|Yuki Ogata＊||Yoshiya Shigehisa＊＊||Yushi Yamashita＊＊|
|Tomoyuki Matsuba＊||Kenji Toyokawa＊＊||Hideaki Kanda＊＊|
|Keisuke Kawaida＊＊||Shinya Kuramoto＊＊||Yoshiharu Soga＊＊|
|Keisuke Kawaida＊＊||Shinya Kuramoto＊＊||Yoshiharu Soga＊＊|
(Cardiovascular Surgery, Kagoshima City Hospital＊, Kagoshima, Japan, Cardiovascular Surgery, Kagoshima University Graduate School of Medical and Dental Sciences＊＊, Kagoshima, Japan, and Cardiovascular Surgery, Fujimoto General Hospital＊＊＊, Miyakonojo, Japan)
Neonatal Marfan syndrome is the most severe form of Marfan syndrome usually showing critical cardio-respiratory symptoms from the neonatal period or early infancy. We report a boy with this syndrome who presented with heart failure at 3 months of age and was referred to our department at 6 months old after intense medical treatment. He had enophthalmos, funnel chest, arachnodactyly, and Steinberg’s thumb sign, but had no family history of Marfan syndrome or other cardiac diseases. Left ventricular dilatation, severe mitral regurgitation and moderate tricuspid regurgitation were noted on echocardiography. Mitral valvuloplasty and tricuspid annuloplasty were performed, and the regurgitation improved to trivial and mild level, respectively. However, rapid exacerbation of mitral regurgitation occurred, and the patient fell into circulatory collapse which needed circulatory support with extracorporeal membrane oxygenator （ECMO） on 18th postoperative day. In the emergency operation, the previous surgical procedures on the mitral valve were intact and we thought that rapid progression of the mitral annular dilatation and valve expansion to be the cause of exacerbation. Mitral valve replacement （Regent® 21 mm aortic） was performed, and the cardiac function improved, but ECMO was still needed because of the depressed respiratory function. Furthermore, tricuspid regurgitation due to annular dilatation and valve expansion was aggravated rapidly which needed tricuspid valve replacement （ATS® 20 mm mitral） 9 days after the mitral valve replacement. ECMO was ceased on the 37th day and the patient was extubated on 71st day. He was discharged from the hospital 5 months after the first operation. One year has passed after discharge, and he is doing well with anticoagulation. In the treatment of neonatal Marfan syndrome, surgical procedure for valve repair is still controversial and it should be remembered that rapid exacerbation of the atrioventricular valve can occur even after satisfactory valve repair and there should be no hesitation regarding surgical intervention when needed.
Jpn. J. Cardiovasc. Surg. 52: 77-82（2023）
Keywords：neonatal Marfan syndrome; mitral valve regurgitation; mitral and tricuspid valvuloplasty; ECMO; double atrioventricular valve replacement
|Atsushi Matsumoto＊||Shota Yasuda＊||Tomoki Cho＊|
|Yusuke Matsuki＊||Yoshiyuki Kobayashi＊||Kaori Mori＊|
(Cardiovascular Center, Yokohama City University Medical Center＊, Yokohama, Japan）
A 55-year-old woman with fever and consciousness disorder diagnosed as infective endocarditis was transported to our hospital. She had atopic dermatitis. A mobile vegetation at the mitral valve was revealed by the transesophageal echocardiography, and a computed tomography （CT） scan showed cerebral infarction, left renal infarction and suspected embolization of the vegetation. Streptococcus aureus was detected in the blood culture test. We conducted emergent surgery, mitral valve plasty was performed. On the second day after the operation, the hemoglobin began to decrease, and the hemodynamics became unstable. The contrast CT examination revealed arterial bleeding from the left kidney, which had an infarction before the operation. We performed emergent catheter liquid embolization for the superior polar branch of the left renal artery, and the hemodynamics improved thereafter. There has been no report of renal hemorrhage after cardiac surgery for infective endocarditis. This case reminded us that cardiac surgery for infective endocarditis may cause various complications of organs.
Jpn. J. Cardiovasc. Surg. 52: 83-87（2023）
Keywords：infective endocarditis; embolization; renal hemorrhage; Staphylococcus aureus
|Makoto Takehara＊||Sanae Tomotsuka＊||Shinichi Tsumaru＊|
(Department of Cardiovascular Surgery, Hamamatsu Rousai Hospital＊, Hamamatsu, Japan)
An 87-year-old woman underwent AVR （CEP 21 mm） for aortic stenosis at age 73 years. Fourteen years later, she was treated with antibiotics for mediastinal abscess, which showed a tendency to shrink and inflammation improved. At that time, no vegetation or aortic regurgitation was observed. Eight months later, the patient was brought to the emergency room with a complaint of respiratory distress. After close examination, a severe transvalvular leakage was found at the aortic valve position. No vegetation was found. Enhanced chest computed tomography （CT） showed an aneurysm of the left sinus of Valsalva. The diagnosis of healed aortic prosthetic valve endocarditis with an aneurysm of the sinus of Valsalva was made. The CEP valve was removed at surgery, and the valve leaflet corresponding to the right coronary cusp was destroyed. The left sinus of Valsalva was dilated and a Perceval was implanted. The patient was doing well postoperatively, but a pacemaker was implanted due to atrioventricular dissection. Transthoracic echocardiography confirmed that there was no problem with prosthetic valve function at the aortic valve position, and CT showed a reduction of aneurysm of the left sinus of Valsalva. The patient was discharged from the hospital on the 30th postoperative day. Aortic valve replacement with Perceval is effective in high-risk cases of prosthetic valve endocarditis.
Jpn. J. Cardiovasc. Surg. 52: 88-92 （2023）
Keywords：prosthetic valve endocarditis; aortic valve replacement; Perceval; aneurysm of the sinus of Valsalva
|Shingo Otaka＊||Kazuhiro Tani＊||Shota Nakagaki＊|
|Masami Sotokawa＊||Akira Murata＊||Tetsuyuki Ueda＊|
（Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital＊, Toyama, Japan）
A 70-year-old woman diagnosed with angina pectoris was scheduled to undergo off-pump coronary artery bypass grafting （OPCAB） using the left internal thoracic artery and the saphenous vein （SVG）. We performed a proximal anastomosis of the SVG to the ascending aorta using a clampless proximal anastomotic device. When this device was removed from the ascending aorta after completion of the SVG proximal anastomosis, we noticed the extensive appearance of an ascending aortic adventitial hematoma. Transesophageal echocardiography revealed a flap in the ascending aorta, which was diagnosed as an iatrogenic aortic dissection. The decision was made to immediately perform an additional aortic replacement. There was an intimal tear consistent with the device insertion site, which was identified as the site for the development of aortic dissection. After performing an ascending aortic replacement, coronary artery bypass grafting was performed. Her postoperative course was uneventful, and enhanced CT on postoperative day 12 showed aortic dissection up to the level of the abdominal aorta, but the false lumen was completely thrombosed. Iatrogenic aortic dissection caused by proximal anastomotic device during OPCAB is a very rare but serious complication, and early intraoperative diagnosis and prompt additional surgical treatment were considered necessary to save the patient’s life.
Jpn. J. Cardiovasc. Surg. 52: 93-97（2023）
Keywords：clampless proximal anastomotic device; iatrogenic aortic dissection; off-pump coronary artery bypass grafting
|Shingo Taguchi＊||Hitomi Naruse＊||Kei Tanaka＊|
（Department of Cardiovascular Surgery, Fuji City Central Hospital＊, Fuji, Japan）
A 71-year-old woman underwent VVI pacemaker implantation for complete atrioventricular block 38 years ago at the cardiovascular department of another hospital. In the course of observation, she developed atrial fibrillation. One year ago, she was admitted to hospital for aggravated congestive heart failure and was subsequently treated by a cardiovascular practitioner. She had persistent shortness of breath and lower leg edema, which were treated with increasing doses of oral diuretics. Due to poor treatment outcomes, she was referred to our hospital. Her echocardiography results suggested severe tricuspid regurgitation （TR） and moderate mitral regurgitation. She was also found to have impaired renal function and liver cirrhosis （Stage A of the Child classification）, and was admitted. In addition, she had undernutrition with suspected cardiac cachexia. She was first treated by inotrope infusion and central venous hyperalimentation before tricuspid annuloplasty and mitral valvuloplasty were performed. Even though her postoperative management was complicated, she was discharged from our hospital. The conservative treatment with the increased dose of the diuretic for TR-associated right heart failure was prolonged in this patient, leading to severe right heart failure and aggravation of impaired renal function or congestive liver-associated hepatic disorders. Eventually, the patient required operative intervention; however, postoperative management is usually complex, and the operation result may be poor in such patients. We suggest that, from the time when right heart failure can be managed with relatively small doses of diuretics, surgeons should be involved in the care of patients with severe TR who do not require left heart valvular surgery, and should discuss the necessity of surgery earlier than the relevant guidelines suggest, depending on the patient’s condition.
Jpn. J. Cardiovasc. Surg. 52: 98-102 （2023）
Keywords：tricuspid valve regurgitation; right heart failure; chronic atrial fibrillation; liver cirrhosis
|Tomoki Tamura＊||Yurie Otomo＊||Tetsuya Horai＊|
（Department of Cardiovascular Surgery, Central Hospital of the National Center for Global Health and Medicine＊, Tokyo, Japan）
Spinal cord ischemia （SCI）, a complication of acute aortic dissection, has no established treatment. Here, we report the successful management of three cases of acute type A aortic dissection （ATAAD） with SCI using a multidisciplinary approach. Case 1: A 55-year-old man presented with paraparesis due to ATAAD （non-communicating type）, cardiac tamponade, and no loss of consciousness. He underwent emergency surgery for ascending aortic replacement. He awoke 3 h after the surgery; however, as his paralysis was not improved, we initiated multidisciplinary treatment with cerebrospinal drainage, continuous infusion of naloxone, and steroid pulse therapy. These treatments led to the complete resolution of his symptom; he was discharged on Day 32, with no neurological deficits. Case 2: A 50-year-old woman presented with complete paralysis of the left lower limb due to ATAAD （communicating type） but no loss of consciousness. She underwent emergency surgery for ascending aortic replacement. She awoke 2 h after the surgery; however, as her paralysis was not improved, multidisciplinary treatment with cerebrospinal drainage, continuous infusion of naloxone, and steroid pulse therapy were initiated, which led to partial resolution of the symptoms. She could walk with orthotics and was discharged on Day 57. Case 3: A 43-year-old man presented with paraparesis of the left lower limb due to ATAAD （non-communicating type）. He was hemodynamically stable, with no loss of consciousness. The ATAAD was conservatively managed, and multidisciplinary treatment with cerebrospinal drainage, continuous infusion of naloxone, and steroid pulse therapy was administered. These therapies led to the complete resolution of his symptoms; he was discharged on Day 46, with no neurological deficits. Hence, for ATAAD with SCI, multidisciplinary treatment, including emergency surgery, is an important therapeutic strategy.
Jpn. J. Cardiovasc. Surg. 52: 103-108 （2023）
Keywords：spinal cord ischemia; acute type A aortic dissection; cerebrospinal drainage; naloxone
|Shinya Takimoto＊||Takanori Taniguchi＊＊||Atsushi Iwakura＊|
|Kyokun Uehara＊||Manabu Morishima＊||Yasue Fujiwara＊|
|Junpei Kobiki＊||Yosuke Sugita＊||Taku Shirakami＊|
(Department of Cardiovascular Surgery＊, and Department of Radiology＊＊, Tenri Hospital, Tenri, Japan)
Among the less reported complications after thoracic endovascular aortic repair （TEVAR） is type II endoleak （T2EL）. The intercostal and bronchial artery are known as feeder vessels to T2EL after TEVAR. We experienced two cases of successful treatment of percutaneous transarterial feeder vessels embolization via right costocervical trunk approach for patients with persistent T2EL and sac enlargement of an arch aneurysm after TEVAR. The costocervical trunk route is possible for key vessels to construct a collateral pathway to feeder vessels of the endoleak nidus of T2EL after TEVAR procedures for aortic arch aneurysm. A preembolizational Catheter-Directed CT angiogram （CTA） can be helpful to prevent harmful complications （e.g., spinal cord infarction）.
Jpn. J. Cardiovasc. Surg. 52: 109-113 （2023）
Keywords：type II endoleak after TEVAR; costocervical trunk; Catheter-Directed CT Angiogram
|Shuichi Okonogi＊||Satoshi Ohki＊||Kiyomitsu Yasuhara＊|
|Ayako Nagasawa＊||Takao Miki＊||Ryo Yamaguchi＊|
|Yusuke Kato＊||Tamiyuki Obayashi＊|
（Department of Cardiovascular Surgery, Isesaki Municipal Hospital＊, Isesaki, Japan）
A 77-year-old woman underwent endovascular abdominal aortic repair （EVAR） for an abdominal aortic aneurysm （AAA）．Five years after surgery, she visited the hospital with the chief complaint of a fever. Enhanced computed tomography （CT） showed enlargement of the AAA around the stent-graft and a mass, which was suspected to be an abscess, outside the aneurysm. A blood test revealed a high level of inflammatory response. The patient was diagnosed with infectious AAA. She received antibiotics; however, the inflammatory response did not completely improve. A second CT scan revealed that the suspected abscess had a spreading tendency. The patient was referred to our hospital for a highly suspected stent-graft infection. We performed Y-graft replacement using a rifampicin-immersed graft, and as much as possible of the wall around the aortic aneurysm was removed. The inflammatory response improved rapidly after the operation, and the patient was discharged 15 days later. According to the results of a pathological examination, a diagnosis of xanthogranulomatous inflammation and fibrosis was made. Here, we report a rare case of xanthogranulomatous inflammation of the aortic aneurysm wall after EVAR.
Jpn. J. Cardiovasc. Surg. 52: 114-117 （2023）
Keywords：post EVAR; xanthogranulomatous inflammation; abdominal aortic aneurysm
|Ryosuke Nawata＊||Ryo Suzuki＊||Toshiki Yokoyama＊|
|Sarii Tsubone＊||Yutaro Matsuno＊||Hiroshi Kurazumi＊|
|Bungo Shirasawa＊||Akihito Mikamo＊||Kimikazu Hamano＊|
（Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine＊, Ube, Japan）
A 62-year-old man presented with hemoptysis and hoarseness. He was diagnosed with an aortopulmonary fistula due to a thoracic aortic aneurysm rupture and was referred to our department. Emergency in-situ reconstruction of the aorta and pulmonary lobectomy were performed. Nine days postoperative, he developed empyema. Intrapleural urokinase and antibiotic therapy were selected as management instead of a video-assisted thoracoscopic debridement and decortication due to his worsening condition. The treatment was successful, and he was discharged from the hospital without any further complications. This study highlights the benefit of intrapleural administration of urokinase and antibiotics in patients with acute empyema, when surgical treatment is inappropriate.
Jpn. J. Cardiovasc. Surg. 52: 118-122 （2023）
Keywords：empyema; urokinase; intrapleural antibiotics; thoracic aortic aneurysm
|Noriko Fujimoto＊||Yuta Doi＊||Akira Hashino＊|
(Department of Cardiovascular Surgery, Matsuyama Red Cross Hospital＊, Matsuyama, Japan)
A 65-year-old woman who had been diagnosed with a thoracic aneurysm was admitted to our hospital because of loss of consciousness. Brain CT revealed that the left corticomedullary junction is obscured. Contrast-enhanced CT demonstrated an acute type A aortic dissection with right internal carotid artery occlusion, left internal carotid artery stenosis, and severe pectus excavatum. Although the consciousness level at the time of admission was JCS200, it gradually improved and she regained spontaneous movement of the right side of her body. Repair of the acute type A dissection was indicated because her neurological deficit had improved. The surgery was performed via an L-shaped approach consisting of a median sternotomy and a left 5th intercostal thoracotomy with moderate hypothermic circulatory arrest and selective cerebral perfusion. An entry was found in the aortic arch between the origins of the brachiocephalic artery and the left common carotid artery, and a partial arch replacement was performed using a four-branched artificial graft. Although the right hemiparesis remained, she recovered well and was transferred to a rehabilitation hospital at 45 days postoperatively. The L-incision approach obtained a good surgical field in a patient with a type A dissection and severe pectus excavatum.
Jpn. J. Cardiovasc. Surg. 52: 123-127 （2023）
Keywords：L-incision thoracotomy; pectus excavatum; Stanford type A aortic dissection
|Itaru Hosaka＊||Yutaka Iba＊||Shingo Tsushima＊|
|Tsuyoshi Shibata＊||Junji Nakazawa＊||Tomohiro Nakajima＊|
(Department of Cardiovascular Surgery, Sapporo Medical University＊, Sapporo, Japan)
A 59-year-old man who was diagnosed with hypertension and a large thoracoabdominal aortic aneurysm was referred to our hospital for surgical treatment. He underwent open surgery and thoracic endovascular aneurysm repair in three stages. He developed paraplegia after the third surgery. Despite acute postoperative treatment and rehabilitation, his lower extremity motor function and bladder and bowel dysfunction did not improve. He was transferred to a recovery hospital 67 days after the third surgery. However, he was readmitted to our hospital about four months later for management of a refractory decubitus ulcer and recurrent urinary tract infections. Computed tomography revealed hematoma and calcification around the femur. Based on the clinical course and imaging findings, we diagnosed neurogenic heterotopic ossification associated with postoperative paraplegia in this patient. He had flap reconstruction for the ulcer. Finally, he was discharged 79 days after readmission. To date, no study has reported neurogenic heterotopic ossification associated with postoperative aortic aneurysm paraplegia. The mechanism underlying this condition is similar to the widely accepted process associated with traumatic spinal cord injury, and conservative treatment comprising pressure ulcer treatment and antibiotics was continued. Although acute rehabilitation is important after highly invasive aortic aneurysm surgery, rehabilitation is limited by the risk of neurogenic heterotopic ossification in patients with postoperative paraplegia, and recovery and maintenance of activities of daily living are challenging. To our knowledge, early diagnosis and prompt treatment for these complications are important considering neurogenic heterotopic ossification.
Jpn. J. Cardiovasc. Surg. 52: 128-132 （2023)
Keywords：thoracoabdominal aortic aneurysm; paraplegia; Neurogenic Heterotopic Ossification
|Katsuaki Magishi＊||Seima Ohira＊＊||Noriyuki Shimizu＊|
（Department of Cardiovascular Surgery, Nayoro City General Hospital＊, Nayoro, Japan, and Department of Vascular Surgery, Asahikawa Medical University＊＊, Asahikawa, Japan）
A 73-year-old man who had undergone right common iliac-right femoral-left femoral artery bypass, and left femoral-popliteal artery bypass at 60, and stent graft for abdominal aortic aneurysm at 69, had a pseudoaneurysm repaired at the left femoral artery anastomosis site at 72. Retention of fluid continued around the prosthesis, so drainage and sartorius muscle flap were carried out at 72. Due to the occlusion of the left popliteal bypass, a cross over bypass was performed from the right iliac artery position to the left above knee popliteal artery through the left obturator foramen route. One month later, CT revealed that the prosthesis had penetrated the bladder. In open surgery, the bladder was incised, and the prosthesis was taken out of it. The postoperative course was uneventful. Oral antibiotics were continued for 3 months. Currently, there are no signs of infection. There are very few opportunities to choose an obturator foramen route. It was necessary to identify the bladder wall under direct vision with great care. Jpn.
J. Cardiovasc. Surg. 52: 133-136 （2023）
Keywords：obturator foramen; crossover bypass; iatrogenic; bladder; injury
(Department of Cardiovascular Surgery, Southern Tohoku General Hospital＊, Koriyama, Japan)
The Basic Lecture Course (BLC) held by U-40 (which is The Japanese Society for Cardiovascular Surgery Under-Forty) aims to improve the basic skills and knowledge of young cardiovascular surgeons. The aim of this report is to survey the strategies of total arch repair for thoracic aortic aneurysms focusing on differences in treatment between hospitals, and to share the results of this questionnaire investigation about this.
Jpn. J. Cardiovasc. Surg. 52(2): U1-U5 (2023).
Keywords：Under Forty; questionnaire survey; thoracic arch aneurysm