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A 58-year-old female who underwent renal transplantation and closure of arteriovenous fistula (AVF) for hemodialysis at age 24 was presented with left forearm pain and cyanosis. Computed tomography revealed an obstructed true brachial aneurysm at the anterior aspect of the elbow joint. Under a diagnosis of true brachial aneurysm associated with AVF, aneurysm resection and brachial to ulnar artery bypass grafting using a reversed great saphenous vein were performed. To prevent graft occlusion due to elbow flexion, it was routed through the ulnar side of the elbow joint. One year after surgery, the patient was asymptomatic with a patent graft. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve implantation (TAVI) for patients with rheumatic aortic stenosis (AS) is not well-known. We herein report a case of TAVI in rheumatic AS without significant calcification and prior mitral valve replacement. An 80-year-old woman underwent TAVI for severe AS. Preoperative computed tomography revealed tricuspid aortic valve leaflets with commissural fusion, minimal calcification, and a minimal distance between the aortic annulus and mechanical mitral valve. TAVI was performed through a transfemoral approach under general anesthesia. After predilatation of the aortic valve with a 20-mm balloon, a 23-mm SAPIEN 3 valve was successfully deployed via slow inflation. Valve embolization did not occur, and the valve did not interfere with the prosthetic mitral leaflets. This report shows that TAVI can be safe, feasible, and effective in patients with rheumatic AS without significant calcification and prior mitral valve replacement. < Learning objective: The reports of the safety of transcatheter aortic valve implantation (TAVI) for patients with rheumatic aortic stenosis (AS) are few. We herein report a case of TAVI in rheumatic AS without significant calcification and prior mitral valve replacement. TAVI is a potential alternative treatment for patients with rheumatic AS.> [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Although concomitant surgery for coronary artery disease (CAD) and thoracic aortic aneurysm is performed often, the long-term patency of the coronary artery bypass grafting (CABG) anastomosed to a vascular prosthesis has not been fully investigated. Here, we explored the long-term patency of the graft in comparison with the proximal anastomosis site on the native ascending aorta or vascular prosthesis. METHODS A total of 84 patients with concomitant CABG who underwent surgery for thoracic aortic aneurysm at 3 Osaka Cardiovascular Research Group institutes were retrospectively investigated for this study. The patency of 109 aortocoronary bypasses using saphenous vein grafts was evaluated with computed tomography angiography or coronary angiography, comparing the grafts anastomosed on the vascular prosthesis (group P, n  = 75) to those anastomosed on the native ascending aorta (group N, n  = 34). RESULTS During 45.9 ± 39.7 months follow-up, significantly worse patency of the grafts in group P was revealed when compared with those in group N (100% vs 77.6% in 12 months, 100% vs 52.7% in 36 months and 100% vs 31.6% in 57 months, log rank P  < 0.001). The poor patency of the grafts was confirmed in each target lesions (left anterior descending artery: P  = 0.050, right coronary artery: P  = 0.045, left circumflex artery: P  = 0.051) and regardless of the severities of the target coronary vessels (severe stenosis: P  = 0.013, mild-to-moderate stenosis: P  = 0.029). Furthermore, an analysis of graft occlusion risk factors using the univariate Cox proportional hazards model revealed that the proximal anastomosis site on the vascular prosthesis was the sole risk factor for graft occlusion (P  < 0.001). CONCLUSIONS In the simultaneous surgery for CAD and thoracic aortic aneurysm, CABG design from vascular prosthesis to coronary artery should be avoided if possible, although further studies are warranted. [ABSTRACT FROM AUTHOR]

Aims: In patients with ischaemic mitral regurgitation (MR), the impact of mitral valve surgery with concomitant coronary artery bypass grafting (CABG) on post‐operative survival and left ventricular (LV) reverse remodelling remains unknown. Therefore, we investigated these outcomes following restrictive mitral annuloplasty (RMA) with and without CABG in those patients. Methods and results: This study included 309 patients with chronic MR and ischaemic cardiomyopathy for whom concomitant CABG was indicated (n = 225) or not indicated (n = 84) with RMA. The primary endpoint was all cause mortality during the follow‐up, and the secondary endpoint was defined as the composite of mortality and re‐admission for heart failure. Linear mixed model was used to analyse serial echocardiographic changes in LV function. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent RMA with and those who underwent it without CABG, we established weighted Cox proportional‐hazards regression models with inverse‐probability‐of‐treatment weighting. Pre‐operatively, there were no intergroup differences in age (RMA with CABG, 67 ± 9 vs. RMA without CABG, 68 ± 11, P = 0.409) and logistic EuroSCORE II (16 ± 14 vs. 15 ± 15%, P = 0.496). The 30‐day mortalities were 2.7% and 3.6%, respectively (P = 0.67). During follow‐up with a mean duration of 72 ± 37 months (range, 5.6–179), there were 157 deaths and 105 re‐admissions for heart failure. Overall 1‐year and 5‐year survival rates were 83 ± 2% and 58 ± 3%, respectively. Patients who did not receive CABG with RMA had a significantly lower 5‐year survival rate (45% vs. 63%, P = 0.049) and freedom from adverse events defined as mortality and/or admission for heart failure (19% vs. 43%, P < 0.001) than those who did. After adjustments for clinical covariates with inverse‐probability‐of‐treatment weighting, concomitant CABG was identified as an independent protective factor for adverse events (hazard ratio: 0.53; 95% confidence interval: 0.44–0.64; P < 0.001). Along with significant MR reduction, LV function parameters changed over time after surgery in both groups, with greater improvements in patients who underwent RMA with CABG (time effect, P < 0.001; and interaction effect, P = 0.002). Conclusions: RMA can be performed with an acceptable operative mortality, irrespective of indications for CABG. Patients with ischaemic MR for whom CABG is indicated with RMA are more likely to show better long‐term and event‐free survival and greater improvements in LV systolic function. The optimal revascularization strategy should be discussed with a heart team whenever indicated in patients with ischaemic MR; otherwise, they may miss the opportunity to benefit from concomitant CABG during subsequent RMA. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES To date, the optimal timing for patients with infective endocarditis (IE) with acute cerebral infarction (CI) to undergo valve surgery is unknown. Although some previous studies have reported that early valve surgery for IE patients within 1 or 2 weeks after CI could be performed safely, an initial strategy has not been identified because of the unmatched cohorts in previous studies. This study aimed to assess the feasibility and safety of early surgery within a few days after cerebral infarction by using propensity score matching. METHODS Between 2009 and 2017, 585 patients underwent valve surgery for patients with active IE at 14 institutions. Among these, 152 had preoperative acute CI. Early surgery was defined as surgery within 3 days after the diagnosis of CI. Of these 152 patients, 67 underwent early valve surgery (early group), whereas 85 underwent delayed valve surgery (delayed group). Of the patients, 45 in each group were analysed using propensity score matching. The primary outcome was in-hospital death after valve surgery, and secondary outcomes included neurological complications. We compared the clinical results of these matched patients. RESULTS Hospital mortality was lower in the early group (2% vs 16%, P  = 0.058). The rate of postoperative intracranial haemorrhage in the early and delayed groups was 4% in both groups. The postoperative modified Rankin scale was not significantly different [early group: 0 (0–2); delayed group: 0 (0–2)]. Incidence of neurological deterioration did not differ significantly between the groups. The survival rates after the first discharge at 1, 3 and 5 years after valve operation were 100%, 97% and 97% in the early group and 91%, 83% and 80% in the delayed group, respectively (P  = 0.029). CONCLUSIONS Early valve surgery for patients with IE within 3 days after a CI measuring <2 cm in size improved clinical results without increasing the incidence of postoperative neurological complications. [ABSTRACT FROM AUTHOR]

Late open conversion (LOC) after endovascular aneurysm repair (EVAR) is associated with high morbidity and mortality. Standard surgical technique of LOC has not been established. This report presents a rapid aneurysmal formation in the unreplaced infrarenal aorta after LOC with complete endograft explantation without suprarenal fixations. A 76-year-old man presented with a left common iliac artery aneurysm (CIAA), for which he underwent EVAR to embolize the left internal iliac artery. Although his aneurysmal sac size initially showed a reduction, computed tomography at the 3-year interval post-EVAR demonstrated an increased sac size. Thus, he underwent open aortic repair of the CIAA. Though the postoperative course was uneventful, the size of the unreplaced infrarenal aorta showed a significant increase one year after open conversion. Reoperation was performed, but vascular prosthesis infection occurred as a complication and the patient died on the 196th postoperative day. [ABSTRACT FROM AUTHOR]

Background: The long-term effects of some surgical treatment procedures of arch replacement for aortic dissection or aortic aneurysm are unknown.Case Presentation: The present study reports the case of a 68-year-old man admitted to our hospital for aortic arch anastomotic pseudoaneurysm with concomitant aortic root enlargement and coronary artery stenosis. Eleven years ago, at the age of 56 years, he underwent total arch replacement with island reconstruction for chronic aortic dissection. We performed a second total arch replacement, aortic root replacement, and coronary artery bypass, using a cardiopulmonary bypass with cannulation through the right subclavian artery, femoral artery, and femoral vein prior to re-sternotomy. We also used selective cerebral perfusion. Postoperatively, the patient temporarily required reintubation; however, he was discharged in good condition on the fiftieth postoperative day.Conclusions: This case suggests that island reconstruction has the potential to cause arch anastomotic pseudoaneurysms, particularly after a long postoperative period. [ABSTRACT FROM AUTHOR]

Anomalous origin of the coronary artery from the aortic arch associated with hypoplastic left heart syndrome is an extremely rare anomaly. Coronary anomalies can significantly deteriorate the clinical outcomes of hypoplastic left heart syndrome. We describe the case of a newborn with concomitant hypoplastic left heart syndrome and abnormal origin of the left coronary artery arising from the distal aortic arch. [ABSTRACT FROM AUTHOR]

Congenital absence of a single pulmonary valve cusp is extremely rare. We report a case of a 38-year-old woman with a confirmed congenital absence of a single pulmonary valve cusp associated with dextrocardia. The other 2 leaflets were moderately hypoplastic, and transthoracic echocardiography showed severe pulmonary regurgitation. This combination of lesions has not been reported previously. Pulmonary valve replacement using a composite biologic valved conduit was performed with an excellent outcome. [ABSTRACT FROM AUTHOR]

The article describes the case of a 32-year-old male patient that was diagnosed with acute type B aortic dissection.

The location of the pump pocket for the left ventricular assist system is of great importance because of its direct relation to subsequent complications. The Novacor device has usually been implanted at the space behind the rectus muscle, which leads to occasional bleeding from raw muscle surfaces and to subsequent pocket infection. Although intraabdominal placement causes less bleeding and is more refractory to later pocket infection, direct contact with the visceral organs sometimes causes serious complications. We constructed a pouch from an expanded polytetrafluoroethylene sheet, and this enabled intraabdominal placement of the Novacor device. [Copyright &y& Elsevier]

The article describes the case of a 74-year-old male who underwent total laryngectomy with a terminal tracheostoma for laryngeal cancer, with silicosis and end-stage chronic kidney failure, requiring permanent hemodialysis. Topics discussed include the result of his echocardiogram which showed a dilated left ventricle and severely impaired left ventricular function, the insertion of a flexible spiral tracheal tube through the tracheostoma, and the collar incision below the trachaeostoma.

Abstract: We report a case of unusual thrombus formation and describe the risk of perioperative myocardial infarction or stroke in severe aortic stenosis after apico-aortic conduit. An 86-year-old woman was admitted with aggravation of dyspnoea on exertion and chest pain. She was complicated with severe aortic stenosis and liver cirrhosis. Echocardiography demonstrated a peak pressure gradient of 50mmHg across the aortic valve with ejection fraction of 51%. Since she had porcelain aorta and severe liver dysfunction, we selected an apico-aortic conduit under left ventricular fibrillation as treatment. Postoperative computed tomography showed a large thrombus in the descending aorta. Using strict anticoagulation therapy, the thrombus almost disappeared and thrombo-embolic events did not occur after surgery. [Copyright &y& Elsevier]

The article presents a case study of a 78-year-old man with exertion dyspnoea and chest pain who was diagnosed with ventricular septal perforation at apex, presenting along with several computed tomographic images.

A 13-year-old boy developed cardiogenic shock secondary to end-stage dilated cardiomyopathy and extracorporeal life support (ECLS) was initiated. However, pulmonary hemorrhage occurred due to severe pulmonary hypertension. He underwent implantation of a left ventricular assist system (LVAS) and right ventricular assist system (RVAS) plus extracorporeal membrane oxygenation (ECMO) shunting between the right and left atrium. Pulmonary damage was resolved and RVAS-ECMO was terminated after 8 days of support. [Copyright &y& Elsevier]

Background: Consensus regarding an optimal atrial fibrillation (AF) ablation lesion set concomitant with aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) has not been established., Methods: We enrolled 125 consecutive patients (89 men; 70 ± 8 years old) with persistent AF who underwent radiofrequency-based pulmonary vein isolation (PVI) (PVI group, n = 53) or a Cox-Maze procedure (Maze group, n = 72) with AVR and/or CABG. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent Cox-Maze with and those who underwent PVI, we established weighted Cox proportional-hazards regression models with inverse probability of treatment weighting. Mean follow-up was 63 ± 34 months (maximum, 154 months)., Results: There was 1 in-hospital death in each group. Patients who underwent Cox-Maze showed a higher freedom from AF at all follow-up examinations. After the operation, there were 32 deaths, 13 thromboembolisms, 8 hemorrhagic events, and 22 heart failure readmissions. The Maze group had higher rates for 5-year survival (88% vs 64%, P = .013) and freedom from composite events (74% vs 42%, P < .001). After adjustment with inverse probability of treatment weighting, the Cox-Maze procedure still showed a lower risk of overall mortality (adjusted hazard ratio, 0.38; 95% confidence interval, 0.21-0.66; P = .001) and composite adverse events (adjusted hazard ratio, 0.52; 95% confidence interval, 0.35-0.76; P = .001)., Conclusions: In patients with persistent AF indicated for nonmitral valve surgery, a concomitant Cox-Maze procedure resulted in superior AF- and event-free survival compared with PVI, without increased risk of early mortality. These findings may assist decision making for surgical management of persistent AF concomitant with AVR and/or CABG., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Early surgery for infective endocarditis (IE) with acute heart failure (AHF) is recommended, despite clinical results being unclear. We investigated the effect of initial treatment in such patients. Methods and Results: Outcomes for 470 patients with active IE who underwent valvular surgery during 2009-2016 were reviewed. Of them, 177 had symptomatic AHF when diagnosed with IE (excluding those with cardiogenic shock or intubated for AHF). They were divided into 2 groups based on initial treatment: Group S (underwent valvular surgery immediately; n=74) and Group M (received initial medical treatment for infection and HF; n=103). The median (interquartile range) waiting period from diagnosis to surgery in Groups S and M was 1 (1-3) and 15 (8-33) days, respectively (P<0.001). The 5-year survival rate was higher in Group S than Group M (80% vs. 64%; P=0.108). Group M was divided into Group P (initial medical treatment was effective and elective surgery was performed; n=62) and Group E (emergency surgery was necessary during medical treatment; n=41); overall 5-year survival was significantly worse in Group E than Group P (42% vs. 79%; P<0.012). In Group M, multivariate analysis indicated that Staphylococcus aureus infection (odds ratio 3.82; 95% confidence interval 1.19-13.3; P=0.024) was a significant risk factor for conversion to emergency surgery., Conclusions: Considering poor outcomes of emergency surgery for medically refractory HF, early surgery may be a reasonable option for IE patients, especially those with S. aureus infection.

Objectives: Left atrial (LA) dimension can predict atrial fibrillation (AF) recurrence after catheter-based or surgical ablation. Pulmonary vein isolation (PVI) may be a surgical option during aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG), though consensus regarding patient selection and late outcome is lacking., Methods: We studied 160 patients (mean age 70 ± 9 years) with paroxysmal AF who underwent radiofrequency-based PVI during AVR and/or CABG, and were followed up postoperatively for at least 6 months. Mean preoperative LA dimension was 44 ± 7 mm. Serial echocardiography was performed to evaluate left ventricular (LV) and LA dimensions, E/e', estimated systolic pulmonary artery (PA) pressure and degree of valvular regurgitation. Follow-up was completed with a mean duration of 47 ± 25 months., Results: At the latest follow-up, 133 patients (83%) remained in sinus rhythm. Preoperative LA dimension was independently associated with increased risk of AF recurrence at 6 months after surgery [adjusted odds ratio 1.3 per 1-mm increase in LA dimension, 95% confidence interval (CI) 1.1-1.6, P < 0.001]. Receiver-operating characteristic curve analysis demonstrated an optimal cut-off value for preoperative LA dimension of 45 mm to predict sinus rhythm restoration (98% for <45 mm vs 55% for ≥45 mm, P < 0.001). Patients with LA dimension ≥45 mm had a significantly lower 5-year survival rate (62 ± 7 vs 82 ± 7%, P = 0.025) and freedom from adverse events defined as cerebral infarction/haemorrhage, admission for heart failure, catheter ablation and permanent pacemaker implantation (58 ± 7 vs 91 ± 4%, P < 0.001). Multivariate analysis showed that preoperative LA dimension ≥45 mm was independently associated with adverse events (adjusted hazards ratio 2.4, 95% CI 1.2-5.1, P = 0.019). Serial echocardiography demonstrated improvement in LV systolic function irrespective of LA dimension, whereas patients with LA dimension ≥45 mm showed less improvement in LA dimension and systolic PA pressure (interaction effect P < 0.001) and persistent higher E/e' (group effect P < 0.001), along with aggravated tricuspid regurgitation., Conclusions: In patients with paroxysmal AF related to aortic valve disease and/or coronary artery disease, a dilated left atrium (≥45 mm) was associated with inferior AF- and event-free survival after PVI, accompanied by persistent abnormalities in cardiac and haemodynamic function. These findings may assist patient selection for PVI during AVR and/or CABG., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background and Aim of the Study: Mitral valve regurgitation (MR) is known to deteriorate following adult atrial septal defect (ASD) repair in the mid to long-term. The study aim was to identify the risk factors for this deterioration., Methods: Between 1995 and 2011, a total of 93 consecutive patients (aged > or = 18 years) underwent ASD repair at the authors' institution. Patients who underwent concomitant procedures, other than tricuspid annuloplasty or maze procedure, were excluded; hence, 74 patients were enrolled in the study. MR was evaluated by transthoracic echocardiography shortly after surgery and subsequently on a regular basis in the outpatient clinic. Risk factors for the deterioration of MR were estimated using Cox proportional hazards regression., Results: The mean patient age at surgery was 48.0 +/- 17.1 years, and 20 patients (27%) had atrial fibrillation (AF) preoperatively. The mean follow up was 6.9 +/- 5.5 years. The degree of MR was not unchanged or not improved in 54 patients (73.0%) (group 1), but was increased by one grade in 12 patients (16.2%) (group 2), and by two or more grades in eight patients (10.8%) (group 3). At surgery, all patients in group 3 were aged > 50 years. In group 3, on echocardiography, the average end-diastolic left ventricular dimension was increased from 41.8 mm to 51.8 mm (p = 0.027), and enlargement of the mitral annulus was noted in seven patients. Four of the group 3 patients required reoperation for MR after ASD repair. The Cox proportional hazards model revealed preoperative AF (p = 0.045, hazard ratio (HR): 11.68, 95% confidence interval (95% CI): 1.05-129.48) and Qp/Qs > or = 2.8 (p = 0.015, HR: 9.19, 95% CI :1.53-55.04) to be independent risk factors of new-onset or aggravated MR (by two or more grades) after ASD repair., Conclusion: An earlier repair of ASD would be preferable in terms of MR aggravated after ASD repair. For elderly patients with a preoperative high Qp/Qs and AF, mitral valve annuloplasty with ASD repair should considered.