Kojiro Furukawa

Operative strategy for descending and thoracoabdominal aneurysm repair with preoperative demonstration of the Adamkiewicz artery.

BACKGROUND Our study aimed to demonstrate the efficacy of preoperative intraarterial computed tomographic angiography to identify the Adamkiewicz artery (AKA). We also aimed to investigate the impact of identification of the AKA on the strategy for preventing spinal cord injury. METHODS Thirty-seven patients (24 cases of descending aortic aneurysms and 13 cases of thoracoabdominal aortic aneurysms), were studied. Average age was 63.8 years old. A pigtail catheter was inserted into the descending aorta and its tip was located immediately below the left subclavian artery. Subsequently, intraarterial computed tomographic angiography was performed and the segmental artery to the AKA was identified. Aneurysms were replaced electively with prosthetic graft in all cases. In cases where the aortic segment that supplied the AKA was cross-clamped, the identified segmental artery-AKA was selectively perfused. In these cases, the segmental artery-AKA was reconstructed with an interposition graft. RESULTS Intraarterial computed tomographic angiography successfully identified the segmental artery-AKA in all patients. The average number of AKA observed per patient was 1.3± 0.6 AKAs. Selective perfusion of preoperatively identified segmental artery-AKAs was performed in 11 cases. The average number of reconstructed segmental arteries was 0.5 in descending aortic aneurysms and 1.7 in thoracoabdominal aortic aneurysms. Although paraparesis occurred in two patients (5%), the remaining 35 patients did not suffer spinal cord injury. CONCLUSIONS Intraarterial computed tomographic angiography reliably identifies the segmental-AKA. Furthermore, selective perfusion of the segmental artery-AKA, based on accurate preoperative identification, might be one option for preventing intraoperative spinal cord ischemia.

Operative technique for tracheo-innominate artery fistula repair

Tracheo-innominate artery fistula is fatal unless treated surgically. We describe our surgical approach and results in seven patients. The average patient age was 15.7 years; all patients had prior severe neurological deficits. Three of seven patients were in hemorrhagic shock; control of preoperative bleeding was achieved with tracheostomy tube cuff overinflation. The innominate artery and the trachea were exposed through a collar incision and partial upper sternotomy. The innominate artery was divided at the aortic arch and at the bifurcation, with one exception. Cerebral blood flow was monitored by the blood pressure difference in the bilateral upper extremities and by near-infrared spectroscopy. The tracheal fistula was left adherent to the innominate artery in all but one patient. All patients were discharged without new neurologic deficits or severe morbidity. Overall survival was 84% at 37 months, without any vascular, tracheal, or neurological events.

Surgical Strategy for Retrograde Type A Aortic Dissection Based on Long-Term Outcomes

BACKGROUND The optimal management of a retrograde type A aortic dissection (RAAD) is controversial, and few reports have discussed the long-term outcomes of surgical strategies. To determine the most appropriate strategy, we studied the early and late outcomes of RAAD cases. METHODS From 1998 to 2014, 44 patients with RAAD (mean age of 63 ± 11 years) underwent surgical repair. Ascending aortic replacement (AAR) was performed in 21 patients and ascending and total arch replacement (TAR) was performed in 23 patients. Eight of the patients who received TAR underwent complete resection of the primary tear in the distal arch or descending aorta (TAR-R[+]), whereas the remaining 15 patients received elephant trunk implantation as an alternative procedure for tear resection (TAR-R[-]). The early and late outcomes (mean follow-up, 86.5 months) were evaluated. RESULTS Hospital mortality occurred in 4 of the 44 (9.1%) patients, with no mortalities among the patients undergoing TAR-R[-]. There was a tendency toward a higher incidence of late aorta-related events in the AAR group, with a significantly higher patency rate of the false lumen in the proximal site of the residual aorta compared with the TAR group (p = 0.009). Furthermore, the 5-year rate of freedom from aortic growth greater than 50 mm was significantly lower after AAR than after TAR (p = 0.04). A multivariate analysis indicated that the initial ascending aortic diameter (odds ratio [OR], 1.5; p = 0.02) and AAR (OR, 29.1; p = 0.01) were independent predictors of late aortic expansion. CONCLUSIONS The surgical outcomes were acceptable in both the AAR and TAR groups. The long-term outcomes potentially support the aggressive adoption of TAR in relatively younger patients with significant ascending aortic enlargement at presentation.

Total arch replacement for acute aortic dissection (Stanford A) in a patient with hemophilia A.

As a result of improvements in medical management, patients suffering from hemophilia have a life expectancy approaching that of the normal population. An increased life expectancy, however, brings an increased risk of developing age-related disorders. Several article have reported elective cardiac operations successfully performed on hemophiliacs. To our knowledge, there are no articles describing such patients undergoing emergent aortic surgery. Our report describes the successful management of an individual with hemophilia A undergoing emergent total arch replacement for acute aortic dissection (Stanford A). We used a continuous infusion of factor VIII concentrate during the perioperative period. The patient was discharged without bleeding complications.

Real-Time Three-Dimensional Transesophageal Echocardiography Is Useful for the Localization of a Small Mitral Paravalvular Leak

The use of multiplane transesophageal echocardiography (TEE) to reconstruct 3-dimensional (3D) images is limited by time-consuming, multiplane image acquisition and the need for offline processing. To overcome these limitations, a 3D fully sampled matrix array transducer was recently developed to allow real-time acquisition and online display of 3D images. In this case, real-time 3D transesophageal echocardiography produced clear image of a small paraprosthetic leak point. Although the surgical view from the left atrium was poor due to severe adhesions, we were able to perform optimal repair of the small leak after intraoperative confirmation of the location of the leak that was identified by preoperative real-time 3D transesophageal echocardiography.

The addition of human iPS cell-derived neural progenitors changes the contraction of human iPS cell-derived cardiac spheroids

BACKGROUND We havebeen attempting to use cardiac spheroids to construct three-dimensional contractilestructures for failed hearts. Recent studies have reported that neuralprogenitors (NPs) play significant roles in heart regeneration. However, theeffect of NPs on the cardiac spheroid has not yet been elucidated. OBJECTIVE This studyaims to demonstrate the influence of NPs on the function of cardiac spheroids. METHODS Thespheroids were constructed on a low-attachment-well plate by mixing humaninduced pluripotent stem (hiPS) cell-derived cardiomyocytes and hiPScell-derived NPs (hiPS-NPs). The ratio of hiPS-NPs was set at 0%, 10%, 20%,30%, and 40% of the total cell number of spheroids, which was 2500. The motionwas recorded, and the fractional shortening and the contraction velocity weremeasured. RESULTS Spheroidswere formed within 48 h after mixing the cells, except for the spheroidscontaining 0% hiPS-NPs. Observation at day 7 revealed significant differencesin the fractional shortening (analysis of variance; p = 0.01). The bestfractional shortening was observed with the spheroids containing 30% hiPS-NPs.Neuronal cells were detected morphologically within the spheroids under aconfocal microscope. CONCLUSION Theaddition of hiPS-NPs influenced the contractile function of the cardiacspheroids. Further studies are warranted to elucidate the underlying mechanism.

Aortic valve replacement and tricuspid valve annuloplasty via a left thoracotomy in an adult with left pulmonary agenesis

We report a case of a 66-year-old man who was diagnosed with severe aortic regurgitation, moderate tricuspid regurgitation and chronic atrial fibrillation. Preoperative computed tomography showed left lung agenesis. We performed aortic valve replacement, tricuspid valve annuloplasty and right pulmonary vein isolation via a left thoracotomy. This approach provided an adequate field of view.

Persistent Gastrointestinal Angiodysplasia in Heyde's Syndrome after Aortic Valve Replacement

A 67-year-old woman with recurrent gastrointestinal bleeding and aortic valve stenosis presented with spurting bleeding from angiodysplasia of the upper jejunum. As electrophoresis revealed decreased levels of high-molecular-weight (HMW) von Willebrand factor (VWF) multimers, she was diagnosed with Heydes syndrome. After aortic valve replacement, her HMW VWF levels quickly recovered to normal, and the gastrointestinal bleeding ceased. However, capsule endoscopy still revealed gastrointestinal angiodysplasia six months later. This case shows that minute analyses of VWF multimers enable the diagnosis and confirmation of the resolution of Heydes syndrome, and implies that gastrointestinal angiodysplasia can be attributed to unknown factors other than decreased VWF multimers.