RESUMEN

OBJECTIVES: This study aimed to evaluate the outcomes of our repair technique using autologous pericardial patches for active infective endocarditis with extensive mitral valve destruction. METHODS: From 2009 through 2016, 12 patients with extensive mitral leaflet destruction due to infective endocarditis underwent mitral valve repair with an autologous pericardial patch. Mid-term clinical outcomes and echocardiographic findings of these patients were retrospectively assessed. RESULTS: The perioperative mortality rate was 8.3% (1/12). Postoperatively, the mitral regurgitation grade was ≤ 1 + in all patients. During 5.0 ± 3.2 years of follow-up, there was no recurrence of infective endocarditis or death. There were no cases of mitral regurgitation grade > + 1 and pressure gradient > 5 mmHg during follow-up among 6 patients who underwent posterior leaflet reconstruction, whereas elevation of the pressure gradient was observed in patients who underwent reconstruction of two areas of the anterior leaflet and survived up till the follow-up phase among 3 patients who underwent anterior leaflet repair. The mitral regurgitation grade worsened and pressure gradient was elevated during the follow-up phase in the 2 patients who underwent bi-leaflet repair, and reoperation was performed. CONCLUSION: Mitral valve reconstruction using autologous pericardial patch is a useful treatment option for extensive mitral valve destruction due to active infective endocarditis. Our clinical data revealed that good mid-term results were obtained for posterior leaflet lesions, while extensive anterior leaflet and bi-leaflet lesion repair did not yield satisfactory results. The indication for surgical repair should be carefully evaluated when an extensive anterior region is involved.

Asunto(s)

Endocarditis Bacteriana , Endocarditis , Insuficiencia de la Válvula Mitral , Endocarditis/complicaciones , Endocarditis/diagnóstico por imagen , Endocarditis/cirugía , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/cirugía , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/cirugía , Estudios Retrospectivos , Resultado del Tratamiento

RESUMEN

PURPOSE: Hybrid aortic arch repair (HAR) has been implemented for extended aortic arch and descending thoracic aortic disease since 2012 in our institution. This study aimed to estimate the early and mid-term efficacy and safety of HAR. MATERIALS AND METHODS: From 2007 to 2019, 56 patients underwent HAR for extended aortic arch disease, and 75 patients underwent total arch replacement (TAR) for arch-limited disease. HAR comprises 3 procedures: replacement of the aorta, reconstruction of all arch vessels, and thoracic endovascular aortic repair (TEVAR) from zone 0 to the descending aorta after cardiopulmonary bypass is off in 1 stage. The type II-1 HAR procedure, in which the ascending aorta and aortic arch distal to the brachiocephalic artery are replaced, was the most frequently selected procedure (40/56 patients). The outcomes of the type II-1 HAR procedure were compared with those of TAR using the Cox regression analysis. RESULTS: The median follow-up period was 36 months. In HAR, the operative mortality, in-hospital mortality, and postoperative permanent neurological deficits were not observed. The paraplegia rate was 1.8%. TEVAR-related complications occurred in 3 patients. Among the patients with non-ruptured atherosclerotic aortic arch aneurysm (31 type II-1 HAR patients and 36 TAR patients, the postoperative respiratory support time in those who underwent type II-1 HAR was quicker than in those who underwent TAR (p<0.01). The rate of 6 year freedom from all-cause death in type II-1 HAR (83.1%) was numerically higher than that in TAR (74.7%), and the rate of 6 year freedom from surgery-related complications in type II-1 HAR (90.3%) was numerically lower than that in TAR (96.9%) due to the occurrence of TEVAR-related complications, and the rate of 6 year freedom from reintervention to the descending thoracic aorta in type II-1 HAR (100%) seemed to be better than that in TAR (83.7%). However, Cox regression analysis did not reveal any statistical difference between the 2 procedures. CONCLUSIONS: HAR, especially the type II-1 procedure, can treat extended aortic arch disease with acceptable survival outcomes. The development of TEVAR technology will further improve the outcomes of HAR in the future.

Asunto(s)

Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/etiología , Aneurisma de la Aorta Torácica/cirugía , Humanos , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento

RESUMEN

BACKGROUND: The right gastroepiploic artery (GEA) is utilized as an excellent in situ arterial graft conduit to right coronary artery territory for coronary artery bypass grafting (CABG). However, there remain great concerns regarding the management of patients with a patent in situ GEA during abdominal surgery following CABG. METHODS: From 1995 to 2016, GEA was used for CABG in 278 patients at our institution. Of the patients, 14 abdominal surgeries were performed for subsequent abdominal diseases in 11 patients with a patent in situ GEA for CABG. We investigated the results of the surgeries and how to manage the GEAs in abdominal surgery. RESULTS: Laparotomy was required for gastric cancer in 3 patients, pancreatic cancer in 3, hepatic cancer in 2, cholangiocarcinoma in 1, duodenal papillary head cancer in 1, and cholecystitis in 1; multiple abdominal surgeries were needed in 2 patients for cancer recurrence and ileus. The intraabdominal adhesions around the GEAs were minimal in all patients. No graft injury occurred at the time of opening of the abdomen, and the planned procedures were completed without any circulatory problems. In 3 patients undergoing pancreaticoduodenectomy, intraabdominal off-pump rerouting of the GEA with a short saphenous vein was necessary for en bloc resection of the cancers and lymph nodes. There was neither operative mortality nor graft-related cardiac event except for 1 due to multiple organ failure. CONCLUSIONS: Although intraabdominal rerouting of GEA is necessary for pancreaticoduodenectomy, abdominal surgery can be safely performed in patients with a patent in situ GEA coronary graft.

Asunto(s)

Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Arteria Gastroepiploica/trasplante , Vena Safena/trasplante , Anciano , Anastomosis Quirúrgica , Estudios de Cohortes , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Laparotomía/métodos , Masculino , Persona de Mediana Edad , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/métodos , Seguridad del Paciente , Reoperación , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

A 44-year-old man presented with an abnormal chest shadow. Computed tomography-guided biopsy showed a chondral tumor of the thoracic vertebrae. Five years later, he developed a walking disorder, left leg numbness, and a vesicorectal disorder. Emergency orthopedic spinal decompression was performed. Eight months later, the residual tumor had become larger and was adjacent to the aorta. Prior to thoracotomy, an intraaortic stent was inserted. The 4th and 5th ribs were invaded by the tumor. The entire tumor and chest wall were excised with the aortic adventitia. The tumor was diagnosed as a low-grade chondrosarcoma of the thoracic vertebrae.

Asunto(s)

Condrosarcoma/cirugía , Descompresión Quirúrgica , Osteotomía , Costillas/cirugía , Neoplasias de la Columna Vertebral/cirugía , Vértebras Torácicas/cirugía , Toracotomía , Adulto , Biopsia , Condrosarcoma/complicaciones , Condrosarcoma/diagnóstico por imagen , Condrosarcoma/patología , Humanos , Masculino , Clasificación del Tumor , Invasividad Neoplásica , Costillas/diagnóstico por imagen , Costillas/patología , Neoplasias de la Columna Vertebral/complicaciones , Neoplasias de la Columna Vertebral/diagnóstico por imagen , Neoplasias de la Columna Vertebral/patología , Vértebras Torácicas/diagnóstico por imagen , Vértebras Torácicas/patología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento

RESUMEN

We describe a very rare case of a 67-year-old man with multiple saccular aortic aneurysms throughout the entire aorta due to antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The patient underwent staged aortic surgical procedures, including stent-graft insertion for a left iliac artery aneurysm, thoracic endovascular aortic repair for a descending aortic aneurysm, and total replacement of the ascending aorta and aortic arch with the use of high-dose steroids to control inflammation. The histologic findings demonstrated that the damage to the vasa vasorum of the adventitia resulting from AAV caused ischemia of the media, resulting in the formation of saccular aneurysmal changes.

Asunto(s)

Angioplastia/métodos , Vasculitis Asociada a Anticuerpos Citoplasmáticos Antineutrófilos/complicaciones , Aneurisma de la Aorta Torácica/inmunología , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/métodos , Angiografía por Tomografía Computarizada/métodos , Anciano , Vasculitis Asociada a Anticuerpos Citoplasmáticos Antineutrófilos/diagnóstico , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Estudios de Seguimiento , Humanos , Imagenología Tridimensional , Masculino , Enfermedades Raras , Medición de Riesgo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/métodos

RESUMEN

Off-pump coronary artery bypass grafting (OPCAB) in patients with acute myocardial infarction (AMI) is difficult because of circulatory deterioration during displacement of the heart. At our institution, we performed minimally circulatory-assisted on-pump beating coronary artery bypass grafting (MICAB) in these patients. During MICAB, support flow was controlled at a minimal level to maintain a systemic blood pressure of approximately 100 mm Hg and a pulmonary arterial systolic pressure of <30 mm Hg, providing optimal pulsatile circulation for end-organ perfusion and prevention of heart congestion. From September 2006 to March 2012, MICAB was performed in 37 patients. Either emergent or urgent MICAB was performed in 27 patients following AMI because of hemodynamic instability during reconstruction. Elective MICAB was performed in the remaining 10 patients because of dilated left ventricle (LV) or small target coronary arteries. The details of bypass grafts, perioperative renal function, and early and mid-term morbidity and mortality were compared between the patients who received MICAB and the 37 consecutive patients who underwent OPCAB during the study period at our hospital. The assist flow indices (actual support flow/body surface area) during anastomosis to the left anterior descending artery, left circumflex artery, and right coronary artery were 0.95 ± 0.48 L/min/m2 , 1.32 ± 0.53 L/min/m2 , and 1.15 ± 0.47 L/min/m2 , respectively, in the emergent and urgent patients following AMI, and 0.44 ± 0.39 L/min/m2 , 1.25 ± 0.39 L/min/m2 , and 1.14 ± 0.43 L/min/m2 , respectively, in the elective patients with either dilated LVs or small target vessels. The lowest mixed venous oxygen saturation during pump support in the MICAB group was significantly higher than that in the OPCAB group (83.8 ± 10.8%, 71.6 ± 7.5%, P < 0.001). Comparing MICAB and OPCAB, the median number of distal bypass grafts for both groups was 4 (25th, 75th percentile: 3, 4) (P = 0.558); the complete revascularization rates were 94.6 and 97.3%, respectively (not significant [NS]); the acute patency rates were 98.9 and 99.2%, respectively (NS); and the 30-day mortality rates were 2.7 and 0%, respectively (NS). No instances of either cerebrovascular complications or newly occurring postoperative renal failure were noted in either group. There were no statistically significant differences between the groups with respect to early and mid-term results (freedom from all-cause death: 82.9 vs. 86.5%, respectively, and freedom from cardiac events at 3 years: 96.4 vs. 96.4%, respectively). MICAB is a safe alternative to OPCAB, particularly in patients with AMI and dilated LV. MICAB is associated with high rates of complete revascularization and acute graft patency, adequate preservation of end-organ function, and early and mid-term results comparable with those observed following OPCAB.

Asunto(s)

Puente Cardiopulmonar , Puente de Arteria Coronaria Off-Pump , Puente de Arteria Coronaria/métodos , Infarto del Miocardio/cirugía , Anciano , Anciano de 80 o más Años , Puente Cardiopulmonar/efectos adversos , Puente Cardiopulmonar/mortalidad , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/mortalidad , Circulación Coronaria , Supervivencia sin Enfermedad , Femenino , Hemodinámica , Humanos , Japón , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Infarto del Miocardio/fisiopatología , Selección de Paciente , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular

RESUMEN

Techniques used in hybrid repair of proximal aortic arch diseases are associated with perioperative complications such as cerebrovascular emboli. We present an easy and safe technique of total debranching thoracic endovascular aortic repair for arch diseases using axilloaxillary arterial bypass. The placement of the axilloaxillary arterial bypass enables perfusion of the brachiocephalic artery even when the artery is clamped. After reconstruction of the brachiocephalic artery and the left common carotid artery, the left subclavian artery is proximally ligated, and it is perfused through the bypass. This procedure is simple, safe, and useful for the prevention of neurologic complications.

Asunto(s)

Aneurisma de la Aorta Torácica/cirugía , Arteria Axilar/cirugía , Humanos , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/métodos

RESUMEN

BACKGROUND: After restrictive mitral annuloplasty (RMAP) for functional mitral regurgitation (MR), the MR frequently recurs. Papillary muscle relocation (PMR) should reduce the recurrence rate. We assessed the influence of procedural differences in PMR on the postoperative mitral valve configuration. METHODS: Thirty-nine patients who underwent mitral valve repair for functional MR were enrolled. In limited tethering cases, RMAP alone was performed (RMAP group; n = 23). In severe tethering cases, in addition to RMAP, bilateral papillary muscles were relocated in the direction of the posterior annulus (posterior PMR group; n = 10) or anterior annulus (anterior PMR group; n = 6). We performed pre- and postoperative transthoracic echocardiographic studies, introducing a new index, mitral inflow angle (MIA), to assess the diastolic mitral leaflet excursion. MIA was measured as the angle between the mitral annular plane and the bisector of the anterior and posterior leaflets. RESULTS: Postoperative MR grade was significantly reduced in each group (P < 0.001). Follow-up echocardiography showed recurrent MR in 13% of the patients in RMAP group. In contrast, no recurrent MR was observed in either the anterior PMR or the posterior PMR group. After surgery, MIA was significantly reduced in both the RMAP group (P < 0.01) and the posterior PMR group (P < 0.001), but was preserved in the anterior PMR group (NS). None of the postoperative variables showed any significant difference between the early and late postoperative phases. CONCLUSIONS: In the surgical treatment of functional MR, a PMR procedure in addition to RMAP was effective in reducing systolic MR. However, mitral valve opening assessed by MIA was restricted even after RMAP alone. The restriction was severely augmented after additional posterior PMR, but was attenuated after additional anterior PMR. The papillary muscle should be relocated in the direction of the anterior annulus to preserve the diastolic opening of the mitral valve.

Asunto(s)

Procedimientos Quirúrgicos Cardíacos/métodos , Insuficiencia de la Válvula Mitral/cirugía , Músculos Papilares/cirugía , Ecocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Periodo Posoperatorio , Recurrencia , Sístole

Asunto(s)

Disección Aórtica/diagnóstico por imagen , Puente de Arteria Coronaria Off-Pump/efectos adversos , Vasos Coronarios/cirugía , Arterias Torácicas/diagnóstico por imagen , Anciano , Anastomosis Quirúrgica , Disección Aórtica/etiología , Vasos Coronarios/diagnóstico por imagen , Humanos , Periodo Intraoperatorio , Masculino , Flujo Sanguíneo Regional/fisiología , Rotura Espontánea , Arterias Torácicas/cirugía , Ultrasonografía Intervencional

RESUMEN

BACKGROUND: Optimal ring size in tricuspid annuloplasty (TAP) surgery to treat functional tricuspid regurgitation (TR) was investigated because optimal ring size remains undefined. METHODS AND RESULTS: Sixty seven patients who underwent TAP at our institution were retrospectively studied. Tricuspid Annuloplasty Ring size Index (TARI) was defined as implanted tricuspid annuloplasty ring size divided by body surface area (BSA). Different TARI cut-off values were tested to determine which value produced the greatest difference in TR improvement (TRI=preoperative minus postoperative TR grade) between patients with TARI smaller (group S) and larger (group L) than the cut-off. Group S was also subdivided by ring type: Cosgrove rings (SC) and MC3 rings (SM). TARI and TRI were negatively correlated (r=-0.307). A TARI threshold of 18.9 mm/m(2) produced the greatest and most significant difference (P<0.0005) in TRI. Defining groups S and L using this threshold, TRI was significantly greater for group S (1.77 ± 0.80) than for group L (0.97 ± 0.83); P <0.0005. There was no difference in TRI between groups SC and SM. CONCLUSIONS: A novel index TARI that normalizes tricuspid annuloplasty ring size by BSA was developed. Choosing ring size to make TARI <18.9 mm/m(2) is likely to be better than setting an upper limit of absolute ring size in the surgical treatment of TR.

Asunto(s)

Anuloplastia de la Válvula Cardíaca/métodos , Insuficiencia de la Válvula Tricúspide/fisiopatología , Insuficiencia de la Válvula Tricúspide/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Anuloplastia de la Válvula Cardíaca/instrumentación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Insuficiencia de la Válvula Tricúspide/patología

RESUMEN

A subclavian artery aneurysm is rare. We report the case of a 61-year-old man with a history of hypertension and angina pectoris who was diagnosed with an atherosclerotic aneurysm of the left subclavian artery. An incidental computed tomography scan revealed a 37-mm saccular aneurysm adjacent to both the proximal left subclavian artery and the distal aortic arch. He underwent an aneurysmectomy with total aortic arch replacement via a median sternotomy. Operative findings revealed that the aneurysm had originated from the left subclavian artery and was located 1 cm distal to the ostium. The final pathological diagnosis was a pseudoaneurysm.

Asunto(s)

Aneurisma Falso/cirugía , Aterosclerosis/cirugía , Arteria Subclavia , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Aterosclerosis/complicaciones , Aterosclerosis/diagnóstico por imagen , Implantación de Prótesis Vascular , Humanos , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos X

RESUMEN

BACKGROUND: It is well known that the plasma concentrations of atrial and brain natriuretic peptides, as cardiac hormones, are elevated in heart failure. HYPOTHESIS: Pericardial fluid in patients with various heart diseases contains both natriuretic peptides that are released into the pericardial fluid. However, it is unknown whether these peptides reflect cardiac function in patients with various heart diseases, more than both the peptides in blood. METHODS: Plasma and pericardial fluid samples were obtained from 22 patients undergoing cardiac surgery for the measurement of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels in plasma and pericardial fluid. RESULTS: The ANP levels in pericardial fluid were higher in patients with impaired left ventricular systolic function (ejection fraction<50% versus>or=50%; 77.0+/-4.9 versus 14.0+/-50.9, p=0.017), but not BNP.However, BNP levels in pericardial fluid were significantly higher in patients with left ventricle dilatation (left ventricular diastolic dimension54 mm; 130.3+/-68.9: 709.7+/-324.7, p=0.0168). Moreover, BNP levels in pericardial fluid were significantly higher in Grade III than Grade II and I (Grade I: echo-free space<5 mm, Grade II: 5-10 mm, Grade III: >10 mm). CONCLUSION: These results suggest that BNP levels in pericardial fluid served as more sensitive and accurate indicators of left ventricular diastolic dysfunction, and that increased BNP levels in pericardial fluid may have an important pathophysiologic role in heart failure as a cardiocyte-derived antifibrotic factor.

Asunto(s)

Factor Natriurético Atrial/análisis , Biomarcadores/análisis , Insuficiencia Cardíaca/fisiopatología , Péptido Natriurético Encefálico/análisis , Derrame Pericárdico/química , Factor Natriurético Atrial/sangre , Biomarcadores/sangre , Procedimientos Quirúrgicos Cardíacos , Insuficiencia Cardíaca/sangre , Humanos , Análisis de los Mínimos Cuadrados , Péptido Natriurético Encefálico/sangre

RESUMEN

A 78-year-old man had previously undergone replacement of ascending aorta using gelatin-resorcin-formalin (GRF) glue for acute aortic dissection. Five years later, a follow-up computed tomography (CT) showed an aortic root pseudoaneurysm. Ultrasound cardiography revealed moderate aortic regurgitation and pseudoaneurysm of aortic root. Aortic root replacement was planned based on a clinical diagnosis of an anastomotic pseudoaneurysm of the aortic root. The patient was discharged without complication 26 days after surgery. In the histopathological examination, the necrotic change of smooth muscle cells in the aortic media was revealed. Previous reports suggests that the use of GRF glue for reconstructing the dissected aorta results in higher rates of postoperative redissection or pseudoaneurysm. Therefore, careful postoperative follow-up is necessary in such cases and further improvements in the quality of glue or alternative methods will be necessary to prevent problems in the first place.

Asunto(s)

Aneurisma Falso/etiología , Aorta/cirugía , Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Formaldehído/efectos adversos , Gelatina/efectos adversos , Complicaciones Posoperatorias/etiología , Resorcinoles/efectos adversos , Enfermedad Aguda , Anciano , Combinación de Medicamentos , Estudios de Seguimiento , Humanos , Masculino