JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Goro Matsumiya Vol. 53, No. 1, January 2024 CONTENTS

Preface

• Work System Reform for Cardiovascular Surgeons in Japan　K. Minatoya

Case Reports

• ［Congenital Heart Disease］
• A Successful Aortic Valve-Sparing Root Replacement Operation (Reimplantation) to Repair Root Dilatation and Aortic Valve Regurgitation after a Ross Procedure　H. Katayama et al. 　1
  A Successful Aortic Valve-Sparing Root Replacement Operation （Reimplantation） to Repair Root Dilatation and Aortic Valve Regurgitation after a Ross Procedure
  

  Hideyuki Katayama＊	Hiroshi Tsuneyoshi＊	Syuji Setozaki＊
  Takuki Wada＊	Syuntaro Shimomura＊	Tsugumitsu Kando＊
  Takanobu Kimura＊	Akira Takeuchi＊	Akio Ikai＊＊
  Kenji Minatoya＊＊＊

  
  

  (Department of Cardiovascular Surgery, Shizuoka General Hospital＊, Shizuoka, Japan, Department of Cardiovascular Surgery, Shizuoka Children’s Hospital＊＊, Shizuoka, Japan, and Graduate School of Medicine, Kyoto University＊＊＊, Kyoto, Japan)
  

  We report a successful case of aortic valve-sparing root replacement for dilated aortic root after a Ross procedure. A 29-year-old male underwent a Ross procedure when he was 11 years old for congenital aortic bicuspid valve. The right ventricular outflow tract was reconstructed using an autologous pericardium as a single leaflet valve. Aortic root dilatation and moderate aortic valve regurgitation were noted. Further investigation with enhanced computed tomography and ultrasonic cardiography revealed good quality of leaflets and sufficient geometric height, and aortic valve-sparing root replacement was performed. In addition, we performed pulmonary valve replacement with a biological valve. The post-operative course was uneventful and the patient was discharged after 8 days with a completely controlled aortic valve regurgitation. No recurrence of aortic valve regurgitation was observed 1 year later. Because surgical outcomes of congenital heart diseases have improved and more patients have an increasing life expectancy, several other problems were revealed, such as the occurrence of aortic root dilatation after a Ross procedure. Aortic roots may dilate due to arterial pressure; however, valve-sparing procedures may be performed if the volume of the leaflets is sufficient.

   

  Jpn.J. Cardiovasc. Surg. 53: 1-5（2024）

  Keywords：dilated aortic root; Ross procedure; congenital bicuspid aortic valve; valve-sparing aortic root replacement

  
  
• A Case of Right Pulmonary Artery-Left Atrial Communication with Brain Abscess　N. Ohashi et al. 6
  A Case of Right Pulmonary Artery-Left Atrial Communication with Brain Abscess
  

  Noburo Ohashi＊	Shuji Chino＊	Masaki Komatsu＊
  Hajime Ichimura＊	Takateru Yamamoto＊	Ko Nakahara＊
  Megumi Fuke＊	Yuko Wada＊	Tatsuichiro Seto＊

  
  

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

  Right pulmonary artery-left atrial communication is a rare congenital heart disease that is usually diagnosed before adulthood, and its main symptoms are cyanosis and dyspnea on exertion. We report a 51-year-old man with a large aneurysm of the right pulmonary artery and left atrial communication, which was diagnosed after a brain abscess. We are concerned that simple ligation alone may cause embolism, so we report on the use of an autologous pericardial patch to close the opening to the left atrium.

   

  Jpn. J. Cardiovasc. Surg. 53: 6-9（2024）

  Keywords：right pulmonary artery-left atrial communication; brain abscess; extracorporeal surgery

  
  
• ［Acquired Cardiovascular Surgery］
• Hybrid Treatment of Multiple Coronary Aneurysms with a Pulmonary Artery Fistula　T. Ishigaki et al.　10
  Hybrid Treatment of Multiple Coronary Aneurysms with a Pulmonary Artery Fistula
  

  Takahiro Ishigaki＊

  Ryo Takayanagi＊

  Yasuhiro Kamikubo＊

  
  

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

  A computed tomography （CT） scan was performed for a man in his 60s to investigate a continuous murmur. An 18-mm coronary aneurysm with a fistula with the pulmonary artery was found on the anterior aspect of the main pulmonary artery （MPA），and a 10-mm coronary aneurysm was found on the lateral aspect. Abnormal inflow vessels originating from the right sinus of Valsalva and the left anterior descending artery （LAD） formed a complicated network around the MPA. Although the patient was asymptomatic, the aneurysms were saccular and considered to be an indication for surgery to prevent rupture. In addition, heart failure, embolism, and myocardial ischemia could be prevented by treatment. We planned a hybrid therapy of open surgery and percutaneous coil embolization. Surgical repair was performed through a median sternotomy. The abnormal vessel originating from the right sinus of Valsalva was ligated under cardiopulmonary bypass. After cardiac arrest, the 18-mm aneurysm located on the anterior surface of the MPA was incised and the orifice of the fistula and inflow vessels were closed from the inside of the aneurysm. The anomalous vessels originating from the LAD and the 10-mm aneurysm on the lateral aspect of the MPA were located near the LAD; therefore, we avoided surgical repair of these lesions. An additional percutaneous coil embolization was performed postoperatively for the remaining lesions. A post-embolization CT scan showed no residual aneurysms or fistula. A hybrid treatment may be a useful method to reduce the risk of complications of each therapy for reliable closures of fistula and aneurysms.

   

  Jpn. J. Cardiovasc. Surg. 53: 10-15（2024)

  Keywords：coronary artery aneurysm; coronary pulmonary arterial fistula; hybrid treatment

  
  
• Treatment Experience of Infective Endocarditis after TAVI　M. Tokushima et al. 　16
  Treatment Experience of Infective Endocarditis after TAVI
  

  Mika Tokushima＊	Hiroyuki Morokuma＊	Kohei Baba＊
  Yuki Takeuchi＊	Nagi Hayashi＊	Kouki Jinnouchi＊
  Shugo Koga＊	Junji Yunoki＊	Keiji Kamohara＊

  
  

  (Department of Cardiovascular Surgery, Saga University Hospital＊, Saga, Japan)
  

  The patient was an 81-year-old woman who had undergone TAVI （Evolut PROⓇ 26 mm） for severe aortic stenosis at our hospital approximately 6 months previously. She was discharged from the hospital without any postoperative complications, but at 6 months after the surgery, fever, back pain, and high inflammatory findings were observed. Based on lumbar spine MRI findings, the patient was diagnosed with pyogenic spondylitis and epidural abscess, and drainage surgery was performed. Enterococcus faecalis was identified from a blood culture. MRI of the head showed scattered subacute infarcts in the right frontal lobe, and transthoracic echocardiography revealed hyperintense deposits at the aortic valve leaflet, suggesting vegetation. The diagnosis of PVE was made and medical therapy was initiated. However, the vegetation gradually increased in size and mobility, and a surgical approach was indicated. A surgical procedure was performed through a median sternotomy to remove the prosthetic valve and replace the aortic valve. The postoperative course was good, with no recurrence of infection, and the patient was transferred to another hospital for rehabilitation on the 26th postoperative day. In general, TAVI patients are older and have more comorbidities, and surgery is associated with a higher degree of risk. However, radical surgery should be considered if medical therapy is not effective in PVE after TAVI. We reported a case of surgical aortic valve replacement for PVE after TAVI.

   

  Jpn. J. Cardiovasc. Surg. 53: 16-19（2024）

  Keywords：TAVI; prosthetic valve endocarditis; infective endocarditis

  
  
• A Case of Takotsubo Cardiomyopathy after Elective Mitral Valve Repair　M. Dohi et al. 　20
  A Case of Takotsubo Cardiomyopathy after Elective Mitral Valve Repair
  

  Masahiro Dohi*

  Takako Miyazaki**

  Kimitoshi Kitani*

  
  

  (Department of Cardiovascular Surgery, Rakuwakai Otowa Hospital*, Kyoto, Japan, and Department of Cardiovascular Surgery, Otsu City Hospital**, Otsu, Japan)
  

  We describe Takotsubo syndrome, which developed after elective mitral valve repair and tricuspid annuloplasty in a 76-year-old woman. A preoperative echocardiogram confirmed severe mitral regurgitation due to posterior leaflet prolapse, moderate tricuspid regurgitation, and normal left ventricular function. Mitral valve repair and tricuspid annuloplasty were performed. After uneventful weaning off cardiopulmonary bypass, intraoperative transesophageal echocardiography revealed adequate mitral leaflet function and normal left ventricular contractions. After being transferred to the intensive care unit, the patient’s hemodynamic parameters progressively deteriorated. Transthoracic echocardiography showed akinesis and ballooning of the apex and hyperkinesis of the base, and the ejection fraction was 20% on postoperative day 1. The serum aminotransferase and CPK-MB levels increased on postoperative day 2. The left ventricular function did not improve despite supportive therapy with vasopressors. She developed cardiogenic cerebral infarction due to obstruction of the right middle cerebral artery on postoperative day 8. Endovascular thrombectomy was performed within 2 h of the onset of cerebral infarction. Thereafter, the patient gradually recovered and was discharged without any sequelae on postoperative day 31. The ejection fraction was 65% with normal left ventricular motion at discharge. An electrocardiogram revealed a deep negative T wave in II, III, aVF, and V3-V6. After 2 months, the electrocardiogram findings were normalized. Coronary lesions were not observed on pre- or postoperative coronary angiographies; therefore, we diagnosed Takotsubo cardiomyopathy after mitral valve repair. Takotsubo cardiomyopathy should be considered as a possible complication of cardiac surgery, especially after mitral valve surgery.

   

  Jpn. J. Cardiovasc. Surg. 53: 20-24（2024）

  Keywords：takotsubo cardiomyopathy; mitral valve repair; tricuspid repair; cardiopulmonary bypass

  
  
• Evaluation of the Aortic Root Using 3D-CT Following Aortic Valve Replacement Employing the Bo Yang Root Enlargement Technique　M. Kambe et al.　25
  Evaluation of the Aortic Root Using 3D-CT Following Aortic Valve Replacement Employing the Bo Yang Root Enlargement Technique
  

  Masaru Kambe＊	Masaaki Ikehara＊	Kei Iizuka＊,＊＊
  Kozo Morita＊,＊＊	Hiroshi Niinami＊,＊＊

  
  

  (Department of Cardiovascular Surgery, Tokyo Heart Center＊, Tokyo, Japan, and Department of Cardiovascular Surgery, School of Medicine, Tokyo Women’s Medical University＊＊, Tokyo, Japan)
  

  A 65-year-old male was diagnosed with severe aortic stenosis with an indication for surgery and referred to our department. The patient opted for aortic valve replacement using a bioprosthesis. Due to the patient’s relatively small native aortic valve area, a concurrent root dilatation maneuver （Bo Yang method） was performed to prevent patient-prosthetic mismatch and to allow for the implantation of a sufficiently larger bioprosthesis, facilitating the valve-in-valve procedure. The successful implantation of an Inspiris 25-mm bioprosthesis was achieved. Post-operative 3D-computed tomography revealed no tilting or misalignment of the bioprosthesis, and a properly sized, undistorted Valsalva sinus was observed. Aortic valve replacement using the Bo Yang root enlargement technique is considered a promising alternative for relatively younger patients requiring aortic valve intervention.

   

  Jpn. J. Cardiovasc. Surg. 53: 25-28（2024）

  Keywords：aortic root enlargement; Bo Yang; aortic valve replacement; lifetime management; patient-prosthetic mismatch

  
  
• A Case of Surgical Treatment for Coronary Artery Ostium Obstruction and Aortic Regurgitation due to Cardiovascular Syphilis　K. Urushino et al. 　29
  A Case of Surgical Treatment for Coronary Artery Ostium Obstruction and Aortic Regurgitation due to Cardiovascular Syphilis
  

  Keiko Urushino＊

  Toru Shimaoka＊

  Tatsunori Kimura＊

  
  

  (Department of Cardiovascular Surgery, Nakatsu Municipal Hospital＊, Oita, Japan)
  

  Cardiovascular syphilis and syphilitic aortitis, known as late complications of syphilis, are rarely encountered in clinical practice. However, an increase in the number of syphilis cases has been reported in recent years, during which it has also manifested as a complicating infection in those with HIV. A 66-year-old man, who had no previous laboratory findings of syphilis and no subjective symptoms, presented with a complaint of dyspnea. A diagnosis of cardiovascular syphilis was made based on a positive syphilis serological reaction in the preoperative examination for surgical treatment of a left coronary artery ostium obstruction and aortic regurgitation. Three weeks after treatment with amoxicillin, the patient underwent an aortic valve replacement with a bioprosthetic valve and coronary artery bypass surgery. The aortic wall was yellowish with marked circumferential wall thickening and erosion of the intima. The area where the left coronary artery originates was occluded by intimal thickening and revealed only a dimple-like scar. The aortic valve was tricuspidate with thickening and a shortening of the left coronary leaflet. Pathology showed inflammatory cell infiltration of the aortic tunica media, consistent with syphilitic vasculitis. The postoperative course was uneventful and the patient continues to be treated with antibiotics on an outpatient basis.

   

  Jpn. J. Cardiovasc. Surg. 53: 29-32（2024）

  Keywords：cardiovascular syphilis; left coronary artery ostium obstruction; flow rate of the bypass graft; aortic regurgitation

  
  
• ［Aortic Disease］
• Chronic Dissecting Abdominal Aortic Aneurysm Coexisting with Horseshoe Kidney Requiring Supra-Renal Clamp and Reattachment of Accessory Renal Arteries　A. Kono et al.　33
  Chronic Dissecting Abdominal Aortic Aneurysm Coexisting with Horseshoe Kidney Requiring Supra-Renal Clamp and Reattachment of Accessory Renal Arteries
  

  Atsunori Kono＊	Atsushi Omura＊	Shunya Chomei＊
  Mari Hamaguchi＊	Kazunori Sakaguchi＊	Hidekazu Nakai＊
  Katsuhiro Yamanaka＊	Takeshi Inoue＊	Kenji Okada＊

  
  

  (Department of Cardiovascular Surgery, Kobe University＊, Kobe, Japan)
  

  A 60-year-old man underwent open surgery for chronic dissecting abdominal aorta accompanied with a horseshoe kidney. Through open laparotomy, the abdominal aortic aneurysm was exposed without revision of the horseshoe kidney. Cold ringer solution was infused to accessory renal arteries for renal protection. After supra-renal clamping, proximal anastomosis was then performed at the level just below the renal arteries. Abdominal cross clamp time at the level of the supra-renal arteries was 23 min. Median and right accessory arteries were reattached with an ischemic time of 73 and 103 min, respectively. Although serum creatine was elevated a preoperative level of 1.17 mg/dl to 3.63 mg/dl at postoperative day 2, that was gradually decreased to nearly preoperative level of 1.25 mg/dl at discharge. Postoperative enhanced CT demonstrated patency of the reattached accessory arteries. The patient was discharged without major complication on postoperative day 21. One year postoperatively, his follow-up course was uneventful without deterioration of renal function.

   

  Jpn. J. Cardiovasc. Surg. 53: 33-37（2024)

  Keywords：horseshoe kidney; chronic dissecting abdominal aortic aneurysm; accessory renal arteries

  
  
• Abdominal Aortic Aneurysm Manifested by Transient Spinal Cord Ischemia : a Case Report　T. Otani・M. Miyoshi　38
  Abdominal Aortic Aneurysm Manifested by Transient Spinal Cord Ischemia: a Case Report
  

  Takashi Otani＊

  Maiko Miyoshi＊

  
  

  (Department of Endovascular Surgery, Japanese Red Cross, Tokushima Hospital＊, Komatsushima, Japan)
  

  We report an extremely rare case of an abdominal aortic aneurysm with transient spinal cord ischemia. A 64-year-old male patient presented with a sudden onset of paralysis upon waking up. He was admitted to the emergency department with bilateral lower extremity paralysis. Computed tomography and ultrasonography were performed, and the findings revealed an aneurysmal dilatation. The maximum aneurysm diameter was 65×62 mm. In addition, there was a mural thrombus that was located on the posterior aspect of the wall of the aneurysmal dilatation, and part of the mural thrombus was liquefied. After admission to the hospital, although the symptoms of spinal cord ischemia began to improve, melena was observed the following day. He was subsequently diagnosed with ischemic colitis by an emergency colonoscopy. The mural thrombus had dispersed into the lumbar and internal iliac arteries, and it was postulated that this had been the cause of the spinal cord ischemia and ischemic colitis. Due to an improvement in the spinal cord ischemia and ischemic colitis, he underwent abdominal aortic replacement two weeks later. Spinal cord ischemia and ischemic colitis resolved without recurrence, and he was discharged 13 days post-operatively.

   

  Jpn. J. Cardiovasc. Surg. 53: 38-42（2024）

  Keywords：abdominal aortic aneurysm; transient spinal cord ischemia; ischemic colitis

  
  
• Placement of an Open Stent Graft for Treatment of a Distal Aortic Arch Aneurysm and Migrated Stent Graft Nine Years after TEVAR for Stanford Type B Dissection　Y. Kitagata et al. 　43
  Placement of an Open Stent Graft for Treatment of a Distal Aortic Arch Aneurysm and Migrated Stent Graft Nine Years after TEVAR for Stanford Type B Dissection
  

  Yuta Kitagata＊	Daisuke Heima＊	Michiya Hanyu＊＊
  Takaaki Koshiji＊	Hideo Kanemitsu＊

  
  

  (Department of Cardiovascular Surgery, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai＊, Osaka, Japan, and Department of Cardiovascular Surgery, Tsukaguchi Hospital＊＊, Hyogo, Japan)
  

  A 76-year-old man who underwent thoracic endovascular aortic repair （TEVAR） of an early chronic phase of Stanford type B dissection developed a 71 mm distal aortic arch aneurysm in conjunction with the migration of its proximal end over 9 years of follow-up. The proximal end of the graft had migrated 7 cm distal to the takeoff of the left subclavian artery. The patient underwent total arch replacement with an open stent graft which was connected with the TEVAR graft. He was discharged home 15 days after surgery without complications.

   

  Jpn. J. Cardiovasc. Surg. 53: 43-47（2024）

  Keywords：dissecting aortic aneurysm; open stent graft; preemptive TEVAR; migration

  
  

U-40

• U-40 Column Current Status of Surgical Training by Young Cardiovascular Surgeons and Their Intention for Off the Job Training System　T. Tsujimoto et al.　U1

Editor’s Post Script

• N. Shiiya