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Abstract Background Acute aortic dissection (AAD) with impaired perfusion of the left coronary artery has a poor prognosis, even after urgent radical aortic surgery, due to extensive myocardial damage. Although Impella, a microaxial-flow catheter pump, is useful in managing acute myocardial infarction, it is generally contraindicated in patients with AAD because it is an intra-aortic device and the aortic structure is compromised in these cases. Here, we introduce a novel intervention that allowed a planned aortic repair after managing circulation using Impella and venoarterial extracorporeal membrane oxygenation in a case of AAD with left main trunk malperfusion. Case presentation A 40-year-old man presented with cardiogenic shock. Percutaneous coronary intervention was performed to address left main trunk obstruction using an intra-aortic balloon pump; however, circulatory instability persisted. The patient was transferred to our hospital after venoarterial extracorporeal membrane oxygenation. Impella CP™ was used to improve his circulatory status. However, a subsequent CT scan confirmed an AAD diagnosis. After 5 days of stable circulatory support, the patient underwent aortic root replacement and coronary artery bypass grafting. Conclusions In patients with AAD and coronary malperfusion, adjunctive circulatory management with Impella may be a valuable therapeutic option.

As posterior fossa acute subdural hematoma (ASDH) right after cardiac surgery is extremely rare, the clinical course and optimal treatment strategy remain undetermined. We performed a retrospective analysis of patients with posterior fossa ASDH right after cardiac surgery requiring neurosurgical treatment at our institution over a 7-year period and, in this study, discussed the neurosurgical strategy and clinical course. Collected data included clinical history, laboratory results, time course, symptoms, neurosurgical treatment, outcome at discharge, and imaging studies. All six patients were women who had no history of head trauma and had received antithrombotic therapy during the perioperative period of cardiac surgery. All patients showed lower platelets count and were diagnosed with ASDH within 3 days (longest time 64 h) right after cardiac surgery. After discontinuation of anticoagulation therapy and administration of reversal agents, they underwent emergency hematoma evacuation craniotomy (n = 5) or burr hole drainage surgery (n = 1), which were performed in the prone (n = 4) or lateral (n = 2) positions. Four of these patients showed favorable outcomes, and two showed poor outcomes. One of the poor-outcome patients received three antithrombotic therapies, and another developed rapidly progressive ASDH. Posterior fossa ASDH associated with antithrombotic therapy right after cardiac surgery is frequently found in women, and emergent neurosurgical treatment with anticoagulation discontinuation and reversal agent administration can be performed safely. Burr hole drainage surgery might be acceptable in nonsevere cases. By contrast, we must pay attention to cases receiving both anticoagulant and antiplatelet drugs and rapid progression cases.

Background. A large thrombus entrapped in the patent foramen ovale (PFO) is an extremely rare condition. Moreover, it is considered even rarer after temporary inferior vena cava filter (TIVCF) placement for the prevention of fatal pulmonary embolism due to venous thromboembolism (VTE). Case Report. A 58-year-old man presented with syncope following chest pain and dyspnea due to PE exacerbation during TIVCF protection, which then led to cardiogenic shock. Echocardiography revealed a large thrombus entrapped in the PFO, and computed tomography (CT) showed a bilateral pulmonary artery embolism. The patient was treated with open surgical embolectomy for a pulmonary artery thrombus and PFO thrombus with simultaneous closure of the PFO. The patient’s postoperative course was uneventful. Results and Conclusion. Surgical embolectomy was useful with respect to the feasibility of resection of both intracardiac thrombus and pulmonary artery thrombus performed simultaneously, contributing to the prevention of systemic embolisms, and echocardiography plays an important role for early diagnosis.

Complete circumferential dissection is a rare clinical presentation of aortic dissection, wherein the dissected flap has the potential to cause intimo-intimal intussusception, which can lead to several catastrophic complications. We report a case of Stanford type A acute aortic dissection with intimo-intimal intussusception causing unstable cerebral ischemic symptoms. An 82-year-old man was taken to another hospital with severe intermittent dizziness. Head magnetic resonance imaging revealed multiple right-hemispheric cerebral infarctions. Computed tomography also showed a “missing flap,” indicating that the intimal flap was observed in the aortic root and arch but not in the ascending aorta. The patient was referred to our hospital for emergent surgery. Intraoperatively, the intimal tear was found to be circumferential, and the transected intima was folded and superimposed from the origin of the brachiocephalic artery to the aortic arch. Ascending aortic replacement and aortic valve replacement were performed; the postoperative course was good.

Papillary muscle rupture is a catastrophic condition, of which most cases manifest posterior papillary muscle rupture. Anterior papillary muscle rupture is a rare condition. Particularly, anterior papillary muscle rupture due to acute myocardial microinfarction of the small high lateral branch is extremely rare. Since papillary muscle rupture can occur even in such a small branch or small area due to myocardial infarction, echocardiographic and/or ventriculographic confirmation is essential in cases of sudden worsening of heart failure. Herein, we report the case of anterior papillary muscle rupture with a good outcome. A 61-year-old man was admitted to our hospital with cardiogenic shock. Echocardiography revealed severe mitral regurgitation due to papillary muscle rupture. Coronary angiography demonstrated high-grade stenosis in the high lateral branch. However, no other significant stenoses were found. Emergency mitral valve replacement was performed. The patient was discharged 19 days after surgery without any complications.

Acute aortic dissection occurs due to a primary tear in the aortic intima, with blood from the aortic lumen entering the adjacent diseased media. In the clinical setting, practitioners often hesitate before the use of anti-thrombotic drugs in the acute phase of aortic dissection. Therefore, we examined the clinical course in patients who had already received antithrombotic therapies at the onset of acute aortic dissection, and who were given anti-thrombotic drugs in the acute phase during hospitalization. We retrospectively enrolled 685 consecutive patients with acute aortic dissection (type A/B: 454/231), who were transferred to Kurume University Hospital from 2004 to 2020. In types A and B, there were no significant differences between in-hospital mortality with or without antithrombotic therapies at the onset (14.3% vs. 16.4%, p = 0.66 in type A, 2.6% vs. 7.3%, p = 0.29 in type B). Patients in type A who survived more than a day and were treated with anti-thrombotic drugs during hospitalization had significantly lower in-hospital mortality compared with those who received no anti-thrombotic drugs in the acute phase (2.2% vs. 16.1%, p < 0.001), while there was no significant difference between in-hospital mortality in the two type-B groups (2.4% vs. 4.9%, p = 0.48). Although there were variations in response among patients with acute aortic dissection, anti-thrombotic drugs did not worsen in-hospital mortality for patients with acute aortic dissection, indicating that medical staff should not hesitate to administer anti-thrombotic drugs if indicated.

Abstract Background Severe carotid and intracranial artery stenosis disease (CIAD) is major risk for perioperative stroke in coronary artery bypass grafting. Then, preoperative risk assessment is quite important. Case presentation A 58-years old Japanese woman with bilateral carotid stenosis and bilateral middle cerebral artery occlusion was suffered from worsening effort angina due to severe three coronary vessel disease. Magnetic resonance imaging angiography demonstrated severe carotid and intracranial vessel stenosis. Selective carotid/cerebral angiography also showed severe stenosis and delayed filling of the right internal carotid artery and moderate stenosis of the left internal carotid artery, with occlusion of the bilateral middle cerebral arteries. However, quantitative evaluation with brain perfusion, single-photon emission computed tomography (SPECT) with acetazolamide showed depleted cerebral perfusion volume and vascular responses, particularly in the left middle cerebral artery area. However, both sides of MCA reserve cerebral blood flow was maintained at > 34 ml/100 g/min. So, we finally considered that her cerebral perfusion reserve was maintained a certain level and could tolerate open heart surgery. Then, she underwent off-pump coronary artery grafting. Before sternotomy, prophylactic intra-aortic balloon pump support was used to minimize possible perioperative stroke. As a result, hemodynamic status and brain regional oxygen saturation were stable throughout the operation, and recovered uneventfully. Conclusions Preoperative quantitative evaluation using brain perfusion SPECT with acetazolamide is useful in assessing hemodynamic cerebrovascular risk in patients with severe obstructive CIAD. Off pump coronary artery bypass grafting with intra aortic balloon pump assist is a good option for prevention of cerebrovascular morbidity in ischemic heart disease with severe CIAD.

Finding an untreated or asymptomatic large ventricular septal defect (VSD) in an elderly patient is uncommon. The present case was an 81-year-old man who suffered from acute myocardial infarction due to three-vessel coronary disease, mitral and tricuspid valve insufficiency, and high-flow perimembranous VSD (Qp/Qs 2.3). Although the patient was elderly and the VSD had been asymptomatic for a long time, we considered that high-flow VSD and valve diseases should be repaired simultaneously with coronary disease. Then, he underwent elective surgery, namely, VSD patch repair concomitant with coronary artery bypass grafting, and mitral and tricuspid annuloplasty. His postoperative course was uneventful. We conclude that, even for an octogenarian, surgical repair of VSD is recommendable, if surgical indications are appropriate.

OBJECTIVES: Ischaemic stroke is a major complication of cardiac surgery. The optimal strategies for operating on patients with obstructive carotid and/or intracranial artery disease (CIAD) are controversial. We aimed to clarify whether single-photon emission computed tomography (SPECT) with acetazolamide, to quantify the cerebral perfusion reserve, could predict the risk of haemodynamic ischaemic stroke during cardiac surgery. METHODS: The incidence of stroke related to obstructive CIAD and the corresponding autoregulatory reserve were prospectively assessed in 514 consecutive patients who underwent elective cardiac surgery with cardiopulmonary bypass (n = 484) and off-pump coronary artery bypass grafting (n = 30) between 2009 and 2013. Preoperative cerebral blood flow and its reactivity to acetazolamide were quantitatively determined in patients (n = 88) with obstructive CIAD, diagnosed by carotid ultrasonography and/or magnetic resonance angiography. RESULTS: An impaired cerebral perfusion reserve was identified in 1 (1.1%) of the 88 patients. This patient underwent prophylactic superficial temporal artery to middle cerebral artery anastomosis 1 month before coronary artery bypass surgery. Subsequently, the patient underwent conventional coronary artery bypass surgery, without experiencing perioperative stroke. Seven (1.4%) patients died in-hospital mortality and 5 (1.0%) experienced perioperative stroke. However, no patients experienced perioperative haemodynamic ischaemic stroke. CONCLUSIONS: It is unusual for CIAD to affect the incidence of haemodynamic ischaemic stroke during cardiac surgery. Brain perfusion SPECT with acetazolamide is effective for narrowing down patients at high risk of ischaemic stroke during cardiac surgery. Meanwhile, the application of brain perfusion single-photon emission tomography should be confined only to patients with obstructive CIAD because it is an expensive examination tool. [ABSTRACT FROM AUTHOR]

Diagnosis of vascular graft prosthesis infection is crucial, but not straightforward. Here we report two cases in which [18 F] fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18 F-FDG PET/CT) was very useful in the diagnosis of aortic graft infection. Case 1: A 77-year-old Japanese man, two months status post aortic arch graft surgery, suffered from repeated fevers. Blood cultures revealed bacteremia. 18 F-FDGPET/ CT ruled out graft infection and diagnosed lumbar pyogenic spondylitis, which was treated with antibiotics, sparing the patient a possible reoperation. Case 2: A 53-year-old Japanese man, seven years status post replacement of the aortic root and ascending aorta, had been suffering from an ostensibly aseptic fistula for over a year and a half. Although repeated CT findings had been negative, 18 F-FDG-PET/CT clearly demonstrated communication between the fistula and the ascending aortic graft. He was treated with repeat ascending aortic replacement, omentopexy, and antibiotics. Our experience supports 18 F-FDG-PET/CT as a promising modality in cases of suspected vascular graft infection. [ABSTRACT FROM AUTHOR]

Background: In rare cases, echo findings of degenerative valve disease is similar to valvular mass.Case Presentation: A 56-year-old woman was evaluated for palpitation. Echocardiography revealed an 8- mm mass on the anterior mitral leaflet with minimal mitral insufficiency. Resection of the valve tumor was attempted to prevent a possible embolism. However, the lesion was not a tumor, but an aneurysm-like bulge on the anterior leaflet without chorda elongation. Triangular resection and ring annuloplasty were performed. The patient's postoperative course was uneventful. Pathological examination revealeddegenerative disease.Conclusions: This case illustrates that a valvular mass that looks like a tumor by echocardiography may actually be degenerative regardless of the presence of mitral insufficiency. [ABSTRACT FROM AUTHOR]