Publications by authors named "Daijiro Hori"

83 Publications

Treatment Site Does Not Affect Changes in Pulse Wave Velocity but Treatment Length and Device Selection Are Associated With Increased Pulse Wave Velocity After Thoracic Endovascular Aortic Repair.

Front Physiol 2021 22;12:739185. Epub 2021 Oct 22.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

Endovascular treatment of aortic aneurysm is associated with an increase in pulse wave velocity (PWV) after surgery. However, the effect of different types of endovascular devices on PWV at different sites of the thoracic aorta remains unclear. The purposes of this study were (1) to investigate the changes in PWV after endovascular treatment of thoracic aortic aneurysm; (2) to evaluate whether there is a difference in the changes in PWV at different treatment sites; and (3) to evaluate the effect of treatment length on changes in PWV. From July 2008 to July 2021, 276 patients underwent endovascular treatment of the true thoracic aortic aneurysm. Of these patients, 183 patients who underwent preoperative and postoperative PWV measurement within 1 year of surgery were included in the study. The treatment length index was calculated by treatment length divided by the height of the patients. Five different types of endovascular devices were used (Najuta, Kawasumi Laboratories, Inc., Tokyo, Japan; TAG, W.L. Gore & Associates, Inc., AZ, USA; Relay, Bolton Medical, Inc., FL, USA; Talent/Valiant, Medtronic, MN, USA; and Zenith, Cook Medical, IN, USA). There was no significant change in PWV in patients receiving Najuta (Before: 2,040 ± 346.8 cm/s vs. After: 2,084 ± 390.5 cm/s, = 0.14). However, a significant increase was observed in other devices: TAG (Before: 2,090 ± 485.9 cm/s vs. After: 2,300 ± 512.1 cm/s, = 0.025), Relay (Before: 2,102 ± 465.3 cm/s vs. After: 2,206 ± 444.4 cm/s, = 0.004), Valiant (Before: 1,696 ± 330.2 cm/s vs. After: 2,186 ± 378.7 cm/s, < 0.001), and Zenith (Before: 2,084 ± 431.7 cm/s vs. After: 2,321 ± 500.6 cm/s, < 0.001). There was a significant increase in PWV in patients treated from aortic arch (Before: 2,006 ± 333.7 cm/s vs. After: 2,132 ± 423.7 cm/s, < 0.001) and patients treated from descending thoracic aorta (Before: 2,116 ± 460.9 cm/s vs. After: 2,292 ± 460.9 cm/s, < 0.001). Multivariate analysis showed that treatment site was not an independent factor associated with changes in PWV. However, Najuta (Coef -219.43, 95% CI -322.684 to -116.176, < 0.001) and treatment index (Coef 147.57, 95% CI 24.826 to 270.312, = 0.019) were independent factors associated with changes in PWV. Najuta did not show a significant increase in PWV, while other commercially available devices showed a significant increase. The treatment site did not have a different effect on PWV. However, the treatment length was an independent factor associated with an increase in PWV.
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http://dx.doi.org/10.3389/fphys.2021.739185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8569554PMC
October 2021

Evaluation of oversizing in association with conduction disorder after implantation of a rapid deployment valve.

J Artif Organs 2021 Nov 2. Epub 2021 Nov 2.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-Shi, Saitama, 330-8503, Japan.

Rapid deployment valve has expanded surgical indication for high-risk patients with aortic stenosis despite its accommodated risk for conduction disorder (CD). The purpose of this study was to evaluate the degree of oversizing in association with postoperative CD. During June 2019 to September 2021, 25 patients underwent aortic valve replacement with Edwards INTUITY. Device size selection was evaluated intraoperatively using provided sizers. Oversizing was evaluated retrospectively by measuring the difference of the dimension of the annulus and left ventricular outflow tract (LVOT) compared to the dimensions of the device used by preoperative-computed tomography. Although there was no incidence of pacemaker implantation, seven patients (28.0%) experienced CD after surgery. There was no difference in device area and annulus area (CD: - 37 ± 22.7 mm vs. no CD: - 56 ± 63.6 mm, p = 0.47), and device circumference and annulus circumference (CD: - 4.4 ± 2.77 mm vs. no CD: - 6.9 ± 5.60 mm, p = 0.26) in patients with and without CD. However, there was a significant difference in area of the device skirt and sub-annular area at the LVOT (CD: 114 ± 28.4 mm vs. no CD: - 8 ± 80.0 mm, p < 0.001), and circumference of device skirt and the LVOT (CD: 3.9 ± 2.08 mm vs. no CD: - 4.6 ± 5.24 mm, p < 0.001) between the two groups. Receiver operating characteristic curve analysis showed that an area difference of 77.7 mm and circumference difference of 0.91 mm at LVOT were associated with postoperative CD with specificities of 0.83, 0.78 and sensitivity of 1.0, 1.0, respectively. Preoperative measurement of the LVOT may be useful in evaluating the risk of postoperative CD in patients receiving rapid deployment valve.
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http://dx.doi.org/10.1007/s10047-021-01301-4DOI Listing
November 2021

An increased prothrombin time-international normalized ratio in patients with acute type A aortic dissection: contributing factors and their influence on outcomes.

Surg Today 2021 Nov 1. Epub 2021 Nov 1.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanumacho, Omiya-ku, Saitama, 330-8503, Japan.

Purpose: We investigated factors contributing to coagulopathy in patients with acute type A aortic dissection (ATAAD) and coagulopathy's influence on patient outcomes.

Methods: We grouped 420 patients who underwent ATAAD repair-none under anticoagulation therapy or with liver disease-by the prothrombin time-international normalized ratio (PT-INR) at admission:  <  1.2 (no coagulopathy, n  =  371), 1.2-1.49 (mild coagulopathy, n  =  33), or  ≥  1.5 (severe coagulopathy, n  =  16). We then compared the clinical presentation, dissection morphology, and outcomes among the groups. We assessed the PT-INR in relation to the preoperative hemodynamics and searched for factors predictive of a PT-INR  ≥  1.2.

Results: The transfusion volume and operation time were increased among patients with coagulopathy (P  <  0.05). The in-hospital mortality (15.2-37.5% vs. 5.1%, P  < 0.001) and 5-year survival (61.1-74.4% vs. 87.6%) were relatively poor for these patients. The median PT-INR was 1.03 (0.97-1.1) for patients with stable hemodynamics (n  =  318), 1.11 (1.02-1.21) for those in shock (blood pressure  <  80 mmHg) not given cardiopulmonary resuscitation (CPR) (n  =  81), and 1.1 (1.0-1.54) for those in shock given CPR (n  =  21) (P  < 0.001). A multivariable analysis identified shock (P  <  0.001), a partially thrombosed false lumen (P  =  0.006), and mesenteric malperfusion (P  =  0.016) as predictive variables.

Conclusions: Shock, a partially thrombosed false lumen, and mesenteric malperfusion appear to be predictive of dissection-related coagulopathy, which influences outcomes negatively.
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http://dx.doi.org/10.1007/s00595-021-02399-yDOI Listing
November 2021

Impact of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation.

J Artif Organs 2021 Oct 19. Epub 2021 Oct 19.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan.

Negative impact of prosthesis-patient mismatch on long-term survival after valve replacement has been reported. However, the effect of prosthesis-patient mismatch after bioprosthetic mitral valve replacement has not yet been well examined. The purpose of this study was to investigate the effect of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation. A total of 181 patients underwent bioprosthetic mitral valve replacement between April 2008 and December 2016. After excluding patients with mitral stenosis and those with incomplete data, 128 patients were included in the study. Postoperative transthoracic echocardiography was performed before discharge for all patients and the effective orifice area of bioprosthetic mitral valve was calculated using the formula: 220/pressure half-time, and the effective orifice area index was calculated by the formula: effective orifice area/body surface area. Prosthesis-patient mismatch was defined as a postoperative effective orifice area index ≤ 1.2 cm/m. The characteristics and outcomes were compared between the groups. There were 34 patients (26.6%) with prosthesis-patient mismatch and 94 patients (73.4%) without prosthesis-patient mismatch. There were no significant differences in the in-hospital mortality and morbidities. Multivariable analysis showed that prosthesis-patient mismatch was an independent predictor of late mortality (hazard ratio 3.38; 95% confidence interval 1.69-6.75; p = 0.001) and death from heart failure (hazard ratio 31.03, 95% confidence interval 4.49-214.40, p < 0.001). Prosthesis-patient mismatch at discharge after mitral valve replacement for mitral regurgitation was associated with long-term mortality and death from heart failure.
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http://dx.doi.org/10.1007/s10047-021-01299-9DOI Listing
October 2021

[Redo Aortic Valve Replacement].

Kyobu Geka 2021 Sep;74(10):740-745

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

With increasing number of patients undergoing aortic valve replacement, many patients are at risk for redo aortic valve surgery. It has been reported that 56.2% of the patients receiving a bioprostheis and 7.4% of the patients receiving a mechanical valve need reoperation 20 years after the primary surgery. Although valve in valve transcatheter aortic valve implantation (TAVI) is a less invasive approach, redo aortic valve replacement is preferred for patients with prosthetic valve endocarditis, small aortic valve prosthesis and poor access for TAVI. Special care should be prepared for safe re-sternotomy, cardiopulmonary bypass management and strategy for cardioplegia. As reported from high volume centers, redo aortic valve replacement could be performed at a similar mortality rate as the primary surgery. New prostheses such as sutureless valve and rapid deployment valve could be useful, as well as minimally invasive cardiac surgery approach, which may prevent tissue injury. However, redo aortic valve replacement via re-sternotomy remains a gold standard. Techniques and strategy for redo aortic valve replacement are reviewed.
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September 2021

[Rapid Growing Thoracic Aortic Aneurysm in a Patient with Relapsing Polychondritis].

Kyobu Geka 2021 Aug;74(8):583-586

Department of Cardiovascular Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan.

A 26-year-old man with relapsing polychondritis was admitted for the treatment of multiple thoracic aortic aneurysms in the ascending and descending aorta. Descending thoracic aortic aneurysm showed rapid expansion, therefore, the patient underwent an extended thoracic aortic repair from the ascending aorta to the descending aorta via anterolateral thoracotomy and partial sternotomy. Although postoperative course was uneventful, aortic root enlargement and severe aortic insufficiency progressed over the next two years. He and his family refused redo surgical intervention and the patient died of heart failure. Careful perioperative follow-up may be mandatory in a patient with relapsing polychondritis complicated by cardiovascular disease.
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August 2021

Effects of Obesity on Outcomes of Acute Type A Aortic Dissection Repair in Japan.

Circ Rep 2020 Oct 23;2(11):639-647. Epub 2020 Oct 23.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University Saitama Japan.

The prevalence of obesity among Japanese acute type A aortic dissection (ATAAD) patients and its effect on repair outcomes remain to be elucidated. The prevalence of obesity (body mass index [BMI] ≥30.0 kg/m) among 1,059 patients (mean [±SD] age 64.3±12.7 years) who underwent ATAAD repair between 1990 and 2018 was compared with that among the general Japanese population (National Health and Nutrition Survey data). The prevalence of obesity among male patients (17.1% [6/35], 20.0% [18/90], and 14.4% [20/139] for those aged 20-39, 40-49, and 50-59 years, respectively) was significantly higher than that among the age- and sex-matched general population. The 1,059 patients were divided into groups according to weight (normal [BMI <25.0 kg/m; n=742], overweight [BMI 25.0-29.9 kg/m; n=248], or obese [BMI ≥30.0 kg/m; n=69]). Comparing the normal weight, overweight, and obese groups revealed significant differences among the 3 groups in median cardiopulmonary bypass time (143, 167, and 183 min, respectively), ventilation >48 h (44.5%, 60.1%, and 78.3%, respectively), and in-hospital mortality (7.0%, 7.3%, and 17.4%, respectively), but not in 30-day survival. Shock, visceral malperfusion, operation time >360 min, obesity, and coronary malperfusion were identified as predictors of in-hospital mortality. The prevalence of obesity is increased among Japanese male patients with ATAAD aged ≤59 years. Obesity may increase these patients' operative risk; overweight does not.
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http://dx.doi.org/10.1253/circrep.CR-20-0098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7937495PMC
October 2020

Modified central extracorporeal membrane oxygenation for distended left ventricle.

J Card Surg 2021 Apr 24;36(4):1557-1559. Epub 2021 Jan 24.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

A 38-year-old man who was resuscitated from ventricular fibrillation was diagnosed with acute aortic dissection complicated by coronary malperfusion. He underwent total aortic arch replacement and coronary artery bypass grafting to the left anterior descending coronary artery. Due to low cardiac output syndrome from cardiac ischemia, central extracorporeal membrane oxygenator (ECMO) was established with aortic cannulation from the side branch of the implanted prosthetic graft and venous drainage from the femoral vein. Ventricular venting was added from the right upper pulmonary vein for the distended left ventricle. ECMO was weaned off on postoperative Day 4. The patient is back on his normal daily life for more than 1 year after the surgery.
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http://dx.doi.org/10.1111/jocs.15352DOI Listing
April 2021

Relationship between endothelial function and vascular stiffness on lower limit of cerebral autoregulation in patients undergoing cardiovascular surgery.

Artif Organs 2021 Apr 15;45(4):382-389. Epub 2020 Dec 15.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

Hemodynamic management based on cerebral autoregulation range is a possible strategy for preserving major organ perfusion during cardiovascular surgery. The purpose of this study was to evaluate the relation of vascular properties with lower limit of cerebral autoregulation (LLA). LLA was monitored in 66 patients undergoing cardiovascular surgery using near-infrared spectroscopy. To determine the clinical importance of LLA monitoring, association of blood pressure excursions below LLA and acute kidney injury (AKI) was evaluated. Flow-mediated dilation (FMD) and pulse wave velocity (PWV) were measured for the evaluation of endothelial function and aortic stiffness. Variables associated with LLA were evaluated. Excluding patients on hemodialysis, there were 15 patients (25.9%) who developed AKI. Blood pressure excursions below LLA were higher in patients who developed AKI (4.55 mm Hg × hr vs. 1.23 mm Hg × hr, P = .017). In the univariate analysis, prevalence of ischemic heart disease (No IHD: 53 ± 13.0 mm Hg vs. IHD: 60.0 ± 13.6 mm Hg, P = .056) and FMD (r = -0.42, 95% CI -0.61 to -0.19, P < .001) were associated with LLA before cardiopulmonary bypass (CPB). During CPB, calcium channel blocker (No Ca blocker: 42 ± 10.6 mm Hg vs. Ca blocker: 49 ± 14.3 mm Hg, P = .033), diabetes (no DM: 44 ± 13.2 mm Hg vs. DM: 55 ± 10.0 mm Hg, P = .024), FMD (r = -0.32, 95% CI -0.55 to -0.05, P = .021), and PWV (r = 0.28, 95% CI 0.012 to 0.513, P = .041) were associated with LLA. Multivariate analysis showed that FMD was correlated with LLA before CPB (r = -2.19, 95% CI -3.621 to -0.755, P = .003), while PWV was correlated with LLA during CPB (r = 0.01, 95% CI 0.001-0.019, P = .023). Endothelial function and aortic stiffness may be important factors in determining LLA at different phases in cardiovascular surgery.
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http://dx.doi.org/10.1111/aor.13868DOI Listing
April 2021

Personalized Blood Pressure Management During Cardiac Surgery With Cerebral Autoregulation Monitoring: A Randomized Trial.

Semin Thorac Cardiovasc Surg 2021 Summer;33(2):429-438. Epub 2020 Nov 10.

Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

The purpose of this study was to determine if setting mean arterial pressure (MAP) targets during cardiopulmonary bypass (CPB) based on individualized cerebral autoregulation data reduces the frequency of neurological complications compared with usual care. Patients (n = 460) ≥ 55 years old at risk for neurological complications were randomized to have MAP targets during CPB to be above the lower limit of transcranial Doppler determined cerebral autoregulation versus usual institutional practices. The primary outcome was the frequency of the composite endpoint of clinical stroke, or new brain magnetic resonance imaging-detected ischemic injury, or cognitive decline 4-6 weeks after surgery from baseline. Secondary outcomes were components of the primary composite outcome and clinically detected delirium. Complete outcome data were available from 194 patients (stroke assessments, n = 460; magnetic resonance imaging data, n = 164; cognitive data n = 336). There was no difference between groups in the frequency of the composite neurological end-point or its components (P = 0.752). Compared with the usual care there was a 45% reduction in the frequency of clinically detected delirium in the autoregulation group (8.2% vs 14.9%, risk ratio = 0.55, 95% confidence interval = 0.32, 0.93, P = 0.035) and improved performance on test of memory 4-6 weeks after surgery from baseline (P = 0.019). Basing MAP during CPB on cerebral autoregulation monitoring did not reduce the frequency of the primary neurological outcome in high-risk patients compared with usual care but it was associated with a reduction in the frequency of delirium and better performance on tests of memory 4-6 weeks after surgery.
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http://dx.doi.org/10.1053/j.semtcvs.2020.09.032DOI Listing
July 2021

Long-Term Outcomes and Echocardiographic Data After Aortic Valve Replacement With a 17-mm Mechanical Valve.

Circ J 2020 11 24;84(12):2312-2319. Epub 2020 Oct 24.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University.

Background: We investigated the long-term clinical and hemodynamic outcomes after aortic valve replacement (AVR) with a 17-mm mechanical valve.Methods and Results:Between January 2005 and December 2011, 80 patients with aortic stenosis underwent AVR with the 17-mm St. Jude Medical Regent prosthetic valve. Echocardiography was performed preoperatively, at discharge, and at follow-up, which was performed at least 2 years postoperatively (median interval, 7.3 years). Prosthesis-patient mismatch (PPM) was defined as an indexed effective orifice area <0.85 cm/mat discharge and occurred in 25 patients (31%). The median follow-up period was 8.7 years (100% complete). Overall in-hospital mortality was 2.5% (2 patients) with 27 late deaths (34%). The 5- and 10-year survival rates were 78.7% and 63.0%, respectively. Peripheral arterial disease and concomitant mitral valve repair were independent predictors of late mortality. The 5- and 10-year freedom from major adverse valve-related events (MAVRE) rates were 91.6% and 83.5%, respectively. PPM at discharge did not affect long-term survival, freedom from MAVRE, or freedom from heart failure. Echocardiographic data at follow-up revealed a significant reduction in the mean left ventricular mass index (LVMI). LVMI reduction observed at follow-up was similar between patients with and without PPM.

Conclusions: AVR with the 17-mm mechanical prosthesis had acceptable long-term clinical and hemodynamic outcomes. Significant reduction in LVMI was observed regardless of PPM.
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http://dx.doi.org/10.1253/circj.CJ-20-0201DOI Listing
November 2020

Dissected thoracoabdominal aortic aneurysm repair with modified parallel endografting.

J Card Surg 2020 Nov 16;35(11):3220-3223. Epub 2020 Aug 16.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

A 67-year-old woman with a prior history of aortic dissection was admitted for enlarging the thoracoabdominal aortic aneurysm (TAAA). She has received multiple treatments including Bentall procedure, hemiarch replacement, and subsequent endovascular procedures for the closure of re-entry. Preoperative computed tomography revealed previously implanted thoracic endograft from distal arch to superior mesenteric artery with dissected TAAA measuring up to 70 mm in diameter. Re-entry was observed at bilateral common iliac arteries. The patient was successfully treated by endovascular treatment using a fenestrated stent graft to obtain a landing zone for parallel endograft technique to the iliac arteries for the closure of re-entry.
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http://dx.doi.org/10.1111/jocs.14962DOI Listing
November 2020

Endothelial-Specific Overexpression of Histone Deacetylase 2 Protects Mice against Endothelial Dysfunction and Atherosclerosis.

Cell Physiol Biochem 2020 Sep;54(5):947-958

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA,

Background/aims: We recently described a novel regulatory role for histone deacetylase 2 (HDAC2) in protecting endothelial cells from oxidized low-density lipoprotein (OxLDL)-induced injury. In this study, we examined the effects of endothelial-specific HDAC2 overexpression on endothelial-dependent vasorelaxation and atherogenesis in vivo.

Methods: Endothelial-specific HDAC2-overexpressing transgenic mice (HDAC2-Tg) were generated under control of the Tie2 promoter. An atherosclerosis model was produced by injecting HDAC2-Tg and wild-type (WT) mice with adeno-associated virus encoding a PCSK9 gain-of-function mutant under control of a liver-specific promoter and feeding them a high-fat diet for 12 weeks. Aortic stiffness in vivo was determined by measuring pulse wave velocity. Wire myography was used to measure endothelium dependent (acetylcholine) and independent (sodium nitroprusside) relaxation in isolated mice aortas. Atherosclerotic plaque burden in aortas was determined by Oil Red O staining and protein expression was determined by western blotting.

Results: At baseline, HDAC2-Tg mice had normal mean arterial blood pressure (MAP) and body weight, but pulse wave velocity (PWV), an inverse measure of vascular health and stiffness, was decreased, suggesting that their vessels were more compliant. Moreover, basal nitric oxide production was enhanced in the vessels of HDAC2-Tg mice as compared to that in WT controls, although no significant differences in acetylcholine (endothelial component)- or sodium nitroprusside (non-endothelial component)-mediated relaxation were observed. However, after exposure to OxLDL, aortas from HDAC2-Tg mice exhibited greater acetylcholine-induced relaxation than did those from WT mice. Thus, endothelial-specific vasodilator production was enhanced despite oxidative injury. Atherosclerosis induction in WT mice led to a significant increase in PWV, but in HDAC2-Tg mice, PWV and MAP remained unchanged. Further, aortic rings from HDAC2-Tg exhibited better endothelial-dependent vascular relaxation than did those from WT mice, but not when treated with nitric oxide synthase inhibitor L-NAME. Finally, plaque burden, determined by Oil red O staining, was significantly increased in WT, but not HDAC2-Tg mice, subjected to the atherogenic model. Deletion of endothelial HDAC2 led to impaired endothelial cell-dependent vascular relaxation and increased PWV, compared with those in littermate controls.

Conclusion: HDAC2 protects against endothelial dysfunction and atherogenesis induced by oxidized lipids. Hence, overexpression or activation of HDAC2 represents a novel therapy for endothelial dysfunction and atherosclerosis. HDAC2-Tg mice provide an opportunity to determine the role of endothelial HDAC2 in vascular endothelial homeostasis.
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http://dx.doi.org/10.33594/000000280DOI Listing
September 2020

Early superior mesenteric artery revascularization for acute type A aortic dissection with cardiac tamponade and mesenteric malperfusion.

J Card Surg 2020 Dec 9;35(12):3581-3584. Epub 2020 Sep 9.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

We report herein the successful treatment of a case of acute type A aortic dissection complicated by cardiac tamponade and mesenteric malperfusion. The patient was a 60-year-old man with back and abdominal pain and in shock, who was transported to our hospital 2 h after symptom onset. Computed tomography revealed DeBakey type I dissection with massive hemopericardium and obstruction of both the celiac artery and superior mesenteric artery. After emergency pericardiotomy and removal of the hematoma, superior mesenteric artery-external iliac artery bypass was constructed with a vein graft, and this restored mesenteric perfusion. Open distal hemiarch replacement was then performed. The postoperative course was uneventful. Superior mesenteric artery revascularization achieved immediately after release of the cardiac tamponade prevented further mesenteric ischemia and paved the way for the aortic repair.
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http://dx.doi.org/10.1111/jocs.15009DOI Listing
December 2020

[Bioprosthetic Mitral Valve Thrombosis in Patient with Antiphospholipid Antibody Syndrome;Report of a Case].

Kyobu Geka 2020 Aug;73(8):619-622

Department of Cardiovascular Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan.

A 66-year-old woman with primary antiphospholipid antibody syndrome (APS) was admitted due to severe dyspnea. Eight months prior to admission, she underwent bioprosthetic mitral valve replacement for mitral valve stenosis and regurgitation. Transthoracic echocardiogram showed thickening bioprosthetic valve leaflets and severe valve stenosis. Emergency reoperation for artificial valve failure was performed. The explanted bioprosthetic valve showed massive thrombus formation. After the operation, she started strict anticoagulant and antiplatelet therapies and was discharged without recurrence of valve thrombosis.
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August 2020

Left thoracotomy approach for left ventricular pseudoaneurysm due to myocardial infarction after mitral valve replacement for papillary muscle rupture.

J Card Surg 2020 Aug 11;35(8):2103-2105. Epub 2020 Jul 11.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

A 59-year-old man with acute mitral regurgitation due to papillary muscle rupture after myocardial infarction was admitted to our hospital. He underwent emergent mitral valve replacement with a mechanical valve by median sternotomy. Although postoperative echocardiography showed no sign of a ventricular aneurysm, echocardiography performed 5 weeks after the surgery showed enlarging left ventricular pseudoaneurysm of the inferior to the posterior cardiac wall. He underwent dacron patch closure of the orifice by fifth intercostal left thoracotomy. The postoperative course was uneventful and he was discharged on postoperative day 10. The patient was successfully treated for two life-threatening complications occurring subsequently after myocardial infarction.
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http://dx.doi.org/10.1111/jocs.14851DOI Listing
August 2020

Effect of Transcatheter Aortic Valve Implantation on the Immune Response Associated With Surgical Aortic Valve Replacement.

Am J Cardiol 2020 08 14;128:35-44. Epub 2020 May 14.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

The immune response after transcatheter aortic valve implantation (TAVI) in comparison to that after surgical aortic valve replacement (SAVR) remains to be fully elucidated. In a 2-part study, we assessed laboratory data obtained before, immediately after, and 24 and 48 hours after SAVR (128 patients; age ≥80 [mean 82] years) or transfemoral TAVI (102 patients; age ≥80 [mean 86] years) performed for aortic stenosis. In-hospital mortalities were similar (3% vs 0%), but leukocyte counts and aspartate aminotransferase and creatine kinas concentrations were decreased immediately and 24 hours after surgery (all, p <0.001). We performed cytokine profiling in a SAVR group (11 patients; mean age, 77 years) and transfemoral TAVI group (12 patients; mean age, 84 years). By measuring normalized concentrations of 71 cytokines at 3 time points, we found a significant difference (defined as fold change >1.7 and p <0.05 [by Mann-Whitney U-test]) in 23 cytokines. The differentially expressed cytokines fell into 3 hierarchical clusters: cluster A (high increase after SAVR and suppressed increase after TAVI only immediately after surgery [CCL2, CCL4, and 2 others]), cluster B (high increase after SAVR and suppressed increase after TAVI at 2 time points [IL-1Ra, IL-6, IL-8, IL-10, and 5 others]), and cluster C (various patterns [TRAIL, CCL11, and 8 others]). Gene enrichment analysis identified multiple pathways associated with the inflammatory responses in SAVR and altered responses in TAVI, including cellular responses to tumor necrosis factor (p = 0.0035) and interleukin-1 (p = 0.0062). In conclusion, a robust inflammatory response follows SAVR, and a comparatively attenuated response follows TAVI.
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http://dx.doi.org/10.1016/j.amjcard.2020.04.037DOI Listing
August 2020

Prosthetic Graft Dilation at the Aortic Arch in the Era of Hybrid Aortic Surgery.

Ann Vasc Dis 2020 Jun;13(2):163-169

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama, Japan.

: This study aims to evaluate the chronological size changes of the prosthetic graft in the aortic arch, which is used as a landing zone for a subsequent stent grafting in hybrid aortic surgery. : Eighty-five patients who underwent total aortic arch replacement followed by computed tomography follow-up for at least 30 months after the surgery were included in the study. : Prosthetic grafts used were Hemashield (Maquet, Rastatt, Germany), J-Graft (Japan Lifeline Inc., Tokyo, Japan) and Triplex (Terumo, Tokyo, Japan). There was an initial increase in diameter compared to package size after implantation (Hemashield, 1.04±0.035 vs. J-Graft, 1.06±0.027 vs. Triplex, 1.04±0.023, p=0.13). Significant difference in graft dilation ratio was observed in Triplex (1.18±0.062) at long-term compared to Hemashield (1.07±0.052, p<0.001) and J-Graft (1.10±0.071, p<0.001). Multivariate analysis showed that age (r=0.002; 95% confidence interval [CI], 0.0001-0.0037; p=0.035), knitted-type prosthesis (r=0.089; 95% CI, 0.0610-0.1163; p<0.0001), and prevalence of cerebral vascular disease (r=0.038; 95% CI, 0.0030-0.0732; p=0.034) were independently associated with graft dilation after surgery. : Prosthetic graft selection and appropriate sizing of the stent graft should be considered for each individual undergoing hybrid aortic surgery to maintain sufficient oversizing of the stent graft.
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http://dx.doi.org/10.3400/avd.oa.20-00005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315240PMC
June 2020

Minimized perfusion circuit for acute type A aortic dissection surgery.

Artif Organs 2020 Nov 7;44(11):E470-E481. Epub 2020 Jun 7.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

A minimized perfusion circuit (MPC) may reduce transfusion requirement and inflammatory response. Its use, however, has not been standardized for complicated cardiovascular surgery. We assessed outcomes of surgery for acute type A aortic dissection (ATAAD) performed with a MPC under circulatory arrest. The study involved 706 patients treated surgically for ATAAD (by hemiarch repair [n = 571] or total arch repair [n = 135]). Total arch repair was performed using selective antegrade cerebral perfusion. Our MPC, a semi-closed bypass system, incorporating a completely closed circuit and a level-sensing reservoir in the venous circuit, was used. Clinical variables, transfusion volume, and outcomes were investigated in patients who underwent hemiarch repair or total arch repair. The overall incidences of shock, organ ischemia, and coagulopathy (prothrombin time-international normalized ratio >1.5) were 26%, 35%, and 8%, respectively. Mean extracorporeal circulation (ECC) time was 149 minutes for the hemiarch repair group and 241 minutes for the total arch repair group, respectively. No patient required conversion to conventional ECC, and there were no complications related to the use of the MPC. The need for transfusion (98% vs. 91%, P = .017) and median transfusion volume (1970 vs. 1680 mL, P = .002) was increased in the total arch repair group. Neither in-hospital mortality (total arch; 12% vs. hemiarch; 7%, P = .11) nor 10-year survival (74.4% vs. 68.4%, P = .79) differed significantly. Outcomes of surgery for ATAAD performed with the MPC were acceptable. The possibility of transfusion and transfusion volume remains high during such surgery, despite the use of the MPC.
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http://dx.doi.org/10.1111/aor.13724DOI Listing
November 2020

Acute Kidney Injury Following Elective Open Aortic Repair with Suprarenal Clamping.

Ann Vasc Dis 2020 Mar;13(1):45-51

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama, Japan.

: To investigate predictors of acute kidney injury (AKI) following open aortic repair (OAR) requiring suprarenal clamping. : The study included 833 nonhemodialysis patients who had undergone elective OAR (with suprarenal clamping, n=73; with infrarenal clamping, n=760). We evaluated AKI as defined by the criteria of the Kidney Disease Improving Global Outcomes (KDIGO) and compared in-hospital outcomes between the two groups. We also investigated the effects of AKI on outcomes, factors related to post-suprarenal clamping AKI, and efficacy of hypothermic renal perfusion (HRP) in the suprarenal clamping group. : For the suprarenal vs. infrarenal clamping group, in-hospital mortality was 0% (0/73) vs. 0.5% (4/760). The incidence of AKI was greater in the suprarenal clamping group (37% vs. 15%, P<0.001), and the hospital stay for patients with AKI was longer than for those patients without AKI (median, 21 days vs. 16 days; P=0.005). Renal ischemia time and bleeding volume >1,000 mL were associated with post-suprarenal clamping AKI. Renal ischemia time was longer with HRP (n=15) than without HRP (n=58) (median, 51 min vs. 33 min; P=0.011), and HRP did not decrease the incidence of AKI (40% vs. 36%; P=0.78). : Prolonged renal ischemia and substantial intraoperative bleeding are associated with postoperative AKI following suprarenal clamping.
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http://dx.doi.org/10.3400/avd.oa.19-00095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140154PMC
March 2020

Etiology and impact on outcomes of polycystic kidney disease in abdominal aortic aneurysm.

Surg Today 2020 Oct 6;50(10):1213-1222. Epub 2020 Apr 6.

Department of General Internal Medicine, School of Medicine, The Jikei University, Tokyo, 105-8461, Japan.

Purpose: We investigated the etiology and impact on outcomes of polycystic kidney disease in patients with abdominal aortic aneurysm.

Methods: Eight-hundred patients who underwent open (n = 603) or endovascular aortic repair (n = 197) were divided into three groups: no cyst (n = 204), non-polycystic kidney (n = 503), and polycystic kidney (≥ 5 cysts in the bilateral kidneys, n = 93). The characteristics and outcomes were compared among the groups.

Results: In the polycystic kidney group, the age was increased and the proportions of patients with male sex, hypertension, and estimated glomerular filtration rate < 30 mL/min/1.73 m were greater. The overall hospital mortality rates were similar. The incidence of acute kidney injury after elective open aortic repair was increased in the polycystic kidney group (12%, 17%, and 29%, P = 0.020). In the polycystic kidney group, 80 patients did not have renal enlargement or a family history of renal disease, while 13 (corresponding to 1.6% [13/800] of the overall patients), had renal enlargement, suggesting the possibility of hereditary polycystic kidney disease.

Conclusions: In our cohort, 1.6% of the patients with abdominal aortic aneurysm who underwent surgery were at risk of hereditary polycystic kidney disease. Polycystic kidney disease was associated with acute kidney injury after open aortic repair.
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http://dx.doi.org/10.1007/s00595-020-01997-6DOI Listing
October 2020

Effect of endoprostheses on pulse wave velocity and its long-term outcomes after thoracic endovascular aortic repair.

Gen Thorac Cardiovasc Surg 2020 Oct 30;68(10):1134-1141. Epub 2020 Mar 30.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan.

Background: The purpose of this study was to evaluate the changes in pulse wave velocity and left ventricular dimensions in patients undergoing stent-graft treatment for aortic arch aneurysm.

Methods: From July 2008 to February 2019, 86 patients underwent thoracic endovascular aortic repair of an aortic arch aneurysm. Changes in pulse wave velocity (PWV), echocardiogram findings, and long-term outcomes were compared between endoskeleton type (n = 60) and exoskeleton type stent-graft (n = 26).

Results: There was no significant difference in patient demographics except for diabetes which was more observed in endoskeleton type (p = 0.017). There was a significant increase in PWV in exoskeleton type after surgery, which further progressed at a median follow-up of 32 months (before: 2047 cm/s vs. after: 2259 cm/s vs. follow-up: 2486 cm/s, p = 0.010, p = 0.017). No significant difference was observed in endoskeleton type (before: 1980 cm/s vs. after: 2058 cm/s, vs. follow-up: 2042 cm/s, p = 0.25, p = 0.34). Echocardiogram performed at a median period of 46.3 months, revealed a significant increase in left ventricular diastolic volume (LVDV) (before: 107.4 ± 20.6 ml vs. follow-up: 127.7 ± 27.5 ml, p = 0.003) and decrease in e' (before: 5.5 ± 1.78 cm/s vs. follow-up: 4.7 ± 1.72 cm/s, p = 0.012) in exoskeleton type, while no significant change was observed in endoskeleton type (LVDV: before: 102.6 ± 32.3 ml vs. follow-up: 96.9 ± 35.4 ml, p = 0.74; e': before: 4.4 ± 1.21 cm/s vs. follow-up: 4.8 ± 1.40 cm/s, p = 0.68). At the median period of 61.3 months, there was no significant difference in long-term mortality (p = 0.89). However, the endoskeleton type was associated with a lower incidence of a cardiac event (p = 0.034) and cerebrovascular event (p = 0.029).

Conclusion: Types of endoprosthesis might affect differently on physiological changes and its accommodated risk factors after surgery.
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http://dx.doi.org/10.1007/s11748-020-01343-0DOI Listing
October 2020

Utility of double arterial cannulation for surgical repair of acute type A dissection.

Eur J Cardiothorac Surg 2020 06;57(6):1068-1075

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

Objectives: Outcomes of planned and unplanned (rescue) double arterial cannulation (DAC) in surgery for acute type A aortic dissection were investigated retrospectively.

Methods: The study involved 805 patients who were divided into 4 groups according to the cannulation strategy: single cannulation of the femoral artery (n = 338), axillary artery (n = 256), left ventricular apex (n = 52) or ascending aorta (n = 5) (total, n = 57), and DAC (n = 154). Patients who underwent DAC were divided between planned (n = 132) and rescue (n = 22) usage. Characteristics and outcomes were compared between groups. Both unmatched and propensity score-matched analyses were performed.

Results: Shock (39%, 19%, 33% and 14%, in the femoral artery, axillary artery, left ventricular apex/ascending aorta and DAC, respectively) and leg malperfusion (5%, 16%, 16% and 26%, respectively) differed significantly (P < 0.001), but in-hospital mortality did not (9%, 8%, 18% and 7%, respectively; P = 0.096). The 5-year survival rates were 79.4%, 79.7%, 78.6% and 82.2%, respectively. Propensity score-matched analysis showed no statistically significant differences in in-hospital mortality rates (10%, 12%, 14% and 9%, respectively; P = 0.78) and 5-year survival rates (78.4%, 72.3%, 82.3% and 78.0%, respectively). The leading vessel combination and indications for planned and rescue DAC were the femoral and axillary arteries (98%) and true lumen narrowing and/or leg malperfusion (34%), and the axillary followed by femoral (77%) artery and low cardiopulmonary bypass flow (36%). In-hospital mortality in the planned and rescue DAC groups was 7% and 9%, respectively.

Conclusions: DAC seems effective for both prevention and management of intraoperative malperfusion.
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http://dx.doi.org/10.1093/ejcts/ezaa007DOI Listing
June 2020

Factors related to white blood cell elevation in acute type A aortic dissection.

PLoS One 2020 6;15(2):e0228954. Epub 2020 Feb 6.

Department of Cardiovascular Surgery, Nihon University, Itabashi-ku, Tokyo, Japan.

Aortic dissection may induce a systemic inflammatory reaction. The etiological backgrounds for elevation of the white blood cell count remain to be clarified. In 466 patients with acute type A aortic dissection treated surgically within 48 hours of symptom onset, the etiologic background of an elevated admission white blood cell count and the effect of such elevation on outcomes were assessed retrospectively. Patients' white blood cell count differed significantly in relation to the extent of dissection, with a median (25th, 75th percentile) white blood cell count of 10.4 (8.1, 13.9) x 103/μL for dissection confined to the ascending aorta, 10.5 (8.2,13.) 103/μL for dissection extending to the aortic arch/descending aorta, 11.1 (8.2, 13.7) x 103/μL for extension to the abdominal aorta, and 13.3 (9.8, 15.9) x 103/μL for extension to the iliac artery (p<0.001). With 11.0 x 103/μL used as the cut-off value for white blood cell count elevation, multivariable analysis showed current smoking (p<0.001; odds ratio, 2.79), dissection extending to the iliac artery (p = 0.006; odds ratio, 1.79), age (p = 0.007, odds ratio, 0.98), and no coronary ischemia (p = 0.027, odds ratio, 2.22) to be factors related to the elevated white blood cell count. Mean age differed significantly between patients with and without an elevated white blood cell count (62.3 vs. 68.3 years, p <0.001). Although in-hospital mortality was similar (7.5% vs.10.9%, p = 0.19), 5-year survival was lower in patients without an elevated count (85.7% vs. 78.6%, p = 0.019), reflecting their more advanced age. In conclusion, our data suggest that dissection morphology and patient age influence the acute phase systemic inflammatory response associated with an elevated white blood cell count in patients with ATAAD. A better understanding of this relation may help optimize diagnosis and perioperative care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228954PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004339PMC
May 2020

Long-Term Outcomes of Open Surgery and Stent Graft Treatment in Patients Undergoing Repeat Thoracic Aortic Aneurysm Repair from Previous Anastomosis Site.

Ann Vasc Dis 2019 Dec;12(4):500-506

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama, Japan.

: The purpose of this study was to compare the long-term outcomes of open surgery and thoracic endovascular aortic repair (TEVAR) in patients undergoing repeat thoracic aortic repair from previous anastomosis site. : From January 2009 to December 2017, 68 patients needed repeat aortic surgery from previous anastomosis site. Twenty-three patients had dissected distal aorta and 45 patients had non-dissected distal aorta. Early and long-term outcomes of open surgery and TEVAR were compared in both groups. : There were no significant differences in patient background between the two treatments in both groups. Open surgery was associated with longer intensive care unit stay, but there was no significant difference in in-hospital mortality in both groups. In patients with dissected distal aorta, there was no significant difference in long-term mortality (p=0.73). However, TEVAR was associated with higher risk of reintervention (p=0.038). In non-dissected distal aorta patients, acute kidney injury (p=0.002) and prolonged ventilation (p=0.032) were more often observed in open surgery. However, there were no significant differences in long-term mortality (p=0.23) and freedom from reintervention (p=0.13). : Long-term outcomes were similar between open surgery and TEVAR in both groups. However, TEVAR in patients with dissected distal aorta was associated with higher risk, for reintervention.
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http://dx.doi.org/10.3400/avd.oa.19-00052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957898PMC
December 2019

Redo Descending Aortic Replacement via Direct Anastomosis to J Graft Open Stent Graft.

Ann Vasc Dis 2019 Sep;12(3):395-397

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama, Japan.

A 64-year-old man with prior history of total arch replacement with frozen elephant trunk was admitted for an enlarging descending thoracic aortic aneurysm. Preoperative computed tomography revealed previously implanted J graft open stent graft, a frozen elephant trunk device approved in Japan, with enlarged dissected aortic aneurysm from distal anastomosis site to the level of the diaphragm. The patient underwent descending aortic replacement. Proximal anastomosis was directly performed at the distal end of the previously implanted J graft open stent graft. Hemostasis at the anastomosis site was uneventful and the patient was discharged from the hospital without any aneurysm-related complication.
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http://dx.doi.org/10.3400/avd.cr.19-00048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766762PMC
September 2019

Risk factors for spinal cord injury in patients undergoing frozen elephant trunk technique for acute aortic dissection.

Gen Thorac Cardiovasc Surg 2020 Apr 29;68(4):328-334. Epub 2019 Aug 29.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-Shi, 330-8503, Saitama, Japan.

Background: The purpose of this study was to evaluate the risk factors for spinal cord injury (SCI) in patients with acute aortic dissection undergoing surgery with frozen elephant trunk technique (FET).

Methods: From December 2014 to February 2018, 17 patients with acute aortic dissection underwent surgical treatment of the aortic arch with FET. SCI occurred in 3 patients. Risk factors for SCI were evaluated.

Results: Mean age of the patients was 56 years and 88.2% were male. The ratio of true lumen to total aortic diameter at the level of carina (before: 0.48 vs. after: 0.75, P < 0.001), aortic valve (before: 0.47 vs. after: 0.67, P = 0.001), and celiac artery (before: 0.48 vs. after: 0.68, P = 0.003) increased after surgery. There were no significant differences in perioperative minimum hemoglobin level and postoperative mean arterial pressure between patients with and without SCI. However, patients with SCI had higher creatinine level before surgery (SCI: 1.32 mg/dL vs. no SCI: 0.81 mg/dL, P = 0.023). Although there was no difference in number of patent intercostal arteries before surgery, those originating from the true lumen were fewer in patients with SCI (SCI: 2.7 vs. no SCI: 8.6, P = 0.021). Furthermore, with entry closure, significant decrease in patency was observed in intercostal arteries originating from the false lumen (before: 3.1 vs. after: 1.0, P < 0.001).

Conclusion: FET was useful in entry closure. However, FET in patients with higher creatinine level and those who may have significant spinal cord perfusion from the false lumen could be a risk factor for postoperative SCI.
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http://dx.doi.org/10.1007/s11748-019-01196-2DOI Listing
April 2020

Additional frozen elephant trunk as a bailout for a misdeployed frozen elephant trunk in the false lumen in a patient with acute aortic dissection.

Eur J Cardiothorac Surg 2020 02;57(2):399-401

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.

Using a frozen elephant trunk (FET) in patients with acute aortic dissection is an effective method to induce aortic remodelling after surgery. A 40-year-old man with Stanford type A acute aortic dissection underwent emergency total arch replacement with FET. The FET was inserted into the descending aorta under direct vision. However, transoesophageal echocardiography after the deployment of the FET revealed that it was misdeployed in the false lumen. An additional FET was deployed in the true lumen to redirect the blood flow to the true lumen. The patient was discharged from the hospital without any major complications. Computed tomography 6 months after surgery revealed enhanced aortic remodelling without any signs of stent graft-induced new entry. Additional deployment of a FET into the true lumen could be an option for a misdeployed FET in the false lumen.
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http://dx.doi.org/10.1093/ejcts/ezz213DOI Listing
February 2020

Prosthesis selection for aortic valve replacement in patients on hemodialysis.

Gen Thorac Cardiovasc Surg 2020 Feb 6;68(2):122-128. Epub 2019 Jul 6.

Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan.

Objective: The purpose of this study was to evaluate the outcomes of prosthesis selection in hemodialysis patients undergoing valve replacement for aortic valve stenosis.

Methods: From July 2008 to December 2016, 76 patients on hemodialysis underwent aortic valve replacement for aortic valve stenosis. Of these patients, 30 patients were treated by a mechanical valve and 46 patients were treated by a bioprosthesis. Early outcomes and long-term outcomes were compared.

Results: The mean age of the patients treated by a mechanical valve was younger than the patients treated by a bioprosthesis (p < 0.001). There were no significant differences in in-hospital mortality (p = 0.52). For the long-term outcomes, complications associated with bleeding were higher in patients who received a mechanical valve (p = 0.032). However, no significant difference was observed in mortality (p = 0.65) and major adverse cardiovascular cerebrovascular event (MACCE: p = 0.59). The actuarial survival rate with a mechanical valve was 56.7% (95% CI 36.4-72.8%) at 3 years and 48.6% (95% CI 28.9-65.8%) at 5 years. The actuarial survival rate with a bioprosthesis was 61.2% (95% CI 44.0-74.5%) at 3 years and 39.5% (95% CI 20.9-57.8%) at 5 years. No patients from both groups needed redo surgery for valvular deterioration. Further, there was no significant difference in long-term mortality (p = 0.91) and MACCE (p = 0.63) in a propensity score-matched patient comparison.

Conclusions: Although bleeding complications were higher in patients who received a mechanical valve, there were no significant differences in early- and long-term mortality, and MACCE between patients treated by a mechanical valve and a bioprosthesis.
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http://dx.doi.org/10.1007/s11748-019-01172-wDOI Listing
February 2020

Effect of Targeting Mean Arterial Pressure During Cardiopulmonary Bypass by Monitoring Cerebral Autoregulation on Postsurgical Delirium Among Older Patients: A Nested Randomized Clinical Trial.

JAMA Surg 2019 09;154(9):819-826

Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery.

Objective: To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care.

Design, Setting, And Participants: This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study.

Intervention: In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice.

Main Outcomes And Measures: The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel.

Results: Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P = .04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P = .04).

Conclusions And Relevance: The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed.

Trial Registration: ClinicalTrials.gov identifier: NCT00981474.
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http://dx.doi.org/10.1001/jamasurg.2019.1163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537779PMC
September 2019
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