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To investigate the relationships between indications for thoracic endovascular aortic repair for acute/subacute complicated Stanford type B aortic dissection and clinical outcomes, and complications specific to thoracic endovascular aortic repair.The J-predictive study retrospectively collected data of patients treated with thoracic endovascular aortic repair for complicated Stanford type B aortic dissection at 20 institutions from January 2012 to March 2017. From the database, those treated for acute/subacute complicated Stanford type B aortic dissection were extracted (n = 118; 96 men; average age, 66.1 years; standard deviation, ± 13) and classified into groups 1, 2, and 3 according to thoracic endovascular aortic repair indications (rupture, superior mesenteric artery malperfusion, and renal or lower extremity malperfusion, respectively). Primary and secondary measures were mortality (overall and aortic-related) and complications related to thoracic endovascular aortic repair, respectively. For each outcome, the risks of being in groups 1 and 2 were statistically compared with that of being in group 3 as a control using Fisher's exact test.Mortality rate (odds ratio, 5.22; 95% confidence interval [CI], 1.33-20.53) and prevalence of paraparesis/paraplegia (odds ratio, 30.46; confidence interval, 1.71-541.77) were higher in group 1 than in group 3. Compared to group 3, group 2 showed no statistically significant differences in mortality or complications related to thoracic endovascular aortic repair.Rupture as an indication for thoracic endovascular aortic repair for type B aortic dissection was more likely to result in worse mortality and high prevalence of spinal cord ischemia.Level 4, Case series.

Aortoduodenal fistula after endovascular treatment of abdominal aortic aneurysm is a very rare but life-threatening complication. Herein, we describe 4 cases of aortoduodenal fistula diagnosed at 15 to 78 months after the index aortic intervention, all successfully treated by surgery. All patients underwent primary repair of the duodenal wall, creation of tube duodenostomy, stent graft removal, and in situ reconstruction using a rifampicin-soaked prosthesis. Patients received prolonged antibiotic treatment for at least 2 months postoperatively, and all were free of recurrent infection at follow-up. Prompt and appropriate surgical intervention is required to effectively manage this condition.

Purpose: To analyze the anatomical characteristics of arch aneurysms and evaluate the anatomical feasibility of 4 next-generation stent-grafts with either branched or fenestrated configurations. Materials and Methods: A retrospective analysis was conducted of 213 patients (mean age 75.0±7.1 years; 179 men) with arch aneurysms treated using total arch replacement or zone 0 or 1 thoracic endovascular aortic repair (TEVAR) from 2007 to 2017 at 2 Japanese hospitals. Anatomical analyses were performed using the centerline of flow technique on a 3-dimensional workstation. The anatomical feasibility of the Zenith A-branch, TAG Thoracic Branch Endoprosthesis (TBE), Terumo Aortic Relay Plus Double Branched (DB), and fenestrated Najuta stent-grafts were evaluated based on the instructions for use (IFU). Results: The mean lengths from the sinotubular junction (STJ) to the innominate artery (IA) and from the IA to the left common carotid artery were 114.9±15.9 and 12.8±5.6 mm, respectively. The mean aortic diameters at the STJ and IA were 31.3±3.4 and 34.1±5.3 mm, respectively. In terms of feasibility, 5.2% of patients were within the Zenith A-branch IFU, 40.8% for the TAG TBE, 24.9% for the Relay Plus DB, and 13.6% for the Najuta. Significant (>50% circumference) thrombus/calcification at the sealing zone affected nearly half of the patients, but there is currently no standardized definition or evaluation method for “significant” thrombus/calcification. Conclusion: Only 5% to 41% of arch aneurysm patients are anatomically suitable for TEVAR using any one of the next-generation branched or fenestrated stent-grafts. Furthermore, a definitive method of evaluating the thrombus/calcification burden needs to be established in future IFU.

Background Management of abdominal branches associated with Stanford type B aortic dissection is controversial without definite criteria for therapy after thoracic endovascular aortic repair (TEVAR). This is in part due to lack of data on natural history related to branch vessels and their relationship with the dissection flap, true lumen, and false lumen. Purpose To investigate the natural history of abdominal branches after TEVAR for type B aortic dissection and the relationship between renal artery anatomy and renal volume as a surrogate measure of perfusion. Materials and Methods This study included patients who underwent TEVAR for complicated type B dissection from January 2012 to March 2017 at 20 centers. Abdominal aortic branches were classified with following features: patency, branch vessel origin, and presence of extension of the aortic dissection into a branch (pattern 1, supplied by the true lumen without branch dissection; pattern 2, supplied by the true lumen with branch dissection, etc). The branch artery patterns before TEVAR were compared with those of the last follow-up CT (mean interval, 19.7 months) for spontaneous healing. Patients with one kidney supplied by pattern 1 and the other kidney by a different pattern were identified, and kidney volumes over the course were compared by using a simple linear regression model. Results Two hundred nine patients (mean age ± standard deviation, 66 years ± 13; 165 men and 44 women; median follow-up, 18 months) were included. Four hundred fifty-nine abdominal branches at the last follow-up were evaluable. Spontaneous healing of the dissected branch occurred in 63% (64 of 102) of pattern 2 branches. Regarding the other patterns, 6.5% (six of 93) of branches achieved spontaneous healing. In 79 patients, renal volumes decreased in kidneys with pattern 2 branches with more than 50% stenosis and branches supplied by the aortic false lumen (patterns 3 and 4) compared with contralateral kidneys supplied by pattern 1 (pattern 2 vs pattern 1: -16% ± 16 vs 0.10% ± 11, P = .002; patterns 3 and 4 vs pattern 1: -13% ± 14 vs 8.5% ± 14, P = .004). Conclusion Spontaneous healing occurs more frequently in dissected branches arising from the true lumen than in other branch patterns. Renal artery branches supplied by the aortic false lumen or a persistently dissected artery with greater than 50% stenosis are associated with significantly greater kidney volume loss. © RSNA, 2019 Online supplemental material is available for this article.

Objective Thoracic endovascular aortic repair (TEVAR) with supra-aortic debranching has recently been introduced as a treatment option for aortic arch disease. Although less invasive than open repair, TEVAR is associated with a risk of perioperative embolic stroke due to dislodgment of atherosclerotic plaque debris, especially in individuals with atheromatous degeneration of the aortic lumen. It is difficult to determine atheroma vulnerability, and there is no current method for predicting the risk of atheroembolism. This study aimed to evaluate the usefulness of our method of quantifying the shagginess of the aorta in predicting the short- and long-term outcomes of TEVAR involving the aortic arch. Methods The study included 77 patients (63 men and 14 women; median age, 78 years) who underwent elective TEVAR for aortic arch disease between 2009 and 2013. The proximal landing of the stent graft was in zone 0 in 22 patients, zone 1 in 23 patients, and zone 2 in 32 patients. The shagginess score of each patient was calculated from preoperative contrast-enhanced computed tomography images of the aorta using a workstation. The relationships between preoperative factors, including the shagginess score, and the development of perioperative stroke and late survival were analyzed retrospectively. Results Perioperative ischemic stroke occurred in nine patients, and no patient died within 30 days postoperatively. Univariate analyses demonstrated that the shagginess score was significantly higher in patients who developed postoperative cerebral infarction than in those who did not (P = .04). The median follow-up period was 1570 days, and the 5-year cumulative survival rate was 69.2%. Cox proportional hazards analyses showed that comorbid hypercholesterolemia was significantly associated with all-cause mortality (hazard ratio [HR], 3.22; 95% confidence interval [CI], 1.24-8.32; P = .02). As for cardiovascular mortality, the shagginess score was a significant predictive factor (HR, 1.84; 95% CI, 1.04-3.28; P = .04), whereas statin use was significantly protective (HR, 0.11; 95% CI, 0.02-0.66; P = .02). Conclusions The shagginess score may be a useful predictive index of perioperative ischemic stroke as well as a prognostic factor of long-term outcomes after TEVAR with aortic arch involvement.

Background: Although right parasternal approach (RPA) decreases the incidence of mediastinal infection, this approach is associated with lung hernia and flail chest. Our RPA employs thoracotomy with bending rib cartilages and wound closure performed by repositioning the ribs with underlying sheet reinforcement. Methods: We evaluated 16 patients who underwent aortic valve replacement via the RPA from January 2010 to August 2013. We compared outcomes of 15 male patients had the RPA with 30 male patients had full median sternotomy. Results: One patient with a history of radical breast cancer treatment underwent RPA with concomitant right coronary artery bypass grafting. No hospital deaths occurred. Four patients developed hospital-associated morbidity (re-exploration for bleeding, prolonged ventilation, cardiac tamponade, and perioperative myocardial infarction). There were no conversions to full median sternotomy, mediastinal infections, and lung hernias. Preoperative computed tomography showed that the distance from the right sternal border to the aortic root was significantly associated with operation times. With RPA, there was no significant difference in outcomes, despite significantly longer operation times compared with full median sternotomy. Conclusion: Our RPA provides satisfactory outcomes without lung hernia, especially in patients unsuitable for sternotomy. Preoperative computed tomography is useful for identifying appropriate candidates for the RPA.

Postoperative spinal cord injury (SCI) is a devastating complication of surgical repair for thoracoabdominal aortic aneurysm or dissection (TAAD), despite the complex reconstruction of inter-costal or lumbar arteries involved in the surgery. As an alternative technique, endovascular thoracoabdominal aneurysm repair (EVTAR) with visceral artery reconstruction has been accepted as a treatment option for severe comorbid patients of TAAD, because there is a permissible frequency of SCI after EVTAR in spite of no reconstruction of inter-costal or lumbar arteries. We report the results of EVTAR at our hospital with a focus on spinal cord injury.We analyzed data from 54 consecutive patients with TAAD (mean age, 74 ± 9.6 years; 42 men) who underwent EVTAR at our hospital between February 2007 and February 2014. Three types of EVTAR technique were used: fenestrated and/or branched stent graft implantation in 39 patients, a hybrid technique (bypass grafts to visceral arteries and straight stent graft implantation) in 10 patients, and intentional coverage of the coeliac artery and straight stent graft implantation in 5 patients. In all patients, mean systemic blood pressure was maintained at ≥80 mmHg. Opioid use was avoided in the perioperative period.According to the Crawford classification, the graft coverage extent was 9% (5/54) in type I, 11% (6/54) in type II, 39% (21/54) in type III, 22%(12/54) in type IV and 19% (10/54) in type V. In most patients (74%, 40/54), cerebrospinal fluid drainage was done intraoperatively and 1 day postoperatively. Hospital mortality was 5.6% (3/54). No patient developed SCI in the perioperative period. However, in the follow-up period 2 patients developed paraplegia as a consequence of shock caused by an aortic event.With close attention to spinal cord protection, EVTAR may be associated with only a low incidence of SCI in the perioperative period. Therefore, EVTAR is expected to become a promising treatment option for appropriately selected patients with TAAD.

Patients with total circumferential mitral annular calcification (MAC) extending into the intervalvular fibrous body and aortic annulus have a high risk of cardiac surgery, which remains a technical challenge for surgeons. Our technique for MAC is characterized as simple supra-mitral annular prosthesis insertion after minimum debridement of calcification ("half-and-half technique"). To date, our technique has been applied in only simple MAC cases and has good results. Herein, we report successful two cases of total circumferential MAC, extending into the intervalvular fibrous body and aortic annulus that were treated by a simple double valve replacement with application of our "half-and-half technique".

An 86-year-old man with an abdominal aortic aneurysm was diagnosed with type B aortic dissection accompanied by a patent false lumen that started at the distal arch of the thoracic aorta and terminated at the left common iliac artery. Meticulous preoperative assessment detected 3 large intimal tears in the descending aorta, abdominal aortic aneurysm, and left common iliac artery. We performed single-stage thoracic and abdominal endovascular aneurysm repair and concomitant axillary-axillary bypass. The abdominal aortic aneurysm with type B aortic dissection was successfully treated using a single-stage endovascular stent graft, without any complications due to the careful preoperative examinations.

A 72-year-old man presented with worsening dyspnea on effort. He underwent right pneumonectomy 40 years ago, then mitral valve replacement through a right thoracotomy 8 years ago with repeat surgery to repair a periprosthetic valve leak; the mediastinum was displaced to the right, and the heart was rotated counterclockwise. Transthoracic echocardiography showed periprosthetic valve leak recurrence near the left atrial appendage. We repaired the periprosthetic valve leak through a median sternotomy. Transecting the main pulmonary artery allowed us to widely open the cranial-sided left atrium. We obtained good exposure of the mitral valve, and repaired the periprosthetic valve leak using pledgeted sutures and a pericardial patch.

We herein report two cases of perigraft effusion mimicking graft infection after debranching thoracic endovascular repair for an anastomotic pseudoaneurysm of the distal ascending aorta. Both patients presented with a bulging tumor on the sternum. Enhanced computed tomography showed no endoleak, but extension of periprosthetic graft fluid to a subcutaneous sternal wound was present. We suspected a deep sternal wound infection; however, cultures of debrided tissues were negative. After drainage of the subcutaneous fluid or negative pressure wound therapy, both patients were doing well without recurrence of effusion. Endotension was considered to have been associated with enlargement of the perigraft effusion.

Atheromatous degeneration of the aorta is considered to be a risk factor for postoperative embolic complications after endovascular treatment, and is associated with a high incidence of vascular events in the long term. We devised a method to quantify the shagginess of the aorta using contrast-enhanced computed tomography (CT) images. This study examined the method's validity and prognostic usefulness in patients undergoing elective endovascular abdominal aortic aneurysm repair (EVAR). We retrospectively investigated 427 patients who underwent elective EVAR between 2007 and 2013. Preoperative contrast-enhanced CT images with a slice thickness of 1 mm were analyzed using a workstation, and the degree of aortic luminal irregularity from the level of the left subclavian artery ostium to that of the celiac artery ostium was quantified by computing a shagginess score. We compared the computed scores with subjective visual assessments of aortic shagginess. Subsequently, we evaluated the relationship between the computed scores and postoperative prognosis. The shagginess scores were significantly correlated with the visual assessments of the aortic lumen, which were performed by 5 experienced vascular surgeons (rho ranged from 0.564–0.654, all P

A 26-year-old man presented chest oppression. He had pectus excavatum associated with Loeys-Dietz syndrome and a history of redo aortic root replacement with the modified Bentall technique using an 8-mm long interposed graft to the left coronary ostium. Coronary angiography revealed severe stenosis of both left coronary ostium and proximal left anterior descending artery, which was supposed to be resulted from thrombosis in the interposed graft. The left coronary system was bypassed through a left thoracotomy, which was suitable in this patient because the pectus excavatum would prevent harvest of the left internal thoracic artery through re-median sternotomy and to avoid potential sternal reentry injury of the heart. Although the left anterior descending artery was easily accessed under off-pump technique, exposure and anastomosis of the circumflex coronary artery was more difficult than expected without cardiopulmonary bypass as the pectus excavatum and adhesion of the heart prevented anterior shift and rotation of the heart.

われわれは稀な右房原発悪性リンパ腫の1手術例を経験した．症例は呼吸困難，全身浮腫を主訴とする85歳，女性で，心臓超音波検査にて右房内に腫瘤病変を指摘され当院紹介となった．腫瘤による血流障害のため重症心不全を呈していたため緊急手術を施行した．手術は体外循環使用心停止下に施行した．右房内腫瘤は最大径50mmで，術中迅速病理検査にて血管肉腫あるいは悪性リンパ腫と診断された．腫瘍が心房中隔から三尖弁輪およびIVCにかけて右房壁へ浸潤していたため完全摘除は困難と判断し，腫瘍を可及的に切除するにとどめた．病理検査によりB cell malignant lymphomaと診断されたので化学療法を開始した．右房内の腫瘍はほぼ消失し，右心不全症状も改善したが，化学療法による副作用のため全身状態の悪化を来たしMRSA肺炎を併発し術後第52日目に死亡した．心臓原発腫瘍の中で悪性リンパ腫は約1%と非常に稀であり，その診断，治療方法につき若干の文献的考察を加えて報告した．

Sorin Bicarbon (SB) and Edwards Mira (EM) valves have an identical mechanical design but different sewing cuffs. The purpose of this retrospective study was to analyze the long-term clinical and echocardiographic outcomes after mitral valve replacement with these two valves in a combined population of patients.We retrospectively reviewed records of 73 patients who underwent mitral valve replacement using SB (n = 19) or EM (n = 54) valves. Preoperatively, 49 patients (68.1%) were in New York Heart Association (NYHA) functional class III or IV. Concomitant procedures were performed in 52 patients (71.2%). Early and late postoperative echocardiography was performed in 69 and 57 patients, respectively.Operative mortality was 4.1%, and early morbidity was 9.6%. Overall patient survival at 9 years was 85.1% +/- 4.8%. Actuarial freedom from valve-related death was 95.4% +/- 2.6% at 9 years. As shown by Doppler echocardiography, the early and late mean transprosthetic pressure gradients were 3.4 +/- 1.4 mmHg and 3.8 +/- 2.1 mmHg, respectively. At the end of follow-up, 98.4% of survivors were in NYHA class I or II.The Sorin Bicarbon and, Edwards Mira mechanical valves in the mitral position provide satisfactory long-term clinical and echocardiographic performance.

We report a rare case of delayed intestinal ischemia after total arch replacement for type A acute aortic dissection. At the onset of acute aortic dissection, computed tomography (CT) angiography revealed celiac trunk occlusion and progressive dissection into the superior mesenteric artery without stenosis. However, following total arch replacement, visceral malperfusion was not detected by exploratory laparotomy. On postoperative day 12, the patient developed paralytic ileus without an elevated lactate level. CT angiography revealed new superior mesenteric artery stenosis by a thrombosed false lumen with persistent celiac trunk occlusion. Endovascular treatment including stent implantation resolved intestinal ischemia.

Association of a right-sided aortic arch with an aberrant left subclavian artery is rare. We present a case of successful endovascular repair of a ruptured Kommerell diverticulum associated with a right-sided aortic arch and aberrant left subclavian artery. We treated a 47-year-old woman with a diagnosis of ruptured aberrant left subclavian artery with thoracic endovascular stent-grafts. The descending aorta above Kommerell diverticulum was a reverse-tapered configuration. We managed the rather hostile neck with an extra-large Palmaz stent. A left carotid-to-subclavian bypass with an 8-mm Dacron graft was also performed to restore left arm perfusion and prevent vertebrobasilar insufficiency.

We report a patient with an arch aneurysm with an aberrant right subclavian artery who underwent successful endovascular treatment with the chimney technique and bilateral carotid artery-to-subclavian artery bypasses. We used a chimney graft in the left carotid artery to preserve its flow. The bilateral carotid-to-subclavian artery bypasses preserved perfusion of the bilateral vertebral arteries. A thoracic stent graft was subsequently deployed in the aortic arch over the chimney graft of the left carotid artery. There have been few reports about less-invasive treatment for arch aneurysm with aberrant right subclavian artery. This technique was an effective strategy to avoid a high-risk open operation.

Giant left atrium is a rare condition, with a reported incidence of 0.3%, that is normally caused by rheumatic mitral valve disease but very rarely is caused by other etiologies. In such patients, annular dilatation with tenting and reduced height of the posterior leaflet result in significant mitral regurgitation. At surgery, the posterior leaflet was incised from the posterior mitral annulus, starting the incision at the mid portion of the mitral annulus and, if necessary, extending it to the anterolateral portion of the mitral annulus and the posteromedial portion of the mitral annulus. An autologous pericardial patch was harvested, depending on the incision. Herein is reported a surgical technique for posterior leaflet extension in patients with giant left atrium, without rheumatic disease.

Artificial chordal reconstruction technique uses several expanded polytetrafluoroethylene loops to achieve mitral valve repair.We studied retrospectively 180 patients who underwent mitral valve repair using the loop technique via median sternotomy: 86 for posterior leaflet prolapse, 48 for anterior leaflet prolapse and 26 for bileaflet prolapse.Of the 180 patients, 138 required 1 loop set; 40 patients required 2 and 2 patients with Barlow's disease required 3. Loop sets contained two to nine loops ranging in length from 14 to 26 mm. Additional techniques required to ensure complete repair using the loop technique included commissural edge-to-edge suture in 78 patients, loop-in-loop technique for extension of the artificial loop in 18 and use of needle-side sutures in 18. Systolic anterior leaflet motion was observed in only 2 patients (1.1%). One patient with immune deficiency died of sepsis. Predischarge echocardiograms showed no or trace mitral regurgitation (MR) in 160 patients (89%), mild MR in 17 patients (9.4)% and mild-to-moderate MR in 3 patients (1.7%). Only 1 patient required redo operation due to recurrent MR freedom from MR greater than moderate was seen in 98.0 ± 1.4% of patients at 1 year, 91.5 ± 2.8% of patients at 3 years, and 91.5 ± 2.8% at 5 years postoperatively. No significant difference was seen in the rate of recurrence of MR among the sites of prolapsing leaflets.The loop technique via median sternotomy to treat posterior, anterior and, especially, bileaflet prolapse provided satisfactory mid-term outcomes.

A 74-year-old woman required surgical treatment of severe aortic valve stenosis and two-vessel coronary artery disease consisted of a significant stenosis of the left anterior descending branch and right coronary ostium. She had previously undergone radical mastectomy and radiation therapy for left breast cancer. Severe dermal sclerosis and subcutaneous tissue defect at the chest midline, which would cause poor wound healing because of insufficient blood flow, precluded conventional median sternotomy and a left mini-thoracotomy. Therefore, we selected a hybrid treatment approach using a combination of surgery and percutaneous coronary intervention. We performed aortic valve replacement and coronary bypass grafting to the right coronary artery using a right parasternal approach followed by percutaneous coronary intervention of the left anterior descending artery on postoperative day 13. Wound healing was quite satisfactory

Controversy exists regarding the optimal operative method or type of prosthesis for patients with a small aortic root. The aim of this retrospective study was to investigate the early and mid-term outcomes of standard aortic valve replacement (AVR) using 16 mm or 18 mm ATS Advanced Performance (AP) or 17 mm St. Jude Medical (SJM) Regent valves for a small aortic root.Between April 2003 and August 2009, 78 patients (age range: 50-86 years; 86% agedor = 65 years) underwent AVR with 16 mm or 18 mm ATS AP valves (16AP group: n = 21, 18AP group: n = 32), or a 17 mm SJM Regent valve (17Regent group: n = 25). Fifty-six patients (72%) had a body surface area (BSA) of1.5 m2; the BSA in the 16AP group was significantly smaller than in the other two groups. The early and mid-term outcomes, and the hemodynamic performance of the prostheses, were evaluated and compared among the groups.No operative deaths were observed in the 16AP and 17Regent groups, but one hospital death occurred in the 18AP group. During follow up, there were four cardiac-related deaths (two patients each in the 16AP and 18AP groups). Although the postoperative pressure gradient of the 16AP group was significantly higher than that of the 18AP group, the left ventricular mass in all groups was decreased significantly during follow up, but the extent of left ventricular mass regression was similar among the groups (-30%, -25% and -28% in the 16AP, 17Regent and 18AP groups, respectively; p = 0.844).The early and mid-term results of AVR with 16 mm or 18 mm ATS AP valves, or with a 17 mm SJM Regent valve, were satisfactory. Therefore, standard AVR using these small mechanical prostheses, which avoids the need to enlarge the annulus or to conduct stentless bioprosthesis implantation, might represent an acceptable method, especially in elderly patients with a small aortic root.

Aneurysmal circumflex coronary artery (Cx) with fistulous connection to the coronary sinus is a rare clinical entity that usually remains asymptomatic until later in life, so the ideal therapeutic strategy is poorly defined. The timing of surgical treatment for asymptomatic patients is a big issue, and whether to leave or exclude the diffuse aneurysm in addition to ligation of the fistula is controversial, considering the native myocardial circulation. Complete surgical repair, including exclusion of a diffusely aneurysmal Cx and coronary revascularization to a graftable branch in the circumflex area combined with ligation of its fistula, is quite challenging and sometimes fatal because of a broad posterolateral myocardial infarction without revascularization caused by a lack of graftable branches. A case of diffuse aneurysmal Cx, which ruptured into the left atrium after surgical ligation of its fistulous connection to the coronary sinus, is presented. Simple ligation of the fistula, leaving a gigantic aneurysmal circumflex artery, is hazardous for later rupture and should be avoided. Therapeutic strategies for this complex disorder are discussed, including the optimal timing of surgical treatment. (Circ J 2007; 71: 1996 - 1998)

A 75-year-old man was referred for treatment of mitral valve prolapse secondary to tendon rupture. He had been receiving oral and inhaled corticosteroids for bronchial asthma and bronchial ectasia. Chest X-ray showed cardiomegaly with protrusion of the right atrium shadow. Computed tomography revealed dislocation and counterclockwise rotation of the heart with the apex of the heart located in the mid-thorax, indicating mesocardia. We believed that it would have been difficult to expose the mitral valve through a right-sided left atrial approach. Thus, we planned to perform mitral valve repair via a trans-septal approach. The right thoracotomy approach was not suitable because of respiratory dysfunction. After a median sternotomy, the left anterior descending coronary artery was identified just beneath the midline of the sternum. Even after decompression of the heart under cardiopulmonary bypass, we could not obtain a good view of the right side of the left atrium. By a transseptal approach with a self-retaining retractor and atrial hooks, we obtained adequate exposure of the mitral valve and performed the mitral valve repair uneventfully.

A 53-year-old man was admitted to our hospital with thoracic back pain and weight loss. Computed tomography revealed inflammatory aortic aneurysm (IAA) of the descending aorta. Sealed rupture of the aneurysm occurred while the patient was under corticosteroid therapy. Endovascular aneurysm repair (EAR) was performed without postoperative complications. Periaortic fibrosis was remarkably decreased three months later while the patient was under prednisolone (20 mg) administration. We believe that EAR could become a practical alternative to open surgical repair. The possibility of an aneurysm rupturing during corticosteroid therapy for IAA should be considered.

Coronary artery bypass grafting (CABG) in patients with left ventricular dysfunction has been considered to be a challenging operation. We assessed the early angiographic and long-term clinical and functional outcomes of patients with poor left ventricular function who underwent isolated CABG.We retrospectively reviewed the records of 78 patients with a poor left ventricular ejection fraction (35% or less) who underwent isolated CABG between January 1991 and November 2006. The mean age of the patients was 66.1+/-9.4 years, and their mean New York Heart Association functional class was 3.1+/-0.8. Their mean end-diastolic left ventricular diameter was 57.4+/-8.1 mm, and their mean grade of mitral regurgitation was 0.7+/-1.0. Early postoperative angiograms were performed at 32.5+/-33.5 days after the operation. Interval echocardiographic data were analyzed, and the long-term survival rate was evaluated.The average number of distal anastomoses per patient was 3.2 +/-1.1. The operative mortality rate was 7.7%. Stroke occurred in 1.3% of patients. The overall patency rates for arterial and venous grafts were 100% and 97.2%, respectively. The left ventricular ejection fraction significantly improved from 28.2%+/-5.1% to 34.4%+/-8.4%. Both the end-diastolic and end-systolic left ventricular dimensions significantly decreased from 57.4+/-8.1 to 55.1+/-8.8 mm and from 47.4+/-8.4 to 45.1+/-9.7, re spectively. The actuarial patient survival rate at 10 years was 73.1%.CABG in patients with left ventricular dysfunction was effective, with favorable early graft patency rates. The long-term outcome was also acceptable, with echocardiographic functional recovery.

This retrospective study was conducted to evaluate the effects of coronary artery disease (CAD) on short- and long-term survival after abdominal aortic aneurysm (AAA) repair. One hundred consecutive patients underwent elective AAA repair between 1991 and 2002. Coronary angiography was performed in all patients, revealing significant coronary artery lesions in 47 (47%). Percutaneous transluminal coronary angioplasty (PTCA) was performed in 11 patients, 20 (median) days before the abdominal surgery. Abdominal aortic aneurysm repair was performed 60 (median) days after coronary artery bypass grafting (CABG) in five patients, and both procedures were performed simultaneously in two patients. The in-hospital mortality rate for AAA repair was 1.0%, but there was no cardiac-related operative morbidity or mortality. The 96 patients discharged were followed up for a mean period of 2.9 years (range 3–143 months). The cumulative survival rates after 1, 2, 3, and 5 years were 98%, 95%, 88%, and 77%, respectively. Only one patient (1%) died of myocardial infarction. There was no significant difference in the long-term survival of the CAD and non-CAD patients. These results emphasize the importance of routine coronary angiography and subsequent coronary revascularization to improve early and late survival rates after AAA repair.

We report the case of a 68-year-old woman with severe mitral valve regurgitation and concomitant multiple systemic artery-to-pulmonary artery fistulas. Endovascular embolization of the fistulas was unable to control her heart failure, and mitral valve replacement was also performed. Steps were taken during mitral valve surgery to ensure an adequate operative field in the left atrium, despite the large volume of in-pouring blood from the pulmonary vein.

There are no previous reports of rupture of a heterologous pericardial patch after aortic annulus enlargement. Our patient, a 72-year-old Japanese female, presented with congestive heart failure resulting from heart compression from pseudoaneurysm formation in the aortic root. At 57 years of age the patient had undergone replacement of the ascending aorta for Stanford type A acute aortic dissection. At 66 years of age she had undergone aortic valve replacement with a mechanical valve, accompanied by enlargement of the aortic annulus using an equine pericardial patch, for severe aortic valve stenosis with a narrow aortic annulus. Equine pericardial patch was used in the aortic annulus enlargement to form the aortic root from the ascending aortic vascular prosthesis to the non-coronary cusp of the aortic valve. We performed repeat median sternotomy under cardiopulmonary bypass with moderate hypothermia. The ascending aorta was balloon-occluded because of dense adhesions around the superior vena cava and ascending aorta due to the pseudoaneurysm. A tear in the equine pericardial patch was noted at the aortic root. The patient underwent pseudoaneurysm excision and repair of the aortic root using a double-layered, Hemashield-reinforced bovine pericardial patch. Routine follow-up with computed tomography should be performed for early detection of complications from a heterologous pericardial patch.