Kyobu geka. The Japanese journal of thoracic surgery最新文献

Objective: To evaluate the outcomes of aortic root preservation in patients undergoing surgery for Stanford type A acute aortic dissection(AAAD)without concomitant root replacement, Methods:We retrospectively analyzed 79 consecutive AAAD patients(mean age 68±13 years;52% male)who underwent supra-coronary repair(SCR)between January 2012 and December 2022, excluding those requiring Bentall or valve-sparing root replacement(VSRR), Preoperative root involvement, aortic regurgitation(AR), surgical procedures, early outcomes, long-term aortic root dilation, AR progression, and reoperation rates were assessed mean follow-up of 5.7±3.4 years, Results:Preoperative root dissection was present in 66%, with moderate or greater AR in 16%, Early mortality was low(30-day mortality 2.5%, in-hospital mortality 3.8%), Long-term follow-up, mean aortic root enlargement was minimal(0.28 mm/year), with no cases of progression to moderate or severe AR, Reoperation occurred in 3.8%(3 cases), primarily due to pseudoaneurysm or new entry formation at the proximal anastomosis, Conclusions:Aortic root preservation with careful proximal anastomosis placement provided excellent early and mid-term outcomes, with minimal late aortic root dilation or AR progression.

Bleeding from the proximal anastomosis site during Stanford type A acute aortic dissection(AAAD)surgery can be a fatal problem, to avoid this, we use the proximal stepwise(PS)method for proximal anastomosis at our institution, and we examined its usefulness and results, we retrospectively analyzed 53 emergency surgeries(22 males, mean age 72.4±9.3 years)performed between October 2016 and December 2024, there were 39 ascending replacements and 12 total ascending replacements, there were no cases of difficult hemostasis during proximal anastomosis, the in-hospital mortality rate was 3.7%(2 cases), during the observation period of 1,245.7±924.6 days, there were no aortic events or aortic-related deaths related to the proximal anastomosis, and the 3-year survival rate was 93.4%, the PS method is useful as a proximal anastomosis technique in AAAD surgery and may contribute to a favorable long-term prognosis by avoiding late complications.

Background: Superior mesenteric artery(SMA)malperfusion in acute aortic dissection(AAD)is a highly lethal complication with no established treatment strategy, We introduced a "perfusion-first strategy," prioritizing SMA revascularization via laparotomy for patients with preoperative computed tomography(CT)evidence of SMA obstruction, Methods:Our strategy involves an initial laparotomy for direct visual assessment of intestinal ischemia, After identifying the occluded segment of the SMA with vascular ultrasound, a bypass is created to the distal SMA using a heparin-coated expanded polytetrafluoroethylene(ePTFE)graft, Initial reperfusion is established via a side branch of the extracorporeal circulation circuit from the femoral artery, This is followed by a median sternotomy for central aortic repair, Finally, the SMA bypass graft is anastomosed to the central aortic graft to complete the revascularization, Results:Between April 2024 and May 2025, this strategy was performed on six consecutive patients, All six patients survived to discharge without requiring bowel resection, Postoperative CT scans confirmed the patency of all SMA bypass grafts, Conclusion:Our perfusion-first strategy, a single-stage hybrid approach, was shown to be a safe and effective treatment for AAD complicated by SMA malperfusion in this initial series, This approach allows for accurate assessment of intestinal ischemia and reliable revascularization while avoiding the risks of delaying central aortic repair, It represents a promising new therapeutic option for this fatal condition.

Background: Emergency surgery remains the standard of treatment for acute Stanford type A aortic dissection(AAAD), Nevertheless, in real-world practice a minority of patients do not undergo immediate surgery due to clinical constraints, We sought to delineate the outcomes and practical limits of such nonoperative management under strict protocols, Methods:Of 668 consecutive AAAD patients(Jan 2019~Mar 2025), we retrospectively analyzed 100 who did not receive immediate surgery after excluding 13 with cardiopulmonary arrest, Patients were stratified into a criteria group(C;thrombosed/occluded false lumen in the ascending aorta with ascending diameter≦50 mm and false lumen≦11 mm;n=59)and a non-criteria group(NC;outside these criteria;n=41), The primary endpoint was in-hospital mortality;secondary endpoints included aortic-related death, post-discharge events, and associations with imaging/clinical indices, Results:NC patients were older and more often female, with larger ascending aortas and false lumens(both p<0.001), In-hospital mortality was 31.7% in NC vs 1.7% in C(p<0.001);48-hour mortality in NC was 12.2%, and aortic-related deaths clustered within 4.56±2.99 days(range 1~12), Seven patients underwent delayed surgery for imaging changes;all survived, Discharge alive occurred in 98.3%(C)and 68.3%(NC), Among those discharged alive, survival up to 2 years was similar, Low body mass index(BMI)and hemodynamically significant tamponade were associated with in-hospital death in NC, Conclusions:These data support surgery as the default strategy for AAAD, When surgery is unavoidably deferred, conservative management should be considered only in strictly selected patients, with early hemodynamic/computed tomography(CT)triggers for conversion, In NC patients, the first hospital week is the highest-risk window, and low BMI or tamponade should prompt heightened vigilance and a low threshold for intervention.

Background: For malperfusion in Stanford type A acute aortic dissection, we resolve static intestinal ischemia prior to central repair, rapidly unload the left ventricle for myocardial ischemia, and resolve cerebral or lower limb ischemia using cardiopulmonary bypass, We evaluated the validity of this strategy, Subjects:Among 165 emergency surgeries for Stanford type A acute aortic dissection performed since 2009, malperfusion was present in 52 cases(brain 23/heart 9/kidney 8/intestine 4/lower extremity 21)[overlap present], Results:Mean age was 63±12 years;29 patients were male;1 case had Marfan syndrome, The median time from onset to extracorporeal circulation initiation was 5 hours(range 2~51), Postoperative extracorporeal membrane oxygenation(ECMO)was used in 5 cases;in-hospital mortality occurred in 8 cases;and 8 cases had residual sequelae of cerebral infarction(controlled reperfusion in 1), Conclusion:Strategies for treating coronary malperfusion require improvement, In cerebral malperfusion, controlled reperfusion may be effective, with fewer residual sequelae in treated cases.

The patient was a 79-year-old male, During the course of treatment for eosinophilic pneumonia, he developed left-sided pneumothorax, Despite the implementation of thoracic drainage, air leakage persisted, Computed tomography(CT)revealed a left pneumatocele, which was deemed to be the underlying cause of pneumothorax, Consequently, thoracoscopy-assisted operation was performed, Six months postoperatively, no recurrence of pneumothorax was observed, and the pneumatocele had significantly decreased in size, Surgical intervention for refractory pneumothorax associated with pneumatocele is therefore considered to be an appropriate and effective therapeutic approach.

Stanford type A acute aortic dissection(AAAD)is a life-threatening cardiovascular emergency, Early surgical repair is essential to prevent fatal outcomes, According to the 2023 Annual Report of the Japanese Association for Thoracic Surgery, AAAD cases increased by 4.4% in 2022, with an in-hospital mortality of 10% for AAAD, Although surgical outcomes have improved with advances in cerebral protection techniques, patients with cerebral malperfusion remain at high risk of poor neurological outcomes and mortality, with postoperative death rates reported between 15~30%, Antegrade selective cerebral perfusion(ASCP)is the standard method for cerebral protection during circulatory arrest, However, in AAAD patients with carotid artery occlusion or severe stenosis, conventional ASCP may result in uneven cerebral perfusion, risking ischemia in the affected hemisphere, To address this, we introduced a two-roller pump technique, in which each carotid artery(affected and non-affected)is perfused independently using separate ASCP circuits, Cerebral perfusion was monitored with transcranial Doppler and regional cerebral oxygen saturation(rSO2), The common carotid artery(CCA)was exposed via median sternotomy without additional neck incision, and direct cannulation was performed to establish targeted perfusion, The two-roller pump technique allowed independent regulation of flow and pressure for each carotid artery, Intraoperative monitoring confirmed stable perfusion to all cerebral vessels, including the previously occluded CCA, The two-pump technique prevented uneven blood distribution, reduced cerebral ischemia time, and was associated with improved immediate neurological outcomes, It enables immediate, controlled reperfusion of the affected hemisphere, potentially improving neurological outcomes, and offers a practical option for urgent surgical management of severe cerebral malperfusion in AAAD.

Objective: This study aimed to evaluate the outcomes of surgical strategies for DeBakey typeⅢ retrograde Stanford type A dissection(RAAD), Methods:We retrospectively analyzed 46 patients with RAAD treated at our hospital, Surgical procedures included ascending aorta repair(AAR, n=20), total arch replacement(TAR, n=17), and thoracic endovascular aortic repair(TEVAR, n=9), Early and late outcomes were assessed, Results:The AAR group had shorter operative times but a higher incidence of long-term aortic-related mortality, The TAR group showed no long-term aortic-related mortality but experienced early complications such as spinal ischemia, In the TEVAR group, several patients required early reintervention, Conclusion:An individualized surgical strategy is essential for the management of RAAD, While secure entry closure may improve long-term outcomes, each approach carries specific risks, AAR and TEVAR remain appropriate options for selected cases.

The optimal management of Stanford type A acute aortic dissection with mesenteric malperfusion(AMI)is controversial, Our strategy of AMI is open superior mesenteric artery(SMA)bypass prior to aortic repair, if we suspect AMI on computed tomography(CT)scan, whatever other findings might be or not, The need of treatment of mesenteric malperfusion prior to aortic repair is not always concerned with digestive symptom, lactate, intraoperative finding, The mortality was 15.8%, which was an allowable result, Our strategy might be proper at instances of, allowable time for management of open SMA bypass, unnecessarily of endovascular treatment, confirming an enteric property and ability to respond to various rapid hemodynamic changes.

In a 77-year-old man, there was difficulty in removing a guidewire that had strayed into the right ventricle during leadless pacemaker insertion. Surgical removal was required. During removal of the wire, the tendon cords of the anterior tricuspid valve were pulled out, resulting in acute severe tricuspid regurgitation. The patient underwent tricuspid valve repair under cardiac arrest. He had a good postoperative course, a permanent pacemaker was implanted on postoperative day 14, and he was discharged on postoperative day 20. Although complications associated with catheter procedures have been increasing in recent years, there have been no reports of cases in which a guidewire became entangled in the tendon cords of the tricuspid valve. We discuss the cause of this case from the viewpoint of preventing recurrence and refer to acute tricuspid regurgitation that occurred during the removal of the catheter.