Publications by authors named "Yoshiyuki Tokuda"

90 Publications

Worsening renal function after transcatheter aortic valve replacement and surgical aortic valve replacement.

Heart Vessels 2021 Jan 25. Epub 2021 Jan 25.

Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan.

Several prior reports have investigated worsening renal function around transcatheter aortic valve replacement (TAVR) procedures. However, in clinical practice, it seems more important to evaluate changes associated with TAVR-related procedures, including preoperative enhanced computed tomography (CT), as well as the TAVR procedure itself, as CT assessment is considered essential for safe TAVR. This study evaluated worsening renal function during the TAVR perioperative period, from the preoperative enhanced CT to 1 month after TAVR, and then compared the incidence with that in patients undergoing surgical aortic valve replacement (SAVR). This retrospective single-center study investigated 123 TAVR patients and 130 SAVR patients. We evaluated baseline renal function before enhanced CT in TAVR patients and before operation in SAVR patients, and again at 1 month post-operatively. We defined worsening renal function at 1 month according to three definitions: (1) an increase in serum creatinine ≥ 0.3 mg/dL or ≥ 1.5-fold from baseline or initiation of dialysis, (2) a decline in eGFR at 1 month ≥ 20% from baseline or initiation of dialysis, (3) a decline in eGFR at 1 month ≥ 30% from baseline or initiation of dialysis. TAVR patients were significantly older and had higher surgical risk scores than SAVR patients. In TAVR patients, serum creatinine levels were 1.00 ± 0.32 mg/dL at baseline and 1.01 ± 0.40 mg/dL at 1 month post-operatively (p = 0.58), while in SAVR patients, these levels were 0.99 ± 0.51 mg/dL and 0.98 ± 0.49 mg/dL, respectively (p = 0.59). In TAVR patients, 7 (5.7%), 14 (11.4%), and 3 (2.4%) patients experienced worsening renal function according to the three definitions, respectively, but there were no significant differences from those in SAVR patients, for any definition. Worsening renal function after TAVR was uncommon, and the incidence rate was comparable to that in SAVR patients, even though TAVR patients had worse baseline characteristics.
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http://dx.doi.org/10.1007/s00380-021-01778-2DOI Listing
January 2021

Hypofibrinogenemia can be estimated by the predictive formula in aortic surgery.

Gen Thorac Cardiovasc Surg 2021 Jan 25. Epub 2021 Jan 25.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.

Objective: Aortic surgery often causes massive bleeding due to hypofibrinogenemia. Predicting hypofibrinogenemia is useful for developing a hemostasis strategy, including preparing for blood transfusion. We made a formula for predicting the serum fibrinogen level (SFL) at the termination of cardiopulmonary bypass (CPB) in aortic surgery and examined its validity.

Methods: We performed a retrospective observational study that consisted of 267 patients (group A) who underwent aortic surgery from July 2013 to December 2016 and made a formula for predicting the SFL at the termination of CPB in group A by a multiple linear regression analysis. The validity of this formula was then examined in another 60 patients (group B) who underwent aortic surgery from January 2017 to December 2017.

Results: We developed the following predictive formula: SFL at the termination of CPB (mg/dL) = 14.7 + 0.44 × preoperative SFL (mg/dL) + (- 0.14) × CPB time (min) + 0.64 × preoperative body weight (kg) + (- 17.3) × lateral thoracotomy (Yes/No, Yes: 1, No: 0). In group B, the predictive formula proved to be statistically valid in group B (R = 0.531, p < 0.001).

Conclusion: The SFL at the termination of CPB in aortic surgery can be predicted by the preoperative SFL, body weight, CPB time and surgical approach. The predictive formula is useful for developing a hemostasis strategy, including preparing for blood transfusion.
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http://dx.doi.org/10.1007/s11748-021-01594-5DOI Listing
January 2021

Beating-heart total arch replacement for an octogenarian patient with severe heart failure.

J Card Surg 2021 Mar 8;36(3):1126-1129. Epub 2021 Jan 8.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Surgical outcomes of total arch replacement (TAR) have improved dramatically over the last decades. However, patients of advanced age and with a severely reduced cardiac function and an extended aortic arch aneurysm may not be candidates for conventional TAR. Endovascular and hybrid treatment for extended aortic aneurysm have demonstrated lower mortality and morbidity, and considered for the advanced age and high-risk patients. But endovascular with total de-branching technique remains challenging with the slightly dilated ascending aorta. Reducing the operation time, cardiac arrest time, and circulatory arrest time should be needed to resolve the problem for the conventional TAR with an advanced age and a severely reduced cardiac function. We herein introduce our surgical technique for the case of an 84-year-old man with a severely reduced cardiac function, who was successfully treated with beating heart TAR with minimization of the operation time, cardiac arrest time, and circulatory arrest time.
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http://dx.doi.org/10.1111/jocs.15282DOI Listing
March 2021

Is Hybrid Repair for an Entire Shaggy Aorta Feasible?

Heart Lung Circ 2020 Oct 30. Epub 2020 Oct 30.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Objective: This paper reviewed clinical experiences to evaluate the feasibility of a surgical strategy for an entire shaggy aorta.

Methods: Fifty-two (52) surgeries (47 men, average age 72±7 years) were performed for an entire shaggy aorta at the current institution from 2002-2017. Open surgery was performed in 30 cases, including total arch replacement in 12, extended aortic arch replacement via L-shaped thoracotomy in 10 and median sternotomy combined with left thoracotomy in two, and thoracoabdominal aortic replacement in six. Hybrid procedures were performed in 22 cases: type I hybrid arch repair in six, type II hybrid arch repair in seven and type III hybrid arch repair in nine.

Results: Hospital mortality was significantly higher with a hybrid repair: surgical, one case (3%); hybrid, six cases (27%), (p=0.0125). Stroke occurred at relatively high rates in both groups: surgical, seven cases (23%); hybrid, six cases (27%) (p=0.75). Spinal cord injury was significantly higher in hybrid repair: surgical, one case (3%); hybrid, seven cases (32%), (p=0.004). Open surgery revealed a better long-term survival rate than the hybrid procedure at 5 and 10 years: surgical, 82%, 65.7%; hybrid, 53%, 35.1%, respectively (p=0.0452). The rate of freedom from aortic events was significantly better with open surgery than a hybrid procedure at 5 and 10 years: surgical, 96%, 85%; hybrid, 83%, 41.3%, respectively (p=0.0082).

Conclusions: Surgery for an entire shaggy aorta was frequently associated with embolic complications such as stroke, paraplegia, renal failure, and bowel necrosis. However, open surgical repair may produce better early and late outcomes and freedom from aortic events compared with hybrid repair.
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http://dx.doi.org/10.1016/j.hlc.2020.09.923DOI Listing
October 2020

Serial Images of Aortic Plaque Rupture During Transfemoral Transcatheter Aortic Valve Replacement.

JACC Cardiovasc Interv 2020 Nov 28;13(22):e203-e204. Epub 2020 Oct 28.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

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http://dx.doi.org/10.1016/j.jcin.2020.09.007DOI Listing
November 2020

Sutures on the Anterior Mitral Leaflet to Prevent Systolic Anterior Motion.

Ann Thorac Surg 2021 03 8;111(3):e213-e215. Epub 2020 Oct 8.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.

Mitral valve systolic anterior motion and associated regurgitation remain a challenging problem in mitral valve plasty. A simple procedure to correct intraoperative systolic anterior motion using sutures applied between the tip of the anterior leaflet and the posterior annulus is presented. This technique reduces the movement of the anterior leaflet toward the septum while maintaining sufficient valve orifice area.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.057DOI Listing
March 2021

Surgery for anomalous papillary muscle directly into the anterior mitral leaflet.

Ann Thorac Surg 2020 Sep 24. Epub 2020 Sep 24.

Nagoya University Graduate School of Medicine, Department of Cardiac Surgery, Nagoya, Japan.

Background: The anomalous insertion of papillary muscle directly into the anterior mitral leaflet is a rare congenital anomaly concomitant with hypertrophic cardiomyopathy. We herein report our surgical technique, which is designed to relieve left ventricular obstruction and preserve the mitral valve and sub-valvular apparatus.

Methods: Among 38 patients who underwent septal myectomy from 2007 to 2020, 4 had an anomalous mitral sub-valvular apparatus with papillary muscle with direct insertion into the anterior mitral leaflets. In all cases, mitral valve repair was accomplished with excision and reconstruction of all anomalous PMs, concomitant with septal myectomy. In other 34 patients, 20 cases needed mitral valve repair with regards to systolic anterior motion by hypertrophic cardiomyopathy. The comparison study was conducted between anomalous papillary muscle group (group A) and the others (group B).

Results: There was no early or late death in group A, three early death and two late death in group B. The mean peak gradient in the left ventricle was significantly decreased in both groups. Mitral valve regurgitation grade was also significantly decreased from 3 to 0.5 without valve replacement in group A, from 2 to 0.6 in group B. Six patients needed mitral valve replacement due to the thickness of anterior mitral leaflet in group B.

Conclusions: Hypertrophic obstructive cardiomyopathy associated with the anomalous insertion of papillary muscle can be successfully treated without mitral valve replacement. Excision and reconstruction with the anomalous papillary muscle seems to be a feasible operation to reduce mitral regurgitation and relieve outflow tract obstruction.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.031DOI Listing
September 2020

Management of Patients With Aortic Stenosis Requiring Non-Cardiac Surgery.

Circ J 2020 06 30;84(7):1064-1066. Epub 2020 May 30.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine.

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http://dx.doi.org/10.1253/circj.CJ-20-0437DOI Listing
June 2020

Correction to: Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in‑hospital mortality and failure to be weaned from extracorporeal membrane oxygenation.

J Artif Organs 2020 Sep;23(3):233

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan.

In the original publication of the article, author group affiliation was published incorrectly.
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http://dx.doi.org/10.1007/s10047-020-01171-2DOI Listing
September 2020

Upper thoracoabdominal aortic repair through partial posterior incision of the diaphragm via left thoracotomy.

Gen Thorac Cardiovasc Surg 2020 Dec 20;68(12):1594-1595. Epub 2020 May 20.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-ku, Nagoya, Aichi, 466-8560, Japan.

During surgical repair of a thoracoabdominal aortic aneurysm, division of the diaphragm should be minimized to avoid pulmonary complications. We herein describe a modified exposure technique that avoids ordinary circumferential division of the diaphragm. The diaphragm was detached from the aneurysm at the level of the aortic hiatus via a modified anterior lateral thoracotomy incision through the pleural space. The diaphragmatic incision around the aneurysm was extended posteriorly. This partial division of the diaphragm provided sufficient exposure of the distal anastomosis site for thoracoabdominal aneurysms that do not extend below the upper part of the abdomen.
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http://dx.doi.org/10.1007/s11748-020-01387-2DOI Listing
December 2020

Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in-hospital mortality and failure to be weaned from extracorporeal membrane oxygenation.

J Artif Organs 2020 Sep 25;23(3):225-232. Epub 2020 Feb 25.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine Japan, Nagoya, Japan.

Postcardiotomy cardiogenic shock (PCCS) is a rare clinical entity associated with substantial morbidity and mortality. It is characterized by heart failure that results in an inability to be weaned from cardiopulmonary bypass (CPB). The aim of this study was to analyze the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with PCCS and to identify predictors of in-hospital mortality and failure to be weaned from ECMO. From January 2002 to August 2016, 3248 patients underwent cardiac surgery in our hospital. Of these, 29 patients (0.89%) required ECMO because of an inability to be weaned from cardiopulmonary bypass. The median duration of ECMO support was 144 h (340-52 h) (range 17-818 h). Sixteen patients (55.2%) were weaned from ECMO, and 6 (20.7%) survived to hospital discharge. The multivariate analysis revealed that reoperation [odds ratio (OR): 13.667, 95% confidence interval (CI): 0.999-187.056, p = 0.05] and ECMO support duration > 130 h (OR: 17.688, 95% CI: 1.324-236.233, p = 0.03) were independent predictors of failure to be weaned from ECMO. Temporarily being weaned from CPB > 15 min (OR: 0.027, 95% CI: 0.001-0.586, p = 0.02) was found to be a protective factor. The multivariate analysis revealed that CPB time > 270 min (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) and ECMO support duration > 60 h (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) were independent predictors of in-hospital mortality. ECMO is an acceptable technique for treating PCCS in patients undergoing cardiac surgery. Our data suggest a reevaluation of therapeutic strategies after 60 h and again after 130 h of ECMO support.
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http://dx.doi.org/10.1007/s10047-020-01160-5DOI Listing
September 2020

Modified sutureless repair using left atrial appendage flap for acquired left-sided pulmonary vein stenosis.

Eur J Cardiothorac Surg 2020 08;58(2):395-397

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Pulmonary vein stenosis is a well-known complication after radiofrequency catheter ablation of atrial fibrillation. Although surgical repair is indicated for younger patients and patients with multiple stenoses, the appropriate procedure for acquired pulmonary vein stenosis has not been established. In this study, we report the successful outcome of our modified sutureless technique using a left atrial appendage flap for left-sided pulmonary vein stenosis after radiofrequency catheter ablation.
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http://dx.doi.org/10.1093/ejcts/ezaa032DOI Listing
August 2020

Contemporary Outcomes of Surgical Aortic Valve Replacement in Japan.

Circ J 2020 01 11;84(2):277-282. Epub 2020 Jan 11.

The Japan Cardiovascular Surgery Database Organization (JCVSD).

Background: Given the rapid expansion in the use of transcatheter aortic valve implantation (TAVI), recent outcomes of surgical aortic valve replacement (SAVR) should be re-evaluated.Methods and Results:Using the data from the Japan Cardiovascular Surgery Database of 160 enrolled hospitals, trends in elective isolated SAVR were evaluated until the introduction of TAVI in Japan. Trend analyses were performed over 4 periods: period 1, 2008-2009 (4,415 cases); period 2, 2010-2011 (4,861 cases); period 3, 2012-2013 (5,674 cases); and period 4, 2014-2015 (5,563 cases). Baseline risk, evaluated on JapanSCORE, increased significantly over the 4 periods, from a median of 1.56 (IQR, 0.99-2.61) in period 1 to 2.08 (IQR, 1.33-3.96) in period 4 (P<0.001, trend test). Despite the increased risk, the composite major complication and operative mortality rate decreased significantly (10.7% in period 1 to 9.2% in period 4, P=0.01). Using a risk-adjusted model, the OR of operative mortality was 1.61 (95% CI: 1.29-2.02) in period 1 (P<0.0001) compared with period 4. An increase in the use of bioprostheses was also observed, from 60.4% to 76.8% (P<0.001) over the 4 periods.

Conclusions: Even in a short 8-year period, SAVR outcomes improved in Japan. This should be taken into account when discussing the indications for aortic valve intervention.
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http://dx.doi.org/10.1253/circj.CJ-19-0674DOI Listing
January 2020

Patient trends and outcomes of surgery for type A acute aortic dissection in Japan: an analysis of more than 10 000 patients from the Japan Cardiovascular Surgery Database.

Eur J Cardiothorac Surg 2020 04;57(4):660-667

Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan.

Objectives: To evaluate the background trends and surgical outcomes for more than 10 000 patients with acute type A dissection in Japan in a recent 8-year period.

Methods: Data on replacement of the ascending aorta and/or aortic arch for acute type A dissection were collected from the Japan Cardiovascular Surgery Database from 2008 to 2015. Linear-by-linear association tests or Cuzick's test for trend was used to evaluate group trends over time. The results were calculated for ascending or hemiarch replacement and arch replacement. A multivariable logistic regression model was used to calculate the risk-adjusted operative mortality rate.

Results: A total of 11 843 patients were included. The overall 30-day mortality and operative mortality rates were 7.6% and 9.5%, respectively. The number of surgically treated cases increased from 2436 patients in 2008-2009 to 3533 in 2014-2015, a 45.0% increase. A trend analysis revealed significant changes in patient characteristics with time, including increasing age and rate of preoperative renal failure. Despite worsening risk factors, the unadjusted operative mortality rate with arch replacement showed a significant downward trend (P = 0.01; test of trend). The risk-adjusted mortality rate showed a downward trend both in ascending aorta or hemiarch replacement and arch replacement, although the trend was not statistically significant (P > 0.05).

Conclusions: Unadjusted and adjusted operative deaths have shown a decreasing trend, although patients undergoing surgery for acute type A dissection have demonstrated worsening of risk factors, such as age and renal failure. The number of surgeries performed for acute type A dissection significantly increased throughout the study period in Japan.
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http://dx.doi.org/10.1093/ejcts/ezz323DOI Listing
April 2020

Bilateral versus single internal thoracic artery grafting in hemodialysis patients.

Gen Thorac Cardiovasc Surg 2020 Aug 23;68(8):768-773. Epub 2019 Nov 23.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan.

Background: The use of the bilateral internal thoracic arteries (BITAs) during myocardial revascularization reportedly provides a survival benefit over using a single internal thoracic artery (SITA). However, the advantages in chronic hemodialysis patients, who generally have multiple comorbidities, is unclear.

Methods: Outcomes of chronic hemodialysis patients who underwent isolated coronary artery bypass grafting (CABG) using a SITA with additional saphenous vein grafts (SVGs) (n = 33) or BITAs (n = 30) for left-side revascularization were retrospectively reviewed.

Results: With the exception of the rate of diabetes mellitus (SITA vs. BITA: 84.8% vs. 50.0%; p = 0.003), the two groups showed similar patient characteristics. Using the off-pump technique, revascularization was completed without manipulation of the ascending aorta in 45.7% of patients in the BITA group, whereas all patients in the SITA group required aortic manipulation (p < 0.001). Of note, the incidence of extensive aortic calcification (>50% of ascending aorta circumference) was not uncommon (14.3%). The in-hospital mortality (3.0% vs. 0%, p = 0.336) and complication rates (including deep wound infection, re-exploration and stroke) were similar in both groups. The 5-year estimated survival rates for freedom from overall death in the SITA and BITA groups were 42.4% and. 57.4%, respectively (p = 0.202).

Conclusions: BITA grafting was able to achieve revascularization with minimal manipulation of the diseased ascending aorta without increasing the complication rate. The long-term survival benefit of BITA grafting, however, was unclear in dialysis patients, especially because such patients have a relatively short life expectancy.
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http://dx.doi.org/10.1007/s11748-019-01254-9DOI Listing
August 2020

The incidence and risk factors of hypofibrinogenemia in cardiovascular surgery.

Gen Thorac Cardiovasc Surg 2020 Apr 17;68(4):335-341. Epub 2019 Sep 17.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8650, Aichi, Japan.

Objective: Cardiovascular surgery often causes massive bleeding due to coagulopathy, with hypofibrinogenemia being a major causative factor. We assessed the intraoperative incidence of hypofibrinogenemia and explored predictors of hypofibrinogenemia.

Methods: The intraoperative serum fibrinogen level (SFL) was routinely measured in 872 consecutive patients [mean age: 66.9 ± 13.3 years; 598 men (68.6%)] undergoing cardiovascular surgery from July 2013 to November 2016 at Nagoya University Hospital. There were 275 aortic surgeries, 200 cases of coronary artery bypass grafting (CABG), 334 valvular surgeries and 63 other surgeries. We estimated hypofibrinogenemia incidence (intraoperative lowest SFL ≤ 150 mg/dL) and identified its predictors by a logistic regression analysis.

Results: The average intraoperative lowest SFL of all cases, aortic surgery, CABG and valvular surgery was 185 ± 71, 156 ± 65, 198 ± 69 and 198 ± 68 mg/dL, respectively. Aortic surgery had a significantly lower intraoperative lowest SFL than CABG (p < 0.001) and valvular surgery (p < 0.001). The incidence of hypofibrinogenemia was 32.8%, 50.2%, 26.5% and 22.8% in all cases, aortic surgery, CABG and valvular surgery, respectively. The predictors of hypofibrinogenemia were the preoperative SFL, re-do surgery and perfusion time. A receiver operating characteristics curve analysis showed that the best preoperative SFL cutoff value for predicting hypofibrinogenemia was 308.5 mg/dL. Assuming preoperative SFL 300 mg/dL as the cutoff, the odds ratio for hypofibrinogenemia was 7.22 (95% confidence interval 5.26-9.92, p < 0.001).

Conclusions: The incidence of hypofibrinogenemia in aortic surgery was high. The preoperative SFL, re-do surgery and perfusion time were identified as predictors for hypofibrinogenemia. Intraoperative measurement of SFL is important for detecting hypofibrinogenemia and applying appropriate and prompt transfusion treatment.
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http://dx.doi.org/10.1007/s11748-019-01201-8DOI Listing
April 2020

Spinal cord injury following aortic arch replacement.

Surg Today 2020 Feb 22;50(2):106-113. Epub 2019 Jul 22.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, 466-8550, Aichi, Japan.

Purpose: Postoperative spinal cord injury is a devastating complication after aortic arch replacement. The purpose of this study was to determine the predictors of this complication.

Methods: A group of 254 consecutive patients undergoing aortic arch replacement via median sternotomy, with (n = 78) or without (n = 176) extended replacement of the upper descending aorta, were included in a risk analysis. The frozen elephant trunk technique was used in 46 patients. The patients' atherothrombotic lesions (extensive intimal thickening of > 4 mm) were identified from computed tomography images.

Results: Complete paraplegia (n = 7) and incomplete paraparesis (n = 4) occurred immediately after the operation (permanent spinal cord injury rate, 1.97%; transient spinal cord injury rate, 2.36%). A multivariable logistic regression analysis identified the use of the frozen elephant trunk technique (odds ratio 36.3), previous repair of thoracoabdominal aorta or descending aorta (odds ratio 29.4), proximal atherothrombotic aorta (odds ratio 9.6), chronic obstructive lung disease (odds ratio 7.1) and old age (odds ratio 1.1) as predictors of spinal cord injury (p < 0.0001, area under curve 0.93).

Conclusions: Spinal cord injury occurs with a non-negligible incidence following aortic arch replacement. The full objective assessment of the morphology of the whole aorta and the recognition of the risk factors are mandatory.
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http://dx.doi.org/10.1007/s00595-019-01853-2DOI Listing
February 2020

Mechanical haemolytic anaemia assessed with four-dimensional flow cardiac magnetic resonance.

Eur J Cardiothorac Surg 2019 Oct;56(4):813-814

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.

A 66-year-old woman developed marked haemolytic anaemia 2 years after total aortic arch replacement using a branched Dacron graft. Echocardiography confirmed bicuspid aortic valve stenosis. A four-dimensional flow magnetic resonance imaging revealed a jet flow arising from the aortic valve along with the vortex and turbulent flow inside the kinked prosthetic graft at the ascending aorta. She underwent a reoperation to replace the aortic valve and correct the kinking. The estimated energy loss after intervention was relieved to 2.9 mJ/cardiac cycle from 4.3 mJ/cardiac cycle before intervention. The patient's anaemia resolved immediately after the reoperation.
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http://dx.doi.org/10.1093/ejcts/ezz031DOI Listing
October 2019

Neurologic Deficit After Aortic Arch Replacement: The Influence of the Aortic Atherosclerosis.

Ann Thorac Surg 2019 07 30;108(1):107-114. Epub 2019 Jan 30.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.

Background: Postoperative neurologic deficits are associated with severe morbidity in aortic arch replacement.

Methods: A group of 198 consecutive patients undergoing isolated total aortic arch replacement with the use of antegrade cerebral perfusion were analyzed for the risk factors for predicting neurologic deficit. With the use of computed tomography, atherothrombotic lesions (defined as extensive intimal thickening exceeding 4 mm) were identified in the proximal aorta (the ascending aorta or aortic arch) in 26.2% of cases and in the distal aorta in 34.9% of cases.

Results: Permanent neurologic deficits occurred in 11.1% (including non-disabling stroke confirmed by imaging) and transient neurologic deficits in 8.1% of patients. A univariate analysis identified proximal atherothrombotic aorta (p = 0.0057), distal atherothrombotic aorta (p = 0.032), and retrograde systemic perfusion from the femoral artery in the presence of distal atherothrombotic aorta (p = 0.0022) as risk factors for neurologic deficits. A multivariate logistic regression analysis identified atherothrombotic proximal aorta (odds ratio 2.4, p = 0.033) as the independent risk factor. The presence of carotid stenosis did not affect the rate of neurologic deficit. Intracranial hemorrhagic lesions were found in 23% of permanent neurologic deficit cases.

Conclusions: Atherothrombotic lesions found by objectively graded computed tomography were predictors of neurologic deficit. Retrograde perfusion in the presence of a distal atherothrombotic lesion should be avoided whenever possible. Strategies based on the full assessment of the whole aortic morphologic characteristics appear to be mandatory. Anticoagulation therapy should be performed carefully to avoid intracranial hemorrhagic changes.
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http://dx.doi.org/10.1016/j.athoracsur.2019.01.004DOI Listing
July 2019

Conservative treatment of type A aortic dissection following hybrid arch repair.

Gen Thorac Cardiovasc Surg 2019 Jul 31;67(7):602-607. Epub 2019 Jan 31.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, Aichi, 466-8550, Japan.

Objective: Type A aortic dissection (TAAD) following hybrid arch repair (HAR) is a lethal complication. Open surgical repair is the ideal treatment, but this can be difficult, as most candidates have complications and are unsuitable for the conventional open aortic repair. We herein report three cases of TAAD after HAR and assess the treatment options.

Methods: Of 261 aortic arch repair cases between April 2010 and March 2018, 38 underwent HAR using debranching of all the arch vessels followed by stent graft implantation landing proximally in zone 0 (type 1 HAR). Three cases suffered from TAAD, and their background characteristics and post-operative outcomes were studied retrospectively.

Results: The three TAAD cases were elderly with a high risk of mortality due to comorbidities. TAAD for Cases 1, 2, and 3 was detected on post-operative day (POD) 11, POD11, and during the procedure, respectively. Case 1 was complicated with both respiratory and renal failures, and Case 3 suffered from severe neurological impairment when TAAD was detected. No additional open aortic repair was performed in any cases. Case 3 died on POD5 due to aortic rupture. Cases 1 and 2 have survived for more than 50 months since their initial surgeries.

Conclusions: TAAD following HAR can be detected with post-operative imaging despite a lack of signs noted during the intra- and post-operative periods. Conservative therapy might, therefore, be an acceptable option for subacute-onset TAAD following HAR with stable hemodynamics, even though such patients do required a very careful follow-up.
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http://dx.doi.org/10.1007/s11748-019-01075-wDOI Listing
July 2019

Strategy of Cardiovascular Surgery for Patients With Dementia as Evaluated by Mini-Mental State Examination.

Circ J 2018 11 27;82(12):2998-3004. Epub 2018 Sep 27.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine.

Background: The strategy for cardiovascular surgery in dementia patients is controversial, so we aimed to investigate whether preoperative dementia and its severity might affect the outcomes of cardiovascular surgery by evaluating with the Mini-Mental State Examination (MMSE). Methods and Results: The study group comprised 490 patients undergoing cardiovascular surgery. Their preoperative cognitive status was evaluated using the MMSE, and analysis was performed to compare the patients with MMSE score <24 (dementia group, n=51) or MMSE score 24-30 (non-dementia group, n=439). Furthermore, the effect of the severity of dementia was analyzed with a cut-off MMSE score of 19/20. Risk factors for surgical outcomes were explored using multivariate logistic regression analysis. Hospital mortality was 11.8% in the dementia group and 2.1% in the non-dementia group (P=0.002). Regarding the postoperative morbidities, the incidence of cerebrovascular disorder (P=0.001), pneumonia (P=0.039), delirium (P=0.004), and infection (P=0.006) was more frequent in dementia group. Among the patients with MMSE <20, hospital mortality was as high as 25%, and the rate of delirium was 58%. Multivariate logistic regression analysis revealed that MMSE score <24 (P=0.003), lower serum albumin (P=0.023) and aortic surgery (P=0.036) were independent risk factors for hospital death.

Conclusions: Preoperative dementia affects the outcomes of cardiovascular surgery with regard to hospital death and delirium. The surgical indication for patients with MMSE <20 might be difficult, but surgery with an appropriate strategy should be considered for patients with MMSE <24.
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http://dx.doi.org/10.1253/circj.CJ-18-0312DOI Listing
November 2018

Fungal endocarditis after transcatheter aortic valve replacement (TAVR): Case report and review of literature.

J Infect Chemother 2019 Mar 20;25(3):215-217. Epub 2018 Sep 20.

Department of Infectious Diseases, Nagoya University Hospital, Japan.

The reported number of transcatheter aortic valve replacement-associated infective endocarditis (TAVR-IE) cases has been increasing worldwide, but information about the incidence and clinical features of fungal TAVR-IE is quite limited. We present a patient who acquired TAVR-IE caused by Candida parapsilosis four month after TAVR, who was successfully treated redo-aortic valve replacement and prolonged antifungal therapy.
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http://dx.doi.org/10.1016/j.jiac.2018.08.017DOI Listing
March 2019

Temporary immobile leaflet following transcatheter aortic valve replacement of a SAPIEN-XT valve.

Cardiovasc Interv Ther 2019 07 4;34(3):277-278. Epub 2018 Jul 4.

The Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.

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http://dx.doi.org/10.1007/s12928-018-0536-7DOI Listing
July 2019

Aortic sarcoidosis complicated by a pulmonary artery aneurysm.

Eur J Cardiothorac Surg 2018 10;54(4):786-788

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.

A 76-year-old woman, who had a history of ocular sarcoidosis, was incidentally found to have a huge pulmonary artery aneurysm, along with aortic, mitral and tricuspid valve insufficiency. She underwent pulmonary artery plication along with surgeries for 3 valves. A specimen of the slightly enlarged ascending aorta revealed the involvement of sarcoidosis in the aortic wall. The systemic granulomatous inflammation process of sarcoidosis possibly affected the valvular and vascular pathology. Herein, we report a rare case of aortic sarcoidosis complicated by a pulmonary artery aneurysm.
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http://dx.doi.org/10.1093/ejcts/ezy131DOI Listing
October 2018

The oral administration of clarithromycin prevents the progression and rupture of aortic aneurysm.

J Vasc Surg 2018 12 14;68(6S):82S-92S.e2. Epub 2018 Mar 14.

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Objective: The pathogenesis of aortic aneurysm (AA) is associated with chronic inflammation in the aortic wall with increased levels of matrix metalloproteinases (MMPs). Clarithromycin (CAM) has been reported to suppresses MMP activity. In this study, we investigated whether CAM could prevent the formation and rupture of AA.

Methods: Male apolipoprotein E-deficient mice (28-30 weeks of age) were infused with angiotensin II for 28 days. CAM (100 mg/kg/d) or saline (as a control) was administered orally to the mice every day (CAM group, n = 13; control group, n = 13). After the administration period, the aortic diameter, elastin content, macrophage infiltration, MMP levels, and levels of inflammatory cytokines, including nuclear factor κB (NF-κB), were measured.

Results: The aortic diameter was significantly suppressed in the CAM group (P < .001). No rupture death was observed in the CAM group in contrast to five deaths (38%) in the control group (P < .01). CAM significantly suppressed the degradation of aortic elastin (56.3% vs 16.5%; P < .001) and decreased the infiltration of inflammatory macrophages (0.05 vs 0.16; P < .01). Compared with the controls, the enzymatic activity of MMP-2 and MMP-9 was significantly reduced in the CAM group (MMP-2, 0.15 vs 0.56 [P < .01]; MMP-9, 0.12 vs 0.60 [P < .01]), and the levels of interleukin 1β (346.6 vs 1066.0; P < .05), interleukin 6 (128.4 vs 346.2; P < .05), and phosphorylation of NF-κB were also decreased (0.3 vs 2.0; P < .01).

Conclusions: CAM suppressed the progression and rupture of AA through the suppression of inflammatory macrophage infiltration, a reduction in MMP-2 and MMP-9 activity, and the inhibition of elastin degradation associated with the suppression of NF-κB phosphorylation.
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http://dx.doi.org/10.1016/j.jvs.2017.12.047DOI Listing
December 2018

Clinical outcomes and quality of life after surgery for dilated ascending aorta at the time of aortic valve replacement; wrapping versus graft replacement.

Nagoya J Med Sci 2017 11;79(4):443-451

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Wrapping and graft replacement are two optional procedures for the treatment of dilated ascending aorta at the time of aortic valve replacement (AVR). Wrapping is considered less invasive. The aim of this study was to compare the short- and long-term clinical outcomes as well as the long-term quality of life in patients undergoing these two procedures.This study enrolled 40 consecutive patients with dilated ascending aorta who had undergone either wrapping (WAA group, n=20) or replacement (RAA group, n=20) of the ascending aorta at the time of AVR. Short-term outcomes, long-term deaths, and aortic events were evaluated, as was quality of life using the SF-36 Short Form. Long-term maximal proximal aortic diameter was also obtained.There were no early deaths in either group. Pump time was shorter, and transfusion (55% vs. 95%, p=0.035) and postoperative atrial fibrillation (5% vs. 30%, p=0.036) rates were lower, in the WAA than in the RAA group. At a mean follow-up of 4.9 years, the overall 5 year survival rates in the WAA and RAA groups were 78.1% and 87.5%, respectively. There were no significant between group differences in SF-36 scores in any subcategory of this survey. Long-term maximal aortic diameter remained stable in both groups. Both surgical interventions for dilated ascending aorta at the time of AVR yield favorable and comparable results in patients with suitable anatomy. Furthermore, we found no differences in quality of life between these procedures.
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http://dx.doi.org/10.18999/nagjms.79.4.443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719203PMC
November 2017

Entire Circumferential Reconstruction of the Right Atrium Surrounded by Angiosarcoma.

Ann Thorac Surg 2017 Jun;103(6):e483-e485

Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.

Primary cardiac angiosarcomas are frequently found at a large size with infiltration into the adjacent heart structure owing to their asymptomatic characteristics until an advanced stage. Therefore, extensive resection is often required to achieve a good prognosis. We herein report a case of entire circumferential resection of the right atrium surrounded by angiosarcoma and excellent three-dimensional reconstruction of the right atrium.
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http://dx.doi.org/10.1016/j.athoracsur.2016.11.032DOI Listing
June 2017

[Total Arch Replacement Using Manufactured Frozen Elephant Trunk after Acute Type-A Dissection Repair].

Kyobu Geka 2017 Apr;70(4):281-285

Department of Cardiac Surgery, Nagoya University, Nagoya, Japan.

The purpose of this study is to assess the result of total arch replacement(TAR) using manufactured frozen elephant trunk(FET) for chronic aortic dissection after initial repair including the effect of aortic remodeling by the FET. Between 2003 and 2015, we performed 11 TAR using manufactured FET. Initial repairs before were 9 ascending aortic replacements and 2 Bentall operations. The entry of residual dissection was located at arch in 7 and at distal anastomosis site in 4. There was no hospital death. The operative complication included 2 surgical site infection, 1 interstitial pneumonia and 1 paraplegia with almost full recovery. Postoperative computed tomography 2.1 months after operation showed distal end of the FET was located at aortic valve level in 7 and at pulmonary bifurcation level in 4. There was no entry in thoracic aorta. Thrombosis of descending aorta was achieved in 7 patients. Significant midterm aortic remodeling (increased diameter of true lumen and decreased diameter of false lumen) was achieved, although the total diameter of aorta was increased. TAR using manufactured FET after type-A dissection repair promoted entry closure and thrombosis of false lumen. It requires long-term observation to judge the effect for aortic remodeling.
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April 2017

Increased expression of the adipocytokine omentin in the epicardial adipose tissue of coronary artery disease patients.

Atherosclerosis 2016 08 6;251:299-304. Epub 2016 Jul 6.

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Background And Aims: Omentin, an adipocytokine secreted by visceral adipose tissue, protects against obesity-linked cardiovascular complications. However, little is known about its role in epicardial adipose tissue (EAT) and coronary artery disease (CAD). We investigated the expression of omentin in EAT from CAD subjects.

Methods: EAT, subcutaneous adipose tissue (SCAT), and plasma samples were collected from CAD (n = 15; 23.3 ± 3.1 kg/m(2)) and non-CAD patients (n = 10; 20.8 ± 3.9 kg/m(2)). Omentin mRNA expression was measured using real-time PCR, while plasma concentrations were measured using an ELISA. EAT volume was determined with 64-slice computed tomography.

Results: Omentin expression in EAT and EAT volume were higher in CAD patients compared with controls (2.49 ± 2.6 vs. 0.85 ± 0.3, p = 0.002 and 113 ± 58 ml vs. 92.4 ± 30 ml, p = 0.045, respectively). Omentin expression in SCAT was similar between CAD and control patients (1.37 ± 0.84 vs. 1.07 ± 0.55, p = 0.267). Plasma omentin levels were lower in CAD patients compared with controls (343 ± 158 ng/ml vs. 751 ± 579 ng/ml, p = 0.025), and were negatively associated with the expression of omentin in EAT, in patients with CAD (β = -0.78, p = 0.049). On the other hand, there was no association between omentin in EAT and clinical variables in patients with non-CAD.

Conclusions: Omentin expression increases in the EAT of non-obese CAD patients, despite a decrease in plasma levels, suggesting that omentin may play a role in the pathogenesis of CAD.
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http://dx.doi.org/10.1016/j.atherosclerosis.2016.07.003DOI Listing
August 2016