Objectives
Although transcatheter aortic valve replacement (TAVR) is an excellent alternative procedure for high-risk patients with severe symptomatic aortic stenosis, it is often associated with ...life-threatening complications. We report on the emergency or elective use of veno-arterial extracorporeal membrane oxygenation (ECMO) to manage these complications.
Methods
Between December 2013 and February 2016, 46 patients underwent TAVR at our institution. Of these, 4 patients required emergency ECMO support and another 3 patients were electively placed on ECMO support at the start of the procedure. The mean age of the ECMO patients was 87.3 ± 3.6 years and all were female. The Society of Thoracic Surgeons-predicted risk of mortality score in these patients was 12.2 ± 6.2%.
Results
TAVR with ECMO was completed through the transapical approach in 6 patients, and the transfemoral approach in 1 patient. The arterial access route for ECMO was the femoral artery in 5, the external iliac artery in 1, and the subclavian artery in 1. Indications for the use of emergency ECMO were hemodynamic instability in 2, cardiogenic shock in 2, while indications for elective ECMO were severe pulmonary hypertension, impaired left ventricular function and a combination of these. There was no 30-day mortality, and the 1-year survival rate was 83.3% with no significant difference compared to patients without ECMO support.
Conclusion
The use of ECMO in very high-risk patients undergoing TAVR may increase safety and contribute to excellent outcomes. Although ECMO support is rarely needed in TAVR, a well-prepared treatment strategy by the heart team is mandatory.
Background: Although endovascular repair for abdominal aortic aneurysm has been found to be beneficial in very elderly patients, some patients have contraindications to this procedure. For ...nonagenarians, the results of open repair remain unclear. The purpose of this study was to compare the outcomes of open vs. endovascular repair for abdominal aortic aneurysm in nonagenarian patients.Methods and Results: Fourteen patients undergoing open surgical repair and 24 undergoing endovascular repair for abdominal aortic aneurysm were evaluated. There was no significant difference in early mortality between the open and endovascular groups (0% vs. 4.1%, p=0.16). The open repair group required much longer hospital stays (26.4 vs. 10.6 days, respectively, p=0.003). Finally, 12 patients (86%) undergoing open repair vs. 21 (88%) undergoing endovascular repair returned home (p=0.49). During a mean follow-up period of 23.4±23.5 months, cumulative estimated 1- and 3-year survival rates were 90.0% and 48.0%, respectively in the open repair group and 90.6% and 54.9%, respectively in the endovascular repair group (p=0.51).Conclusion: Although endovascular repair for abdominal aortic aneurysm was superior in terms of recovery, the results of conventional open repair were acceptable even in nonagenarian patients. Open repair remains an alternative for patients with contraindications to endovascular repair.
Background
Tricuspid valve regurgitation due to pacemaker leads is a well-known complication. Although some reports have suggested that pacemaker leads should be surgically explanted, strongly ...adhered leads cannot always be removed. The aim of this study was to describe our tricuspid valve repair techniques with pacemaker leads left in situ.
Methods
Our retrospective study investigated 6 consecutive patients who required tricuspid valve surgery for severe regurgitation induced by pacemaker leads.
Results
From the operative findings, we identified 3 patterns of tricuspid valve and pacemaker lead involvement. In 3 patients, the leads were caught in the chordae, in 2 patients, tricuspid regurgitation was caused by lead impingement on the septal leaflet, and in 3 patients, tricuspid valve leaflets had been perforated by the pacemaker leads. During surgery, all leads were left in situ after being separated from the leaflet or valvular apparatus. In addition, suture annuloplasty was performed for annular dilatation in all cases. In one patient, the lead was reaffixed to the annulus after the posterior leaflet was cut back towards the annulus, and the leaflet was then closed. There was one hospital death due to sepsis. The degree of tricuspid regurgitation was trivial in all surviving patients at discharge. During a mean follow-up of 21 months, one patient died from pneumonia 20 months after tricuspid valve repair.
Conclusion
In patients undergoing tricuspid valve surgery due to severe tricuspid regurgitation caused by pacemaker leads, the leads can be left in situ after proper repair with annuloplasty.
An 80-year-old female patient underwent redo aortic valve replacement for haemolysis caused by moderate paravalvular leakage 1 year after a 21-mm Intuity Elite valve implantation. The elevatorium ...passed at the segment with paravalvular leakage. The frame was then bent inward using a hook and the peel around the sawing ring was shaved by an elevatorium. After explantation of the Intuity Elite valve, endoscopic examination showed no sign of annular or sub-annular damage. Conventional aortic valve replacement using a biological valve was performed. We introduce a safe alternative technique for explantation of a rapid deployed valve.
The surgical outcomes of total arch replacement in patients both with atherosclerotic aneurysm and Stanford type A acute aortic dissection have been improved. The development of brain protection ...contributed to excellent results in aortic arch surgery. Total arch replacement with four branched vascular graft using antegrade selective cerebral perfusion under mild hypothermia has been standardized in Japan, resulting in lower operative mortality and perioperative cerebral complications. However, severely atherosclerotic aorta with diffuse ulcers, "shaggy aorta", still has a potential high-risk for neurological deficits. Herein, the strategies to prevent neurological complications in total arch replacement, including preoperative images, cannulation/cerebral perfusion, temperature, monitoring systems are discussed. Finally, surgical approaches to shaggy aorta are reviewed. The combination of each step can lead to satisfactory surgical outcomes.
Objective Thromboembolism remains a serious complication during endovascular surgery. Commercially available filter devices, which are unified with the stenting systems, provide short-time ...performance owing to the adhesion of thrombus to the filters themselves. We have, therefore, developed a new detachable filter that can be used in all major aortic branches and shows greater longevity. The present study assessed the efficacy of the new detachable filter and examined the feasibility of deploying and retrieving the filters. Methods We first performed in vitro studies. Our experimental flow model used silicon tubing to simulate the aortic branches. Polystyrene-divinylbenzene microspheres (100 and 200 μm in diameter), which simulated embolic particles, were injected into the tubing after the detachable filter was deployed. The capture efficacy (number of microspheres trapped in the detachable filter/total injected microspheres) was calculated. In the in vivo studies, the detachable filters were implanted into the carotid, visceral, and renal arteries of 5 mongrel dogs. Angiography was performed every 30 minutes. At 5 hours after implantation, each detachable filter was retrieved by a gooseneck snare catheter. Results In the in vitro studies, our detachable filters showed high capture efficacy, capturing 99.2% of the 100-μm microspheres and 99.4% of the 200-μm microspheres. In the in vivo studies, all detachable filters were successfully deployed into the major branches. Each angiographic study revealed smooth flow without any embolic obstruction of the filter. At 5 hours after deployment, all devices were completely retrieved by the snare catheter without aortic injury. Conclusions The new detachable filter showed high efficacy in capturing the particles. All detachable filters were successfully deployed for 5 hours, and the filters were retrieved from the aortic branches without any complications. This novel detachable filter can help prevent serious distal thromboembolism during endovascular surgery.
Background Amiodarone is a potent anti-atrial fibrillation (AF) agent; however, its systemic administration induces serious side effects such as interstitial pneumonia. To avoid such effects, we ...developed a local sustained-release system for amiodarone. Methods A biodegradable, cross-linkable dextran disc was developed as a sustained-release carrier for amiodarone. Under general anesthesia, Japanese white rabbits underwent median sternotomy and the biodegradable disc with or without amiodarone (30 mg) was implanted onto the surface of the right atrium. Three days after implantation, we measured tissue amiodarone concentrations (n = 5), the AF threshold, and the atrial effective refractory period of the left atrium by using the Langendorff apparatus. The incidences of induced AF evoked by rapid pacing were measured and compared. Results The right atrial concentration of amiodarone was far higher than that in the lungs, ventricles, or other organs ( p < 0.01). The blood concentration of amiodarone was below detectable levels. The amiodarone biodegradable disc significantly increased the AF threshold (amiodarone group, 6.9 ± 4.6 mA versus control group, 0.5 ± 0.6 mA; p < 0.01) and the effective refractory period (amiodarone group, 53.9 ± 8.9 milliseconds versus control group, 43.9 ± 9.5 milliseconds; p = 0.035) of the left atrium, indicating the electrophysiologic effect of the amiodarone biodegradable disc on the left atrium. Further, the amiodarone group was significantly less likely to experience AF, as compared with the control group ( p < 0.01). Conclusions This approach may be a less invasive and effective therapeutic option for preventing postoperative AF.
The surgical indications for acute type A aortic dissection (AAAD) in patients in cardiopulmonary arrest remain controversial. Outcomes of AAAD for patients who underwent cardiopulmonary ...resuscitation (CPR) were evaluated.
Between 2004 and 2018, of the 519 patients who underwent AAAD repair, 34 (6.6%) required CPR before or on starting AAAD repair. The patients were divided into 2 groups, survivors (n = 13) and nonsurvivors (n = 21), to compare the early operative outcomes, including mortality and neurological events.
The major cause of cardiovascular collapse requiring CPR was aortic rupture/cardiac tamponade (n = 21 61.8%), followed by coronary malperfusion (n = 12 35.3%) and acute aortic valve regurgitation (n = 3 8.8%). There were 3 (23.1%) patients in the survivors group and 11 (52.4%) in the nonsurvivors group who required ongoing CPR at the beginning of AAAD repair (P = .039). Of these patients, 1 survivor and 6 nonsurvivors could not achieve return of spontaneous circulation after pericardiotomy (P = .045). Although the duration from onset or arrival to the operating room was similar (P = .35 and P = .49, respectively), overall duration of CPR was shorter in survivors (10 minutes range, 7.5-16 minutes vs 16.5 minutes range, 15-20 minutes; P = .044). All survivors without any neurological deficits showed return of spontaneous circulation after pericardiotomy. Multivariate regression modeling showed that CPR duration >15 minutes was a significant risk factor for in-hospital mortality (P = .0040).
CPR duration beyond 15 minutes may be a contraindication for AAAD repair. Moreover, we should reconsider surgery for patients who cannot achieve return of spontaneous circulation after pericardiotomy.
PDF
