Editor in Chief : Goro Matsumiya Vol.52, No.3, May 2023 CONTENTS

Preface

• Is AI Our Friend or Enemy ?　T. Sakaguchi

Originals

• Mitral Surgery for Severe Mitral Annular Calcification: Calcium Resection or Exclusion Procedure　M. Yoshida et al.　143
  Mitral Surgery for Severe Mitral Annular Calcification: Calcium Resection or Exclusion Procedure
  

  Minoru Yoshida＊

  Tadashi Isomura＊

  Takuya Miyazaki＊

  
  

  (Department of Cardiovascular Surgery, Kasai Shoikai Hospital＊, Tokyo, Japan)
  

  Backgroundː Extensive calcification of the mitral annulus （MAC） represents a problem for mitral surgery due to a technical difficulty for implanting prosthetic valves, because the calcium does not allow placing direct sutures through the annulus and para-prosthetic leakage or cardiac rupture may result. We describe our experience with mitral valve surgery with or without decalcification of the annulus. Methodsː Since 2005, we performed mitral valve operations in 1,327 patients and among them, severe mitral annular calcification was present in 25 （1.9%）. Resultsː The mean age was 75±9 years and there were 6 men and 19 women, with hemodialysis in 4. Mitral valve replacement （MVR） was performed in all patients. A concomitant operation was aortic valve replacement in 19 and coronary artery bypass grafting in 4 patients. The MAC was resected in 14 （Group-R） and was excluded in 11（Group-E）．In-hospital mortality was four patients in Group-R. The cause of death was congestive heart failure in two, cerebellar infarction in one, and respiratory failure in one. Postoperative morbidity included one patient with reexploration and one with prolonged respiratory failure The aortic cross clamp time was a mean of 180±44 min （range 108～266 min） in Group-R and 139±32 min （range 61～ 186 min） in Group-E （p＝0.009）. The size of the prosthetic mitral valve was 24.3±1.0 mm in Group-R and 24.6±0.8 mm in Group-E （ p＝0.618）. The postoperative echocardiography showed no abnormal mean pressure gradient of mitral valve prosthesis nor para-valvular leak in any patients in either group. Conclusionsː The mitral valve replacement without annular decalcification in a severely calcified mitral annulus is a safe and an effective approach in an elderly patient.

   

  Jpn. J. Cardiovasc. Surg. 52: 143-148 （2023）

  Keywords：mitral annular calcification; mitral valve surgery; resection procedure; exclusion procedure; mitral valve replacement

  
  
• Surgical Treatment for Aseptic Mediastinitis in the Late Phase after Aortic Root and Arch Replacement　T. Yamamoto et al.　149
  Surgical Treatment for Aseptic Mediastinitis in the Late Phase after Aortic Root and Arch Replacement
  

  Takashi Yamamoto＊	Kenji Mogi＊	Manabu Sakurai＊
  Maiko Nagahama＊	Yoshiharu Takahara＊

  
  

  (Division of Cardiovascular Surgery, Heart and Vascular Institute, Funabashi Municipal Medical Center＊, Funabashi, Japan)
  

  Objective: A few cases of an aseptic abscess after thoracic aortic surgery have been reported. However, it sometimes requires surgical treatment because the rapid growth of perigraft fluid collection results in exposure towards the body surface. We discuss the results of our treatment of these cases. Methods: This study was a retrospective analysis. Four of 341 cases who underwent thoracic aortic surgery between April 2013 and March 2020 were included. These cases presented with a bulge of the body surface 10.3 （range, 3-27） months after surgery. Results: Although the fluids looked purulent in all cases, no bacteria were detected. We diagnosed them as aseptic abscess, for which omental implantation was performed. No signs of recurrence have been found in any cases even after 5.4 （range, 1-8.5） years. Conclusions: Omental implantation was effective for controlling aseptic abscess for long-term periods.

   

  Jpn. J. Cardiovasc. Surg. 52: 149-153 （2023）

  Keywords：aseptic abscess; mediastinitis; perigraft seroma; omental implantation

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• Surgical Management of Aortic Stenosis and Regurgitation and Ascending Aortic Aneurysm in a Patient with Thalassemia　A. Sakai and M.Ikeda　154
  Surgical Management of Aortic Stenosis and Regurgitation and Ascending Aortic Aneurysm in a Patient with Thalassemia
  

  Ai Sakai＊

  Masahiro Ikeda＊

  
  

  (Department of Cardiovascular Surgery, Toyama Red Cross Hospital＊, Toyama, Japan)
  

  Thalassemia is an inherited hemoglobin disorder characterized by hemolytic anemia. Reportedly, cardiopulmonary bypass （CPB） causes hemolysis; therefore, extreme caution is warranted during CPB. However, few studies have reported open heart surgery in patients with thalassemia. We report successful surgery for aortic stenosis and regurgitation（ASR）and an ascending aortic aneurysm （AsAA） in a patient with thalassemia. A 69-year-old woman was referred to our hospital for surgical management of ASR and AsAA. Comprehensive evaluation of microcytic anemia led to diagnosis of beta-thalassemia minor. We performed aortic valve and ascending aorta replacement; we used a biologic valve and performed open distal anastomosis under hypothermic circulatory arrest （25℃） combined with retrograde cerebral perfusion. Non-pulsatile flow circulation was maintained using a centrifugal pump during CPB. The suction and ventilatory pressures were decreased, and we performed dilutional ultrafiltration. A spare artificial lung was connected to the CPB to avoid complications in the event of artificial lung blockage. We did not observe any hemolysis-induced adverse event during the clinical course, and the patient was discharged 20 days postoperatively. Careful preoperative evaluation is essential to confirm thalassemia before cardiovascular surgery to establish an optimal surgical strategy and avoid the risk of CPB-induced hemolysis in patients with the hematological disorder.

   

  Jpn. J. Cardiovasc. Surg. 52: 154-158 （2023）

  Keywords：thalassemia; aortic valve replacement; ascending aortic replacement; cardiovascular surgery

  
  
• Right Atrial Approach for Ventricular Septal Perforation　D. Hirayama et al.　159
  Right Atrial Approach for Ventricular Septal Perforation
  

  Daiki Hirayama＊	Susumu Manabe＊	Norihisa Yuge＊
  Tomohiro Saito＊

  
  

  (Department of Cardiac Surgery, International University of Health and Welfare Narita Hospital＊, Narita, Japan)
  

  An 84-year-old man visited a local doctor, complaining of general fatigue for the last 2 months and dyspnea at rest since the last few days. His echocardiogram revealed a defect hole measuring 1.5 cm at the base of the ventricular septum and left-to-right shunt blood flow. The diagnosis of ventricular septal perforation due to subacute myocardial infarction was confirmed, and an emergency surgery was performed. A right atrial oblique incision revealed a perforation just below the tricuspid valve septal apex.The perforation site was closed using the sandwich patch technique with two bovine pericardial membrane patches. The patient was transferred to the hospital for rehabilitation on day 18 postoperatively.

   

  Jpn. J. Cardiovasc. Surg. 52: 159-162 （2023）

  Keywords：ventricular septal perforation; right atrial approach

  
  
• Valve-Sparing Excision of Multiple Papillary Fibroelastomas in the Aortic Valve and Left Ventricular Outflow Tract　K. Ueno et al.　163
  Valve-Sparing Excision of Multiple Papillary Fibroelastomas in the Aortic Valve and Left Ventricular Outflow Tract
  

  Kazuhiro Ueno＊	Shingo Hirao＊	Jota Nakano＊
  Go Yamashita＊	Atsushi Sugaya＊	Tatsuhiko Komiya＊

  
  

  (Department of Cardiovascular Surgery, Kurashiki Central Hospital＊, Kurashiki, Japan）
  

  Primary cardiac fibroelastoma is a relatively rare tumor and is often detected incidentally by echocardiography. We report a case of multiple fibroelastomas that were found incidentally by follow-up echocardiography for hypertrophic cardiomyopathy and were treated with valve-sparing excision. The patient was a 71-year-old man, in whom a 10-mm tumor on the ventricular septum below the right coronary cusp and 3-mm tumors on the left ventricular side of the left and right coronary cusps were detected. Although he had no symptoms, because the tumors were mobile, surgery was performed for preventing embolization and making a definitive diagnosis. The tumor on the ventricular septum was excised together with the surrounding endocardium and part of the myocardium. The tumors on the valve leaflets were excised with the aortic valve cusps spared. Histopathologically, all the tumors were fibroelastomas. The postoperative course was uneventful.

   

  Jpn. J. Cardiovasc. Surg. 52: 163-167（2023）

  Keywords：cardiac tumor; papillary fibroelastoma; multiple; tumor excision; valve-sparing

  
  

［Aortic Disease］

• A Case of Total Arch Replacement Using Coil Embolization for a Thoracic Aortic Aneurysm Derived from a Kommerell Diverticulum　R. Sakamoto et al.　168
  A Case of Total Arch Replacement Using Coil Embolization for a Thoracic Aortic Aneurysm Derived from a Kommerell Diverticulum
  

  Ryunosuke Sakamoto＊	Masaya Takahashi＊	Yoshitaka Ikeda＊
  Hiroshi Ito＊

  
  

  (Department of Cardiovascular Surgery, Saiseikai Shimonoseki General Hospital＊, Shimonoseki, Japan)
  

  An 81-year-old man who visited a local physician for evaluation of hoarseness was admitted to our hospital for management of a thoracic aortic aneurysm. Careful examination revealed a thoracic aortic aneurysm, aortic regurgitation, and left ventricular aneurysm. We performed total arch replacement using a frozen elephant trunk prosthesis （combined right axillary artery bypass and coil embolization）, aortic valve replacement, papillary muscle approximation, and a septal anterior ventricular exclusion operation. The patient’s postoperative course was uneventful, and he was discharged on the 25th postoperative day. A Kommerell diverticulum is located at the origin of an aberrant subclavian artery, and subclavian artery reconstruction via thoracotomy is challenging in such cases. Although increasing numbers of thoracic endovascular aortic repairs have been performed in recent years, the procedure is associated with complications such as endoleak and aortic esophageal fistula, and the surgical risk-benefit ratio should be carefully determined. We report a case of safe non-anatomical subclavian artery reconstruction and coil embolization.

   

  Jpn. J. Cardiovasc. Surg. 52: 168-171 （2023）

  Keywords：Kommerell diverticulum; coil embolization

  
  
• In Situ Replacement for a Mycotic Aneurysm on the Porcelain Aorta Using the Superficial Femoral Artery as a Vascular Graft　N. Kawai et al.　172
  In Situ Replacement for a Mycotic Aneurysm on the Porcelain Aorta Using the Superficial Femoral Artery as a Vascular Graft
  

  Norikazu Kawai＊	Narihiro Ishida＊	Yasuhito Nakamura＊
  Yoshitaka Kumada＊

  
  

  (Department of Cardiovascular Surgery, Matsunami General Hospital＊, Gifu, Japan）
  

  Infected thoracic aortic aneurysms are rare. Standard treatment methods have not yet been established for medical treatment, timing of surgery, or surgical techniques. In this study, we report a case in which an ascending aortic reconstruction using an autologous superficial femoral artery was successfully performed for an infected pseudoaneurysm of the thoracic aorta without the use of artificial materials. The patient was a 78-year-old man with bacteremia caused by Staphylococcus aureus and an infected pseudoaneurysm of the thoracic aorta. The patient underwent replacement of the ascending aorta and coronary artery bypass grafting. The patient was discharged from the hospital with no recurrence of infection and no abnormality of the reconstructed aorta.

   

  Jpn. J. Cardiovasc. Surg. 52: 172-175 （2023）

  Keywords：infectious aneurysm; mycotic aneurysm; autologous graft; replacement of ascending aorta

  
  
• A Case of Aortoesophageal Fistula in Advanced Esophageal Cancer Treated with SB-Tube and TEVAR　S. Negoto et al.　176
  A Case of Aortoesophageal Fistula in Advanced Esophageal Cancer Treated with SB-Tube and TEVAR
  

  Shinya Negoto＊	Hiroyuki Otsuka＊	Tomoyuki Anegawa＊
  Yasuyuki Zaima＊	Takanori Kono＊	Yusuke Shintani＊＊
  Eiji Nakamura＊	Takahiro Shojima＊	Tohru Takaseya＊
  Eiki Tayama＊

  
  

  (Department of Surgery, Kurume University School of Medicine＊, Kurume, Japan, and Department of Cardiovascular Surgery, St.Mary’s Hospital＊＊, Kurume, Japan)
  

  The patient is a 71-year-old man. After receiving chemoradiotherapy （CRTx） for an unresectable esophageal cancer, he developed sudden hematemesis during a follow-up examination. Subsequent imaging via contrast-enhanced computed tomography （CT） showed leakage of the contrast medium from the descending aorta into the esophagus. Consequently, an aortoesophageal fistula （AEF） was diagnosed and an emergency thoracic endovascular aortic stent graft repair （TEVAR） was scheduled. However, during the preparation for surgery, the patient vomited a large amount of blood and went into cardiopulmonary arrest. Following the administration of cardiopulmonary resuscitation, a Sengstaken-Blakemore tube （SB-tube） was inserted intranasally to control bleeding and TEVAR was performed to save his life. Although a gastrostomy was necessary after the surgery, the patient was transferred from the hospital on the 32nd day without any complications. Nonetheless, his general condition deteriorated as the cancer progressed and he died on the 103rd postoperative day. It is generally reported that the risk for esophageal perforation is 10-20% in CRTx for unresectable esophageal cancer. Although issues regarding the long-term prognosis of patients treated with TEVAR have been highlighted in recent years, there have also been reports of life-saving cases following its use; in this case, the patient was discharged home after SB-tube insertion and TEVAR with prompt treatment, resulting in his life being prolonged for an estimated 3 months.

   

  Jpn. J. Cardiovasc. Surg. 52: 176-180 （2023)

  Keywords：aortoesophageal fistula; thoracic endovascular aortic repair; SB-tube

  
  
• Debranching Thoracic Endovascular Aortic Repair for Kommerell’s Diverticulum with Right-Sided Aortic Arch　T. Nakagawa et al.　181
  Debranching Thoracic Endovascular Aortic Repair for Kommerell’s Diverticulum with Right-Sided Aortic Arch
  

  Takaya Nakagawa＊	Hajime Matsue＊	Yasuo Suehiro＊
  Hisashi Uemura＊	Ayaka Satoh＊	Hisashi Satoh＊

  
  

  (Department of Cardiovascular Surgery, Higashi Takarazuka Satoh Hospital＊, Takarazuka, Japan)
  

  We report a case of debranching thoracic endovascular aortic repair for Kommerell’s diverticulum with right-sided aortic arch in 78-year-old women. The computed tomography （CT） demonstrated Kommerell’s diverticulum with a right-sided aortic arch and the trachea and esophagus were compressed by the diverticulum. The diverticulum had a maximum diameter of 32 mm, and surgical intervention was chosen because of the aneurysmal change and the possibility of rupture. We performed endovascular aortic repair for Kommerell’s diverticulum with a right-sided aortic arch because of low lung function and low frailty. The patient was discharged on the 21st postoperative day. There was no evidence of aortic event during 2 years follow up.

   

  Jpn. J. Cardiovasc. Surg. 52: 181-184 （2023）

  Keywords：right-sided aortic arch; Kommerell’s diverticulum; aberrant left subclavian artery; TEVAR

  
  
• Extracardiac Rupture of Giant Left Valsalva Sinus Aneurysm　J. Tanaka et al.　185
  Extracardiac Rupture of Giant Left Valsalva Sinus Aneurysm
  

  Jin Tanaka＊

  Michihiro Nasu＊

  Mikito Inouchi＊

  
  

  (Department of Thoracic and Cardiovascular Surgery, Toyooka Hospital＊, Toyooka, Japan)
  

  We report a case of extracardiac rupture of the left Valsalva sinus aneurysm, which is an extremely rare and fatal lesion. The three drugs, clindamycin, ethambutol and rifampicin, had been administered for eleven years because of lung mycobacterium infection. An emergency surgery was performed because of cardiac tamponade. The left Valsalva sinus was entirely enlarged without an aneurysmal neck. The other Valsalva sinuses seemed to be almost normal. The aneurysmal wall adhered the pulmonary artery and the left atrium. The left descending and circumflex arteries independently originated from the aneurysmal wall. The left main trunk seemed to become a part of the aneurysmal wall. Additionally the intraoperative transesophageal echocardiography showed severe aortic regurgitation. The Bio-Bentall procedure was performed. The right coronary artery was reconstructed with the Carrel patch method and the saphenous vein grafts were anastomosed to the proximal portions of the left anterior descending and circumflex arteries, individually. On the thirty-third postoperative day, the patient was discharged uneventfully expect for the delayed sternal closure on the second postoperative day. Five and half years after surgy, the patient is living a normal life and rifampicin has been administered without any anticoagulation drugs.

   

  Jpn. J. Cardiovasc. Surg. 52: 185-188 （2023）

  Keywords：left Valsalva sinus aneurysm; extracardiac rupture; cardiac tamponade; Bentall operation; anticoagulation therapy

  
  

［Peripheral Artery Disease］

• A Case of Successful Surgical Management of Tracheo-Innominate Artery Fistula after Endovascular Repair　S. Suzuki et al.　189
  A Case of Successful Surgical Management of Tracheo-Innominate Artery Fistula after Endovascular Repair
  

  Shuhei Suzuki＊	Hiroyuki Hirahara＊	Masaaki Sugawara＊

  
  

  (Department of Cardiovascular Surgery, Japanese Red Cross Nagaoka Hospital＊, Nagaoka, Japan)
  

  A 15-year-old girl who had undergone a tracheostomy 4 years earlier because of holoprosencephaly and severe mental and physical disabilities had tracheo-innominate artery fistula with sudden-onset bleeding after endotracheal suctioning. Due to respiratory and circulatory instability, VIABAHN® was implanted in the brachiocephalic artery, and the patient was discharged on postoperative day 33. Three months later, rebleeding from the tracheostomy site was observed, and the patient was transported to our hospital. Although the bleeding stopped spontaneously on arrival, the patient experienced multiple bleeding episodes after admission. Therefore, transection of brachiocephalic artery was performed, after which the patient was discharged on postoperative day 20. Tracheo-innominate artery fistula is a rare complication that occurs after tracheostomy, but it is associated with a poor prognosis, and has a mortality rate of 100% if left untreated. Our case suggests that endovascular treatment using VIABAHN® for tracheo-innominate artery fistula is useful for temporary hemostasis.

   

  Jpn. J. Cardiovasc. Surg. 52: 189-192 （2023）

  Keywords：tracheo-innominate artery fistula; after endovascular repair; transection of brachiocephalic artery

  
  
• A Case of Innominate Artery Transection after the Covered Stent Placement for the Recurrent Tracheo-Innominate Artery Fistula　J. Osaki et al.　193
  A Case of Innominate Artery Transection after the Covered Stent Placement for the Recurrent Tracheo-Innominate Artery Fistula
  

  Jun Osaki＊	Kazuhisa Rikitake＊	Takahiro Miho＊
  Hiroaki Yamamoto＊

  
  

  (Department of Cardiovascular Surgery, Ureshino Medical Center＊, Ureshino, Japan）
  

  Tracheo-Innominate artery fistula is a rare but devastating complication after tracheostomy. We report a 17-year old man who underwent the transection of the innominate artery and tracheal patch closure （under partial sternotomy） after the endovascular covered stent placement for the recurrent tracheo-innominate artery fistula. Fortunately, his postoperative course was uneventful without any new neurological, bleeding, or infective complication 34 months after the surgery.

   

  Jpn. J. Cardiovasc. Surg. 52: 193-196 （2023）

  Keywords：tracheo-innominate artery fistula; after covered stent placement; innominate artery transection; partial sternotomy

  
  

Special Issue: Various Issues Hindering the Introduction of Nurses Trained for Specific Interventions （3）

• Current Issues in Promoting the Introduction of Nurses Trained for Specific Interventions　Y. Tayama et al.　197　

• Progress in Surgery for Heart Failure　N. Tadokoro et al.　203
• A Comprehensive Analysis of Aortic Surgery in Japan in 2022: An Overview　K. Shimamura et al.　206

• U-40 Column 　Current Status and Issues of Cardiovascular Surgery Institution in Community Medicine　S. Sugimoto et al.　U1
  Current Status and Issues of Cardiovascular Surgery Institution in Community Medicine
  

  Satoshi Sugimoto＊	Ryota Murase	Hiroki Uchiyama
  Takamitsu Tatsukawa	Naohiro Wakabayashi	Ayaka Arihara
  Masato Fusegawa	Yoshinobu Watabe	Hiroyuki Miyamoto
  Kei Mukawa

  
  

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

  Lately, there has been a trend towards integration among cardiovascular surgery institutions. However, local institutions continue to play a crucial role in community-based medicine, given the emergent nature of cardiovascular diseases and the challenges involved in transporting patients with such conditions over long distances. We present the results of a questionnaire survey we conducted to examine the current status and issues faced by cardiovascular surgery institutions in community-based medicine.

   

  Jpn. J. Cardiovasc. Surg. 52(3): U1-U8 (2023).

  Keywords：U-40; cardiovascular surgery institution in community medicine; questionnaire survey

  
  

• T. Abe