Tomonobu Abe

Hybrid versus open repair of aortic arch aneurysms: comparison of postoperative and mid-term outcomes with a propensity score-matching analysis

OBJECTIVES Operative strategies for repairing aortic arch aneurysms should be re-evaluated following recent technical advances. METHODS Of 364 patients who underwent aortic arch repair between 2002 and 2014, 58 were high-risk subjects who received isolated hybrid arch repair (HAR) via median sternotomy (type I n = 32, type II n = 1 and type III n = 25). During this period, excluding patients with type A dissection or extensive aneurysms, 124 patients received isolated open arch repair via median sternotomy. The patients in the HAR and open arch repair groups were compared. A propensity score-matching analysis was applied to adjust for baseline risk factors. RESULTS The patients in the HAR group were older (77 years ± 6 vs 69 ± 9, P < 0.0001), exhibited a greater rate of malignancy (21 vs 4.8%, P = 0.0022) and had higher logistic EuroSCORE values (31 ± 18 vs 20 ± 15, P < 0.0001) than those in the open arch repair group. Following propensity score matching creating 38 matched pairs, the differences in preoperative risk diminished. Operative complications, including the mortality rate (2.6 vs 0%), were similar between the groups. Apart from the lower rates of cardiopulmonary bypass (CPB) and circulatory arrest, there was no apparent superiority of HAR with respect to patient recovery. The mean follow-up duration was 52.5 months, during which the rate of freedom from aortic events in the HAR and open arch repair groups was 79 and 99% at 24 months, respectively (P < 0.0001). CONCLUSIONS HAR achieves equivalent short-term results to standard open arch repair, with a decreased need for CPB. However, considering the inferior mid-term outcomes of this procedure, its indications should be limited to high-risk patients.

Twenty-Year Outcome of Aortic Valve Replacement With St. Jude Medical Mechanical Valves in Japanese Patients

BACKGROUND Bioprostheses have become increasingly popular for aortic valve replacement (AVR) in recent years, but mechanical valves are still the standard choice, especially for younger patients. The aim of this study was to assess the very long-term outcomes in Japanese patients who underwent AVR with St. Jude Medical (SJM) mechanical valves. METHODSANDRESULTS From 1991 to 2001, a total of 816 patients underwent AVR with SJM mechanical valves in 5 hospitals. Of these, 801 patients (mean age, 58.3±11.7 years) were analyzed in this study. There were 24 in-hospital deaths (3.0%). Mean follow-up duration was 11.6±6.7 years and the 10-year follow-up rate was 84.1%. Freedom from valve-related death at 5, 10, 15, and 20 years was 96.2%, 92.7%, 88.8%, and 86.6%, respectively. The linearized ratio of major bleeding events and thromboembolic events was 1.1% per patient-year and 1.0% per patient-year, respectively. Freedom from reoperation for the aortic prosthesis was 98.0% and 94.8% at 10 and 20 years, respectively. CONCLUSIONS The SJM mechanical valve provided excellent long-term freedom from valve-related death and reoperation in patients undergoing AVR. Therefore, this valve should be recommended to younger patients who wish to avoid reoperation.

Late mortality and morbidity in elderly patients with mechanical heart valves.

A retrospective study was performed in patients under and over 65 years old implanted with a mechanical valve, to compare late mortality and morbidity. Of 381 patients who underwent mechanical valve replacement at Nagoya University in the 1990s, 357 (11 hospital deaths and 13 lost to follow-up; 96.4% follow-up rate) were followed up for 7.9 ± 3.3 years (2,811 patient-years). They were divided into two groups either side of 65 years of age at operation. The young and elderly patient groups contained 275 and 82 patients, respectively. The survival rate in the young group was 96.1% (95% confidence interval, 93.7%–98.5%) at 5 years and 92.0% (95% confidence interval, 88.3%–95.7%) at 10 years, which was significantly better than 88.0% (95% confidence interval, 80.6%–95.4%) at 5 years and 73.8% (95% confidence interval, 66.2%–85.4%) at 10 years in the elderly group. The two groups did not differ significantly in the incidence of thromboembolic events, bleeding events, endocarditis, or reoperation. We are also encouraged by the fact that mechanical valves are not a risk factor for late mortality or morbidity, even in elderly patients.

Unruptured Left Coronary Sinus of Valsalva Aneurysm Causing Mitral Valve Obstruction

A 77-year-old man was admitted for congestive heart failure. He had started to have palpitations after eating supper 2 days before the admission and had experienced dyspnea on exertion since then. He visited his family physician, who referred him to the cardiology clinic of our hospital. The patient was under the family physicians care for diabetes mellitus, hypertension, and paroxysmal atrial fibrillation. He had never been diagnosed as having any organic heart disease. He was an ex-smoker and drank alcohol on social occasions. The patient was on β-blockers and Coumadin. His cardiovascular physical examination was significant for a 3/6 systolic murmur and a rapid, irregular heart beat. His ECG showed atrial fibrillation with a ventricular rate of 150 bpm. His portable chest x-ray (Figure 1A) showed bilateral pleural effusion and pulmonary edema. An emergency transthoracic echocardiogram showed normal left and right ventricular function. A large mass in the left atrium was seen that was causing functional mitral stenosis. The patient was admitted to the hospital, given digoxin, and started on intravenous diuresis. His ECG on normal sinus rhythm (Figure 1B), which was …

Right Heart Failure Secondary to Compression of the Right Pulmonary Artery by a Large Proximal Aortic Aneurysm

A 73-year-old woman, who was known to have a large proximal aortic aneurysm, was referred from the Gastroenterology Department for reevaluation for possible aortic surgery. At that time, she complained of fatigue and shortness of breath, which corresponded to New York Heart Association class III symptoms. The patient had initially consulted us 1 year before this presentation. She had been diagnosed recently as having gastric cancer at that time, and additional tests revealed that she also had a proximal aortic aneurysm. Although the aneurysm was large, with a maximum diameter of 67 mm, her gastric cancer, classified as being in stage 4, was considered inoperable. The gastroenterologist estimated that she could probably live for ≈1 year. We discussed the options with the patient, and she rationally decided not to undergo aortic surgery at that time. She did not have any cardiac-related symptoms at that time. A chest radiograph showed a right-sided bulge of the mediastinum (Figure 1). Figure 1. A , A chest radiograph taken at the patient’s first visit …

Aortocarotid bypass at the time of central aortic repair for type A acute aortic dissections

retractor (Rultract, Cleveland, Ohio) is secured to the head of the operating table and used to retract the left costal margin cephalad. The abdomen and preperitoneal pump pocket are entered. Dissection is conducted to mobilize the outflow graft screw and the inflow segment screw, displacing these downward into the abdomen, thus enabling detachment of the body of the pump for replacement (Figure 1). Before attempting replacement of the pump, CPB is established and the ascending aorta is vented as described above. Next,

Foldback technique for aortic anastomosis of free right internal thoracic artery in coronary artery bypass grafting

We herein report a new technique that we term “foldback plasty” for stenosis-free proximal anastomosis of free arterial grafts without using any other interposition materials. The arterial graft is first anastomosed to the aorta in side-to-side fashion, leaving 1 cm of remnant tissue at the proximal end. The reverse side of the graft is then opened longitudinally, starting at the proximal end, to just distal to the aortic anastomosis site. The new proximal graft flap is folded back and sutured onto the graft to close the longitudinal opening. The proximal anastomosis site is enlarged only by the graft tissue, and stenosis can be avoided even if the graft has a small caliber.

A pilot randomized study of the neutrophil elastase inhibitor, Sivelestat, in patients undergoing cardiac surgery.

The primary objective of this study was to determine the feasibility and safety of treatment with Sivelestat in humans to attenuate post-cardiopulmonary bypass lung injury. Twenty patients scheduled to undergo on-pump coronary artery bypass surgery were randomized to receive either 0.3 mg/kg/h intravenous Sivelestat sodium (Sivelestat group; n=10) or isotonic sodium chloride solution (placebo group, n=10), peri-operatively. Postoperative adverse events were recorded until hospital discharge. The alveolar-arterial oxygen gradient (A-aDO(2)), intrapulmonary shunt (Qs/Qt) and dynamic lung compliance were determined four times peri-operatively as secondary exploratory outcomes. All patients completed study protocol without discontinuation of intervention. The number of total adverse clinical outcomes, including atrial fibrillation and superficial wound infection, was nine in seven patients in the placebo group and four in four patients in the Sivelestat group (P=0.37). The mean duration of the postoperative hospital stay was shorter in the Sivelestat group (19.0+/-3.4 vs. 25.6+/-9.1, P=0.04). The exploratory analysis of relative changes in lung functions showed trends toward attenuation of lung injury in the Sivelestat group in all three pulmonary parameters, though the inter-group difference could be due to chance (P>0.05). It is feasible to administer Sivelestat as a preventive measure against lung dysfunction after cardiopulmonary bypass.

Cervical aortic arch with multiple aortic aneurysms that required two aortic replacements with a 34-year interval

A 57-year old female was referred to our hospital after symptoms of hoarseness and dysphagia for a few years. She was diagnosed with a cervical vessel anomaly during childhood and had undergone surgery for a right-sided thoracic descending aortic aneurysm through a right thoracotomy at the age of 23 years. Now, enhanced computed tomography revealed newly developed multiple aneurysms in the aorta between the left carotid artery and the proximal descending aorta in the left hemithorax. A successful aortic surgical repair was accomplished via a left posterolateral thoracotomy. To our knowledge, this is the first case of a cervical aortic arch with formation of multiple aneurysms that required multiple surgeries via bilateral thoracotomies. This case suggests the inherent fragility and possibility of later aneurysmal formation in malformed vessels, thereby emphasizing the importance of periodical imaging tests in this rare congenital anomaly.

Early clinical results of St. Jude Medical Symmetry aortic connector

An automated anastomosis device named St. Jude Medical symmetry aortic connector has been used worldwide for off-pump coronary artery bypass grafting. However, early graft obstruction was recently reported, and its predictors should be clarified. From April 2002 to March 2004, 38 patients in our institution underwent off-pump coronary artery bypass grafting using the St. Jude Medical Symmetry aortic connector for saphenous vein graft (SVG) procedures; measurement of intraoperative graft flow and postoperative coronary angiography was performed. Early SVG events occurred in 9 (24%) patients: 8 occlusion cases and 1 case of stenosis. Predictors of early SVG events were assessed from a comparative study. Univariate logistic regression identified hyperlipidemia as the only significant predictor of early SVG events (P = 0.02, odds ratio 7.78). Lower SVG flow rate and poor ejection fraction did not show statistical significance (P = 0.09, odds ratio 1.09 and P = 0.09, odds ratio 0.96). The SVG event rate was much higher for the left circumflex branch compared with other locations (31% vs. 9%, P = 0.03) and decreased with increasing aortic connector size (small, 32%; median, 14%; large, 0%). Multivariate analysis did not identify a predictor of SVG events. The aortic connector is associated with a high incidence of early SVG events. Patients should be cautiously selected and the procedure should not be used for left anterior descending coronary artery or culprit lesions.