Endovascular Aortic Repair for Thoracic Aortic Compression Resulting From Chance Fracture of the Thoracic Spine

Blunt aortic injury is a serious condition with a high mortality rate. Although rare, blunt aortic injury associated with spinal fracture has also been reported, and appropriate management of aortic disease is key to a good outcome. This report is a case of a 78-year-old man who was found to have a transverse fracture (Chance fracture) in the ninth thoracic vertebra, with a sharp bone fragment compressing the thoracic aorta. Early spinal surgery was needed; however, there was concern about the possibility of bleeding from the aorta and surrounding small arteries associated with the bone fragment during spinal surgery. Therefore, thoracic endovascular aortic repair was performed before spinal surgery. The next day after thoracic endovascular aortic repair, posterior spinal instrumentation was performed, and the postoperative course was uneventful. Because aortic injury associated with vertebral fracture can lead to massive bleeding and spinal cord injury, endovascular repair before spinal surgery is reasonable.

Short-Term Outcomes of Impella Support in Japanese Patients With Cardiogenic Shock Due to Acute Myocardial Infarction - Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD)

BACKGROUND

The Impella^®percutaneous left ventricular assist device has been available in Japan since 2017. This is the first large-scale registry study to analyze the efficacy and safety of Impella in Japanese patients with acute myocardial infarction with cardiogenic shock (AMICS).Methods and Results: The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) has registered all consecutive Japanese patients treated with Impella. We extracted data for 593 AMICS patients from J-PVAD and analyzed 30-day survival and safety profiles. Overall 30-day survival was 63.1%. The 30-day survival of the Impella alone and Impella plus venoarterial extracorporeal membrane oxygenation (ECPELLA) groups was 80.9% and 45.7%, respectively. The Impella alone group was older and had a lower rate of cardiac arrest, milder consciousness disturbance, less inotrope use, lower serum lactate concentrations, higher B-type natriuretic peptide concentrations, and higher left ventricular ejection fraction (LVEF) than the ECPELLA group. Cox regression analysis revealed that older age and comorbid renal disturbance were common risk factors affecting 30-day mortality in both groups. Major adverse events were hemolysis (10.8%), hemorrhage/hematoma (7.6%), peripheral ischemia (4.4%), stroke (1.3%), and thrombosis (0.7%). LVEF improved in both groups during support.

CONCLUSIONS

AMICS treatment with Impella showed favorable 30-day survival and safety profiles. The survival rate of patients treated with Impella alone was particularly high. Further studies are needed to improve outcomes of patients with ECPELLA support.

Evaluation of coronary flow is useful in patients with left coronary cusp thrombus formation after left ventricular assist device implantation

Left ventricular assist device (LVAD) is essential for patients with severe heart failure, but there is a risk of thrombus formation on the aortic root and cusps, leading to coronary artery occlusion. Even with the narrowing of the echo-window due to LVAD, careful observation of coronary flow by transthoracic echocardiography can evaluate the patency of coronary flow non-invasively and immediately.

Successful Total Management of Multi-Causative Sleep-Disordered Breathing Complicated with Patient with Adult Congenital Heart Disease

Sleep-disordered breathing is one of the complications commonly seen in patients with adult congenital heart disease (ACHD) due to multiple causes including complex underlying cardiac defects, cardiomegaly, previous thoracotomies, obesity, scoliosis, and paralysis of the diaphragm. It is often hard to determine its main cause and predict the efficacy of each treatment in its management. We herein report a 30-year-old woman after biventricular repair of pulmonary atresia with intact ventricular septum diagnosed as sleep-related hypoventilation disorder. Simultaneous treatment targeting obesity, paralysis of the diaphragm, and cardiomegaly followed by respiratory muscle reinforcement through non-invasive ventilation resolved her sleep-related hypoventilation disorder. Such management for each factor responsible for the hypoventilation is expected to provide synergetic therapeutic efficacy and increase daily activity in a patient with ACHD.

[Extracorporeal Ventricular Assist Device for Acute Cardiogenic Shock]

Various diseases cause acute cardiogenic shocks, such as fulminant myocarditis and acute myocardial infarction, but if medical treatment as an induction therapy is not effective, mechanical circulatory support (MCS) should be promptly converted. Intraaortic balloon pumping (IABP) and peripheral veno-arterial extracorporeal membrance oxygenation( V-A ECMO)[percutaneous cardiopulmonary support (PCPS)] are generally used as MCS that can be easily introduced via the groin. Still, there are some cases in which recovery of cardiac function cannot be achieved even after the acute phase therapies. This article will explain the extracorporeal ventricular assist device as a more powerful MCS after IABP or V-A ECMO as induction therapy.

Redo Aortic Valve Replacement With Perceval Prosthesis via Minithoracotomy in a Patient With Permanent Tracheostoma and Tracheoesophageal Shunt

A 76-year-old male patient had undergone aortic valve replacement with a 19-mm Carpentier-Edwards Perimount valve 12 years prior and underwent laryngopharyngo-esophagectomy for hypopharyngeal carcinoma followed by permanent tracheostomy and tracheoesophageal shunt creation 2 years later. Echocardiography showed exacerbated structural valve deterioration of the bioprosthesis, necessitating redo surgery. A permanent tracheostoma, located just above the upper edge of the sternum, seemed to be at high risk of serious infections when median resternotomy was performed. To minimize the risk of infection, we performed implantation of a Perceval prosthesis via the right anterior minithoracotomy after sufficient anatomical assessments. There was no evidence of mediastinitis or wound infection during the follow-up period. This report highlights that the less invasive Perceval implantation strategically allowed reduction in the resternotomy-associated infection risks in this patient.

[Robot-assisted Cardiac Surgery Council and Current Status and Future Prospect of Robotic Mitral Valve Surgery in Japan]

The Robot-assisted Cardiac Surgery Council (RACSC) was established in 2015, and consists of the members of three closely related surgical societies and associations. The RACSC conducts the review and approval of applicant surgeons and institutions. A registry system has also been established through the Japan Cardiovascular Surgery Database-National Clinical Database( JCVSD-NCD). For the last five years, including the time when robotic mitral valve surgery was first approved as a procedure covered by the Japanese social insurance system in 2018, a total of 1,161 patients were enrolled in the JCVSDNCD, with an increase of nearly 500 cases per year. These cases underwent operations in 25 approved hospitals. The mean patient age was 59±13 years( range:20-90 years), and the male to female patient ratio was 1.8 male dominant. The most common procedure was mitral valve reconstruction, and 79% of all patients underwent annuloplasty. The mean operative time was 238±100 min, the mean cardiopulmonary bypass (CPB) time was 158±69 min, and the mean aortic cross-clamp (AXC) time was 102±49 min. When these results were compared with those of the Cleveland Clinic, which treated more than 1,000 cases as an initial institutional experience, both CPB and AXC times were nearly the same. It is believed that 200 cases are needed to stabilize the CPB and AXC time. Currently in Japan, only 3 or 4 out of the 25 approved hospitals have performed more than 200 cases over the past 5 years. The 30-day hospital mortality and redo operation rate for persisting mitral regurgitation was 0.3% and 0.6%, respectively, almost equivalent to that of the Cleveland Clinic. We believe that the 5-year result for robotic mitral surgery in Japan is acceptable. It is of note, however, that the length of hospital stay was 10.8±7.6 days, much longer than that of patients at the Cleveland Clinic( 5.2±2.8 days), and the homologous blood transfusion rate was 40.3%, twofold higher than that of the Cleveland Clinic( 20.5%). Therefore, the full benefits of less invasive robotic mitral repair surgery have not yet been achieved. Further improvements in results are both essential and anticipated.

Effect of Diabetes Mellitus on Outcomes in Patients With Left Ventricular Assist Device - Analysis of Data From a Japanese National Database

BACKGROUND

The objective of this study is to investigate the effect of preoperative diabetes on all-cause mortality and major postoperative complications among patients with continuous-flow left ventricular assist device (LVAD) by using data from a national database.Methods and Results: The 545 study patients who underwent primary HeartMateII implantation between 2013 and 2019 were divided into 2 groups according to their diabetes mellitus (DM) status; patients with DM (n=116) and patients without DM (n=429). First, the on-device survival and incidence of adverse events were evaluated. Second, after adjusting for patients' backgrounds, the change of laboratory data in the 2 groups were compared. Overall, on-device survival at 1, 2, and 3 years was almost equivalent between the 2 groups; it was 95%, 94%, and 91% in patients without DM, and 93%, 91%m and 91% in patients with DM (P=0.468) The incidence of adverse events was similar between 2 groups of patients, except for driveline exit site infection in the adjusted cohort. Cox proportional hazards regression analysis revealed younger age (HR: 0.98 (95% confidence interval (CI): 0.97-0.99, P=0.001) and presence of DM (HR: 1.83 (95% CI: 1.14-2.88), P=0.016) as significant predictors of driveline infection. Laboratory findings revealed no differences between groups throughout the periods.

CONCLUSIONS

The clinical results after LVAD implantation in DM patients were comparable with those in non-DM patients, except for the driveline exit site infection.

[The Trend of Minimally Invasive Cardiac Surgery:Where Robot-assisted Cardiac Surgery in Japan is Now]

The trend in cardiac surgery is moving toward minimally invasive procedures worldwide. In Japan, robot-assisted cardiac surgery has started simultaneously with the insurance coverage of minimally invasive cardiac surgery in April 2018. Technology innovations such as the miniaturization of the robot arm, the development of various type of instruments have improved operability and has contributed to the spread of robot-assisted cardiac surgery. On the other hand, there are several issues that may be barriers to its widespread use. The number of facilities for robot-assisted cardiac surgery has not increased as expected probably due to the current insurance system, that is still being developed, the requirement for implementation, and the cost. The current status and issues of robot-assisted cardiac surgery in Japan will be discussed.

Quadruple valve replacement for repaired transposition of the great arteries

A 37-year-old man with repaired transposition of the great arteries developed extensive infective endocarditis, and a multidisciplinary therapeutic strategy was planned based on surgical indications, invasiveness, and future prospects. After adequate antibiotic treatment, simultaneous replacement of quadruple valve and aortic root using mechanical valves was performed to intervene healed valvular disease and the concurrent anatomical and functional abnormalities. We believe that this extensive one-stage surgery contributed to maximizing the quality of life and minimizing the number of future reoperations. Our approach can provide suggestions for the management of adult patients with repaired congenital heart disease.

Case Report: Bronchogenic Cyst in the Right Atrium of a Young Woman

A 31-year-old woman was referred to our hospital for evaluation of a cardiac mass in the right atrium. Cardiac magnetic resonance imaging indicated a cystic mass filled with fluid accumulation in the right atrium. The mass was identified as a cardiac cyst and was surgically removed. Pathological examination revealed an extremely rare bronchogenic cyst. Bronchogenic cysts are benign congenital abnormalities of primitive foregut origins that form in the mediastinum during embryonic development. There is unusual clinical dilemmas surrounding the treatment plan for cardiac surgery or biopsy of cardiac masses, especially in patients with rare cardiac cysts. The anatomical location of the cyst can be related to various clinical symptoms and complications. In cases of indeterminate cardiac cysts, direct cyst removal without prior biopsy is of utmost importance.

Fulminant necrotizing eosinophilic myocarditis after COVID-19 vaccination survived with mechanical circulatory support

A 69‐year‐old man was hospitalized for heart failure 7 days after coronavirus disease 2019 (COVID‐19) mRNA vaccination. Electrocardiography showed ST‐segment elevation and echocardiography demonstrated severe left ventricular dysfunction. Venoarterial extracorporeal membrane oxygenation and Impella 5.0 were instituted because of cardiogenic shock and ventricular fibrillation. Endomyocardial biopsy demonstrated necrotizing eosinophilic myocarditis (NEM). Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2) PCR test was negative. He had no infection or history of new drug exposure. NEM was likely related to COVID‐19 vaccination. He was administered 10 mg/kg of prednisolone following methylprednisolone pulse treatment (1000 mg/day for 3 days). Left ventricular function recovered and he was weaned from mechanical circulatory support (MCS). Follow‐up endomyocardial biopsy showed no inflammatory cell infiltration. This is the first report of biopsy‐proven NEM after COVID‐19 vaccination survived with MCS and immunosuppression therapy. It is a rare condition but early, accurate diagnosis and early aggressive intervention can rescue patients.

Endovascular therapy for intracranial infectious aneurysms associated with a left ventricular assist device: illustrative case

BACKGROUND

Cerebrovascular events and infection are among the most common complications of left ventricular assist device (LVAD) therapy. The authors reported on a patient with an infectious intracranial aneurysm (IIA) associated with LVAD infection that was successfully occluded by endovascular therapy.

OBSERVATIONS

A 37-year-old man with severe heart failure received an implantable LVAD. He was diagnosed with candidemia due to driveline infection 44 months after LVAD implantation, and empirical antibiotic therapy was started. After 4 days of antibiotic treatment, the patient experienced sudden dizziness. Computed tomography (CT) revealed subarachnoid hemorrhage in the right frontal lobe, and CT angiography revealed multiple aneurysms in the peripheral lesion of the anterior cerebral artery (ACA) and middle cerebral artery. Two weeks and 4 days after the first bleeding, aneurysms on the ACA reruptured. Each aneurysm was treated with endovascular embolization using n-butyl cyanoacrylate. Subsequently, the patient had no rebleeding of IIAs. The LVAD was replaced, and bloodstream infection was controlled. He received a heart transplant and was independent 2 years after the heart transplant.

LESSONS

LVAD-associated IIAs have high mortality and an increased risk of surgical complications. However, endovascular obliteration may be safe and thus improve prognosis.

Global population structure of the Serratia marcescens complex and identification of hospital-adapted lineages in the complex

Serratia marcescens is an important nosocomial pathogen causing various opportunistic infections, such as urinary tract infections, bacteremia and sometimes even hospital outbreaks. The recent emergence and spread of multidrug-resistant (MDR) strains further pose serious threats to global public health. This bacterium is also ubiquitously found in natural environments, but the genomic differences between clinical and environmental isolates are not clear, including those between S. marcescens and its close relatives. In this study, we performed a large-scale genome analysis of S. marcescens and closely related species (referred to as the 'S. marcescens complex'), including more than 200 clinical and environmental strains newly sequenced here. Our analysis revealed their phylogenetic relationships and complex global population structure, comprising 14 clades, which were defined based on whole-genome average nucleotide identity. Clades 10, 11, 12 and 13 corresponded to S. nematodiphila, S. marcescens sensu stricto, S. ureilytica and S. surfactantfaciens, respectively. Several clades exhibited distinct genome sizes and GC contents and a negative correlation of these genomic parameters was observed in each clade, which was associated with the acquisition of mobile genetic elements (MGEs), but different types of MGEs, plasmids or prophages (and other integrative elements), were found to contribute to the generation of these genomic variations. Importantly, clades 1 and 2 mostly comprised clinical or hospital environment isolates and accumulated a wide range of antimicrobial resistance genes, including various extended-spectrum β-lactamase and carbapenemase genes, and fluoroquinolone target site mutations, leading to a high proportion of MDR strains. This finding suggests that clades 1 and 2 represent hospital-adapted lineages in the S. marcescens complex although their potential virulence is currently unknown. These data provide an important genomic basis for reconsidering the classification of this group of bacteria and reveal novel insights into their evolution, biology and differential importance in clinical settings.

Myxoid type and non-myxoid type of intimal sarcoma in large vessels and heart: review of histological and genetic profiles of 20 cases

Intimal sarcoma is one of the most common and well-known primary malignant neoplasms of the aorta and heart. The authors reviewed cases of intimal sarcoma from histological, immunohistochemical and genetic perspectives. Twenty cases of intimal sarcoma were retrieved. Immunohistochemistry and FISH of MDM2 and PDGFRA genes were performed. All 20 tumours were composed of spindle-shaped, stellate, oval or polygonal tumour cells with irregular hyperchromatic nuclei arranged in a haphazard pattern, accompanied by nuclear pleomorphism and frequent mitotic figures. Other histological findings were as follows: abnormal mitosis in 10 cases (50%), necrosis in 15 cases (75%), myxoid stroma in 12 cases (60%), cartilaginous formation in 1 case (5%), haemorrhage in 12 cases (60%) and fibrinous deposition in 14 cases (70%). The tumours were positive for MDM2 in 16 cases (80%), ERG in 4 cases (20%), alpha-smooth muscle actin in 6 cases (30%), desmin in 5 cases (25%) and AE1/AE3 in 4 cases (20%). Immunohistochemical positivity was focal in each case. Loss of H3K27me3 expression was noted in 2 cases (10%). MDM2 and PDGFRA gene amplifications were detected in 11 cases (55%) and 1 case (5%), respectively. Fisher's exact test revealed a significant correlation between MDM2 gene amplification and myxoid stroma (p = 0.0194). No parameters showed any association with the anatomical location of the tumours. It was suggested that myxoid histology of intimal sarcoma may be associated with MDM2 gene amplification and that intimal sarcoma may be divided into myxoid and non-myxoid types.

[Heart Transplantation for Older Patients]

The number of older donors is increasing in the limited number of donors in Japan. The number of older donors is increasing, and recipients are also ageing as the waiting period for transplantation becomes longer. The age of 60 years is one of the most important criteria for heart transplantation in Japan. Forty-two heart transplantations performed in our institution, and 12 cases were from donors aged over 60 years and seven recipients were older than 60 years at the time of transplantation. In four cases, both donor and recipient were over 60 years of age. All of these patients were discharged home after transplantation. As the number of older donors and recipients is expected to increase in the future, the number of marginal cases based on the status of not only the donor but also the recipient is expected to increase. The evaluation of coronary lesions and the identification of comorbid diseases, including malignant diseases, will become more important. A positive and careful overall decision at the time of transplantation is essential.

Valve-Sparing Reimplantation for Right Coronary Artery Compression after Fontan Procedure

An incidental finding of right coronary artery compression, between the dilated aortic root and the sternum, was detected on follow-up cardiac catheterization after Fontan completion for tricuspid atresia with transposition of the great arteries. Although this 31-year-old man had no subjective symptoms, an exercise stress test and perfusion scan revealed ischemic changes in the inferior region. Valve-sparing aortic root replacement using the reimplantation technique proved to be an effective approach for this condition. The possibility of coronary artery compression associated with aortic root dilatation should be considered in patients with adult congenital heart disease.

Left atrial myxoma resection through right mini-thoracotomy in a patient with retrosternal gastric tube

We report a case with a retrosternal gastric tube after oesophagectomy, who required left atrial myxoma resection, pulmonary vein isolation and left atrial appendage closure. A right mini-thoracotomy approach was adopted to avoid neo-oesophagus injury, and nitric oxide inhalation was useful to facilitate one-lung ventilation while dissecting the pleural adhesion.

Fatal Pulmonary Hemorrhagic Infarction Caused by Pulmonary Vein Thrombotic Occlusion During Venoarterial Extracorporeal Membrane Oxygenation

A 20-year-old man with arrhythmogenic right ventricular cardiomyopathy (ARVC) was resuscitated from ventricular fibrillation. He was transferred to our hospital because of progressive multiorgan dysfunction despite mechanical circulatory support with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP). At admission to our hospital, chest X-ray showed bilateral complete lung opacification, and echocardiography revealed a massive thrombus occupying the left atrium (LA) and left ventricle (LV). Conversion to central ECMO with transapical LV venting and thrombectomy were performed. The huge LA thrombus occluded all pulmonary veins (PVs). Despite the surgery and intensive care, complete lung opacity remained, and he died of multiorgan failure associated with sepsis. Autopsy demonstrated bilateral pulmonary multiple red infarctions, and histopathology showed alveolar wall necrosis with extensive hemorrhage, confirming a diagnosis of pulmonary hemorrhagic infarction. Extensive pulmonary infarction was attributable to PV occlusion due to massive LA thrombus. PV thrombosis should be considered when refractory lung opacities are encountered during VA-ECMO and necessitates early intervention.

Double valve replacement after ventricular assist device implantation in a Fontan patient

Few reports have described the implantation and management of an implantable ventricular assist device in patients with functional uni-ventricular anatomy. We herein report a case who underwent HVAD implantation due to severe cardiac dysfunction and Fontan failure in the remote period following total cavo-pulmonary connection. Double valve replacement was subsequently required one year later due to repeated Fontan failure caused by the progression of aortic and atrioventricular regurgitation. The low-profile and saddle-shaped sewing cuff design of the MITRIS were beneficial for avoiding the HVAD inflow and atrioventricular valve interference in the less-dilated ventricle.