosis undergoing open heart surgery

ObjectiveClinical outcomes after open heart surgery in patients with liver cirrhosis are not satisfactory. For evaluating hepatic function, the Child-Pugh classification has been widely used. It has been reported that open heart surgery can be performed safely in patients with mild liver cirrhosis. In this study, we examined the clinical outcomes after open heart surgery in patients with liver cirrhosis and evaluated the usefulness of the Child-Pugh classification.MethodsThere were 12 liver cirrhosis patients who underwent open heart surgery between January 2002 and December 2006 at our institution. The severity of cirrhosis was graded according to the Child-Pugh classification. We reviewed clinical outcomes, such as postoperative mortality and morbidity, and tried to determine the risk factors. Finally, we assessed the usefulness of the Child-Pugh classification.ResultsSix patients were classified as having Child class A, and the other six patients were classified as B. The overall mortality of group A was 50%, and that of group B was 17%. Postoperative major morbidities occurred in half of the patients of Child class A and in all of the patients of Child class B. Patients who experienced major morbidities had markedly lower levels of serum cholinesterase (106 ± 46 vs. 199 ± 72 IU/l; P = 0.02) and lower platelet level (7.5 ± 2.9 vs. 11.9 ± 3.6 × 104/μl; P = 0.04).ConclusionThe mortality and morbidity rates were high even in the Child class A patients. The Child classification may be an insufficient method for evaluating hepatic function. We have to assess other factors, such as the serum cholinesterase level or the platelet count.

Preoperative characteristics and surgical outcomes of acute intramural hematoma involving the ascending aorta: A propensity score–matched analysis

OBJECTIVE We aimed to evaluate the preoperative characteristics and surgical outcomes of acute type A intramural hematoma. METHODS Between January 2000 and June 2011, 460 consecutive patients underwent emergency open surgery for type A acute aortic syndrome at Sakakibara Heart Institute. Among these patients, 121 had intramural hematoma and 339 had typical aortic dissection. We compared the clinical characteristics and surgical outcomes using propensity score matching. RESULTS In all patients, the intramural hematoma group had an older age (69.2 ± 10.4 years vs 63.4 ± 13.5 years; P < .001), included a higher ratio of female patients (56.2% vs 44.0%, P = .020), and more frequently had hypertension (94.2% vs 83.5%, P = .005), hyperlipidemia (25.6% vs 12.7%, P < .001), and cardiac tamponade (33.1% vs 18.3%, P < .001) than patients with aortic dissection. Cerebral malperfusion (0.8% vs 5.3%, P = .033), myocardial malperfusion (0.8% vs 8.2%, P = .002), lower limb malperfusion (1.7% vs 7.9%, P = .015), Marfan syndrome (0% vs 3.5%, P = .042), and aortic valve insufficiency (2.5% vs 15.0%, P < .001) were less frequently observed in the intramural hematoma group than in the aortic dissection group. After propensity score matching, 116 matched pairs were created. In the matched analysis, operative mortality was 0.9% in the intramural hematoma group (1/116) and 3.4% in the aortic dissection group (4/116, P = .179). The intramural hematoma group demonstrated higher actuarial 1- and 5-year survivals than the aortic dissection group (99.1 % vs 93.6% and 97.3% vs 85.9%, respectively, P = .006). In the multivariate analysis, intramural hematoma was shown to be associated with lower midterm mortality (hazard ratio, 0.316; 95% confidence interval, 0.102-0.974; P = .045). CONCLUSIONS Patients with intramural hematoma have different preoperative clinical characteristics compared with patients with aortic dissection. Emergency open surgery for type A intramural hematoma demonstrated low operative mortality and excellent 5-year survival.

Pneumopericardium caused by a permanent endocardial pacing lead

A 59-year-old woman with a history of bronchiectasis was admitted due to a two-day history of fever and hemosputum. A permanent pacemaker (DDD mode, screw-in lead) had been implanted three months previously to treat complete atrioventricular block. On computed tomography, pneumopericardium was seen, and the right atrium pacing lead was stuck into the right lung. A semi-emergency operation to remove the pacing lead and part of the right middle lobe was performed through a right thoracotomy. Although pneumopericardium caused by pacing lead perforation is rare, the possibility of perforation by the pacing lead should always be considered.

Impact of initial aortic diameter and false-lumen area ratio on Type B aortic dissection prognosis

OBJECTIVES Medical treatment is the gold standard for uncomplicated acute Type B aortic dissection (ATBAD). Although endovascular treatment could become an alternative therapy, it is unclear which ATBAD patients should undergo endovascular intervention. We aimed to evaluate the outcomes of patients with uncomplicated ATBAD and identify the risk factors for major adverse events. METHODS We retrospectively reviewed 134 consecutive patients who underwent initial treatment for uncomplicated ATBAD between 2004 and 2015. Follow-up rate was 98.5%, and the median follow-up period was 47 months. We evaluated the incidence of major adverse events (aortic-related death, aortic surgery and dilated aorta ≥ 55 mm) and identified the predictors of major adverse events using multivariable analysis. RESULTS In-hospital mortality rate was 0.7% (1/134). During follow-up, 46 patients had major adverse events. The 1-, 3-, and 5-year rates of freedom from major adverse events were 79.8%, 71.4%, and 63.6%, respectively. The independent risk factors for major adverse events were initial aortic diameter ≥40 mm (hazard ratio 3.735, 95% confidence interval 1.888-7.390; P < 0.001) and false-lumen diameter > true-lumen diameter (hazard ratio 3.411, 95% confidence interval 1.491-7.806; P = 0.004). CONCLUSIONS Initial aortic diameter ≥40 mm and false-lumen diameter > true-lumen diameter are predictors of major adverse events after uncomplicated ATBAD. Patients with these risk factors may benefit from early endovascular intervention. Clinical registration number UMIN 000025388, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000029229.

FT11. The Optimal Aortic Diameter for Risk of Late Aortic Events in Uncomplicated Stanford Type B Aortic Dissection

with passive arterial shunt and two-graft technique to reduce these ischemic complications. A first bifurcated graft is anastomosed laterally to the distal descending thoracic aorta, before left renal artery bypass and intraoperative perfusion of both superior mesenteric and right renal arteries. A second graft is used for in-line aneurysm reconstruction. We herein present our experience of type IV TAA open repair using this technique. Methods: Twenty-four patients (mean age, 68 years) underwent elective open repair for type IV TAA with this technique between January 2011 and December 2017. The intervention was achieved through a left thoracophrenic lumbotomy, with retroperitoneal and retrorenal approach. A bifurcated graft was anastomosed laterally to the distal descending thoracic aorta to bypass the left renal artery before aortic cross-clamping. The second limb of this bifurcated graft was connected to a Y-shaped cannula to simultaneously perfuse both superior mesenteric and right renal arteries during supraceliac aortic cross-clamping (Fig 1). An additional tube or bifurcated graft was then used for in-line aneurysm reconstruction. The visceral aortic patch was anastomosed to the aortic graft with the Crawford inclusion technique. The prosthetic limb graft used as a temporary arterial shunt was ligated at the end of the intervention; the left renal artery bypass was preserved as part of the definitive arterial reconstruction (Fig 2). Patients’ records were analyzed for demographics, comorbidities, arterial lesions, operative variables, complications, and 30day mortality. Results: Mean left renal ischemia time was 10.5 minutes. Mean aortic cross-clamping was 31 minutes. The creatinine level at discharge was not significantly different from the preoperative level (15 vs 13; P 1⁄4 .01). Three patients (12.5%) had transient renal failure (Acute Kidney Injury Network stage 1) postoperatively. Prolonged ventilatory support (>2 days) was necessary in two patients (8%). No cardiac event, no dialysis, and no multivisceral organ failure have been recorded. The postoperative mortality rate was 4% (one patient). Conclusions: Type IV TAA repair with our passive shunt and two-graft technique provides short visceral and renal ischemia times and leads to low rates of end-organ ischemic damages. This technique could be an option to consider for visceral protection in type IV TAA open repair and spurs us on to maintain it for our future cases.

Late Disruption of a Polyethylene Terephthalate Aortic Graft 30 Years after Initial Graft Placement

A 71 year old male who had undergone extra-anatomic bypass grafting between the ascending aorta and the thoraco-abdominal aorta at 41 years of age for aortic coarctation was admitted with back pain and dyspnea. A 16 mm Cooley double velour knitted polyethylene terephthalate (PET) graft was used in the initial operation in 1983. Computed tomography showed disruption of the initial PET graft perforating the right atrium, and a pseudoaneurysm at the distal anastomosis. The patient was in acute cardiac failure because of left to right shunting. A two stage operation was performed. The first stage comprised emergency re-grafting and right atrium repair, and the second stage re-grafting for the pseudoaneurysm. The patient is doing well 48 months post-operatively; however, monitoring of the patient will continue for potential PET graft rupture.

Simultaneous Surgery for Thoracic Aortic Aneurysm with Coronary Artery Disease

Objective: We describe our strategy and the outcomes of simultaneous coronary artery bypass grafting (CABG) during surgery for thoracic aortic aneurysms in patients with coronary artery disease.