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

An 87-years-old woman with a history of right mastectomy for breast cancer, currently undergoing chemotherapy for multiple metastasis via a central venous catheter placed in the left subclavian vein, presented with bradycardia and dyspnea. Electrocardiogram revealed a 2:1 atrioventricular block. Implantation of a leadless pacemaker (LLPM) was planned for the patient. During implantation, right ventricular rupture occurred. Percutaneous cardiopulmonary support was initiated immediately. Subsequently, emergency surgery was performed. LLPM is considered a useful and safe device;however, serious complication, such as cardiac injury, have been reported in a small number of cases. Thorough risk assessment and preparation for complication, including cardiac surgery, may be life-saving.

Left main coronary artery (LMCA) malperfusion due to acute aortic dissection (AAD) is relatively rare but life-threatening. Almost all such patients suffer from cardiogenic shock, and cardiopulmonary arrest occurs in approximately half of them. A 64-year-old man with chest pain was taken to our hospital by ambulance. Acute coronary syndrome was suspected as electrocardiography showed changes in ST segment. Coronary angiography revealed severely stenotic LMCA. Percutaneous cardiopulmonary support was initiated for subsequent cardiogenic shock. Dissection in the LMCA on intravascular ultrasonography suggested that AAD occurred and dissection extended into the LMCA. Percutaneous coronary intervention (PCI) to the LMCA was performed with a drug-eluting stent. Post-PCI contrast-enhanced computed tomography (CT) scan demonstrated Stanford type A AAD. Subsequently, ascending-aortic replacement was successfully carried out. Postoperative echocardiography showed well preserved cardiac contraction. Primary PCI under percutaneous cardiopulmonary support for AAD and LMCA malperfusion shortens myocardial ischemic time and improves prognosis.

A 60-year-old man was admitted to our hospital with chest and back pain. Electrocardiogram, echocardiography, and contrast-enhanced computed tomography (CT) confirmed a Stanford type A acute aortic dissection with right ventriclar infarction and left ventricular inferior wall asynergy due to right coronary artery malperfusion. The patient presented with shock vital signs. So, immediately percutaneous coronary intervention (PCI) was performed to obtain the right coronary revascularization, after which total arch replacement and frozen elefant trunk was performed. Postoperatively, the patient remained stable without right heart failure. In patients with right ventricular infarction, preoperative PCI prior to surgery may be a useful option.

A 59-year-old woman consulted our hospital because of an abnormal shadow on chest X-ray. A chest computed tomography (CT) revealed a tumor on the diaphragm. A diagnosis of lung tumor was suspected and she underwent video-assisted thoracoscopic surgery. The intraoperative findings revealed a tumor through the defect hole in the right diaphragm. Histological examination revealed fibrotic tissue. The final diagnosis was a diaphragmatic hernia. For lung tumors on the diaphragm, diaphragmatic hernia should also be considered in the differential diagnosis.

Objectives: In Japan, surgical repair for Stanford type A acute aortic dissection(AAAD)has been increasingly performed, accompanied by gradual improvement in early outcomes, While ascending or hemiarch replacement remains the mainstream strategy, late aneurysmal dilatation of the residual dissected aorta is still a concern, The frozen elephant trunk(FET)technique, which facilitates aortic remodeling, has been increasingly adopted in AAAD surgery, Since the introduction of a domestic integrated four-branched FET device in late 2022, expectations have risen for improved procedural safety and simplicity, We report our early institutional outcomes of total arch replacement(TAR)using the integrated four-branched FET, Methods:Among 211 AAAD cases treated between December 2022 and April 2025, 110 underwent TAR with FET, of which the first 50 consecutive cases using the integrated four-branched FET[FROZENIX 4 Branched(FZX4B)]were retrospectively analyzed, The primary endpoint was early postoperative outcome, including mortality and spinal cord ischemia(SCI), Secondary endpoints included midterm survival, freedom from aortic events, and morphologic changes in the descending aorta, Results:The median age was 65 years[interquartile range(IQR):56~74], and 29 patients(58%)were male, The median operative time was 372 minutes(IQR:315~506), and the hypothermic circulatory arrest time was 42 minutes(IQR:38~50), The distal anastomosis was performed in zone 3 in 84% of cases, The FZX4B diameter most used was 25 mm(60%), In-hospital mortality was 4%, SCI occurred in one patient(2%), Two patients(4%)required additional thoracic endovascular aortic repair(TEVAR)for FET stenosis, The median follow-up was 248 days(IQR:165~472), Overall survival was 93% at 1 year and 86% at 2 years, and freedom from aortic events was 87% and 81% at 1 and 2 years, respectively, The FET distal level was mainly at Th6(62%), The aortic diameter at the distal edge of the FET decreased from 30 mm(IQR:28~33)preoperatively to 27 mm(25~31)at 1 year(p<0.001), The FET tip diameter correlated with the preoperative outer diameter at the anastomotic site(r=0.66, p<0.001), Conclusions:Although FET-related stenosis should be recognized as a potential procedural risk, TAR using the integrated FET for AAAD achieved acceptable early outcomes, A larger comparative study with conventional repair is warranted to elucidate its statistical impact.

Objective: This single-center retrospective study evaluated postoperative outcomes in Stanford type A acute aortic dissection(AAAD)patients presenting with preoperative cardiopulmonary arrest(CPA)between January 2021 and May 2025, Methods:Among 390 consecutive AAAD cases undergoing emergency surgery, 18(4.6%)presented with CPA, We assessed 30-day mortality, return of spontaneous circulation(ROSC), and use of preoperative veno-arterial extracorporeal membrane oxygenation(VA-ECMO), Results:The 30-day mortality was 72.2%, ROSC occurred in 4 cases(22.2%), and ROSC-positive patients had significantly lower mortality(p=0.022), Preoperative VA-ECMO was used in 7 cases(38.9%), none of whom survived(p=0.013), Conclusions:AAAD with preoperative CPA carries extremely high mortality, but patients achieving ROSC may benefit from urgent surgical intervention, VA-ECMO appears to confer no survival advantage, Early survivors often achieve favorable long-term outcomes, in line with prior literature.

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: 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: 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.