Editor in Chief : Goro Matsumiya Vol. 52, No. 1, January 2023 CONTENTS

Preface

Case Reports

  • ［Congenital Heart Disease］
  • A Case of Intermediate Type Atrioventricular Septal Defect Associated with a Membranous Ventricular Septal Aneurysm in a 70-Year-Old Female Patient R. Hojo et al.…1
    A Case of Intermediate Type Atrioventricular Septal Defect Associated with a Membranous Ventricular Septal Aneurysm in a 70-Year-Old Female Patient
    Ryuji Hojo* Athuhiro Nakashima* Eiichi Teshima*
    Osamu Tominaga* Shinya Higuchi** Munetaka Masuda*
    Ryuji Tominaga*

    (Department of Cardiovascular Surgery, Fukuoka Wajiro Hospital＊, Fukuoka, Japan, and Department of Cardiovascular Surgery, Shin Yukuhashi Hospital＊＊, Yukuhashi, Japan)

    The case was a 70-year-old female. Atrioventricular septal defect was diagnosed in her childhood, however, surgical treatment had not been performed. The patient had suffered from heart failure at the age of 69, and she was referred to our hospital for treatment. Her diagnosis was intermediate type atrioventricular septal defect, moderate left atrioventricular valve regurgitation, membranous ventricular septal aneurysm and atrial flutter. An autologous pericardial patch was used to close the ostium primum type atrial septal defect associated with simultaneous covering of membranous ventricular septal aneurysmal wall. Concomitant left and right atrioventricular valvuloplasty and arrhythmia surgery were performed. Her postoperative course was uneventful and the patient was discharged from our department on the 16th postoperative day. To our knowledge, there are few reports of surgery for incomplete type atrioventricular septal defect in the elderly and no report for intermediate type atrioventricular septal defect in Japan. In incomplete type atrioventricular septal defect, symptoms such as supraventricular arrhythmia and heart failure develop according to aging. Reported surgical results in the elderly are quite good, and improvement of excise tolerance is expected. Precise evaluation and proper indication of surgical treatment is mandatory even in older patients.

     

    Jpn. J. Cardiovasc. Surg. 52: 1-4 （2023）

    Keywords：intermediate type atrioventricular septal defect; left atrioventricular valve regurgitation; adult congenital heart disease


  • ［Acquired Cardiovascular Surgery］
  • Surgical Case of Coronary-Pulmonary Arterial Fistula with Giant Coronary Artery Aneurysm　M. Tanabe et al.…5
    Surgical Case of Coronary-Pulmonary Arterial Fistula with Giant Coronary Artery Aneurysm
    Makoto Tanabe＊ Saki Bessho＊＊ Bun Nakamura＊＊
    Shuhei Kogure＊＊ Hisato Ito＊＊ Yu Shomura＊＊
    Motoshi Takao＊＊

    (Department of Cardiovascular Surgery, Mie General Medical Center＊, Yokkaichi, Japan, and Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, Mie University＊＊, Tsu, Japan)

    A 73-year-old woman was diagnosed with coronary artery aneurysms associated with coronary-pulmonary arterial fistula in a preoperative examination for transverse colon cancer. One of the aneurysms (28 mm) originated from a branch of the right coronary artery and the other two (16 and 12 mm) originated from a branch of the left coronary artery. We performed surgery to prevent their rupture because the right coronary artery aneurysm showed a tendency to enlarge. Surgery was performed through a median sternotomy under cardiopulmonary bypass. Suture closure of the inflow and outflow of the aneurysm was performed. The coronary-pulmonary arterial fistula was ligated. In addition, suture closure of the outflow of the coronary-pulmonary artery fistula into the pulmonary artery was performed, under direct view after incision of the pulmonary trunk. No residual shunt blood flow in the coronary-pulmonary arterial fistula was observed on postoperative echocardiography. Furthermore, no coronary aneurysm and coronary-pulmonary arterial fistula was recognized on postoperative coronary computed tomography. The patient made an uneventful recovery and was discharged from the hospital on postoperative day 12.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 5-8 （2023）

    Keywords：giant coronary artery aneurysm; coronary-pulmonary arterial fistula

  • A Case of Antiphospholipid Syndrome Underwent Cardiac Surgery Performed Using Coagulation Management by Measuring Heparin Concentration during Extracorporeal Circulation　R. Umeta et al.…9
    A Case of Antiphospholipid Syndrome Underwent Cardiac Surgery Performed Using Coagulation Management by Measuring Heparin Concentration during Extracorporeal Circulation
    Riko Umeta＊ Tomohiro Nakajima＊ Yutaka Iba＊
    Itaru Hosaka＊ Akihito Okawa＊ Naomi Yasuda＊
    Tsuyoshi Shibata＊ Junji Nakazawa＊ Nobuyoshi Kawaharada＊

    (Department of Cardiovascular Surgery, Sapporo Medical University＊, Sapporo, Japan)

    A 72-year-old female was diagnosed with systemic lupus erythematosus and antiphospholipid syndrome (APS) in 2014 and was followed up. Severe mitral regurgitation coexisted with APS, but the case was nonsymptomatic, and surgery involved high risk. Therefore, the physicians continued their observation. In 2020, the patient experienced rheumatic severe mitral stenosis and shortness of breath on exertion. Paroxysmal atrial fibrillation and coronary stenosis were also detected. Therefore, we planned mitral valve replacement, tricuspid annuloplasty, coronary artery bypass, pulmonary vein isolation and left atrial appendage closure. During extracorporeal circulation (ECC), we performed coagulation management based on blood heparin concentration using HMS PLUS. Because the APS patient showed prolonged activated clotting time (ACT), and coagulation therapy based on ACT is unreliable. She was discharged from our hospital on postoperative day 23. No complications, including bleeding and thrombosis, were observed 2 years after the operation. We experienced a case of APS who underwent cardiac surgery and performed coagulation management by measuring heparin concentration during ECC. We targeted a 3.5 U/ml heparin concentration, and her clinical course was uneventful.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 9-13 （2023）

    Keywords： activated clotting time; extracorporeal circulation; coagulation management; antiphospholipid antibody syndrome; heparin concentration

  • Acquired Left Ventricle to Right Atrial Communication Following Infective Endocarditis of the Native Aortic Valve Diagnosed Using Cardiac Computed Tomography　M. Ikuchi et al.…14
    Acquired Left Ventricle to Right Atrial Communication Following Infective Endocarditis of the Native Aortic Valve Diagnosed Using Cardiac Computed Tomography
    Mizuho Ikuchi＊ Kentaro Honda＊ Kota Agematsu＊
    Hideki Kunimoto＊ Ryo Nakamura＊ Koji Tajima＊
    Masahiro Kaneko＊ Yoshiharu Nishimura＊

    (Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University＊, Wakayama, Japan)

    Left ventricle to right atrial communication is a rare cardiac pathology, and it is either congenital or acquired. Recently, case reports of acquired left ventricle to right atrial communication have been increasing because of the increased numbers of cardiovascular procedures and improved cardiac diagnostic techniques. We report a case of acquired left ventricle to right atrial communication in a patient with native aortic valve infective endocarditis. A 52-year-old man with worsening dyspnea on exertion and lower leg edema was admitted to a hospital. Blood examination revealed elevated inflammatory marker levels, and transthoracic echocardiography (TTE) showed an aortic valve vegetation. The patient was subsequently transferred to our hospital for infective endocarditis with congestive heart failure. Medical treatment with antibiotics and diuretics was initiated. Cardiac computed tomography (CT) demonstrated left ventricle to right atrial communication. An urgent operation was performed wherein the defect was closed with autologous pericardial patches from both the right atrium and left ventricle. Aortic valve replacement was performed with a mechanical valve. The postoperative course was uneventful, and TTE showed no residual shunt. In our case, cardiac CT was useful for accurately diagnosing left ventricle to right atrial communication.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 14-17 （2023）

    Keywords：left ventricle to right atrial communication; infective endocarditis; cardiac CT

  • A Life-Threatening Case of Infective Endocarditis Complicated by Destruction of the Aortic Valve and Embolism of the Left Anterior Descending Coronary Artery　H. Terada et al.…18
    A Life-Threatening Case of Infective Endocarditis Complicated by Destruction of the Aortic Valve and Embolism of the Left Anterior Descending Coronary Artery
    Hirohito Terada＊ Taishi Kawahata＊ Keisuke Nakamura＊
    Hirofumi Nakagawa＊ Hiroshi Okuyama＊ Akihiro Nabuchi＊

    (Division of Cardiovascular Surgery, Department of Surgery, Showa University Northern Yokohama Hospital＊, Yokohama, Japan)

    A 39-year-old man with fever and dyspnea from 3 days earlier was taken to the emergency room. He was diagnosed with infective endocarditis because echocardiography showed a mobile 10 mm-sized vegetation on the aortic valve and severe aortic regurgitation. Acute coronary syndrome was negative because the tests at the first visit did not show an increase in myocardial deviation enzymes or a decrease in wall motion. However, his hemodynamics deteriorated during the same day, so he underwent emergency surgery. The left and right leaflets and the right aortic annulus were highly destroyed, and the aortic annulus was reconstructed with his pericardium and the valve was replaced by a mechanical valve. After declamping of the aorta, the wall motion of the left ventricle was extremely reduced, and the cardiopulmonary bypass(CPB) was not able to be withdrawn. Since the left anterior descending (LAD) coronary artery may have been occluded by vegetation, we added bypass surgery to the LAD under cardiac arrest using a saphenous vein graft. After the bypass surgery, the wall motion of the left ventricle improved, and we were able to withdraw the CPB. Though he developed a cerebral infarction as a complication and required long-term rehabilitation, he was able to be discharged from the hospital 74 days after the operation. We evaluated the coronary arteries after his discharge and found an occlusion that was thought to be due to vegetation scattered in the LAD. No preoperative coronary artery evaluation was performed, however, the graft was anastomosed to the distal side of the LAD occlusion. Currently, 3 years and 2 months have passed and the infection has not recurred.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 18-23 （2023）

    Keywords：infective endocarditis; coronary artery embolism; myocardial infarction

  • A Case of Off-Pump Coronary Artery Bypass Grafting Following High-Dose Dexamethasone Therapy in a Patient with Idiopathic Thrombocytopenic Purpura　S. Sugimoto et al.…24
    A Case of Off-Pump Coronary Artery Bypass Grafting Following High-Dose Dexamethasone Therapy in a Patient with Idiopathic Thrombocytopenic Purpura
    Satoshi Sugimoto＊ Tomoyoshi Yamashita＊ Akira Adachi＊
    Hidetoshi Yamauchi＊

    (Department of Cardiovascular Surgery, Obihiro Kosei Hospital＊, Obihiro, Japan)

    Man in his 70s, who had suffered from idiopathic thrombocytopenic purpura (ITP)，was admitted to our hospital with chest pain at rest. Coronary angiography revealed obstruction of the right coronary artery and triple vessel disease. Because a bleeding tendency was expected during coronary artery bypass grafting, we performed percutaneous coronary intervention to the culprit lesion first, and then intravenous immunoglobulin and high dose dexamethasone were tried. His platelet count rose from 49,000 to 103,000/mm3, so we performed coronary artery bypass grafting. The patient had no postoperative hemorrhagic complications. We believe that high dose dexamethasone therapy is useful for patients with ITP who need surgery immediately.A 70-year-old woman who was bedridden because of right hemiplegia attributable to a history of cerebral hemorrhage underwent surgical thrombectomy for pulmonary embolism four years previously. Symptoms of heart failure appeared one year previously, and she was diagnosed with constrictive pericarditis and had been treated with medication by a previous doctor. In the current situation, she visited the previous doctor with the chief complaint of fever, and pericardial effusion was observed on echocardiography. Cardiac tamponade was suspected and she was transferred to our hospital. She was then diagnosed with purulent pericarditis because purulent fluid was observed during pericardiocentesis drainage. Bacteroides fragilis was isolated from the culture of the abscess. The abscess was resistant to conservative antibiotic therapy;therefore, we performed a pericardiotomy with a left small thoracotomy. The pleural effusion was found to be negative for culture and the patient exhibited a good postoperative course. Purulent pericarditis is refractory with poor prognosis. An appropriate surgical procedure must be chosen considering the patient’s activities of daily living. Here, we report a surgical case wherein we chose the left thoracotomy approach and achieved positive results.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 24-28 （2023)

    Keywords：idiopathic thrombocytopenic purpura; off-pump coronary artery bypass grafting; high-dose dexamethasone therapy; high-dose immunoglobulin therapy

  • A Case of Redo-Mitral Valve Replacement for a Björk-Shiley Delrin Valve Implanted 47 Years Previously R. Ikeda et al.…29
    A Case of Redo-Mitral Valve Replacement for a Björk-Shiley Delrin Valve Implanted 47 Years Previously
    Ryo Ikeda＊ Chizuo Kikuchi＊ Yusuke Tsuboko＊＊
    Masaaki Ikehara＊, ＊＊＊, Saeki Watanabe＊ Yukiko Yamada＊
    Yuki Ichihara＊ Azumi Hamasaki＊ Kiyotaka Iwasaki＊＊＊
    Hiroshi Niinami＊

    (Department of Cardiovascular Surgery, School of Medicine, Tokyo Women’s Medical University＊, Tokyo, Japan, Waseda Research Institute for Science and Engineering, Waseda University＊＊, Tokyo, Japan, and Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women’s Medical University and Waseda University, Waseda University＊＊＊, Tokyo, Japan)

    We report a case of redo mitral valve replacement (MVR) for a Björk-Shiley Delrin valve implanted 47 years previously. A 71-year-old man initially underwent MVR for mitral regurgitation at our hospital at the age of 16 years. Following the operation, follow-up examinations were performed at the outpatient clinic and annual transthoracic echocardiogram findings showed only mild mitral regurgitation, with no adverse events noted. However, a transthoracic echocardiogram examination performed 45 years after the operation revealed mild to moderate mitral regurgitation, while dyspnea with exertion was also noted at that time. As part of a more detailed examination, transesophageal echocardiogram results showed moderate transvalvular leakage. Redo MVR was subsequently performed under the diagnosis of prosthetic valve dysfunction. Analysis of the explanted prosthetic valve revealed wear of the Delrin disk, and widening of the gap between the disk and strut, which were presumed to be the cause of transvalvular leakage. A half century has passed since introduction of the Björk-Shiley valve and the present is a rare case of valve malfunction. Presented here are related details, along with a review of existing literature and results of Björk-Shiley valve use at our hospital.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 29-33 （2023）

    Keywords：tilted disk valve; Björk-Shiley valve; redo-mitral valve replacement; trans-valvular leakage

  • Totally Endoscopic Pulmonary Valve Surgery　T. Wada et al.…34
    Totally Endoscopic Pulmonary Valve Surgery
    Takeshi Wada＊ Hidenori Sako＊ Kenya Kizu＊
    Ryotaro Nagashima＊ Tetsushi Takayama＊ Shinji Miyamoto＊＊

    (Department of Cardiovascular Surgery, Oita Oka Hospital＊, Oita, Japan, and Department of Cardiovascular Surgery, Oita University Hospital＊＊, Yufu, Japan)

    Introduction: To date, totally 3D-endoscopy has primarily been employed in mitral, tricuspid, and aortic valve surgeries. Herein, we describe the first case of a pulmonary valve surgery using totally 3D-endoscopy. To the best of our knowledge, this is the first case of a totally endoscopic pulmonary valve surgery. Case report: A 56-year-old woman was provisionally diagnosed with a tumor arising from the left cusp of the pulmonary valve. Totally 3D-endoscopy was planned for tumor resection. The patient was placed in a modified right lateral decubitus position and underwent mild hypothermic cardiopulmonary bypass using the left femoral artery, right jugular vein, and right femoral vein. An on-pump beating-heart technique was used during this surgery. Trocars for the 3D-endoscopic system and surgical instruments were inserted through the third and fourth intercostal spaces. Upon incision of the pulmonary artery, the suspected tumor was revealed to be a hyperplastic left pulmonary cusp; therefore surgical resection was abandoned. The patient was discharged without any complications. Conclusion: This case demonstrates that a totally 3D-endoscopic approach may provide optimal views of the pulmonary valve. Moreover, this procedure would be a novelty in MICS. Jpn.
    　　

    J. Cardiovasc. Surg. 52: 34-36 （2023）

    Keywords：pulmonary valve surgery; totally endoscopic surgery; MICS

  • Totally Endoscopic MICS via Left Atriotomy Using a Right-Side Approach for Patch Closure of an Unroofed Coronary Sinus Atrial Septal Defect　C. Aichi et al.…37
    Totally Endoscopic MICS via Left Atriotomy Using a Right-Side Approach for Patch Closure of an Unroofed Coronary Sinus Atrial Septal Defect
    Chiaki Aichi＊ Yusuke Imamura＊ Mototsugu Tamaki＊
    Hideki Kitamura＊

    （Department of Cardiovascular Surgery, Nagoya Heart Center＊, Nagoya, Japan）

    A 51-year-old male was unexpectedly diagnosed with unroofed coronary sinus atrial septal defect （CSASD） by coronary computed tomography angiography for a complaint of epigastric pain. As there was no persistent left superior vena cava （LSVC）, we planned to undertake a totally endoscopic MICS approach. A 4-cm skin incision was made on the right lateral chest wall under general anesthesia. The 4th intercostal space was used to enter the chest and the right femoral vessels were cannulated for cardiopulmonary bypass. After cross-clamping of the aorta, a right-sided atriotomy incision was made on the left atrium. The CSASD was located at the ventral and caudal regions of the mitral valve and the defect was closed using a bovine pericardial patch. No major postoperative complications were observed. The patient was discharged 7 days after the operation as postoperative transthoracic echocardiography revealed no residual shunt. We thus observed that totally endoscopic MICS patch closure via left atriotomy using a right-side approach for CSASD without LSVC was beneficial to the patient.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 37-40 （2023）

    Keywords：MICS; coronary sinus ASD

  • ［Aortic Disease］
  • Two Cases of Descending Aortic Diverticulum Associated with the Right-Sided Aortic Arch　Y. Nishino et al.…41
    Two Cases of Descending Aortic Diverticulum Associated with the Right-Sided Aortic Arch
    Yoshifumi Nishino＊ Masahiko Ozaki＊ Takuya Miyahara＊
    Masanori Ogiwara＊

    (Department of Cardiovascular Surgery, Showa General Hospital＊, Tokyo, Japan)

    Case 1 is a 70-year-old male. He has a history of cholelithiasis and left inguinal hernia. A preoperative examination of the inguinal hernia showed the enlargement of the mediastinal shadow, and he was referred to our department. A close examination revealed a right-sided aortic arch, a right descending aorta, and a descending aortic diverticulum. No subjective symptoms, intracardiac malformations, or other cardiovascular diseases were observed. The surgery was scheduled for descending aorta replacement including a diverticulum with right posterior lateral 4th intercostal thoracotomy and lower body partial extracorporeal circulation. However, due to aortic intima injury at the proximal end, hypothermic cerebral circulatory arrest and proximal anastomosis were performed by the open proximal method. There was no problem with the postoperative course, and he was discharged 19 days after surgery. Case 2 is a 51-year-old female. Born in China, she has lived in Japan for 15 years. No notable history. An abnormal shadow was shown on chest Xp performed in a medical examination, and aortic malformation was suspected on chest CT. She was referred to our department. The diagnosis was right-sided aortic arch, right descending aorta, aberrant left subclavian artery, and Kommerell diverticulum. There were no subjective symptoms and no intracardiac malformations. The operation was a two-stage operation. As the initial surgery, median sternotomy was performed, total arch replacement with intrathoracic reconstruction of the left subclavian artery, and open stent graft insertion, and the Kommerell diverticulum was covered with an open stent graft. We did not treat the diverticulum because it was located on the dorsal side. At 15 days after surgery, we performed embolization of the origin of the left subclavian artery from the Kommerell diverticulum. There was no problem with the postoperative course, and she was discharged 19 days after the initial surgery.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 41-45 （2023）

    Keywords：Kommerell diverticulum; right-sided aortic arch; aberrant subclavian artery; descending thoracic aortic aneurysm

  • Successful Use of a Stent-Graft for Treating a Pseudoaneurysm Located at the Anastomosis of the Ascending Aorta and the Great Saphenous Vein　R. Ayata et al.…46
    Successful Use of a Stent-Graft for Treating a Pseudoaneurysm Located at the Anastomosis of the Ascending Aorta and the Great Saphenous Vein
    Ryo Ayata＊ Masaya Takahashi＊ Yoshitaka Ikeda＊
    Noriyasu Morikage＊＊ Hiroshi Ito＊

    (Department of Cardiovascular Surgery, Saiseikai Shimonoseki General Hospital＊, Shimonoseki, Japan, and Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine＊＊, Ube, Japan)

    Takayasu Arteritis causes annuloaortic ectasia and coronary ostial stenosis, which may necessitate open heart surgery. However, pseudoaneurysms are sometimes observed postoperatively, making subsequent treatment difficult. We report thoracic endovascular aortic repair of a pseudoaneurysm of the ascending aorta with an anastomosis of the great saphenous vein in a 61-year-old female with a history of multiple open-heart procedures. Thirty years earlier, she underwent aortic valve replacement and coronary artery bypass surgery for aortic regurgitation, and right coronary ostial stenosis. Eleven years after surgery, an ascending aortic aneurysm was found and Bentall’s surgery was performed. Multiple open thoracotomies were subsequently performed. Postoperatively, a pseudoaneurysm was found at the anastomosis between the ascending aorta and the great saphenous vein. The patient was transferred to the emergency room owing to hemoptysis and was diagnosed with a ruptured pseudoaneurysm at the anastomosis of the ascending aorta and the great saphenous vein. By inserting a stent graft into the ascending aorta, we avoided further complications and her prognosis was good. She was discharged on postoperative day 18 and did not experience any end leak for a year. Thoracic endovascular aortic repair in the ascending aorta is a minimally invasive procedure that may be useful for high-risk patients.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 46-49 （2023）

    Keywords：thoracic endovascular aortic repair; pseudoaneurysms; ascending aorta; Takayasu arteritis

  • Surgical Case of Tuberculous Abdominal Aortic Aneurysm and Thoracic Aortic Aneurysm with Miliary Tuberculosis　T. Tamura et al.…50
    Surgical Case of Tuberculous Abdominal Aortic Aneurysm and Thoracic Aortic Aneurysm with Miliary Tuberculosis
    Tomoki Tamura＊ Yuta Murai＊ Tsuyoshi Taketani＊＊
    Tetsuya Horai＊

    (Department of Cardiovascular Surgery, Central Hospital of the National Center for Global Health and Medicine＊, Tokyo, Japan, and Department of Cardiovascular Surgery, Mitsui Memorial Hospital＊＊, Tokyo, Japan)

    A 48-year-old woman was scheduled to undergo wrist surgery at the orthopedic surgery clinic. She was adventitiously diagnosed with miliary tuberculosis and saccular-type aneurysms in the suprarenal abdominal aorta and descending thoracic aorta during preoperative examination. Consequently, she received antituberculosis medications. However, the abdominal aortic aneurysm had enlarged rapidly 2 months later. Accordingly, we used an artificial graft patch bonded with rifampicin for the abdominal aortic aneurysm and resected the aneurysm and reconstructed the aorta through partial extracorporeal circulation by clamping the descending thoracic aorta and infrarenal abdominal aorta. Finally, we performed a thoracic endovascular aortic repair of the thoracic aortic aneurysm. Culture of the samples from the wall of the abdominal aortic aneurysm indicated Mycobacterium tuberculosis; therefore, the patient was diagnosed with a tuberculous aneurysm of the aorta. Her postoperative course was good, and she was discharged on day 36. At postoperative month 7, the patient is still on antituberculosis medications and has not experienced a recurrence.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 50-54 （2023）

    Keywords：tuberculous aneurysm of the aorta; patch closure; miliary tuberculosis

  • A Case of Effective Zone 0 TEVAR Using Squid-Capture Assisted in situ Stent-Graft Fenestration, for Endoleak from the Fenestration of Najuta　S. Otake et al.…55
    A Case of Effective Zone 0 TEVAR Using Squid-Capture Assisted in situ Stent-Graft Fenestration, for Endoleak from the Fenestration of Najuta
    Satoshi Otake＊1） Yu Kawahara＊1） Miku Konaka＊1）
    Eiichi Oba＊1） Atsushi Yamashita＊1） Kazuo Abe＊1）
    Kotaro Suzuki＊2） Norio Hongo＊3） Shinji Miyamoto＊4）

    (Department of Cardiovascular Surgery, Yamagata Prefectural Central Hospital＊1）, Yamagata, Japan, Department of Cardiovascular Surgery, Yonezawa Municipal Hospital＊2）, Yamagata, Japan, Department of Radiology＊3), and Department of Cardiovascular Surgery＊4), Oita University, Oita, Japan)

    We report the case of a 76-year-old man who developed type IA endoleak through the fenestration after 1-debranch TEVAR using a Najuta endograft. The patient was admitted with expansion of the aneurysm after TEVAR, for additional therapy. Type IA endoleak through a fenestration has remained a significant clinical concern and its treatment is challenging. We performed Zone 0 TEVAR using the “Squid-Capture” technique assisted in situ stent-graft fenestration. Cerebral vessels were perfused by a percutaneous cardiopulmonary support system during in situ stent-graft fenestration, and the cerebral branch was clamped at the proximal site. It is difficult to operate the catheter inside the endoskeleton structure of a Najuta endograft, but several innovations were effective. Test dilation of the balloon catheter was performed to ensure that the wire did not interfere with the endoskeleton. Avoiding interference with the endoskeleton is important. The Squid-Capture technique allows safe and secure puncture of the graft. The operation was completed successfully. After this procedure, the endoleak disappeared. It is considered to be a useful method for treatment of endoleak through the fenestration.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 55-58 （2023）

    Keywords：thoracic aortic aneurysm; endoleak; stent graft; in situ fenestration; Squid-Capture

  • Thoracic Endovascular Aortic Repair for Chronic Aortic Dissection with an Isolated Left Vertebral Artery　T. Hayashi et al.…59
    Thoracic Endovascular Aortic Repair for Chronic Aortic Dissection with an Isolated Left Vertebral Artery
    Takuto Hayashi＊ Fumitaka Suzuki＊ Takuya Ito＊
    Masatoshi Sunada＊ Satoru Maeba＊

    (Department of Cardiovascular Surgery, Tokyo General Hospital＊, Tokyo, Japan)

    Thoracic endovascular aortic repair (TEVAR) is valuable in the treatment of type B aortic dissection. An isolated left vertebral artery (ILVA) is a common anomaly of the aortic arch. The ILVA is covered during TEVAR in specific cases; however, whether the ILVA should be reconstructed in all cases remains controversial. We report a case of TEVAR performed for chronic aortic dissection in a patient with an ILVA. A 57-year-old woman with an ILVA had a type B acute aortic dissection one year prior to presentation and underwent TEVAR owing to dilation of an ulcer-like projection. We performed ILVA-left common carotid artery (LCCA) anastomosis and LCCA-left axillary artery bypass prior to TEVAR using our usual procedure. The postoperative course was favorable without any major complication. ILVA reconstruction may reduce the incidence of postoperative stroke and spinal cord injury. Usually, an ILVA is easily accessible through the supraclavicular approach, and the anatomical position of the vessel facilitates ILVA-LCCA anastomosis. ILVA reconstruction requires additional features and further consideration.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 59-61 （2023）

    Keywords：isolated left vertebral artery; aberrant vertebral artery; thoracic endovascular aortic repair; TEVAR

  • Surgical Strategy for Protecting Major Branch Arteries during Thoracic Endovascular Aortic Repair for Shaggy Descending Aortic Aneurysms　R. Ueda et al.…62
    Surgical Strategy for Protecting Major Branch Arteries during Thoracic Endovascular Aortic Repair for Shaggy Descending Aortic Aneurysms
    Ryoma Ueda＊ Jiro Esaki＊ Masanori Honda＊
    Masafumi Kudo＊ Takehiko Matsuo＊ Hitoshi Okabayashi＊

    (Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital＊, Kyoto, Japan)

    Surgery for a shaggy aortic aneurysm requires a meticulous strategy to prevent embolic complications since the complications are associated with longer length of hospital stay and higher mortality. However, until now, there are no established treatment options to prevent embolic complications. We report a case of a 75-year-old man with a descending aortic aneurysm and a shaggy aorta who underwent thoracic endovascular aortic repair （TEVAR） with major branch artery protection. During the procedure, we placed balloon catheters in the left subclavian and left common iliac arteries, a filter device in the superior mesenteric artery, and a sheath at the ostium of the right common iliac artery. The patient did not develop embolic or other complications and was discharged on the eighth postoperative day. Our strategy of using the balloon occlusion technique and filter placement at the major vessels effectively prevented embolic complications during TEVAR for a shaggy aorta.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 62-66 （2023）

    Keywords：thoracic endovascular aortic repair （TEVAR）; shaggy aorta; thoracic descending aorta aneurysm

  • Intra-Aortic Intimal Band Treated as a Chronic Type A Aortic Dissection　H. Yamauchi et al.…67
    Intra-Aortic Intimal Band Treated as a Chronic Type A Aortic Dissection
    Hidetoshi Yamauchi＊ Satoshi Sugimoto＊ Tomoyoshi Yamashita＊
    Akira Adachi＊

    （Department of Cardiovascular Surgery, Obihirokosei General Hospital＊, Obihiro, Japan）

    We present a case of a 76-year-old woman who was diagnosed with sarcoidosis due to enlarged hilar lymph nodes 6 year earlier. Computed tomography （CT） revealed asymptomatic Stanford type A dissection at that time. A chest radiograph taken a year ago showed obvious cardiac enlargement; therefore, echocardiography was performed for further investigation, which revealed severe aortic regurgitation. The patient was referred to our department for surgery after the contrast-enhanced CT revealed the same intra-aortic intimal flap as before. Transthoracic echocardiography showed cardiac enlargement with a left ventricular end-diastolic diameter of 61 mm and aortic regurgitation of 3/4 degree. Contrast-enhanced CT showed an approximately 3-mm-wide band-like structure （linear shadow） that appeared to be the intima of the ascending aorta; however, no entry or false lumen was apparent. The structure in the ascending aorta had an appearance distinct from that of a typical aortic dissection, but was deemed possible in chronic aortic dissection. Nevertheless, intraoperative findings revealed that the linear shadow shown on CT was not due to dissection. The band-like structure was actually the intima, and it was excised. The aortic valve was replaced with a biological valve and the ascending aorta was replaced with a prosthetic graft. She was discharged home on the 11th postoperative day after a favorable recovery. Pathological findings of the band-like structure revealed the intima of the blood vessel and no evidence of inflammatory cell infiltration. There was no evidence of aortic dissection. We encountered a rare case of intra-aortic intimal band that was misdiagnosed and treated as an aortic pseudodissection. It is difficult to rule out aortic dissection prior to surgery; therefore, it is preferable to prepare the operation as a dissection.
    　　

    Jpn. J. Cardiovasc. Surg. 52: 67-70 （2023）

    Keywords：pseudodissection；intra-aortic intimal band；aortic dissection

  • Special Issue: Various Issues Hindering the Introduction of Nurses Trained for Specific Interventions （1） Cardiovascular Surgeons Need the Nurses Who Certified Specific Interventions and Work as Physician Assistants !　T. Watanabe…71

U-40

  • U-40 Column Lecture Summaries and Survey Results of the Basic Lecture Course (BLC) on Postoperative Management (Delirium and Pain) in Cardiovascular Surgery M. Noda et al.…U1
    Lecture Summaries and Survey Results of the Basic Lecture Course (BLC) on Postoperative Management (Delirium and Pain) in Cardiovascular Surgery
    Mika Noda＊ Yusuke Imaeda Hideyasu Ueda
    Kohei Kitamura Hiroto Suenaga Takuya Tsuruoka
    Daisuke Toritsuka Yuji Nakamura Toshihiko Nishi
    Saki Bessho Keita Yano Toshiyuki Yamada

    (Department of Cardiovascular Surgery, Aichi Children’s Health and Medical Center＊, Obu, Japan)

    As part of U-40 activities, chapters have traditionally held sessions of lectures and hands-on as the Basic Lecture Course (BLC) to improve the basic skills and knowledge of young cardiovascular surgeons. Because of the COVID-19 epidemic, we have shifted our activities from onsite to online. This column focuses on “management of postoperative delirium and pain” in the lecture of “Postoperative Management in Cardiovascular Surgery” given by the Chubu Chapter in 2020. We summarize the lecture and report the results of a questionnaire survey of the U-40 members.
    　　

    Jpn. J. Cardiovasc. Surg. 52(1): U1-U9 (2023).

    Keywords：online lecture; postoperative management in cardiovascular surgery; postoperative delirium and pain

Editor’s Post Script

  • S. Wakasa