Suguru Ohira

Surgical Removal of Extensive Left Pulmonary Vein Stump Thrombus After Pulmonary Lobectomy: A Rare Cause of Acute Cerebral Embolism

A 46-year-old woman presented with loss of consciousness and was diagnosed with acute cerebral embolism. She had undergone left upper lobectomy for primary lung cancer 6 months before this event. Transesophageal echocardiography and computed tomography showed a large mobile thrombus in the left upper pulmonary vein (LSPV). An emergent operation was performed through a median sternotomy. Cardiopulmonary bypass was performed and the heart was arrested, and the LSPV was incised. A fresh thrombus had formed in the stump of the LSPV and was removed successfully. The postoperative course was uneventful. During a 1 year of follow-up, there was no recurrence of the thrombus.

Does Age at Operation Influence the Short- and Long-Term Outcomes of Off-Pump Coronary Artery Bypass Grafting?

BACKGROUND To investigate the relationship between age and both short- and long-term outcomes of off-pump coronary bypass grafting (OPCAB). METHODSANDRESULTS The 780 patients undergoing OPCAB were divided into 3 groups: 262 aged <65 years (young), 329 aged 65-74 years (early elderly), and 189 aged >75 years (late elderly), and retrospectively analyzed. The follow-up rate was 94.9%, and mean follow-up period was 5.6±3.4 years. In-hospital mortality rates were similar among the groups (0.8% in young, 1.2% in early elderly, and 1.1% in late elderly; P=0.862). In logistic regression analysis, the risk factor for predicting major complications was the New York Heart Association (NYHA) classification (odds ratio: 1.555, P=0.001), and not age. The 10-year estimated rates free from cardiac death (89.6±3.2, 95.0±2.1, and 96.5±2.1%, log rank, P=0.16) and cardiac events (71.8±3.8, 66.8±4.3, and 59.9±7.7%, P=0.61) were not significantly different among the groups. In multivariate Cox models, independent risk factors predicting cardiac events were the NYHA classification (hazard ratio (HR): 1.265, P=0.009), and ejection fraction (HR: 0.986, P=0.016), but not age (young HR: 1.0, early elderly HR: 1.276; P=0.210, late elderly HR: 0.910; P=0.707). CONCLUSIONS Both short- and long-term cardiac outcomes of OPCAB are not influenced by age at operation.

Impact of Chronic Kidney Disease on Long-Term Outcome of Coronary Artery Bypass Grafting in Patients With Diabetes Mellitus

BACKGROUND The aim of this study was to compare the short- and long-term outcomes of CABG in diabetes mellitus (DM) patients according to eGFR. METHODS AND RESULTS A total of 573 DM patients receiving CABG between 1997 and 2012 were stratified according to preoperative eGFR: normal or mild chronic kidney disease (CKD), eGFR ≥60 ml/min/1.73 m(2); moderate CKD, eGFR 30-60 ml/min/1.73 m(2); severe CKD, eGFR <30 ml/min/1.73 m(2); and severe CKD requiring hemodialysis (HD). Off-pump and bilateral internal thoracic artery (BITA) grafting rates were 83.4 and 62.3%, respectively. Mediastinitis and in-hospital mortality rates were both 1.4%. On logistic regression analysis, preoperative congestive heart failure and CKD severity were independent predictors of postoperative renal failure and major complications. The mean follow-up period was 5.7 years (range, 0-15.5 years). Estimated 5-year survival (92.9±1.6%, 82.8±3.3%, and 47.3±7.0%, respectively, P<0.001) significantly decreased with declining kidney function. On Cox hazard modeling, CKD severity was an independent predictor of major cerebrocardiovascular events (normal/mild: hazard ratio [HR], 1; moderate: HR, 1.35; severe: HR, 1.83; HD: HR, 2.0, P=0.016) and of overall survival (normal/mild: HR, 1; moderate: HR, 1.65; severe: HR, 5.96; HD: HR, 10.93, P<0.001). BITA grafting was a strong protective factor for overall survival (HR, 0.63; P=0.022). CONCLUSIONS In DM patients, early- and long-term outcomes after CABG are strongly influenced by CKD progression.

Nine-year Experience of Recurrent Anastomotic Pseudoaneurysms after Thoracoabdominal Aneurysm Graft Replacement in a Patient with Behçet Disease

A 47 year-old woman with Behçet disease presented with back pain. Computed tomography showed an extent IV thoracoabdominal aneurysm. Graft replacement with reconstruction of all visceral arteries was performed. At five years postoperatively, anastomotic pseudoaneurysm of the left renal artery occurred, and it was reconstructed with an 8-mm graft. Two years after the second reconstruction, anastomotic pseudoaneurysms of the abdominal aorta developed. Y-shaped graft replacement was performed. There has been no recurrence for one year since the last operation. In situ graft reconstruction for recurrent pseudoaneurysms in a Behçet disease patient more than five years after graft replacement with reconstruction of all visceral arteries is rare.

Endocardial linear infarct exclusion technique for infarcted lateral wall

We report a novel method of surgical ventricular restoration for an infarcted lateral wall: the endocardial linear infarct exclusion technique. First, transmural ventriculotomy is performed at the centre of the scar longitudinally along the coronary artery. Second, the inner layer is sutured in a longitudinal direction with 4-0 polypropylene continuous sutures to approximate the border between the normal and infarcted myocardium. Finally, the outer layer is closed with a combination of interrupted buttress and continuous over-and-over sutures with outer felt reinforcement. The advantages of endocardial linear infarct exclusion technique are as follows: the risk of bleeding is low; it is not technically demanding and is reproducible; the coronary artery can be preserved; approximation of the base of the anterior and posterior papillary muscles is possible in the case of ischaemic mitral regurgitation and it can also be applied to the anterior and inferior walls.

Risk model of aortic valve replacement after cardiovascular surgery based on a National Japanese Database

OBJECTIVES: The aims of this study were to investigate early results of aortic valve replacement (AVR) after cardiovascular surgery and create a risk model using a national database in Japan. METHODS: We used the Japan Adult Cardiovascular Surgery Database. Between 2008 and 2013, 2157 patients who underwent AVR for aortic stenosis after cardiovascular surgery or redo AVR were retrospectively analysed. RESULTS: The background of prior surgery (including overlapping cases) was as follows: coronary artery bypass grafting (CABG), 31.9%; valve, 67.5% and thoracic aorta, 9.0%. The mean age was 70.4. Concomitant procedures were as follows: CABG, 14.5%; mitral valve surgery, 29.9% and aortic surgery, 5.9%. The 30-day and operative mortality rates were 5.5 and 8.5%, respectively. Major morbidity occurred in 25.7%. The incidence rate of stroke was 3.8%, and that of pacemaker implantation was 3.7%. There were seven risk factors for both the operative mortality and composite outcome: age, active endocarditis, ejection fraction <30%, New York Heart Association classification IV, mitral regurgitation ≥2, renal failure and other concomitant cardiac procedure. The C-indexes of operative mortality and the composite outcome were 0.761 and 0.709, respectively. CONCLUSIONS: We could identify risk factors predicting the operative mortality and composite outcome associated with AVR after prior cardiovascular surgery based on a national Japanese database. Early outcomes were acceptable despite these operations being associated with a higher risk than primary AVR. Our results may be informative when treating such high-risk patients.

A Novel Technique of Aortic Root Reconstruction for Extensive Endocarditis: The Pericardial Skirt Technique

Extensive aortic valve endocarditis requires thorough debridement of the paravalvular tissue, and reconstruction of the destroyed aortic root can be technically difficult. In the present report, we describe a simple technique for aortic root reconstruction. In this technique, a doughnut-shaped bovine pericardial sheet (skirt) is attached to the proximal end of a valved conduit and then sewn onto the destroyed aortic annulus. Because skirt flexibility facilitated excellent adaptation to the irregular annular plane, we did not encounter any severe bleeding from the proximal anastomosis of the valved conduit in any of the cases. We believe that our procedure may be beneficial for aortic root reconstruction in patients with extensive endocarditis.

Label-free detection of myocardial ischaemia in the perfused rat heart by spontaneous Raman spectroscopy

Raman spectroscopy, which identifies intrinsic molecular constituents, has a potential for determining myocardial viability under label-free conditions. However, its suitability for evaluating myocardial ischaemia is undetermined. Focusing on cytochromes, i.e., representative molecules reflecting mitochondrial activity, we tested whether Raman spectroscopy is applicable for evaluating myocardial ischaemia especially during early ischaemic phase. We obtained spontaneous Raman spectra of the subepicardial myocardium in the Langendorff-perfused rat heart upon 532-nm excitation before and during the “stopped-flow,” global ischaemia. Semi-quantitative values of the peak intensities at 750 and 1127 cm−1, which reflect reduced cytochromes c and b, increased immediately and progressively after induction of the stopped flow, indicating progressive reduction of the mitochondrial respiration. Such spectral changes emerged before the loss of 1) mitochondrial membrane potentials measured by the fluorescence intensity of tetramethyl rhodamine ethyl ester or 2) staining of the triphenyl tetrazolium chloride dye in the myocardium. The progressive increases in the Raman peaks by stopped flow were significantly retarded by ischaemic preconditioning. Sequential measurements of the peak intensities at 750 and 1127 cm−1 enabled early detection of the myocardial ischaemia based on the mitochondrial functions. These data suggest that Raman spectroscopy offers the potential to evaluate acute ischaemic heart under label-free conditions.

Layered wrapping technique combined with oxidized cellulose and vascular prosthesis for effective haemostasis in aortic surgery

Bleeding from anastomotic sites is one of the major complications of aortic surgery. We describe a novel double-layer wrapping technique using a combination of oxidized cellulose and a vascular prosthesis to effectively achieve haemostasis. The anastomotic site is surrounded by a prosthetic graft inlaid with a strip of Nu-Knit. These are fixed by horizontal mattress and over-and-over sutures. Nu-Knit acts as an ideal cushion to achieve haemostasis, because it has a haemostatic effect and fills the space between the anastomotic site and wrapping graft. This technique is simple, and facilitates adequate haemostasis without complications.

Pancreaticoduodenal artery aneurysm involving papilla of vater successfully treated with endovascular approach despite intraoperative rupture.

An 81-year-old woman presented with dizziness and nasal bleeding. Gastrointestinal fiberscopy (GIF) showed a pulsatile aneurysm in the duodenum, and that the orifice of the papilla of Vater was involved. Three-dimensional computed tomography imaging showed an unruptured aneurysm in the pancreatic duodenal arcade. The patient underwent an emergent endovascular embolization of the donor arteries using coils and gelatin sponge particles. She was discharged without any complications. This case was extremely rare because of the anatomic location of the unruptured pancreaticoduodenal artery aneurysm and the fact that it involved the papilla of Vater, was detected with GIF, and was successfully treated endovascularly.