Yoshiro Higuchi

Additional percutaneous transluminal pulmonary angioplasty for residual or recurrent pulmonary hypertension after pulmonary endarterectomy

BACKGROUND Pulmonary endarterectomy (PEA) has been the most effective therapy for chronic thromboembolic pulmonary hypertension (CTEPH). However, residual or recurrent pulmonary hypertension often persists after PEA. Recently, catheter-based angioplasty, called percutaneous transluminal pulmonary angioplasty (PTPA) or balloon pulmonary angioplasty, has been developed as a promising strategy for CTEPH. Therefore, the usefulness of PTPA for residual or recurrent pulmonary hypertension after PEA was investigated. METHODS Thirty-nine patients underwent PEA from January 2000, and a total of 423 consecutive PTPA sessions in 110 patients were performed from January 2009 to May 2014. Of them, 9 patients (23.0% of 39 patients undergoing PEA and 8.2% of 110 patients undergoing PTPA) had undergone previous PEA and additional PTPA. RESULTS In these 9 patients, pulmonary vascular resistance (PVR) was 15.6 (7.8-18.9) wood units at baseline, and significantly improved after PEA [5.6 (3.5-6.5) wood units] (p<0.05). However, PVR gradually deteriorated before PTPA [8.1 (6.1-12.3) wood units] compared to after PEA, suggesting that these 9 patients had residual or recurrent pulmonary hypertension after PEA. PTPA was performed at 4.1 (2.7-7.9) years after PEA. Follow-up catheterization at 1.9 (1.3-3.3) years after PTPA revealed significant improvement of PVR [4.2 (2.8-4.8) wood units] (p<0.05). CONCLUSIONS A hybrid approach combining PEA and additional PTPA may be reasonable for patients with both proximal and very distal lesions not easily approachable by PEA. PTPA could be a promising alternative therapeutic strategy for residual or recurrent pulmonary hypertension after PEA.

Respiratory and Hemodynamic Changes in Patients with Chronic Thromboembolic Pulmonary Hypertension 1 Year after Pulmonary Endarterectomy

We reviewed the results of thromboembolectomy, which was performed for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), 1 year after the operation. We obtained hemodynamic and respiratory data of 60 patients from the 112 patients who were operated at our institute. The hemodynamic parameters such as mean pulmonary arterial pressure (PAP), pulmonary vascular resistance (PVR), and cardiac index (CI) were significantly improved after the operation, and this improvement of pulmonary hemodynamics persisted even a year after the operation. A significant improvement in gas exchange was observed immediately after the operation and a further elevation in the partial pressure of oxygen in arterial blood (PaO2) was observed 1 year after the operation. (English Translation of J Jpn Coll Angiol 2012; 52: 53-58).

The importance of preoperative magnetic resonance imaging in valve surgery for active infective endocarditis

PurposeValve surgery for active infective endocarditis (IE) can cause fatal brain hemorrhage. Our current study aimed to evaluate the incidence of septic cerebral lesions in active IE patients by performing preoperative magnetic resonance imaging (MRI) including T2*- weighted sequences and magnetic resonance angiography (MRA) before urgent valve surgery, and to investigate whether such preoperative evaluation affects postoperative outcomes.MethodsEighteen patients were referred to our department for native valve IE during 2006–2010. Urgent surgery was indicated in cases of hemodynamic failure resulting from valve destruction, refractory sepsis, and mobile vegetations measuring >10 mm. For these patients, we performed preoperative MRI and MRA.ResultsMales comprised 67% of the subjects, with average age 53 ± 15 years. No clinical evidence of acute stroke was noted. Of the 18 patients, urgent surgery was indicated in 15; of these, 10 (67%) showed a brain lesion related to IE: 6 patients had acute or subacute brain infarctions, 2 patients had brain infarction with brain abscess, and 2 patients had hemorrhagic brain infarction and so did not undergo urgent surgery. Thus, 13 patients underwent urgent valve surgery. Among the 5 patients who did not undergo urgent surgery, 4 patients later underwent valve surgery for healed IE. No hospital deaths or neurological complications occurred.ConclusionMRI of patients with active IE revealed a high incidence of cerebral lesions caused by IE. The use of MRI to detect septic embolism and intracerebral hemorrhage may provide important information for better surgical outcomes.

Recent Outcomes of Surgery for Chronic Type B Aortic Dissection

OBJECTIVE Chronic type B dissection though optimal is still considered to be a controversial procedure, even in the advent of stent grafts. Recently, we used a novel surgical technique involving left axillary perfusion to analyze the results of our surgical strategy and compare them with those reported in the literature. MATERIALS AND METHODS Between August 2004 and July 2009, 39 patients underwent graft replacement for chronic type B aortic dissection. The left axillary artery was used for perfusion inflow. Perfusion was maintained at approximately 23˚C during open proximal anastomosis. The graft was anastomosed to the distal true lumen whenever possible. RESULTS Open proximal anastomosis was performed in 22 patients (56%). In 24 cases (62%), grafts were anastomosed to the true lumen of the peripheral aorta. The early overall mortality rate was 3% (1 patient). Permanent cerebral infarction occurred in 2 patients (5%); and paraparesis, in 1 patient (3%). The Kaplan-Meier survival estimates were 91% at 2 years and 88% at 5 years. CONCLUSION Our surgical strategy is associated with excellent short-term and midterm outcomes. Although further investigation is needed, this strategy may be useful for patients with chronic type B dissection.

Recurrence of Aneurysm of the Ascending Aorta after Patch Repair: The Fate of an Aortic Patch

Pseudoaneurysm of the ascending aorta is a rare but life- threatening complication after aortic cannulation and cardiovascular surgery, and it has the potential to rupture. We experienced a rare case of recurrence of aneurysm of the ascending aorta 7 years after patch repair of a small aneurysm at an aortic cannulation site. The repaired aorta had been wrapped with a Teflon felt strip during the previous surgery, and the wrapped aorta had become thin with deterioration of the normal structure of the aortic wall.

Recovery from anthracycline-induced cardiomyopathy with biventricular assist and valve repairs: A case report and literature review:

Introduction: Ventricular assist device is used in the patients with severe heart failure due to cardiotoxicity of anthracyclines, which are widely used chemotherapeutic agents for a wide range of malignant tumors. However, recovery of cardiac function is rare. Methods: We present the clinical course of a 43-year-old woman in remission from diffuse large B-cell lymphoma after the chemotherapy including anthracyclines, who presented in cardiogenic shock 8 months after the end of chemotherapy. Results: The patient was initially treated with intra-aortic balloon pumping, followed by conversion to left ventricular assist device with an Abiomed AB5000 (Abiomed, Inc, Danvers, MA) and right ventricular assist device with a centrifugal pump and a membrane oxygenator, in addition to tricuspid annuloplasty, due to rapid deterioration to cardiogenic shock. With intensive medical treatments during biventricular support, her cardiac and respiratory functions gradually improved, although moderate mitral regurgitation persisted despite of left ventricular unloading. At 64 days of biventricular support, she underwent mitral valve annuloplasty to correct regurgitation under cardiopulmonary bypass. She was consequently weaned from biventricular assist successfully 8 days after mitral surgery (72 days of biventricular support). The patient discharged uneventfully from our hospital and survives at home 12 months after weaning from the ventricular assist devices. Conclusion: Our case and the literature review highlight potential usefulness of aggressive mechanical biventricular support for cardiac recovery in patients with anthracycline-induced cardiomyopathy. Additional valve surgery and neurohormonal medications may be also promising in such patients with cancer, who are contraindicated for heart transplantation.

Retrograde Ascending Aortic Dissection after Stent Grafting for Stanford Type B Aortic Dissection with Severe Limb Ischemia

We report a rare case of retrograde Stanford type A aortic dissection after endovascular repair for complicated Stanford type B aortic dissection. A 45-year-old man presented with a sudden onset of back pain and was transferred to our hospital. Computed tomography demonstrated acute Stanford type B aortic dissection with lower limb ischemia. Emergency endovascular surgery was planned for repair of the Stanford type B aortic dissection. The patient suddenly developed recurrent chest pain 10 days after the initial procedure. Computed tomography revealed retrograde Stanford type A aortic dissection involving the ascending aorta and aortic arch. The patient underwent a successful emergency total aortic arch replacement.

Paraplegia following the emergency surgical repair of a nonruptured symptomatic abdominal aortic aneurysm: Report of a case

This report presents an extremely rare case of paraplegia following emergency surgery for a nonruptured symptomatic abdominal aortic aneurysm. A 62-year-old man underwent an emergency surgical repair for a symptomatic nonruptured infrarenal abdominal aortic aneurysm. On postoperative day 2 paraplegia following spinal cord ischemia occurred at the T8 level. The site of the ischemia was situated too high for clamping to have caused this condition, unless the patient had a congenital anomaly in the blood supply to the spinal cord or it had been caused by the previously occluded great radicular artery, which was maintained by the collateral blood supply from the iliac circulation.

Circulatory assistance and surgery for residual pulmonary hypertension following thromboendarterectomy.

Chronic thromboembolic pulmonary hypertension (CTEPH) complicated by pulmonary hypertension is resistant to medical therapy and has a poor prognosis. The only therapy effective for CETPH is thromboendarterectomy (TEA). CTEPH is divided into four types, depending on the presence of thrombus in the pulmonary arteries. In Japan, CTEPH is generally divided into central and peripheral types. The results of surgery for the central type have recently become more favorable. However, the results of surgery for the peripheral type are not favorable due to inadequate surgical indications, surgical procedures, and perioperative care. To improve the results of surgery for peripheral CTEPH, the most important issue is treating residual pulmonary hypertension. For patients with residual pulmonary hypertension, it is impossible to perform removal from extracorporeal circulation during surgery. In addition, it is difficult to save lives unless percutaneous cardiopulmonary support (PCPS) is introduced in all cases. However, with circulatory assistance with PCPS alone, several deaths have occurred due to left ventricular failure during the procedure. Therefore, the authors began to use circulatory assistance with intraaortic balloon pumping (IABP). The authors compared circulatory assistance with PCPS alone with concomitant use of PCPS and IABP for postoperative residual pulmonary hypertension in patients with CTEPH. Although there have been few surgeries for this disease in Japan, we discuss the results of 30 recent surgical cases.