Wahei Mihara

Acute heart failure due to local dehiscence of aortic wall at aortic valvular commissure

Spontaneous dehiscence of the aortic wall at the aortic commissure is not recognized as one of the usual pathological causes of aortic regurgitation. We describe the case of a 56-year-old man with hypertension, who experienced acutely progressive congestive heart failure due to massive aortic regurgitation. Local layer dehiscence around the commissure was noted with partial detachment of the commissure resulting in the loss of commissural support with secondary rupture of a non-coronary cusp, which led to massive aortic regurgitation.

Acute thrombosis after endarterectomy of stented left anterior descending artery

Acute thrombosis of the endarterectomized coronary artery is a serious complication after coronary endarterectomy. Herein, we describe a case of a 65-year-old man who had undergone percutaneous stent implantation in the left anterior descending artery, then after he received an endarterectomy with the removal of stents severe in-stent restenosis occurred. Three days after the operation, sick sinus syndrome developed with acute myocardial infarction. Coronary angiography revealed thrombosis at the reconstructed site of the left anterior descending artery. Pacemaker implantation, intra-aortic balloon pumping, and aggressive anticoagulation produced recanalization of the left anterior descending artery.

Coronary endarterectomy and stent removal after iatrogenic perforation

Coronary perforation is a rare complication of percutaneous coronary intervention. We report a case of type 3 coronary artery perforation after stenting of the left anterior descending coronary artery. Pericardiocentesis was required to treat cardiac tamponade and prolonged balloon inflation did not stop the bleeding. Urgent surgical intervention with coronary endarterectomy, removal of the stent, and bypass grafting using the left internal mammary artery to the left anterior descending artery was successful. Complete removal of stent with endarterectomy is a feasible option for perforation as a complication of coronary stenting.

Pulmonary Atelectasis from a Posttraumatic Pseudoaneurysm of the Thoracic Aorta A Case Report and Review of the Literature

Atelectasis of the left lung due to tracheobronchial compression is a rare complication of posttraumatic pseudoaneurysms of the thoracic aorta. We describe the case of a 57-year-old man with a chronic posttraumatic pseudoaneurysm of the thoracic aorta with acute progressive dyspnea and complete atelectasis of the left lung. The patient underwent aneurysmectomy with an interposition of a Dacron graft using both median sternotomy and lateral thoracotomy. A diagnosis of posttraumatic aneurysm should be considered in patients with both acute left pulmonary atelectasis and a history of major chest trauma. A review of the literature regarding this clinical condition is also discussed.

Impact of initial aortic diameter and false-lumen area ratio on Type B aortic dissection prognosis

OBJECTIVES Medical treatment is the gold standard for uncomplicated acute Type B aortic dissection (ATBAD). Although endovascular treatment could become an alternative therapy, it is unclear which ATBAD patients should undergo endovascular intervention. We aimed to evaluate the outcomes of patients with uncomplicated ATBAD and identify the risk factors for major adverse events. METHODS We retrospectively reviewed 134 consecutive patients who underwent initial treatment for uncomplicated ATBAD between 2004 and 2015. Follow-up rate was 98.5%, and the median follow-up period was 47 months. We evaluated the incidence of major adverse events (aortic-related death, aortic surgery and dilated aorta ≥ 55 mm) and identified the predictors of major adverse events using multivariable analysis. RESULTS In-hospital mortality rate was 0.7% (1/134). During follow-up, 46 patients had major adverse events. The 1-, 3-, and 5-year rates of freedom from major adverse events were 79.8%, 71.4%, and 63.6%, respectively. The independent risk factors for major adverse events were initial aortic diameter ≥40 mm (hazard ratio 3.735, 95% confidence interval 1.888-7.390; P < 0.001) and false-lumen diameter > true-lumen diameter (hazard ratio 3.411, 95% confidence interval 1.491-7.806; P = 0.004). CONCLUSIONS Initial aortic diameter ≥40 mm and false-lumen diameter > true-lumen diameter are predictors of major adverse events after uncomplicated ATBAD. Patients with these risk factors may benefit from early endovascular intervention. Clinical registration number UMIN 000025388, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000029229.

Percutaneous vertebral angioplasty before coronary artery bypass grafting.

We report a case of a 63-year-old male with three-vessel coronary heart disease complicated by stenosis of the bilateral vertebral arteries. Triple coronary bypass grafting, using arterial conduits, was successfully performed after percutaneous balloon angioplasty of the left vertebral artery. Precedent angioplasty of a stenotic vertebral artery is safe and protects the brain from ischemia during extracorporeal circulation.

A Cause of Sudden Death: Rupture of Thoracic Aortic Aneurysm

Sudden death occurred during antihypertcnsive therapy of a Stanford type A dissecting aortic aneurysw. Hemodynamic and electrocardiograpbic events were recorded including deterioration of ventricular fibrillation 4 minutes after rupture.

FT11. The Optimal Aortic Diameter for Risk of Late Aortic Events in Uncomplicated Stanford Type B Aortic Dissection

with passive arterial shunt and two-graft technique to reduce these ischemic complications. A first bifurcated graft is anastomosed laterally to the distal descending thoracic aorta, before left renal artery bypass and intraoperative perfusion of both superior mesenteric and right renal arteries. A second graft is used for in-line aneurysm reconstruction. We herein present our experience of type IV TAA open repair using this technique. Methods: Twenty-four patients (mean age, 68 years) underwent elective open repair for type IV TAA with this technique between January 2011 and December 2017. The intervention was achieved through a left thoracophrenic lumbotomy, with retroperitoneal and retrorenal approach. A bifurcated graft was anastomosed laterally to the distal descending thoracic aorta to bypass the left renal artery before aortic cross-clamping. The second limb of this bifurcated graft was connected to a Y-shaped cannula to simultaneously perfuse both superior mesenteric and right renal arteries during supraceliac aortic cross-clamping (Fig 1). An additional tube or bifurcated graft was then used for in-line aneurysm reconstruction. The visceral aortic patch was anastomosed to the aortic graft with the Crawford inclusion technique. The prosthetic limb graft used as a temporary arterial shunt was ligated at the end of the intervention; the left renal artery bypass was preserved as part of the definitive arterial reconstruction (Fig 2). Patients’ records were analyzed for demographics, comorbidities, arterial lesions, operative variables, complications, and 30day mortality. Results: Mean left renal ischemia time was 10.5 minutes. Mean aortic cross-clamping was 31 minutes. The creatinine level at discharge was not significantly different from the preoperative level (15 vs 13; P 1⁄4 .01). Three patients (12.5%) had transient renal failure (Acute Kidney Injury Network stage 1) postoperatively. Prolonged ventilatory support (>2 days) was necessary in two patients (8%). No cardiac event, no dialysis, and no multivisceral organ failure have been recorded. The postoperative mortality rate was 4% (one patient). Conclusions: Type IV TAA repair with our passive shunt and two-graft technique provides short visceral and renal ischemia times and leads to low rates of end-organ ischemic damages. This technique could be an option to consider for visceral protection in type IV TAA open repair and spurs us on to maintain it for our future cases.

Late Disruption of a Polyethylene Terephthalate Aortic Graft 30 Years after Initial Graft Placement

A 71 year old male who had undergone extra-anatomic bypass grafting between the ascending aorta and the thoraco-abdominal aorta at 41 years of age for aortic coarctation was admitted with back pain and dyspnea. A 16 mm Cooley double velour knitted polyethylene terephthalate (PET) graft was used in the initial operation in 1983. Computed tomography showed disruption of the initial PET graft perforating the right atrium, and a pseudoaneurysm at the distal anastomosis. The patient was in acute cardiac failure because of left to right shunting. A two stage operation was performed. The first stage comprised emergency re-grafting and right atrium repair, and the second stage re-grafting for the pseudoaneurysm. The patient is doing well 48 months post-operatively; however, monitoring of the patient will continue for potential PET graft rupture.

An unusual ectopic calcification in the aorta.

A 49-year-old woman with end-stage renal failure who had been maintained on chronic hemodialysis since she was 40 was referred to our hospital for surgical treatment of mitral regurgitation. She had no history of infectious endocarditis. Transthoracic echocardiography (TTE) performed at the referring hospital showed severe mitral regurgitation with severely impaired left ventricular function (ejection fraction, 33%). Both anterior and posterior leaflets of the mitral valve were thickened and the annulus was dilated. No calcification was identified in a cardiac chamber by TTE. Coronary arteriography showed total occlusion of the right coronary artery. Findings on transesophageal echocardiography were extremely unusual. A hyperechoic mass was attached to the inside wall of the sinus of Valsalva (Fig 1). Although the mass was not floating, the patient was transferred urgently to the operating theater for resection of the mass. After cardiopulmonary bypass was established and the heart arrested, the aorta was incised transversely. The mass was attached to the right coronary sinus, just above the right coronary ostium, and resembled an icicle (Fig 2). This mass was dissected carefully from the intima of aorta. It was heavily calcified and friable, although its surface was smooth. The aortic valve and aortic wall were not calcified. The mitral valve was replaced with a bileaflet mechanical valve, and aorto-coronary bypass to the right coronary artery was performed using a saphenous vein graft. The postoperative course was uneventful. Histopathologic examination confirmed that the mass was fibrous tissue with dense calcifications. Address reprint requests to Dr Fukui, Department of Cardiovascular Surgery, Shin-Tokyo Hospital, 473-1 Nemoto, Matsudo City, Chiba 2710077, Japan; e-mail: tm-fukui@gem.hi-ho.ne.jp. Fig 1. Fig 2.