Shinzo Torii

Key success factors for thoracic endovascular aortic repair for non-acute Stanford type B aortic dissection †

OBJECTIVES We aimed to determine the key factors associated with successful early and late outcomes after thoracic endovascular aortic repair (TEVAR) for non-acute Stanford type B aortic dissection at our institution. METHODS Inpatient and outpatient records were retrospectively reviewed. Patients operated on within 14 days after the onset of acute aortic dissection and those with rupture or malperfusion were excluded. RESULTS Forty-five patients (mean age, 55.5 ± 13.1 years; 23-79 years) underwent 53 TEVAR operations for non-acute Stanford type B aortic dissection between 1998 and 2012. Thirty-four patients had a patent false lumen and 19 had an ulcer-like projection (ULP). No early mortality was observed. At late follow-up (7.5 ± 3.9 years) of the 45 patients, survival after the initial TEVAR was 100, 86 and 63%; freedom from aortic reintervention was 87, 73 and 59%; and freedom from open aortic surgery was 89, 84 and 73%, at 1, 5 and 10 years, respectively. Of 15 late deaths, 2 were due to aortic rupture and 2 were operative deaths associated with aortic surgery. Of the 34 patients with patent false lumens before TEVAR, 25 had their descending false lumens thrombosed; of these 25, 16 had remodelling of the descending aorta; and of these 16, 4 had complete obliteration of the false lumen of the entire aorta. By bivariate analysis, the site of the primary entry and age were significantly associated with thrombosis of the descending false lumen, maximum aortic diameter was associated with remodelling of the descending aorta, and absence of abdominal branches arising from the false lumen was associated with complete obliteration of the false lumen of the entire aorta. CONCLUSIONS The early results of TEVAR for non-acute Stanford type B aortic dissection were favourable. However, for cases with patent false lumens, complete obliteration of the false lumen of the entire aorta was difficult to achieve. Absence of the primary entry at the outer curvature of the distal aortic arch, younger age, small aortic diameter and absence of the abdominal aortic branches arising from the false lumen were the key success factors.

Double-patch closure using gelatin resorcine formol glue of a ventricular septal perforation following acute myocardial infarction.

Complete closure is most important when attempting acute-phase closure of a ventricular septal perforation following acute myocardial infarction. Here, we present a case of a 76-year-old male with a ventricular septal perforation following acute myocardial infarction. The ventricular septal perforation was repaired by stitching small and large bovine pericardial patches onto the affected septum from the side of the left ventricle, then cementing the two patches together with gelatin resorcine formol glue injected into the space between them. Complete closure of the ventricular septal perforation was accomplished. Simultaneously, right coronary artery bypass grafting was performed using a saphenous vein. The postoperative course was uneventful, and the patient was discharged, with a favorable post-discharge course for 24 months to date after surgery.

Impact of the entry site on late outcome in acute Stanford type B aortic dissection

OBJECTIVES This study aimed to investigate whether the entry site of acute type B aortic dissection affects late outcomes. METHODS Inpatient and outpatient records were retrospectively reviewed. RESULTS We identified 224 cases of acute type B aortic dissection between 1998 and 2013. Of these 224 patients, 168 were men and the age was 64.2 ± 12.6 (range 23-94) years, from which 130 presented with the entry at a location downstream of the distal aortic arch, 67 with the entry at the outer curvature of the distal aortic arch and 27 with the entry at the inner curvature. At the initial presentation, 127 patients had descending false lumen thrombosis. The 30-day mortality rate was 2%, and 8% of patients had malperfusion. The entry at the outer curvature was associated with a higher risk of 30-day mortality. Patients with the entry at a location downstream were significantly older, and had a higher chance for primarily thrombosed descending false lumen and a lower risk of malperfusion. At follow-up (6.0 ± 4.1 years), the actuarial survival rates were 97, 83 and 60%, freedoms from open aortic surgery were 96, 91 and 86%, aortic intervention were 73, 66 and 63% and aortic events were 71, 60 and 52% at 1, 5 and 10 years, respectively. Multivariate logistic regression analysis revealed that the outer curvature entry and maximum aortic diameter were correlated with open aortic surgery, aortic intervention and aortic events. Of the 127 patients with primarily thrombosed false lumen, the outer curvature entry was significantly correlated with aortic events. CONCLUSIONS The primary entry at the outer curvature of the distal aortic arch, as well as the large aortic diameter, is associated with a higher risk of late open aortic surgery, aortic intervention and aortic events in acute type B aortic dissection. Thus, the entry site should be taken into consideration in the establishment of an appropriate treatment indication of type B aortic dissection.

For what type of constrictive pericarditis is the waffle procedure effective

The waffle procedure is performed in patients with marked thickening and calcification of the epicardium and no substantial improvement in hemodynamic parameters after pericardiectomy. We retrospectively investigated the efficacy of the waffle procedure in 6 of 11 patients who underwent pericardiectomy. These 6 patients showed no improvement in central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, or cardiac index after pericardiectomy. After the waffle procedure, all hemodynamic parameters improved, and there were no significant differences compared to those of the 5 patients who did not require the waffle procedure, despite higher pulmonary capillary wedge pressure and lower cardiac index values preoperatively in the waffle group. The waffle procedure was considered effective in patients with persistent epicardial constriction.

Ulnar artery graft for myocardial revascularization.

We present a 60-year-old man who underwent coronary artery bypass grafting using an ulnar artery as one of the grafts intended to release angina pectoris. Previously, his right leg had been amputated following a traffic accident. The blood supply of his left leg was reduced due to atherosclerotic stenotic change (left ankle pressure index 0.6). He had been under treatment for severe diabetes mellitus for 4 years. Coronary angiography revealed severe stenosis in the triple coronary artery system. Immediate myocardial revascularization was considered necessary. We considered that saphenous vein grafts and bilateral internal thoracic artery grafts were unsuitable for this patient. Moreover, Allens test was positive in the bilateral forearms. Coronary artery bypass surgery consisted of left internal thoracic artery grafting to the left anterior descending artery, right gastroepiploic artery grafting to the right coronary artery, and left ulnar artery grafting to the diagonal branch. No myocardial or hand complications were observed after surgery. Following a review of the Japanese literature, we conclude that our case is the first report of an ulnar artery graft for coronary artery bypass grafting in Japan.

Repair of Ventricular Septal Perforation after Inferior Myocardial Infarction

Various techniques have been used for repair of ventricular septal perforation complicating inferior myocardial infarction, but no standard method has been established. An effective technique for closing ventricular septal perforation using double patches via a right atrial approach is described. In our experience, no residual shunt was observed after repair using this procedure.

Markers of Peripheral Perfusion during High-Flow Regional Cerebral Perfusion for Aortic Arch Repair

Objectives: High‐flow regional cerebral perfusion (HFRCP) provides cerebral and somatic oxygen delivery through collateral vessels during aortic arch repair in small children; however, optimal flow conditions during HFRCP have not been established. We sought to identify markers of peripheral perfusion during HFRCP. Methods: Between 2009 and 2016, in total 20 consecutive pediatric patients undergoing aortic arch repair with HFRCP were enrolled in this prospective, observational study. Median age was 20 days (range, 6–116 days); median body weight was 2.77 kg (range, 1.8–4.98 kg). Oxygen delivery ratio (Do2R) was calculated as the oxygen delivery during HFRCP divided by the oxygen delivery before HFRCP. Regional oxygen saturations on the forehead and on the thigh (rSo2T) were monitored during HFRCP, and postoperative creatinine kinase and lactate concentrations were measured as postoperative outcomes. Multivariate analyses were performed to clarify the effectiveness of Do2R and rSo2T as markers of peripheral perfusion during HFRCP. Results: No deaths or neurologic impairments occurred. Multivariate analysis showed that the lowest rSo2T (P = .005) and cardiopulmonary bypass time (P = .012) predicted postoperative creatinine kinase concentration. Do2R was the only factor to predict postoperative lactate concentration (P < .001). Receiver operating characteristic analysis showed that Do2R less than 0.66 predicted risk of high postoperative lactate concentration (>5.0 mmol/L), with area under the curve of 0.95. Conclusions: For aortic arch repair in small children, rSo2T and Do2R during HFRCP are useful markers for predicting peripheral perfusion. Maintaining higher Do2R during HFRCP minimizes postoperative increases in lactate and creatinine kinase concentrations.

Outcomes of patients who declined surgery for acute Stanford type A aortic dissection with patent false lumen of the ascending aorta

OBJECTIVES This study aimed to evaluate the outcomes of patients who did not undergo initial aortic surgery for acute Stanford type A aortic dissection with a patent false lumen of the ascending aorta. METHODS Inpatient and outpatient records were retrospectively reviewed. RESULTS We identified 195 patients with acute type A aortic dissection with a patent ascending false lumen between January 1998 and March 2016. Of these, 137 underwent aortic surgery, 16 died before surgery and 42 declined aortic surgery. The ages of the patients who underwent and those who declined aortic surgery were 60.0 ± 10.6 years and 72.3 ± 12.4 years, respectively. The mortality rate of those who underwent and those who declined aortic surgery was 15 and 62% at 30 days and 19% and 67 at 90 days, respectively ( P  < 0.0001). In the 58 patients who did not undergo initial aortic surgery, the maximum aortic diameter was correlated with survival ( P  = 0.0037). At follow-up (3.7 ± 4.5 years; range 0-16.4 years), survival at 1, 5 and 10 years in those who underwent and those who declined initial aortic surgery was 78, 68 and 49%, and 29, 24 and 12%, respectively ( P  < 0.0001). CONCLUSIONS In this study of patients with acute Stanford type A aortic dissection with a patent false lumen of the ascending aorta, the mortality of those who declined initial aortic surgery was 62% at 30 days and 67% at 90 days, respectively, and a smaller aortic diameter was significantly associated with better survival.

Complications after implantation of subcutaneous central venous ports (PowerPort

Background The aim of our study was revised as follows: to clarify the postoperative complications of multifunctional central venous ports and the risk factors for such complications to promote the safe use of the PowerPort system in the hospital. Methods The study group comprised 132 patients in whom implantable central venous access ports (PowerPortⓇ) were placed in our hospital from March 2014 through December 2015. The approach used for port placement was the subclavian vein in 43 patients (33%), the internal jugular vein in 87 patients (66%), and the femoral vein in 2 patients (1%). Results Postoperative complications occurred in 8 patients (6%). The catheter was removed because of infection in 4 patients and catheter kinking in 1 patient. Port extravasation occurred in 3 patients. No patient had catheter pinch-off. The mean operation time was 74 min (range, 32 to 171). No patients had intraoperative bleeding or pneumothorax. Benign disease was a risk factor for postoperative complications (p = 0.009). Conclusion PowerPort is a multifunctional port. Benign disease was a risk factor for postoperative complications. Because many types of subcutaneously implanted ports are used in our hospital, we had to inform the hospital staff about the functions of PowerPort.

Cardiac hemangioma with epicardial infiltration

Cardiac hemangioma is a rare primary cardiac tumor which accounts for only 2–3% of all benign primary tumors of the heart (1). It is usually well circumscribed with apparent surgical margins (2). However, the characteristics of cardiac hemangioma remain unknown owing to its rarity. Here, we report the case of a cardiac hemangioma invading the right atrium and the right ventricle and presenting with characteristics similar to a malignant tumor. This hemangioma was treated with surgical resection.