Editor in Chief:Takashi Nitta Vol.51, No.2, March 2022 CONTENTS

Preface

• Treatment of Dilated Cardiomyopathy Patient ―Medical Device Development by a Cardiac Surgeon―　T. Akita

Original

• Impact of Frailty on the Course and Walking Ability after Cardiac Surgery　T. Honda et al.…67
  Impact of Frailty on the Course and Walking Ability after Cardiac Surgery
  

  Tasuku Honda*	Nobuhiko Mukohara*	Hirohisa Murakami*
  Hiroshi Tanaka*	Yoshikatsu Nomura*	Syunsuke Miyahara*
  Gaku Uchino*	Jun Fuzisue*	Motoharu Kawashima*
  Shuto Tonoki*

  
  

  (Department of Cardiovascular Surgery, Hyogo Brain and Heart Center*, Himeji, Japan)
  

  Objective: Frailty has been noticed as an important preoperative risk factor for cardiac surgery. The purpose of this study was to evaluate the effect of frailty on the rehabilitation process and walking ability after cardiac surgery. Methods: A total of 213 patients aged 65 years or older who underwent elective cardiac surgery at our hospital between August 2018 and October 2020 and who underwent a preoperative frailty assessment were included. The patients were divided into two groups: group F with frailty and group N without frailty, and the perioperative factors, postoperative course, and walking ability in both groups were examined. Results: Of all patients, 70 (33%) were diagnosed as frail. In the preoperative factors, gait speed and grip strength were significantly lower in group F, and there were more cases of sarcopenia and malnutrition. There was no significant difference in surgical factors between the two groups, except for a bias in the surgical category. In the postoperative course, there were no significant differences in intubation time, ICU stay, postoperative complications, or hospital stay between the two groups, but more patients in group F were transferred to another hospital. In the F group, the start of walking and the day of achieving 100 m walking were significantly delayed, and the number of patients who achieved 300 m walking was 52 (74%), which was significantly lower than 197 (89%) in the N group. The cutoff value of gait speed was 0.88 m/s. Conclusions: Frailty was associated with delayed rehabilitation and reduced walking ability after cardiac surgery, and increased hospital transfers. In addition, the preoperative gait speed was adopted as one of the factors related to the possibility of a 300 m walk after surgery. We believe that preoperative rehabilitation is a promising strategy to improve the condition of frail patients who require cardiac surgery.

   

  Jpn. J.Cardiovasc Surg. 51 : 67-72 （2022）

  Keywords：cardiac surgery ; frailty ; risk assessment ; gait speed ; preoperative rehabilitation

  
  
• Efficacy of Aortic Valve Replacement with Ascending Aorta Grafting under Hypothermic Circulatory Arrest for the Patients with Shaggy/Calcified Aorta　M. Kondo et al.…73
  Efficacy of Aortic Valve Replacement with Ascending Aorta Grafting under Hypothermic Circulatory Arrest for the Patients with Shaggy/Calcified Aorta
  

  Mayo Kondo＊	Masanori Nakamura＊	Hirotaro Sugiyama＊
  Takeshi Uzuka＊	Junichi Sakata＊

  
  

  (Department of Cardiovascular Surgery, Sapporo City General Hospital＊, Sapporo, Japan)
  

  Purpose : The aim of this study is to evaluate the outcome of aortic valve replacement （AVR）with ascending aorta grafting under hypothermic circulatory arrest for patients with shaggy/calcified ascending aorta based on preoperative and intraoperative assessment of ascending aorta. Methods : From April 2010 to July 2019, 133 patients with aortic stenosis underwent AVR. Based on preoperative computed tomography and intraoperative epi aortic ultrasound, 121 patients were able to have their aorta clamped （C-AVR）, while clamping was not possible for 12 patients due to shaggy/calcified in the ascending aorta （Asc-AVR）. In Asc-AVR, ascending aorta was replaced to the vascular graft under hypothermic circulatory arrest with retrograde cerebral perfusion followed by AVR. Results : Although operative time and cardiopulmonary bypass time were prolonged and blood transfusion volume was significantly high in Asc-AVR, there were no significant differences in postoperative complications. Although postoperative MRI revealed two silent strokes, no symptomatic neurologic complications occurred in Asc-AVR. Five-year survival rates between groups were comparable （64.2% in Asc-AVR vs. 79.9% in C-AVR, p＝0.420）. Replacement of ascending aorta was not a risk factor of late death. Conclusion : AVR with ascending aorta grafting under hypothermic circulatory arrest based on preoperative and intraoperative assessment of ascending aorta is an acceptable method for patients with shaggy/calcified aorta.

   

  Jpn. J. Cardiovasc. Surg. 51 : 73-79（2022）

  Keywords：shaggy aorta ; calcified aorta ; aortic valve replacement ; hypothermic circulatory arrest ; stroke

  
  
• Prevention of SSI in Cardiac Surgery by Using Intraoperative Measures for High-Risk Patients as Standard Precautions against Mediastinitis　S. Taguchi et al.…80
  Prevention of SSI in Cardiac Surgery by Using Intraoperative Measures for High-Risk Patients as Standard Precautions against Mediastinitis
  

  Shingo Taguchi＊,＊＊	Makoto Hanai＊	Masataka Yamazaki＊＊＊
  Makoto Sumi＊	Humitake Momokawa＊

  
  

  （Department of Cardiovascular Surgery, Saitama Cardiovascular and Respiratory Center＊, Kumagaya, Japan, Department of Cardiovascular Surgery, Fuji City Central Hospital＊＊, Shizuoka, Japan, and Department of Cardiovascular Surgery, Keio University School of Medicine＊＊＊, Tokyo, Japan)
  

  Background : Risk factors for surgical site infection （SSI） are thought to include poorly controlled diabetes mellitus, dialysis, and a long operating time, but patients without risk factors can also develop infection. Therefore, it is possible that SSI could be prevented by routinely using the precautions against SSI developed for high-risk patients. We investigated the route and pathogenetic mechanism of mediastinitis, which is the most frequent SSI after cardiac surgery. We hypothesized that mediastinitis occurred when the deep sternal marrow was contaminated by skin bacteria. Based on this hypothesis, we investigated the efficacy of various intraoperative prophylactic methods for preventing mediastinitis. Methods : We evaluated 658 patients undergoing cardiac surgery at our institution between April 2011 and July 2016. They were classified into two groups. Group C comprised 406 patients who received standard insertion of a sternal retractor after sternotomy. Group S was 252 patients in whom a retractor was inserted after covering the sternal marrow with oxidized cellulose hemostats and belt-like thin towels, with surplus parts of the towels being used to fill subcutaneous dead space at the superior and inferior margins of the midline wound. We investigated the following 10 risk factors for mediastinitis: diabetes （HbA1c≥7.5）, renal failure （Cr≥2）, smoking, obesity （BMI≥30）, reoperation, urgent/emergency operation, intubation in the preoperative period, long operating time （≥8 h）, reopening the chest for hemostasis, and coronary artery bypass grafting （CABG）. Factors associated with mediastinitis were determined using univariate modeling analysis followed by multi-variate logistic regression analysis. Results : Mediastinitis occurred in 13 patients （2.0%）. The significant risk factor for mediastinitis were urgent/emergency operation and CABG, but 1 patient had no risk factors. A univariate analysis showed statistical significance in CABG, presence of maneuver covering the sternal marrow, JapanSCORE-II in mortality and deep sternum infection （DSI）. Reopening the chest for hemostasis, CABG, aortic aneurysm, plural risk factors, and JapanSCORE-II in DSI were identified as a risk factor by multiple logistic regression, not all factors showed a significant difference. Mediastinitis only occurred in group C, and it was significantly less frequent in group S with additional precautions against infection including propensity score matching analysis （p<0.05）. Conclusion : When the bone marrow of the transected sternum was covered tightly to protect it from contamination by skin bacteria during cardiac surgery, the frequency of postoperative mediastinitis was significantly reduced.

   

  Jpn. J. Cardiovasc. Surg. 51 : 80-88（2022）

  Keywords：surgical site infection ; cardiac surgery ; mediastinitis ; absorbable hemostat （oxidized regenerated cellulose）

  
  
• Practice of Cardiovascular Surgery on Patients with COVID-19 : a Questionnaire Survey　S. Ike et al.…89
  Practice of Cardiovascular Surgery on Patients with COVID-19 : a Questionnaire Survey
  

  Soichi Ike1	Kimikazu Hamano1,2	Minoru Ono3,4
  Hitoshi Yokoyama5,6

  
  

  （Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine1, Ube, Japan, Chairman of Clinical Research Promotion Committee, Japanese Society for Cardiovascular Surgery2, Tokyo, Japan, Department of Cardiac and Thoracic Surgery, Tokyo University Graduate School of Medicine3, Tokyo, Japan, Chairman of COVID-19 Countermeasures Working Group, Japanese Society for Cardiovascular Surgery4, Tokyo, Japan, Department of Cardiovascular Surgery, Fukushima Medical University5, Fukushima, Japan, and Chairman of Japanese Society for Cardiovascular Surgery6)
  

  The purpose of this study is to assess the impact of coronavirus disease 2019 (COVID-19) on the performance of cardiovascular surgery in Japan. The information gathered may be useful to prepare for a surgery in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) positive patients and prevent COVID-19 transmission from surgical patients to healthcare workers. [Methods] A web-based questionnaire was distributed to all accredited cardiovascular surgery centers in Japan. A total of 550 questionnaires were sent, and 310 (56.4%) were returned. [Results] Preoperative PCR or antigen testing was performed in all patients at 68.8% of centers. The proportion of surgeries postponed or cancelled was the highest for elective valvular and aortic surgeries and for emergency aortic surgeries. In most facilities elective surgeries were restricted to less than 50% of usual case volumes, while approximately 40% did not experience any negative impact on the case volume. Among the surgical patients, 32 were suspected to be SARS-CoV-2 positive, and 10 were confirmed. As preventive measures against spreading infection, more than 90% of the patients wore N95 masks, 33.3% full PPE, and 66.7% N95 mask+face shield. No case of patient-to-healthcare-worker transmission was reported. There were no postoperative deaths among the confirmed SARS-CoV-2 patients. [Conclusion] Restriction of surgical practice was placed on many institutions in the COVID-19 pandemic, but the degree of restrictions varied. Preoperative screening of all surgical patients and intraoperative use of PPE in those with suspected or confirmed SARS-CoV-2 infection adequately prevented transmission to healthcare workers. Since COVID-19 has a nationwide impact, it is important to continuously monitor surgical outcomes and infection rate by conducting perioperative surveys of COVID-19 patients.

   

  Jpn. J.Cardiovasc Surg. 51 : 89-95（2022）

  Keywords：COVID-19；cardiovascular surgery；PPE

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• TRALI as a Cause of Massive Tracheal Secretions during Cardiac Surgery　Y. Hirata et al.…96
  TRALI as a Cause of Massive Tracheal Secretions during Cardiac Surgery
  

  Yuichiro Hirata＊	Kenichi Imasaka＊	Ryuya Nomura＊
  Tomofumi Fukuda＊	Yuma Motomatsu＊	Shigeki Morita＊

  
  

  (Department of Cardiovascular Surgery, Clinical Research Institute, Kyushu Medical Center, National Hospital Organization＊, Fukuoka, Japan)
  

  A 46 year-old man underwent double valve replacement for valve insufficiency due to infective endocarditis. Upon withdrawal from extracorporeal circulation and administration of 8 units of fresh frozen plasma, a large amount of yellow serous secretion was aspirated from the trachea, and rapid and exacerbated oxygenation was observed. We determined that the patient was not congested, based on his hemodynamics; instead, he appeared to have acquired transfusion-related acute lung injury （TRALI）. The patient was given a steroid infusion. By the time the patient returned to the intensive care unit, his oxygenation capacity improved and the secretions from his trachea decreased. The patient was weaned off the ventilator on the second post-operative day. Inhaled nitric oxide was very effective in improving oxygenation. We conjectured that TRALI should be recognized as a differential diagnosis for poor oxygenation after withdrawal from extracorporeal circulation.

   

  Jpn. J. Cardiovasc Surg. 51 : 96-99 （2022）

  Keywords：TRALI ; congestive heart failure ; inhaled nitric oxide

  
  
• The Six Cases of Redo Cardiac Surgery via Partial Lower Hemi-sternotomy　B. Inoue et al.…100
  The Six Cases of Redo Cardiac Surgery via Partial Lower Hemi-sternotomy
  

  Bon Inoue*	Masanori Katoh*	Yuika Kameda*
  Masaaki Toyama**

  
  

  (Department of Cardiovascular Surgery, SUBARU Health Insurance Ota Memorial Hospital＊, Ota, Japan, and Department of Cardiovascular Surgery, Kameda Medical Center**, Kamogawa, Japan）
  

  In poststernotomy redo cardiac surgery, injury to cardiac structures during sternal division can lead to untoward results in the operation. These days, Minimally Invasive Cardiac Surgery （MICS） such as the right anterolateral thoracotomy approach is becoming popular. By using MICS technique in redo cardiac surgery, it may be possible to reduce the risk of injury to the vital structures because of avoiding full sternotomy with the reduction of the dissection area. Six redo cardiac surgery cases in which innominate vein or bypass graft was in close contact with the sternum were is considered difficult to perform via the right thoracotomy approach. We report the cases in which operations were safely conducted through the lower hemi-sternotomy.

   

  Jpn. J. Cardiovasc. Surg. 51 : 100-104 （2022）

  Keywords：redo cardiac surgery ; Minimally Invasive Cardiac Surgery （MICS） ; partial lower hemi-sternotomy

  
  
• Chronic Expanding Hematoma with Constrictive Pericarditis　M. Komatsu et al.…105
  Chronic Expanding Hematoma with Constrictive Pericarditis
  

  Masaki Komatsu＊	Kazuki Naito＊	Shuji Chino＊
  Haruki Tanaka＊	Hajime Ichimura＊	Takateru Yamamoto＊
  Kou Nakahara＊	Megumi Fuke＊	Yuko Wada＊
  Tatsuichiro Seto＊

  
  

  (Division of Cardiovascular Surgery, Department of Surgery, Shinshu University School of Medicine＊, Matsumoto, Japan)
  

  We report the successful treatment of a rare case of chronic expanding hematoma and visceral pericardium thickening constrictive pericarditis with no history of trauma or surgery. A 70-year-old woman, who had no history of trauma or surgery was admitted for exertional dyspnea. An echocardiographic study demonstrated a mass located anterior to the right ventricle that severely compressed the right ventricle toward the ventricular septum. Enhanced chest computed tomography demonstrated pericardial calcification and a 125-mm heterogeneous mass in the middle mediastinum. A mosaic pattern was seen on T1, T2-weighted magnetic resonance imaging. Surgical resection of the mass and removal of the visceral pericardium were planned to treat heart failure and to confirm the diagnosis of the mass. The mass was old degenerated coagula. Histopathological examination confirmed the diagnosis of chronic expanding hematoma. The postoperative course was uneventful. There has been no sign of recurrence 19 months after the operation.

   

  Jpn. J. Cardiovasc. Surg. 51 : 105-109 （2022）

  Keywords：chronic expanding hematoma ; constrictive pericarditis ; heart failure

  
  
• Reoperation after Coronary Artery Bypass Grafting; On-Pump Beating Heart Minimally Invasive Mitral Valve Replacement for Single Leaflet Device Attachment after MitraClip Placement　T. Koga et al.…110
  Reoperation after Coronary Artery Bypass Grafting; On-Pump Beating Heart Minimally Invasive Mitral Valve Replacement for Single Leaflet Device Attachment after MitraClip Placement
  

  Tomonori Koga＊	Noriyuki Hatanaka＊	Yuuki Setogawa＊
  Takashi Ueda＊

  
  

  （Department of Cardiovascular Surgery, Sapporo Higashi Tokushukai Hospital＊, Sapporo, Japan）
  

  A 50-year-old man with a history of coronary artery bypass grafting （CABG） 5 years prior to presentation underwent MitraClip placement for severe mitral regurgitation. Subsequently, he underwent on-pump beating heart endoscopic minimally invasive cardiac surgery （MICS） for mitral valve replacement for acute heart failure secondary to single leaflet device attachment. Endoscopic MICS via a right small thoracotomy approach is useful for reoperation after CABG in patients with a high risk of graft injury. Beating-heart surgery may be an effective option to avoid the risks associated with prolonged cardiac arrest time in patients with low left ventricular function.

   

  Jpn. J. Cardiovasc Surg. 51 : 110-113 （2022）

  Keywords：redo surgery ; MICS ; beating heart ; SLDA ; MitraClip

  
  
• A Case Report of Reoperation for Björk-Shiley Mechanical Valve 38 Years after Mitral Replacement　T. Miura et al.…114
  A Case Report of Reoperation for Björk-Shiley Mechanical Valve 38 Years after Mitral Replacement
  

  Takuya Miura＊	Hitoshi Suhara＊	Yuichi Atsuta＊
  Yuji Miyamoto＊

  
  

  (Department of Cardiovascular Surgery, Otemae Hospital＊, Osaka, Japan)
  

  The patient was a 68-year-old woman who had undergone initial mitral repair at 24 years of age, and had undergone mitral replacement using the Björk-Shiley convexo-concave valve at 30 years of age. She developed exertional dyspnea 38 years after mitral replacement with hemolytic anemia. Precise examination revealed mitral stenosis and perivalvular leak. At the reoperation, severe calcified pannus was found at the ventricular side just beneath the mitral artificial valve, and made stenosis with the inadequate leaflet opening. The mitral valve remnant ring was severely calcified and the sawing ring was detached partially. Repeated valve replacement was successfully done by the reinforcement of the mitral valve ring with xenopericardium.

   

  Jpn. J. Cardiovasc. Surg. 51 : 114-117 （2022）

  Keywords：Björk-Shiley valve ; prosthetic valve dysfunction ; perivalvular leak ; pannus formation

  
  
• ［Peripheral Artery Disease］
• Surgical Explantation of Difficult Removal PICC Involving Intravascular Compound in a Child Case　I. Hosaka et al.…118
  Surgical Explantation of Difficult Removal PICC Involving Intravascular Compound in a Child Case
  

  Itaru Hosaka＊	Tomohiro Nakajima＊	Riko Umeta＊
  Akihito Ohkawa＊	Naomi Yasuda＊	Tsuyoshi Shibata＊
  Yutaka Iba＊	Nobuyoshi Kawaharada＊

  
  

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

  The peripherally inserted central catheter （PICC） is widely used as a central venous catheter for both pediatric and adult patients. Fewer procedure-related complications have been reported than for conventional methods using the internal jugular, femoral, or subclavian veins for access. On the other hand, thrombosis and phlebitis are more common than in conventional methods, and sometimes the catheter cannot be removed by manual traction. In this study, a 13-year-old girl had received long-term sedation from a PICC due to neurodegenerative disease. The patient was referred to our department because of difficulty in manual drawing for removal of the PICC. A CT scan showed that the PICC was bent at the right axillary vein and there was a high-density area around it. Surgical treatment was chosen after a joint conference between the department of pediatrics and us to discuss the reliability and invasiveness of the several treatments. Under general anesthesia, an incision was made under the right subclavian bone, and her axillary vein was exposed. The lumen of the vein was filled with a white plaster-like compound, and the catheter itself was buried inside it. The compound was removed, and the bent PICC was straightened and removed from the puncture site. There is no other case for difficult removal of PICC in this form without calcification. We believe that surgical removal was effective in this case because of her vascular structure.

   

  Jpn. J.Cardiovasc Surg. 51 : 118-122 （2022）

  Keywords：difficult PICC removal ; intravascular foreign body ; surgical treatment

  
  

Report of Experience Studying Abroad

• Studying in US from Over 40 Years Old　T. Nakajima…123

NP Report

• Activity and Future Vision of Nurse Practitioner in Cardiovascular Surgery　M. Ichikawa and K. Yamanaka…126

U-40

• U-40 Column Advanced Lecture Course　K. Yoshino et al.…U1
  U-40 Advanced Lecture Course
  

  Kunihiko Yoshino＊	Kenichiro Takahashi	Eigo Ikushima
  Ai Ishizawa	Keiichi Ishida	Yuki Imamura
  Yusuke Kinugasa	Kazuma Date	Sayako Nakagawa
  Toshihiko Nishi	Ryosuke Numaguchi	Shotaro Higa
  Yutaro Matsuno	Chiharu Tanaka

  
  

  (U-40 Advanced Lecture Course Project)
  

  The importance of off the job training in surgical education are widely recognized. The Japanese Board of Cardiovascular Surgery has required a board candidate to do at least 30 hours of off the job training from 2017. U-40 Basic Lecture Course are held annually for young cardiovascular surgeon to learn about basic surgical skills. U-40 Advanced Lecture Course was started to provide opportunity to have more advanced hands-on lecture for young cardiovascular surgeon. However, after the COVID-19 pandemic, the opportunity to hold hands-on seminars are highly limited. In such circumstances, we held a hybrid hands-on seminar. We report details about the hybrid hands-on seminar.

   

  Jpn. J. Cardiovasc. Surg. 51(2) : U1-U0 (2022)

  
  

• H. Izutani