Toshihiro Fukui

A systematic approach to improve the outcomes of type A aortic dissection

Objectives: The aims of this study are to evaluate the outcomes and trends of contemporary emergency surgery for acute type A aortic dissection on the basis of a systematic approach and to assess the impact of temporary aortic crossclamping during systemic cooling on early and late outcomes. Methods: We retrospectively reviewed 702 consecutive patients who underwent emergency surgery for acute type A aortic dissection between March 2004 and May 2015. Our clinical protocol includes rapid transfer to the operating room, quick establishment of cardiopulmonary bypass, temporary aortic crossclamping during cooling, primary entry resection, and open distal anastomosis. We analyzed the perioperative data, survival, freedom from aortic reinterventions, and impact of aortic crossclamping on early and late outcomes. Results: The median time from hospital arrival to cardiopulmonary bypass establishment was 115 minutes and has decreased over the last decade (trend test P < .001). We perfused the femoral artery in 615 patients (87.6%), placed aortic crossclamping in 616 patients (87.7%), and performed open distal anastomosis in all patients. The operative mortality was 5.4% (38/702), and the incidence of stroke was 10.8% (76/702). The 7‐year overall survival and freedom from aortic reinterventions were 80.4% and 87.5%, respectively. Compared with the nonclamping group, the crossclamping group had a shorter operation time, similar operative mortality, incidence of stroke, and freedom from aortic reinterventions. Conclusions: Emergency surgery for acute type A aortic dissection based on our systematic approach demonstrated excellent early and late outcomes. The temporary aortic crossclamping during cooling decreased the operation time without increasing early and late adverse events.

Causes of repair failure for degenerative mitral valve disease and reoperation outcomes

OBJECTIVES This study aimed to evaluate the causes of initial mitral valve (MV) repair failure, the details of reoperation and the long-term outcomes of mitral valve re-repair (Re-MVP). METHODS We retrospectively reviewed 86 patients who underwent reoperation after MV repair for MR due to degenerative disease from October 1991 to December 2015. First, we analysed the initial MV repair data, causes of MV repair failure, reoperation data and long-term outcomes including survival. Second, the patients were classified into 2 groups based on valve related failure or procedure related failure , and the differences between the groups were analysed. RESULTS Leaflet prolapse at the initial operation affected the bilateral leaflets in 37 (43%) patients, the anterior leaflet in 30 (35%) patients and the posterior leaftlet in 19 (22%) patients. Median duration from first operation to reoperation was 47.5 (interquartile range 4.8-85.8) months. Reoperation indication included recurrent mitral regurgitation alone in 59 patients, haemolysis combined with recurrent mitral regurgitation in 15 patients, infectious endocarditis combined with recurrent mitral regurgitation in 8 patients, mitral stenosis in 2 patients and left ventricular pseudoaneurysm in 2 patients. The cause of MV repair failure was valve-related in 61 (71%) patients, procedure-related in 20 (23%) patients and both in 5 (6%) patients. Re-MVP was successful in 23 (27%) patients. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Freedom from all-cause death was significantly better after Re-MVP. The 5-year freedom from reoperation after Re-MVP was 95.7%. CONCLUSIONS Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Durability of re-repaired MVs and survival of re-repaired patients were acceptable.

Management of acute aortic dissection and thoracic aortic rupture

BackgroundBoth acute aortic dissection and ruptured aortic aneurysm are leading causes of death in cardiovascular disease. These life-threatening conditions have recently been categorized as acute aortic syndrome. This review describes the etiology, clinical presentation, and therapeutic options for acute aortic syndrome including acute aortic dissection and ruptured aortic aneurysm.Main bodySeveral diagnostic tools for detecting these critical conditions have been developed including computed tomography, ultrasonography, magnetic resonance imaging, and laboratory tests. Early and accurate diagnosis is most important to determine appropriate treatment. Initial treatment for these conditions should be aimed at controlling pain and the hemodynamic state with further treatment based on the imaging diagnosis and hematological assessment. Surgical outcomes after acute aortic syndrome are improving gradually; however, mortality remains high. Recently, thoracic endovascular aortic repair has become an alternative technique to treat complicated type B aortic dissection. Rapid treatment after early diagnosis is essential to save patients’ lives.ConclusionsContinuous advances in imaging and treatment technologies are improving short- and long-term outcomes in patients with acute aortic syndrome. Knowledge and interest in intensive care medicine in this area are contributing to improved outcomes, and further research into this life-threatening disease will lead to improvements in diagnosis and management.

Early and Mid-Term Outcomes after Vascular Reconstruction for Patients with Lower-Extremity Soft-Tissue Malignant Tumors

Objective: To evaluate limb-salvage surgery including vascular resection for lower-extremity soft-tissue sarcomas and carcinomas for adult patients. Materials and Methods: Eight consecutive patients (median age, 59 years) who underwent vascular replacement during surgery for malignant tumors in the lower limbs between November 2006 and March 2018 were evaluated. Patient data were retrospectively obtained in a computerized database. Arterial and venous reconstructions were performed for seven patients, with one additional patient receiving venous reconstruction only. Autologous-vein (n=6) and synthetic bypasses were used for arterial repairs, whereas only autologous veins were implanted for venous repairs. Results: Morbidity was 62.5%, and in-hospital mortality was 12.5%. At a median follow-up of 24 months, the primary patency rates of arterial and venous reconstructions were 85.7% and 62.5%, respectively. Limb salvage was achieved in all cases. Conclusion: Early and mid-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of soft-tissue tumors involving major vessels of the lower limbs. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma and carcinoma resections. However, efforts to achieve better control over systemic spread are required for long-term survival.

Concomitant aorto-right subclavian artery bypass with off-pump coronary artery bypass grafting: a case report

BackgroundAtherosclerotic stenosis of the brachiocephalic artery sometimes occurs in patients with coronary artery disease, and can cause stroke during the perioperative period of coronary artery bypass grafting.Case presentationWe describe the case of a 77-year old male with severe stenosis of the brachiocephalic artery and severe coronary artery disease. He successfully underwent aorto-right subclavian artery bypass that was performed concomitantly with off-pump coronary artery bypass.ConclusionConcomitant aorto-subclavian artery bypass with off-pump coronary artery bypass grafting is a therapeutic option that minimizes the risk of perioperative stroke in patients with brachiocephalic artery stenosis and coronary artery disease.

Multiple Giant Coronary Artery Aneurysms

A 74-year-old man was admitted to our hospital with chest pain and dyspnea associated with ST elevation in leads II, III and aVF. An echocardiogram showed an enlarged mass lesion measuring nearly 80 mm. Coronary angiography showed two giant coronary artery aneurysms (CAAs) in the right coronary artery (RCA). CAAs were also seen in the left main trunk and left anterior descending artery. Computed tomography showed the CAA in the RCA was ruptured into the right atrium. We therefore diagnosed this patient with multiple CAAs, myocardial infarction and coronary artery rupture. He underwent successful surgical excision and coronary bypass surgery.

Repair of left ventricular rupture in a patient with mitral annular calcification

Left ventricular free wall rupture is a complication following acute myocardial infarction or mitral valve replacement. We report the case of a 56-year-old female patient with idiopathic left ventricular rupture confirmed by contrast-enhanced computed tomography (CT). CT also showed no coronary artery obstruction and severe mitral annular calcification. Left ventricular rupture was successfully repaired internally with bovine pericardium. Mitral valve replacement with annular decalcification was also performed.

When Is the Optimal Timing of Surgical Intervention for Severe Functional Tricuspid Regurgitation

Functional tricuspid regurgitation (TR) is a serious pathology to be noted for severe right heart failure (HF) and poor prognosis; however, the conventional assessment of TR has some limitations and the optimal timing of surgical intervention remains unclear. A 79-year-old Japanese female was admitted to our hospital to undergo cardiac surgery, because edema gradually got worse despite the increase in diuretics. She had a history of atrial fibrillation (AF) and chronic HF due to severe TR and had been treated with a furosemide for leg edema 4 years ago. A transthoracic echocardiogram (TTE), transesophageal echocardiogram, cardiac magnetic resonance imaging, and cardiac pool scintigraphy demonstrated severe functional TR with tricuspid annular dilation, insufficient tricuspid valve coaptation, and reduced right ventricular ejection fraction (EF) but preserved left ventricular EF. In addition, Swan-Ganz catheter study showed normal pulmonary arterial wedge pressure and mean pulmonary arterial pressure. Tricuspid ring annuloplasty was performed with MC3 ring. Postoperative TTE showed trivial TR, and she had no edema with normal sinus rhythm two months later. Annuloplasty to severe functional TR caused by tricuspid annular dilation due to AF dramatically improved right HF. Cardiologist should pay strict attention to the optimal timing of surgical intervention for TR.

Controversy: Composite Grafts Versus Individual Grafts

Multiple arterial myocardial revascularizations are increasingly being performed off pump using various arterial grafting techniques. The superior patency rate of the internal thoracic artery as an in situ graft makes it the most reliable, and in situ right gastroepiploic artery grafting for a severely stenotic right coronary artery is another established technique. However, it is sometimes necessary to combine these grafts with a free arterial graft in order to achieve complete revascularization. The combination of an in situ left internal thoracic artery with free right internal thoracic and radial arteries is an excellent choice in this situation. These composite grafts have the advantage of preventing postoperative stroke because manipulation of the ascending aorta can be avoided, but they may risk hypoperfusion or jeopardize graft patency. In contrast, an individual free graft with proximal anastomosis to the aorta is still widely used. Its safety is improving with the aid of epiaortic ultrasonography and a clampless anastomotic device. The present chapter addresses the advantages and disadvantages of individual and composite arterial grafts.

Aortic Regurgitation due to Commissural Dehiscence of the Aortic Valve

Commissural dehiscence of the aortic valve is a rare cause of aortic regurgitation. We report a 53-year-old male who had progressive aortic regurgitation and aortic root dilatation. A flap or intimal tear of the proximal aorta was absent with echocardiography and computed tomography. Transesophageal echocardiography revealed prolapse of the right and left coronary cusps with no intimal flap in the ascending aorta. During the operation, there was no dissection or intramural hematoma in the ascending aorta. However, there was dehiscence of the commissure between the right and left coronary cusps of the aortic valve. Aortic root and ascending aortic replacements were successfully performed. Commissural dehiscence of the aortic valve should be taken into account when prolapse of the aortic cusp is the cause of aortic regurgitation.