Search

Background Mycobacterium abscessus subsp. massiliense (MMA) comprises a group of non-tuberculous, rapidly growing mycobacteria. Although MMA can cause pulmonary diseases, surgical site infections, and disseminated diseases, aortic endograft infection has not been reported. Here, we describe the first case of aortic endograft infection caused by MMA. Case presentation Two months after stent-graft insertion for an abdominal aortic aneurysm, an 85-year-old man was admitted with fever and abdominal pain and was diagnosed with aortic endograft infection. Despite 14 days of meropenem and vancomycin intravenous administration, periaortic fluid pooling increased as compared to that before antibiotic administration. The abscess was drained, and fluorescent acid-fast staining of the abscess fluid revealed bacilli. The organism was identified as MMA by genetic testing. Intravenous imipenem–cilastatin (IPM/CS), amikacin (AMK), and oral clarithromycin (CAM) were administered. After 2 months, oral CAM and sitafloxacin were administered because the abscess had decreased in size. However, after 6 weeks, the abscess increased in size again. Antimicrobial susceptibility testing of the drainage fluid from the abscess resulted in the isolation of an MMA strain that had acquired resistance to CAM. Intravenous IPM/CS, AMK, and oral linezolid were added to the treatment regimen along with oral CAM and STFX. However, he was not fully cured and died 6 months later. Neither the full-length erythromycin ribosome methyltransferase (erm)(41) gene nor the rrl or rpIV gene mutations were found by Sanger sequencing in the pre- and post-treatment strains. Whole-genome sequence analysis of the post-treatment strain revealed mutations in genes with no previous reports of association with macrolide resistance. Conclusions Aortic endograft infection caused by MMA strain is extremely rare; nonetheless, MMA should be suspected as the causative microorganism when broad-spectrum antimicrobials are ineffective.

Haemophilus parainfluenzae is a gram-negative coccobacillus that is a part of the normal flora in the human upper airway and sometimes causes infective endocarditis. We present a case of a 68-year-old Japanese man who had vascular graft infection caused by H. parainfluenzae 4 years after surgery for chronic aortic dissection.

A 27-year-old Caucasian male traveler with well-controlled asthma was admitted to our hospital because of severe heart failure (HF). He had a history of cocaine use. Transthoracic echocardiography (TTE) showed severe diffuse hypokinesis of the left ventricle (LV) and a large mobile thrombus in the LV. He was treated with diuretics, inotropes and anticoagulants which led to small improvements in the HF and LV thrombus, however, he needed to undergo left ventricular assist device (LVAD) implantation and surgical removal of a residual LV thrombus due to inotrope-dependency.It is necessary to consider the possibility of cocaine or illicit drug use in a young individual with cardiovascular disease or sudden death even in Japan where cocaine and drugs are prohibited by law, as recreational drug use has been increasing in many countries around the world.

Background: Degos disease, also known as malignant atrophic papulosis, is characterized by cutaneous manifestations due to chronic thrombo-obliterative vasculopathy. There have been reports of rare late-onset Degos disease complicated by constrictive pericarditis (CP). We report a case of CP caused by Degos disease that developed 20 years after diagnosis.Case presentation: A 62-year-old woman who has been taking aspirin for 20 years for Degos disease was hospitalized for worsening heart failure. The patient was diagnosed with CP and underwent pericardiectomy. Pathological findings suggested the involvement of Degos disease. The postoperative course was uneventful, and her heart failure and Degos disease did not worsen.Conclusions: This report suggests that Degos disease can cause long-term CP. Aspirin effectively inhibited the progression of Degos disease, and surgical treatment is necessary when heart failure due to CP is refractory to treatment.

Objectives: Endovascular repair of the thoracic aorta (TEVAR) represents a therapeutic option for type B aortic dissection. However, the optimal timing for TEVAR is controversial. We examined the outcomes of TEVAR for chronic type B dissection and reviewed aortic morphology using pre- and postoperative CT scan images. Methods: Between 2012 and 2017, 12 patients underwent TEVAR for chronic type B dissection at our institution. We retrospectively reviewed the clinical and operative data including CT scan images, comparing the values between early group (5 cases, 3 months to 1 year from initial dissection) and late group (7 cases, more than 1 year from initial dissection). Results: There were no paraplegia, stroke, and death in our cohort. There was no difference in degree of the aortic remodeling between two groups. Conclusions: Outcomes after TEVAR for chronic type B aortic dissection were favorable. Aortic remodeling could be obtained in selected patients by closing an entry with TEVAR procedure. (This is a translation of Jpn J Vasc Surg 2018; 27: 281-287.).

Objectives A novel surgical strategy using haemodynamic analyses based on virtual operations with computational simulations has been introduced for complicated pulmonary stenosis. We evaluated the efficacy of this strategy. Methods Six patients were enrolled. Before surgery, the optimal pulmonary arteries were constructed based on computational fluid dynamics using 3-dimensional computed tomography. Energy loss (EL, mW) and wall shear stress (WSS, Pa) were calculated. We compared the shapes of preoperative and optimal pulmonary arteries to determine the surgical strategy, including the incision line and the shape of the patch (virtual surgery). EL and WSS were compared between virtual and actual surgeries using flow analysis. Results In both the virtual and actual surgeries, postoperative EL tended to be lower than the preoperative EL, although there were no significant differences (P = 0.12 and P = 0.17, respectively). The mean WSS in the virtual surgery was significantly reduced from 112 ± 130 Pa to 25 ± 24 Pa (P = 0.028). After the actual surgery, the mean WSS was also significantly reduced to 30 ± 23 Pa (P = 0.047). There were no significant differences in the values for EL and WSS before and after surgery or between virtual and actual surgery (P = 0.94 and P = 0.85, respectively). Conclusions Pulmonary artery plasty, using computational fluid dynamics based on virtual surgery, is an efficient surgical strategy. This novel strategy can easily and successfully provide an optimal pulmonary artery plasty equivalent to that using the conventional approach, which is based on the surgeon's personal experience and judgement.

Objectives High-flow regional cerebral perfusion (HFRCP) provides cerebral and somatic oxygen delivery through collateral vessels during aortic arch repair in small children; however, optimal flow conditions during HFRCP have not been established. We sought to identify markers of peripheral perfusion during HFRCP. Methods Between 2009 and 2016, in total 20 consecutive pediatric patients undergoing aortic arch repair with HFRCP were enrolled in this prospective, observational study. Median age was 20 days (range, 6-116 days); median body weight was 2.77 kg (range, 1.8-4.98 kg). Oxygen delivery ratio (D o 2R) was calculated as the oxygen delivery during HFRCP divided by the oxygen delivery before HFRCP. Regional oxygen saturations on the forehead and on the thigh (rS o 2T) were monitored during HFRCP, and postoperative creatinine kinase and lactate concentrations were measured as postoperative outcomes. Multivariate analyses were performed to clarify the effectiveness of D o 2R and rS o 2T as markers of peripheral perfusion during HFRCP. Results No deaths or neurologic impairments occurred. Multivariate analysis showed that the lowest rS o 2T (P = .005) and cardiopulmonary bypass time (P = .012) predicted postoperative creatinine kinase concentration. D o 2R was the only factor to predict postoperative lactate concentration (P o 2R less than 0.66 predicted risk of high postoperative lactate concentration (>5.0 mmol/L), with area under the curve of 0.95. Conclusions For aortic arch repair in small children, rS o 2T and D o 2R during HFRCP are useful markers for predicting peripheral perfusion. Maintaining higher D o 2R during HFRCP minimizes postoperative increases in lactate and creatinine kinase concentrations.

Early extubation in the operating room after congenital open-heart surgery is feasible, but extubation in the intensive care unit after the operation remains common practice at many institutions. The purpose of this study was to evaluate retrospectively the adequacy of our early-extubation strategy and exclusion criteria through analysis based on the Risk Adjustment in Congenital Heart Surgery method (RACHS-1).This retrospective analysis included 359 cases requiring cardiopulmonary bypass (male, 195; female, 164; weight > 3.0 kg; aged 1 month to 18 years). Neonates and preoperatively intubated patients were excluded. Other exclusion criteria included severe preoperative pulmonary hypertension, high-dose catecholamine requirement after cardiopulmonary bypass, delayed sternal closure, laryngomalacia, serious bleeding, and delayed awakening. The early-extubation rates were compared between age groups and RACHS-1 classes.Overall, 83% of cases (298/359) were extubated in the operating room, classified by RACHS-1 categories as follows: 1, 59/59 (100%); 2, 164/200 (84%); 3, 61/78 (78%); and 4-6, 10/22 (45%). The early extubation rate in categories 1-3 (86%, 288/337) was significantly higher than for categories 4-6 (45.5%, 10/22) (P < 0.001). Because they met one of the exclusion criteria, 61 patients (17%) were not extubated in the operating room. Eight patients (2.7%) required re-intubation after early extubation in the operating room, and longer operation time was significantly associated with re-intubation (P < 0.001).Extubation in the operating room after congenital open-heart surgery was feasible based on our criteria, especially for patients in the low RACHS-1 categories, and involves a very low rate of re-intubation.

Objectives Inefficient aortic flow after the Norwood procedure is known to lead to the deterioration of ventricular function due to an increased cardiac workload. To prevent the progression of aortic arch obstruction, arch reconstruction concomitant with second-stage surgery is recommended. The aim of this study was to determine the indications for reconstruction based on numerical simulation and to reveal the morphology that affects the haemodynamic parameters. Methods Fifteen patients who underwent the Norwood procedure or arch repair and Damus-Kaye-Stansel anastomosis were enrolled. The pressure gradient in aortic arch was 1.6 ± 3.9 mmHg (ranged from 0 to 12 mmHg) on catheter examination. Six patients who had prominent turbulent flow accompanied with a large flow energy loss index greater than 40 mW/m2 and high wall shear stress greater than 100 Pa underwent arch reconstruction. Results After arch reconstruction, the energy loss index significantly decreased from 88.5 ± 50.0 mW/m2 to 23.1 ± 10.4 mW/m2 (P = 0.026) and wall shear stress significantly decreased from 194.5 ± 87.4 Pa to 60.3 ± 40.5 Pa (P = 0.0062). There were 3 late deaths due to heart failure caused by progressive atrioventricular valve regurgitation during the follow-up period (60 months). The systemic ventricular function was preserved in the remaining patients without any pressure gradients in the arch. Conclusions Determining the surgical strategy for arch reconstruction based on numerical flow analysis may effectively reduce the ventricular load even if no stenosis or pressure gradients are observed on catheter examination or echocardiography.

The use of measured data as boundary conditions renders hemodynamic simulations more patient-specific. However, synchronized acquisition of data at multiple locations is often difficult in clinical practice. This study proposes a method for resynchronizing measured data for use as boundary conditions for flow simulations using frequency analyses, and discusses the optimal cut-off frequency for differentiating cardiac and respiratory variation in hemodynamic data during resynchronization. To demonstrate the utility of the method, a Fontan circulation, which is the final palliative result with single-ventricle physiology, was used. The results suggest that it is optimal to set a cut-off frequency that gives a local minimum in the power spectrum that is slightly lower than the peak frequency of the heartbeat. Additionally, the total energy loss depended on the cut-off frequency, although the overall flow patterns appeared to be similar. The method is applicable to cardiovascular systems other than the Fontan circulation, where hemodynamic data with multifactorial fluctuations are required at various locations but simultaneous measurements are not possible.

In operations for acute Stanford type A aortic dissection, several cannulation options are available for cardiopulmonary bypass arterial perfusion. These are femoral, axillary, Seldinger ascending aortic, transapical, and transatrial, each of which has advantages and drawbacks. We describe our surgical technique of direct true lumen cannulation ("Samurai" cannulation), which represents an easy, safe, and practical option in operations for acute type A aortic dissection.

We report a rare case of Stanford type A acute aortic dissection involving an aberrant right subclavian artery and originating from Kommerell's diverticulum in a 52-year old man. Initially, as an emergency measure, total arch replacement and right axillary artery reconstruction were performed. However, due to the subsequent enlargement of the false lumen, thoracic endovascular aortic repair and right subclavian artery coiling were performed successfully 5 months after the first operation. Herein, we describe surgical management approaches for the treatment of a Stanford type A acute aortic dissection with aberrant right subclavian artery.

Background In tetralogy of Fallot (TOF), it is well known that postoperative pulmonary regurgitation reduces right ventricular function during long-term follow-up. Complete repair without a transannular patch should help avoid pulmonary regurgitation. Recently, primary complete repair has been preferred to the staged repair with use of a Blalock-Taussig shunt (BTS) even in neonates or small infants; however, little has been reported about the influence of a BTS on pulmonary annular growth. Methods We examined 40 patients with TOF or double-outlet right ventricle with pulmonary stenosis. Twenty-one patients received a BTS before complete repair, whereas 19 patients underwent primary complete repair. Pulmonary annular size was measured by echocardiography before BTS, complete repair, or both, and ventricular volume was measured by cardiac catheterization. Results There were no significant differences in complete repair age or body size between the groups. Pulmonary annulus sizes in the BTS group were smaller than those in the primary repair group (Z score, −5.1 ± 2.5 vs −3.7 ± 1.8). After the BTS, significant annular growth (Z score, −2.8 ± 2.1) was observed ( p = 0.0028), with a significant increase in left ventricular end-diastolic volume ( p = 0.015). When patients with severe pulmonary stenosis (Z score > −7.0) were excluded, pulmonary annular preservation at complete repair was achieved in 64.7% (11/17) of the BTS group and 36.8% (7/19) of the primary repair group ( p = 0.088). Conclusions The BTS increased the pulmonary annular size and the left ventricular volume during the 6 months before complete repair, resulting in preservation of the pulmonary valve function.

We previously reported renal arterial periarteritis after implantation of a continuous-flow left ventricular assist device in calves. The purpose of the present study was to investigate whether the same periarteritis changes occur in the intrapulmonary arteries after implantation of a continuous-flow right ventricular assist device (CFRVAD) in calves and to determine the mechanism of those histologic changes.Ten calves were implanted with a CFRVAD for 29 ± 7 days, and we compared pulmonary artery samples and hemodynamic data before and after CFRVAD implantation prospectively.After implantation, the pulsatility index (pulmonary arterial pulse pressure/pulmonary arterial mean pressure) significantly decreased (0.88 ± 0.40 before vs 0.51 ± 0.22 after; p0.05), with severe periarteritis of the intrapulmonary arteries in all animals. Periarterial pathology included hyperplasia and inflammatory cell infiltration. The number of inflammatory cells positive for the angiotensin II type 1 receptor was significantly higher after implantation (7.8 ± 6.5 pre-CFRVAD vs 313.2 ± 145.2 at autopsy; p0.01). Serum angiotensin-converting enzyme activity significantly decreased after implantation from 100% to 49.7 ± 17.7% at week 1 (p = 0.01). Tissue levels of angiotensin-converting enzyme also demonstrated a significant reduction (0.381 ± 0.232 before implantation vs 0.123 ± 0.096 at autopsy; p = 0.043).Periarteritis occurred in the intrapulmonary arteries of calves after CFRVAD implantation. The local renin-angiotensin system (not the angiotensin-converting enzyme pathway) plays an important role in such changes.

OBJECTIVES This study aimed to evaluate the outcomes of patients who did not undergo initial aortic surgery for acute Stanford type A aortic dissection with a patent false lumen of the ascending aorta. METHODS Inpatient and outpatient records were retrospectively reviewed. RESULTS We identified 195 patients with acute type A aortic dissection with a patent ascending false lumen between January 1998 and March 2016. Of these, 137 underwent aortic surgery, 16 died before surgery and 42 declined aortic surgery. The ages of the patients who underwent and those who declined aortic surgery were 60.0 ± 10.6 years and 72.3 ± 12.4 years, respectively. The mortality rate of those who underwent and those who declined aortic surgery was 15 and 62% at 30 days and 19% and 67 at 90 days, respectively ( P

The use of measured data as boundary conditions renders hemodynamic simulations more patient-specific. However, synchronized acquisition of data at multiple locations is often difficult in clinical practice. This study proposes a method for resynchronizing measured data for use as boundary conditions for flow simulations using frequency analyses, and discusses the optimal cut-off frequency for differentiating cardiac and respiratory variation in hemodynamic data during resynchronization. To demonstrate the utility of the method, a Fontan circulation, which is the final palliative result with single-ventricle physiology, was used. The results suggest that it is optimal to set a cut-off frequency that gives a local minimum in the power spectrum that is slightly lower than the peak frequency of the heartbeat. Additionally, the total energy loss depended on the cut-off frequency, although the overall flow patterns appeared to be similar. The method is applicable to cardiovascular systems other than the Fontan circulation, where hemodynamic data with multifactorial fluctuations are required at various locations but simultaneous measurements are not possible.

We describe the implantation of an implantable cardioverter defibrillator (ICD) in a 2-month-old infant with frequent sustained ventricular tachycardia (VT) refractory to antiarrhythmic agents. An epicardial ICD shock coil lead and pacing leads were placed, as was a cumbersome device console that was stored in a pocket between the left external and internal oblique muscles. These methods were safe and feasible even for such a small infant, and possible adverse events were avoided.

Objective Cardioscopy is a novel imaging method that allows closed-chest, real-time fiberoptic imaging of intracardiac structures. This study tested the feasibility and safety of cardioscopy as a platform for mitral and tricuspid valve surgery in the beating heart. Methods Through a median sternotomy, cardiopulmonary bypass was established in 10 calves. Lactated Ringer’s solution was administered through the pulmonary artery to eliminate residual blood volumes in the lung vasculature and was drained through a left ventricular cannula. A fiberoptic cardioscope within its translucent outer sheath was inserted through the left ventricle. Irrigating solution was continuously administered through the cardioscope sheath for clearer visualization. An endoscopic clip was used for edge-to-edge repair of the mitral and tricuspid valves. After mitral valve clipping, the cardioscope was inserted into the right ventricle. The solution was administered from the right atrium and continuously drained from the pulmonary artery. After tricuspid valve repair, the animal was weaned from cardiopulmonary bypass. Results Successful double-valve repair was carried out in all 10 cases. All calves were weaned from cardiopulmonary bypass with dobutamine only. Hematocrit values were maintained during the procedure (pre 29.0% ± 3.1% vs post 28.5% ± 3.6%, P = .70). Conclusions This study showed the technical feasibility of beating heart valve surgery using direct cardioscopic visualization. Cardioscopy represents a promising platform for future interventions and surgery under direct visualization in the beating heart.

The DexAide right ventricular assist device (RVAD) is a magnetically and hydrodynamically levitated implantable centrifugal pump. Recent progress includes 1) redesign of the inflow/outflow conduits, which yielded two successful 3-month experiments, 2) development of alternative journal bearing materials, and 3) completion of an 18-month duration of in vitro endurance testing. Verification testing of the RVAD electronics has been completed, and a prototype biventricular assist device (BVAD) system has been tested. Acute DexAide/CorAide BVAD implantations via median sternotomy in two calves documented BVAD control algorithms and anatomical fit. A drug-induced chronic calf heart failure model, currently under development in our laboratory, resulted in a successful BVAD implantation in a calf with heart failure. Our future plans are to complete in vitro and in vivo validation of alternative bearing materials, perform preclinical DexAide in vivo and in vitro reliability studies, and obtain Food and Drug Administration (FDA) approval for an Investigational Device Exemption to conduct a clinical pilot study. In conclusion, two successful 3 month in vivo experiments and an 18-month in vitro endurance test were completed. After final bearing material selection, the DexAide design will be "frozen" so that preclinical systems can be manufactured. BVAD experiments using a chronic heart failure model are in progress.

Objective Occlusion of the left atrial appendage is proposed to reduce the risk of stroke in patients with atrial fibrillation. The third-generation atrial exclusion device, modified to provide uniform distribution of pressure at appendage exclusion, was assessed for safety and effectiveness in a canine model and compared with a surgical stapler. Methods The atrial exclusion device consists of 2 parallel, straight, rigid titanium tubes and 2 nitinol springs with a knit-braided polyester fabric. Fourteen mongrel dogs were implanted with the device at the base of the left atrial appendage via a median sternotomy. In each dog, the right atrial appendage was stapled with a commercial apparatus for comparison. The animals were evaluated at 7 days (n = 3), 30 days (n = 5), and 90 days (n = 6) after implantation by epicardial echocardiography, left atrial and coronary angiography, gross pathology, and histology. Results Left atrial appendage exclusion was complete and achieved without hemodynamic instability, and coronary angiography revealed that the left circumflex artery was patent in all cases. A new endothelial tissue layer developed on the occluded orifice of the left atrium 90 days after implantation. This endothelial layer was not evident on the stapled right atrial appendage. Conclusion In dogs, the third-generation atrial exclusion device achieved easy, reliable, and safe exclusion of the left atrial appendage with favorable histologic results. Clinical application could provide a new therapeutic option for reducing the risk of stroke in patients with atrial fibrillation.

The modified Blalock-Taussig shunt (mBTS) is one of the most important palliative procedures in congenital heart surgery. However, in neonates and small infants, operative mortality and morbidity due to excessive pulmonary blood flow or shunt failure remains high. In this study, a small shunt graft (3.0-mm diameter) was estimated to determine the optimal shunt graft size of BTS as an initial palliation for ultimate biventricular circulation. Eighteen patients weighing an average 3.5 kg who underwent mBTS from July 2004 to January 2013 at our institute were reviewed. We divided the study cohort into two groups: group S (n = 10) included patients with 3.0-mm diameter shunt grafts, and group L (n = 8) included patients with 3.5-mm diameter shunt grafts. There were no hospital deaths or shunt occlusion in either group. One group L patient (12.5%) had cardiogenic shock due to excessive pulmonary blood flow. There were no differences in postoperative arterial oxygen saturation (SaO2) between the groups. There were no differences in body weight at intracardiac repair (ICR) between the groups. During the interstage to ICR, body weight gain was significantly greater in group S than in group L (P = 0.008). The small shunt graft (3.0-mm diameter) in BTS was safe, provided adequate pulmonary blood flow, and led to significant weight gain between mBTS and ICR for ultimate biventricular circulation in neonates and small infants with low body weight.

Trisomy 13 is associated with a variety of congenital anomalies, some of which are life-threatening and related to poor prognosis. Therefore, cardiac surgery is rarely offered to these patients, especially to those with complex cardiac anomalies. We report the case of a neonate weighing 2324 g who was born with severe congenital heart defects. Transthoracic echocardiography revealed the diagnoses of asplenia, single ventricle, aortic stenosis, coarctation of the aorta, hypoplastic aortic arch, and total anomalous pulmonary venous return. She was hemodynamically unstable. Palliative Norwood procedure with right ventricle-pulmonary artery conduit (RV-PA conduit) was performed at the age of 1 day to save her life. On postoperative day 7, chromosome analysis revealed trisomy 13. Echocardiography revealed good heart function; stable hemodynamic status was achieved with minimal amounts of inotropic agents. However, she developed anuria, which did not improve despite situational possible interventions, including peritoneal dialysis and continuous hemodiafiltration. On postoperative day 37, she succumbed to sudden cardiorespiratory failure. Nevertheless, this case indicates that a neonate with trisomy 13 can have a better chance at survival with cardiac surgery such as the Norwood procedure with an RV-PA conduit.

OBJECTIVES: The elephant trunk technique for aortic dissection is useful for reducing false lumen pressure; however, a folded vascular prosthesis inside the aorta can cause haemolysis. The purpose of this study was to investigate whether an elephant trunk in a small-calibre lumen can cause haemolysis. METHODS: Inpatient and outpatient records were retrospectively reviewed. RESULTS: Two cases of haemolytic anaemia after aortic surgery using the elephant trunk technique were identified from 2011 to 2013. A 64-year-old man, who underwent graft replacement of the ascending aorta for acute Stanford type A aortic dissection, presented with enlargement of the chronic dissection of the descending aorta and moderate aortic regurgitation. A two-stage surgery was scheduled. Total arch replacement with an elephant trunk in the true lumen and concomitant aortic valve replacement were performed. Postoperatively, he developed severe haemolytic anaemia because of the folded elephant trunk. The anaemia improved after the second surgery, including graft replacement of the descending aorta. Similarly, a 61-year-old man, who underwent total arch replacement for acute Stanford type A aortic dissection, presented with enlargement of the chronic dissection of the descending aorta. Graft replacement of the descending aorta with an elephant trunk inserted into the true lumen was performed. The patient postoperatively developed haemolytic anaemia because of the folded elephant trunk, which improved after additional stent grafting into the elephant trunk. CONCLUSIONS: A folded elephant trunk in a small-calibre lumen can cause haemolysis. Therefore, inserting an elephant trunk in a smallcalibre true lumen during surgery for chronic aortic dissection should be avoided.

OBJECTIVES: This study aimed to investigate whether the entry site of acute type B aortic dissection affects late outcomes. METHODS: Inpatient and outpatient records were retrospectively reviewed. RESULTS: We identified 224 cases of acute type B aortic dissection between 1998 and 2013. Of these 224 patients, 168 were men and the age was 64.2±12.6 (range 23–94) years, from which 130 presented with the entry at a location downstream of the distal aortic arch, 67 with the entry at the outer curvature of the distal aortic arch and 27 with the entry at the inner curvature. At the initial presentation, 127 patients had descending false lumen thrombosis. The 30-day mortality ratewas 2%, and 8% of patients had malperfusion. The entry at the outer curvature was associated with a higher risk of 30-day mortality. Patients with the entry at a location downstream were significantly older, and had a higher chance for primarily thrombosed descending false lumen and a lower risk of malperfusion. At follow-up (6.0±4.1 years), the actuarial survival rates were 97, 83 and 60%, freedoms from open aortic surgery were 96, 91 and 86%, aortic intervention were 73, 66 and 63% and aortic events were 71, 60 and 52% at 1, 5 and 10 years, respectively. Multivariate logistic regression analysis revealed that the outer curvature entry and maximum aortic diameter were correlated with open aortic surgery, aortic intervention and aortic events. Of the 127 patients with primarily thrombosed false lumen, the outer curvature entry was significantly correlated with aortic events. CONCLUSIONS: The primary entry at the outer curvature of the distal aortic arch, as well as the large aortic diameter, is associated with a higher risk of late open aortic surgery, aortic intervention and aortic events in acute type B aortic dissection. Thus, the entry site should be taken into consideration in the establishment of an appropriate treatment indication of type B aortic dissection.

Previous studies have reported that the extracardiac Fontan procedure has excellent outcomes and a lower incidence of postoperative complications than the lateral tunnel procedure. However, thromboembolic events that occur after the Fontan procedure are a well-known cause of morbidity. We experienced a case of thrombosis of intra-atrial extracardiac conduit and the left pulmonary artery 2 years after a modified Fontan operation due to infective endocarditis (IE) despite prophylactic antiplatelet therapy. The patient underwent reoperation. The conduit in the right atrium (RA) was excised, and the thrombus in the vessels was removed. Because the fibrous tissue in the RA around the conduit was firm, the tissue was used as the "tunnel" for the Fontan route between the IVC and the ePTFE graft outside the RA instead of replacement using another alien graft. He was discharged on postoperative day 45 and was medicated with coumadin and aspirin. He is now being followed in our outpatient clinic and is still without any sign of infection.

Mitral valve replacement was performed on a 75-year-old man with a history of pulmonary tuberculosis. Computed tomography showed a collapsed left lung and counterclockwise rotation of the heart due to a hard abscess. Surgery was performed through a median sternotomy, and extensive pericardial suspension was useful for obtaining an adequate view. Despite poor pulmonary function, the patient was extubated on the day of surgery and had an uneventful postoperative course. Cardiac surgery can be performed in patients with a single functional lung if their preoperative respiratory function is good enough to have daily life without dyspnea.

The purpose of the current study was to demonstrate that a proprietary surfactant polymer coating does not adversely affect the hemodynamic performance of cardiopulmonary bypass (CPB) or gas exchange in oxygenators. The new coating was applied to a CPB circuit including cannulae, reservoir, oxygenator, and blood pump implanted into 12 pigs, divided into groups with either coated or noncoated pumps. CPB flow was maintained at a fixed level of approximately 2.4 L/min for 6 hrs with full heparinization. Hemodynamic data and pump performance were recorded every hour, and blood samples were taken every 2 hrs. After sacrifice, the CPB circuit and major organs were macroscopically examined. There was no significant difference in the oxygen transfer rate between the two groups. The coating did not adversely affect oxygenator inlet or outlet pressures. There was no significant difference between the two groups in microthrombi seen in the oxygenators. No thromboemboli were noted in the major organs on gross or histologic examination. In conclusion, this new surfactant polymer coating did not decrease gas exchange performance and its biocompatibility evaluations revealed no differences between coated and noncoated groups under aggressive heparin use.

This study was performed to evaluate the efficacy of a novel chest drainage system. This system employs guide wire-based active chest tube clearance to improve drainage and maintain patency. A 32 Fr chest tube was inserted into pleural cavities of five pigs. On the left, a tube was connected to the chest canister, and on the right, the new system was inserted between the chest tube and chest canister. Acute bleeding was mimicked by periodic infusion of blood. The amount of blood drained from each chest cavity was recorded every 15 min for 2 h. After completion of the procedure, all residual blood and clots in each chest cavity were assessed. The new system remained widely patent, and the amount of drainage achieved with this system (670+/-105 ml) was significantly (P=0.01) higher than that with the standard tube (239+/-131 ml). The amount of retained pleural blood and clots with this system (150+/-107 ml) was significantly (P=0.04) lower than that with the standard tube (571+/-248 ml). In conclusion, a novel chest drainage system with active tube clearance significantly improved drainage without tube manipulations.

The clinical use of left ventricular assist devices (LVADs) is becoming more widely accepted, due in large part to the introduction of continuous-flow blood pumps.1-6 These newer devices show significant improvements in size, simplicity, reliability, durability, and clinical results. However, 20-50% of patients undergoing LVAD implantation also have significant right ventricular failure, which limits the utility of implantable LVAD therapy.7-11 Existing total artificial hearts (TAHs) are either a temporary pneumatic system (CardioWest™, SynCardia, Tucson, AZ) with an externalized pneumatic driver or a permanent pulsatile implantable system (AbioCor™, Abiomed®, Danvers, MA). To date, they have demonstrated significant limitations in initial clinical trials because of their large size, limited durability, and incidence of thrombus formation and embolization.12 The inherent design characteristics of these pulsatile systems prevent significant reductions in size. The feasibility of native heart replacement with two separate continuous-flow pumps has recently been demonstrated at the Texas Heart Institute (Houston, TX)13 and Tohoku University (Sendai, Japan).14 These systems require duplication of pump components, increasing the potential for component failure and necessitating the development of complex algorithms to appropriately coordinate the outputs of the two pumps. We are developing a continuous-flow TAH (CFTAH) that is extremely innovative, exploring radical new concepts in TAH design. The proposed concept involves the use of a valveless, sensorless, continuous-flow pump and automatic control system. This double-pump concept comprises a single, continuously rotating, brushless DC motor and a pump assembly with a centrifugal pump on both ends. Pump speed will be modulated to create pulsatile flow and pressure. This report details the CFTAH design concept and our initial in vitro data in a mock circulatory loop.

Background— Allograft rejection remains the nemesis of solid organ transplantation. Soul Mate is a novel implantable wireless data transmission system that analyzes 9 intramyocardial electrogram parameters recorded from 4 or 6 configurations of 2 or 3 epicardial leads to detect allograft rejection. This study determined the ability of the Soul Mate to detect early rejection of transplanted hearts. Methods and Results— Five dogs underwent heterotopic cervical heart transplantation and simultaneous implantation of the Soul Mate’s Cardiac Rejection Monitoring Device. Dogs were initially immunosuppressed, but subsequent drug discontinuation allowed allograft rejection to appear. Allograft biopsies were performed at regular intervals to determine rejection grade, which was compared to a calculated rejection score determined as percent change from baseline of values for each intramyocardial electrogram. There was significant correlation between the biopsy results and the evolution of 5 parameters. The strongest correlation ( r =0.939; P Conclusions— The Soul Mate allograft rejection monitoring system accurately detected transplanted heart rejection in a canine model noninvasively with continuous sampling. This proof-of-concept study suggests that the Soul Mate could be used to more intensely and more frequently monitor cardiac allografts for rejection.

Background Although some continuous-flow left ventricular assist device algorithms have been created to respond to varying patient physiology, very little research has been conducted on control of right ventricular support in uni- or biventricular application. The purpose of this study was to develop and evaluate a simple and reliable fixed-flow algorithm for the DexAide right ventricular assist device (RVAD). This algorithm automatically adjusts speed to maintain a target flow while preventing ventricular suction when a requested target flow exceeds available tricuspid flow. Methods Fixed-flow control mode was evaluated in 17 DexAide RVAD long-term bovine studies, with a duration ranging from 14 to 90 days (33 ± 24 days). Targeted fixed-flow levels ranged from 4.0 to 6.5 liters/min. Data were monitored on an hourly basis. Pump-flow data were also recorded on a weekly basis to document the speed increment required to increase pump flow from 5 to 8 liters/min at 0.5-liter/min increments. Results The fixed-flow control mode was evaluated for a total duration of 5,283 hours without complications related to pump flow or left/right circulation imbalance. The pump speed varied between 2,000 and 3,220 rpm to maintain the flow constant at each target level. The average absolute mismatch between the target flow and measured flow was 0.6 ± 0.5 liter/min. Conclusions Fixed-flow control mode with a pre-determined maximum automatic pump speed can be used safely and effectively in the DexAide RVAD. It can provide target flows by adjusting the pump speed while monitoring pump-flow response to automatic speed increment requests.

The PediPump is a small ventricular assist device (VAD) with a hydraulic output range designed to support children from newborns to adolescents. The present report describes our initial evaluation of the PediPump as a left VAD in an acute sheep model. The PediPump was implanted in two sheep (50.8 and 62.7 kg). Pump speed was adjusted to achieve a flow of 2 L/min with the naturally occurring preload and afterload conditions to evaluate pump performance under a steady hemodynamic state for 4 hours. Upon completion, pump performance was evaluated under various blood pressure and heart rate conditions. During steady-state evaluations, the ascending aortic flow and pump speed varied slightly depending on systemic arterial pressure variations. During the hemodynamic manipulation studies, flows ranged between 0.5 and 3.2 L/min with pump speeds of 5,200-16,200 rpm and motor current of 0.06-0.75 A. The PediPump demonstrated good initial hemodynamic performance for use as an implantable left VAD. However, some depositions were detected at the time of explanation, mainly at the rear of the pump. We are continuing with further acute studies to evaluate pump performance in anticipation of beginning chronic studies to evaluate long-term biocompatibility.

Emergency conversion to cardiopulmonary bypass in off-pump coronary artery bypass grafting is recognized to increase operative mortality and morbidity. We conducted a retrospective review of 616 consecutive patients who were planned for off-pump coronary artery bypass grafting from April 2001 to July 2004. Fourteen patients (2.3%) required emergency conversion to cardiopulmonary bypass. Operative mortality was 13.3% in the conversion group and 1.2% in the non-conversion group (P

Renal dysfunction is a predictor of increased morbidity and mortality after coronary artery bypass grafting, whether it is dialysis-dependent or not. Several studies have shown the efficacy of off-pump technique in reducing morbidity and mortality in patients with renal dysfunction. However, the actual effect of renal dysfunction in off-pump coronary artery bypass grafting has not been well understood.We conducted a retrospective review of 402 consecutive patients undergoing off-pump coronary artery bypass grafting from April 2001 to June 2003. Sixty-eight patients had chronic renal dysfunction (group A); 19 patients were dialysis-dependent; 334 patients had normal renal function (group B). Operative variables, morbidity, and mortality were compared between the two groups. Furthermore, multivariable analysis was performed to identify predictors for short-term survival.Preoperative characteristics were similar in the two groups. Blood transfusion rate was higher in group A than group B (57.4% and 25.7%, respectively; p0.001). In-hospital mortality was similar (1.5% and 1.2% in group A and B, respectively; p = 0.853). Multivariable analysis revealed that unstable angina, low ejection fraction, peripheral vascular disease and redo surgery are significant risk factors for poor early result of off-pump coronary artery bypass grafting.Early outcomes of off-pump coronary artery bypass grafting in patients with renal dysfunction were comparable to those in patients with normal renal function. Renal dysfunction is not a predictor of poor early outcomes after off-pump coronary artery bypass grafting.

A 36-year-old man, who was referred for severe chest pains, was found to have acute type II aortic dissection associated with a dilated ascending aorta, aortic coarctation, and congenitally bicuspid valve. A single-stage surgical repair consisting of valve-sparing aortic root implantation and graft replacement of the ascending aorta, arch, and the coarctation segment was successful.