Arudo Hiraoka

Clinical outcomes of different approaches to aortic arch disease.

OBJECTIVE The aim of this study was to evaluate the midterm clinical outcomes of various approaches, including hybrid procedures, to aortic arch pathologies. METHODS Of 305 consecutive patients who underwent aortic arch repair between 2005 and 2013, 244 underwent conventional open total aortic arch repair (CTAR) with antegrade cerebral perfusion under circulatory arrest, 35 underwent debranching of the arch with thoracic endovascular aortic repair (DTEVAR), and 26 underwent staged TEVAR after TAR with elephant trunk (TARET). We retrospectively evaluated the outcomes of the three groups. RESULTS The DTEVAR group had a greater percentage of patients with preoperative comorbidities. Significant differences were observed in 30-day mortality (DTEVAR, 14.3% [5 of 35] vs TARET TEVAR, 0% [0 of 26] vs CTAR, 5.3% [13 of 244]; P = .045) and stroke (DTEVAR, 28.6% [10 of 35] vs TARET TEVAR, 7.7% [2 of 26] vs CTAR, 8.2% [20 of 244]; P = .001). In overall midterm survival, the DTEVAR group had a lower survival rate (63.9% 3-year survival) compared with the CTAR (90.1% 7-year survival) and the TARET TEVAR (95.5% 2.5-year survival) groups. In elective cases, better midterm results were observed in CTAR and TARET TEVAR groups. An increased number of debranching graft and emergency operations resulted in a much lower follow-up survival rate in the DTEVAR group. Atherosclerotic disease had a great effect on midterm outcomes in the DTEVAR (P = .045) and CTAR groups (P = .002). CONCLUSIONS The clinical feasibility of DTEVAR for high-risk patients requiring zone 0 landing or emergency surgery is still controversial. Atherosclerotic disease of the aorta has a significant negative effect on midterm outcomes in any surgical approach.

Re-expansion pulmonary oedema after minimally invasive cardiac surgery with right mini-thoracotomy

OBJECTIVES Re-expansion pulmonary oedema (RPO) sometimes occurs after minimally invasive cardiac surgery (MICS) with single-lung ventilation. However, it has not been widely recognized as a serious complication. The aim of this study is to evaluate the occurrence rate and risk factors of RPO. METHODS A total of 381 consecutive patients who underwent MICS with right mini-thoracotomy from March 2005 to October 2013 were retrospectively reviewed. RESULTS RPO was observed in 8 (2.1%) patients. In the preoperative data, greater percentages of preoperative use of steroid or immunosuppressant were found in patients with RPO (25% [2/8] vs 1% [4/373]; P = 0.0056). In the operative data, significantly longer operation, cardiopulmonary bypass (CPB) and aortic cross-clamping (ACC) times as well as greater percentages of second CPB run were found in patients with RPO (388 ± 80 vs 272 ± 61 min; P < 0.0002, 253 ± 79 vs 158 ± 50 min; P = 0.0009, 162 ± 65 vs 108 ± 38 min; P = 0.020 and 38% [3/8] vs 1.3% [5/373]; P < 0.0003). The overall 30-day mortality rate was 0.8% (3/381) and the 30-day mortality rate of patients with RPO was 12.5% (1/8). Significantly prolonged initial ventilation time, intensive care unit and postoperative hospital stay were observed in patients with RPO (P = 0.0022, <0.0001 and 0.0003, respectively). Multivariate logistic analysis detected preoperative use of steroid or immunosuppressant and prolonged ACC time (≥156 min) as independent risk factors for RPO after MICS (odds ratio [OR]: 87.6 [95% confidence interval, CI: 4.1-2463.8]; P = 0.006 and OR: 36.0 [95% CI: 4.8-731.4]; P < 0.001). CONCLUSIONS RPO should be recognized as one of the most serious complications after MICS with right mini-thoracotomy. More accurate risk factors of prolonged lung malperfusion and steroid use on RPO after MICS should be investigated.

Evaluation of late aortic insufficiency with continuous flow left ventricular assist device

OBJECTIVES The aim of this study was to evaluate late development of aortic insufficiency (AI) with continuous flow left ventricular assist device (CLVAD). Development of AI is an increasingly recognized important complication in CLVAD therapy, but there are still few reports about this topic. METHODS We analysed data from 99 patients who underwent CLVAD implantation. De novo AI was defined as the development of mild or greater AI in patients with none or trace preoperative AI. Anatomic and functional correlates of de novo AI were investigated. RESULTS Among the 17 patients with preoperative mild AI, no improvements were observed in mitral regurgitation or LV end-systolic dimension. Of the remaining 82 patients, de novo AI was identified in 43 patients (52%), on the most recent follow-up echocardiography, and did not influence survival nor improvement of LV geometry. Rate of freedom from de novo AI at 1 year after CLVAD implantation was 35.9%. Development of significantly greater AI was observed in patients without valve opening (AI grade 1.3 ± 1.0 vs 0.7 ± 0.9; P = 0.005). By multivariate Cox hazard model, smaller body surface area (BSA) [hazard ratio: 0.83 [95% confidence interval (CI): 0.72-0.97], P = 0.018], larger aortic root diameter (AOD) [hazard ratio: 1.11 (95% CI: 1.02-1.22), P = 0.012] and higher pulmonary artery systolic pressure (PASP) [hazard ratio: 1.24 (95% CI: 1.10-1.41), P < 0.001] were identified as the independent preoperative risk factors for de novo AI. In a subset of patients with speed adjustments, increase of CLVAD speed worsened AI and led to insufficient LV unloading in patients with aortic dilatation (AOD ≥ 3.5 cm). CONCLUSION Any significant mortality difference related to preoperative or development of postimplant AI was not found. AI was associated with changes in LV size, and there appears to be an interaction between BSA, preoperative PASP, time since implant, aortic valve opening, aortic size and development of AI. Longitudinal clinical management in CLVAD patients, particularly in terms of CLVAD speed optimization, should include careful assessment.

Influencing Factors for Abdominal Aortic Aneurysm Sac Shrinkage and Enlargement after EVAR: Clinical Reviews before Introduction of Preoperative Coil Embolization

BACKGROUND We previously reported effectiveness of coil embolization (CE) to aortic branched vessels before endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) because of significant shrinkage of aneurysmal sac. In this study, we investigated EVAR cases to clarify influential factors of aneurysmal shrinkage and enlargement. METHODS 148 consecutive cases before the introduction of CE were retrospectively reviewed based on the presence of PT2EL (persistent type 2 endoleak) and change in sac diameter after EVAR by multivariate analysis. RESULTS (A) PT2EL risk factors were patent inferior mesenteric artery (IMA) and thinner mural thrombus inside aneurysmal sac. (B) Sac enlargement risk factors were antiplatelet intake, PT2EL, and female gender

Preoperative Coil Embolization to Aortic Branched Vessels for Prevention of Aneurysmal Sac Enlargement Following EVAR: Early Clinical Result

OBJECTIVE Persistent Type 2 endoleaks (PT2) after endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) are associated with increased adverse outcomes, including aneurysmal sac enlargement and rupture. The aim of this study was to report early clinical outcomes of coil embolization (CE) to aortic branched vessels prior to EVAR and assess the effectiveness of this strategy in terms of prevention of sac growth due to PT2. MATERIALS AND METHODS Between May 2007 and April 2012, EVAR was performed for 215 cases, divided into two groups (150 cases in Group A, before introduction of CE; 21 in Group B, receiving CE before EVAR). Early clinical outcomes were compared between groups. RESULTS Fifty percent of cases in Group B had a marked reduction of aneurysmal sac diameter based on multi-detector row computed tomographic angiography (MDCTA) findings at the 6-month follow-up after EVAR, whereas, only 25% of cases in Group A had shrinkage of the aneurysmal sac during the same time period after EVAR. CONCLUSION This strategy has the possibility of improving late outcomes of EVAR by reducing endoleak volumes beforehand.

Mitral valve reoperation under ventricular fibrillation through right mini-thoracotomy using three-dimensional videoscope

BackgroundConventional reoperative mitral valve surgery by median sternotomy has several difficulties. We performed mitral valve replacement (MVR) under ventricular fibrillation (VF) through right mini-thoracotomy with three-dimensional videoscope for avoiding the problems.MethodsBetween 2006 and 2011, we performed 257 cases of MVR, in which 125 cases underwent isolated MVR. Ten cases of patients underwent reoperative MVR under VF through thoracotomy with three-dimensional videoscope (Group I), and 27 cases of patients underwent reoperative conventional MVR through median sternotomy (Group II). We retrospectively reviewed the outcomes and compared Group I with Group II. Preoperative left ventricular ejection fraction (LVEF) was significantly lower (50.5 ± 19.8% vs 64.4 ± 12.0%; p = 0.046), and significantly higher Euro SCORE was found in Group I (4.8 ± 2.0 vs 3.8 ± 2.4; p = 0.037).ResultsAlthough Group I required cooling and rewarming time, average operative times was significantly shorter in Group I (262 ± 46 min vs 300 ± 57 min; p = 0.044), and cardiopulmonary bypass times and average VF times in Group I and aortic cross-clamp times in Group II were equivalent. There was no significant difference in the average of postoperative maximum creatine kinase (CK)-MB. In-hospital mortality was 0/10 (0%) and 1/27 (3.7%), and postoperative paravalvular leakage occurred in 0/10 (0%) and 1/27 (3.7%), and stroke occurred in 1/10 (10%) and 1/27 (3.7%) for Groups I and II. Two patients underwent reoperation for bleeding in Group II. Intensive care unit stay in Group I was significantly shorter than in Group II (1.8 ± 0.6 days vs 3.0 ± 1.7 days; p = 0.025).ConclusionsThe higher risk of preoperative background in Group I had no effect on the operation. Mitral valve surgery under VF through right mini-thoracotomy can be an alternative procedure for reoperation after conventional various cardiothoracic surgeries.

Intraoperative direct hemoperfusion with a polymyxin-B immobilized fiber column for treatment of infective endocarditis

PurposeEndotoxin adsorption treatment (direct hemoperfusion using a polymyxin-B immobilized fiber column, or PMX-DHP) is now considered a useful option for treating severe sepsis. However, the efficacy of PMX-DHP for infective endocarditis (IE), in which the causative microorganisms are usually Gram-positive cocci, remains unclear. In the present study, we investigated the impact of intraoperative PMX-DHP on clinical parameters during the treatment of IE.MethodsFrom November 2006 to December 2009, a total of 11 patients with active IE underwent emergent surgery using intraoperative PMX-DHP. The perioperative courses of these patients were compared with those of seven patients who underwent emergent surgery for active IE with the conventional method from January 2003 to October 2006.ResultsPMX-DHP was associated with a significant decrease in the postoperative catecholamine dose and duration. Intubation time and intensive care unit length of stay for the PMX-DHP group was significantly shorter than that for the conventional therapy group. There was also a significant difference in the number of failed organs postoperatively between the two groups.ConclusionIntraoperative PMX-DHP demonstrated several positive effects, such as a drastic decrease in the doses of inotropic agents and shortening of the duration of mechanical ventilation, in patients who underwent emergent surgery for active IE. Intraoperative PMX-DHP can be a useful option for the treatment of critically ill patients with IE.

Objective analysis of midterm outcomes of conventional and hybrid aortic arch repair by propensity-score matching

Objective: The aim of this study is to evaluate the objective outcomes of conventional total aortic arch repair (CTAR) and hybrid arch repair by using propensity‐score matching to reduce selection bias. Methods: Between January 2006 and April 2016, 470 consecutive patients underwent isolated aortic arch repair (excluding hemiarch or partial arch reconstruction, and cases with concomitant cardiac surgeries) at a single cardiovascular institute. We categorized 337 total aortic arch repair with antegrade cerebral perfusion under circulatory arrest as the CTAR group and 58 hybrid aortic arch repair (HAR) with thoracic endovascular aortic repair as the HAR group. Seventy‐five patients with scheduled and staged thoracic endovascular aortic repair after total aortic arch repair with elephant trunk were excluded. Then, we compared early and midterm outcomes between the propensity‐matched group (43 CTAR vs HAR pairs). Results: There were no significant differences in 30‐day and operative deaths between the CTAR and HAR groups (4.7% [2/43] vs 7.0% [3/43]; P = .4142 and 11.6% [5/43] vs 16.3% [7/43]; P = .5637). Although there were no significant differences in the incidences of other major complications, permanent stroke was observed more frequently in the HAR group (0% [0/43] vs 11.6% [5/43]; P = .0064) compared with the CTAR group. Matching analysis, however, revealed an equivalent 5‐year survival rate between the CTAR and HAR groups (80.5% vs 59.9%; P = .1300). Conclusions: Matching analysis revealed a significantly greater incidence of stroke in the HAR group but equivalent midterm outcomes in the hybrid group compared with the CTAR group.

Concomitant septal myectomy during minimally invasive aortic valve replacement through a right mini-thoracotomy for the treatment of aortic stenosis with systolic anterior motion of the mitral valve

This paper reports concomitant septal myectomy during minimally invasive aortic valve replacement through a right mini-thoracotomy. A 76-year-old woman was diagnosed as having aortic stenosis with systolic anterior motion of the mitral valve. The bulging septum was exposed by pulling up a traction suture placed at the annulus of the right coronary cusp; the anomalous chordae and muscle bundles attached to the septum were also resected. By setting an adequate intercostal thoracotomy and placing a traction suture, concomitant myectomy was safely performed even through a right mini-thoracotomy.

Acute Kidney Injury After Total Aortic Arch Repair with Moderate Hypothermic Circulatory Arrest

The aim of this study is to evaluate acute kidney injury (AKI) after total aortic arch repair (TAR) with moderate hypothermic circulatory arrest (MHCA) and selective antegrade cerebral perfusion (SACP).