Shintaro Katahira

Medical intervention for ischemic heart disease began approximately 150 years ago with nitrates, and for nearly a century thereafter, little fundamental progress was made. With the advent of the left internal thoracic artery to the left anterior descending artery (LITA-LAD) bypass in the 1960s, treatment entered a new stage; however, its essential significance remained insufficiently recognized for many years. Numerous studies were subsequently conducted to evaluate alternative or parallel treatment strategies, but these investigations also helped bring the durable capacity of LITA-LAD to perfuse ischemic myocardium into sharper focus. Over the past quarter century, the treatment of ischemic heart disease has remained in a state of uncertainty, and its central prognostic foundation has often been obscured, although in recent years this uncertainty has begun to resolve. In this review, we reexamine the historical process by which the significance of LITA-LAD remained incompletely appreciated in parts of the cardiology and cardiac surgical communities. We further outline how the principal basis of the long-term prognostic benefit conferred by LITA-LAD gradually became evident and define the contemporary roles of medical therapy and percutaneous coronary intervention in relation to LITA-LAD-based coronary artery bypass grafting (CABG).

Significant progress has been achieved in the treatment of acute aortic dissection over the past 90 years, following the first surgical intervention. This review pays tribute to the dedication of pioneers and innovators who developed advanced medical devices and therapeutic strategies to address this challenging condition. While navigating uncertainties in treatment optimization, the primary focus of the therapeutic strategies has been to save lives by increasing survival rates during the acute phase and to prevent aorta-related lethal events and late-stage thoracoabdominal aortic replacements. From a neutral standpoint, this review traces over 90 years of progress in treating acute aortic dissection. We hope that as many patients as possible will receive treatment rationally, without over- or under-treatment.

Significant progress has been achieved in the treatment of acute aortic dissection over the past 90 years, following the first surgical intervention. This review pays tribute to the dedication of pioneers and innovators who developed advanced medical devices and therapeutic strategies to address this challenging condition. While navigating uncertainties in treatment optimization, the primary focus remains on saving lives by increasing survival rates during the acute phase and preventing aorta-related lethal events and late thoracoabdominal aortic replacements. A strategy for managing this disease was established in 2013, demonstrating excellent early and long-term outcomes. From a fair and neutral standpoint, this review traces over 90 years of progress in treating acute aortic dissection. It outlines the journey that led to the establishment of the Oda strategy as the optimal approach and provides valuable insights for exceptional cardiovascular surgeons who will be utilizing this strategy in the future. We hope that as many patients as possible will benefit from this strategy and will receive treatment rationally, without over- or under-treatment.

Background: Rapid deployment aortic valve replacement (RDAVR) has been widely adopted, but concerns about postoperative paravalvular leak (PVL) associated with its use remain. PVL is linked to an increased risk of long-term mortality; however, there is no consensus on its treatment. Case presentation: Case 1: A 76-year-old female with severe aortic stenosis underwent RDAVR via median sternotomy. Intraoperative transesophageal echocardiography (TEE) revealed moderate PVL at the left-noncoronary cusp commissure. Three horizontal mattress stitches were applied from outside the aorta through the prosthetic sewing cuff to address the PVL site; however, the leak persisted. It was noted that the balloon-expandable sealing frame was slightly protruding inward at a location corresponding to the PVL site. Accordingly, balloon dilatation was performed under direct vision, and the PVL resolved. Postoperatively, no conduction disorders were observed. At the 24-month follow-up, echocardiography showed no recurrence of PVL. Case 2: A 78-year-old male with severe aortic stenosis underwent RDAVR in a standardized fashion. Intraoperative TEE revealed moderate PVL at the right coronary cusp side. The balloon-expandable sealing frame was found not to have fully expand outward at the PVL site. Balloon dilatation was therefore performed as in Case 1, successfully resolving the PVL. No postoperative conduction disorder was encountered. At the 12-month follow-up, echocardiography revealed no recurrent PVL. Conclusions: Direct intraoperative re-ballooning is a potentially effective option for addressing intraoperatively identified PVL after RDAVR.

Background: Degenerative aortic valve disease (DAVD) is a multifactorial process. We developed an animal model to analyze the isolated, local effect of reactive oxygen species (ROS) on its pathophysiology. Methods: We utilized a photodynamic reaction (PDR) as a source of ROS in the aortic valve by aiming a laser at the aortic valve for 60 min after the administration of a photosensitizer 24 h prior. ROS, laser, and sham groups (n = 7 each) for every observation period (t = 0; t = 8 d; t = 84 d; t = 168 d) were established. The amount of ROS generation; morphological changes; inflammatory, immune, and apoptotic reactions; and hemodynamic changes in the aortic valves were assessed using appropriate histological, immunohistological, immunohistochemical, and echocardiographic methods. Results: The ROS group displayed an increased amount of ROS (p < 0.01) and increased inflammatory activation of the endothelium (p < 0.05) at t = 0. In the ROS group, aortic valves were calcified (p < 0.05) and the transvalvular gradient was increased (p < 0.01) at t = 168 d. Conclusion: The small animal model employed here may serve as a platform for analyzing ROS’s isolated role in the DAVD context.

Background: The operative field in subclavian vessel surgery is limited by thoracic inlet and outlet structures. Although endovascular therapy for the subclavian artery could be an option, open repair management is occasionally required in cases of large aneurysms, infectious vasculopathy, and trauma. The transmanubrial osteomuscular sparing approach, commonly used in thoracic surgery area to resect superior sulcus tumors, is a simple and safe procedure providing an excellent view of the operative field. Herein, we present three cases that underwent open repair of the subclavian artery using the transmanubrial osteomuscular sparing approach, and we also highlight the utility of the technique along with the procedural details. Case presentation: Case 1: A 54-year-old man presented with a true aneurysm of the proximal portion of the right subclavian artery. The aneurysm measured 50 × 80 mm and compressed the right lung and trachea. We performed an aneurysm resection and a right subclavian artery reconstruction via the transmanubrial osteomuscular sparing approach under cardiopulmonary bypass support. Case 2: A 72-year-old man who presented with an abscess that formed around the left subclavian artery due to an unremoved guidewire during thoracic endovascular aortic repair for an aortic arch aneurysm in another hospital. After the antibiotics administration, debridement and axillary-axillary bypass were performed, and the guidewire was removed via a transmanubrial osteomuscular sparing approach with a use of cardiopulmonary bypass. Case 3: A 60-year-old man presented with misplacement of an indwelling dialysis catheter inserted for acute renal failure and hyperkalemia. The catheter was placed through the right neck, but had penetrated the right internal jugular vein and was misplaced from the right subclavian artery into the proximal aortic arch. Emergently, we removed the catheter using the transmanubrial osteomuscular sparing approach. Conclusions: The transmanubrial osteomuscular sparing approach to the subclavian artery provides an excellent view and a wide surgical field, even in different pathological situations. This is a simple, safe, and highly useful procedure and could be the standard approach for subclavian artery surgeries.

Salmonella infection typically causes self-limiting gastroenteritis. However, in rare cases, it can lead to prosthetic valve endocarditis (PVE), especially in older adults with a history of valve replacement surgery. In this case study, we describe a case of Salmonella PVE in a man with a prosthetic aortic valve. Complications of PVE include abscess formation, which is associated with increased mortality. If a patient with a history of prosthetic valve replacement presents with symptoms suggestive of gastroenteritis or bacteremia, a thorough investigation should be conducted with suspicion of PVE. The prognosis of Salmonella PVE can be improved by promptly initiating appropriate antibiotics and administering them for an adequate duration, as well as by considering surgical intervention when necessary. Additionally, confirming negative blood cultures after treatment of Salmonella bacteremia is important to prevent the development of PVE and paravalvular abscesses.

Background: We aimed to examine the anti-calcification and anti-inflammatory effects of pioglitazone as a PPAR-gamma agonist on bioprosthetic-valve-bearing aortic grafts in a rat model of diabetes mellitus (DM). Methods: DM was induced in male Wistar rats by high-fat diet with an intraperitoneal streptozotocin (STZ) injection. The experimental group received additional pioglitazone, and controls received normal chow without STZ (n = 20 each group). Cryopreserved aortic donor grafts including the aortic valve were analyzed after 4 weeks and 12 weeks in vivo for analysis of calcific bioprosthetic degeneration. Results: DM led to a significant media proliferation at 4 weeks. The additional administration of pioglitazone significantly increased circulating adiponectin levels and significantly reduced media thickness at 4 and 12 weeks, respectively (p = 0.0002 and p = 0.0107, respectively). Graft media calcification was highly significantly inhibited by pioglitazone after 12 weeks (p = 0.0079). Gene-expression analysis revealed a significant reduction in relevant chondro-osteogenic markers osteopontin and RUNX-2 by pioglitazone at 4 weeks. Conclusions: Under diabetic conditions, pioglitazone leads to elevated circulating levels of adiponectin and to an inhibition of bioprosthetic graft degeneration, including lower expression of chondro-osteogenic genes, decreased media proliferation, and inhibited graft calcification in a small-animal model of DM.