JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 53, No. 5, September 2024 CONTENTS

Preface

• Towards a Changing Era　D. Akamatsu

Case Reports

• ［Acquired Cardiovascular Surgery］
• Penetrating Nail-Gun Injury of the Left Ventricle and Thoracic Descending Aorta　R. Kanno et al.　251
  Penetrating Nail-Gun Injury of the Left Ventricle and Thoracic Descending Aorta
  

  Reiko Kanno＊	So Izumi＊	Soichiro Henmi＊
  Takuro Tsukube＊

  
  

  （Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center＊, Kobe, Japan）
  

  A 68-year-old man was brought to our emergency department because of an accidental nail-gun injury to the chest. Chest computed tomography in the hybrid emergency room revealed a 9 cm length of nail that had penetrated the anterior chest wall, left ventricle, and descending aorta, and was lodged in the 11th thoracic vertebral body. Immediate surgical repair was performed under left anterolateral thoracotomy using partial cardiopulmonary bypass, and closure of the penetrating site in the left ventricle and aorta was successfully conpleted. He had no major complications postoperatively.

   

  Jpn. J. Cardiovasc. Surg. 53: 251-254（2024）

  Keywords：nail-gun; penetrating cardiac injury; penetrating aortic injury; cardiopulmonary bypass

  
  
• A Case Report of Coronary Malperfusion and Aortic Regurgitation Caused by Intimal Flap Associated with Localized Acute Aortic Dissection with Difficulty in Preoperative Diagnosis　T. Urashima et al. 　255
  A Case Report of Coronary Malperfusion and Aortic Regurgitation Caused by Intimal Flap Associated with Localized Acute Aortic Dissection with Difficulty in Preoperative Diagnosis
  

  Tetsuhiro Urashima＊	Kenji Sakakibara＊	Hiroyuki Nakajima＊
  Yudai Hagihara＊	Chie Nakamura＊	Daichi Shikata＊
  Yuuki Takesue＊	Satoru Shiraiwa＊	Yoshihiro Honda＊
  Shigeaki Kaga＊

  
  

  （Department of Surgery （II）, University of Yamanashi＊, Chuo, Japan）
  

  A woman in her 60 s presented with chest pain. The electrocardiography showed ST depressed in V3-V6, ST elevation in aVR, and negative T in I, II, aVL, and aVF. Laboratory examination revealed that creatinine kinase isoenzyme-MB and troponin I were elevated. Transthoracic echocardiography revealed moderate aortic regurgitation. Enhanced computed tomography did not show an aortic dissection. Acute coronary syndrome was suspected and cardiac catheterization was done. Aortography showed an intimal flap inside the Valsalva sinus. An emergency operation was performed. Surgical view: the intimal tear affected almost all the circumference of the aorta in the Valsalva sinus and the aortic dissection with a localized and moving intimal flap affected the coronary flow and the aortic dissection caused severe aortic regurgitation and decreased the coronary flow. An aortic root replacement was successfully performed, and the postoperative course was uneventful.

   

  Jpn. J. Cardiovasc. Surg. 53: 255-258（2024）

  Keywords：sinus of Valsalva; localized acute aortic dissection; aortic root replacement

  
  
• A Surgical Case of Left Atrial Myxoma Complicated with Massive Hemorrhagic Cerebral Infarction　H. Mori et al.　259
  A Surgical Case of Left Atrial Myxoma Complicated with Massive Hemorrhagic Cerebral Infarction
  

  Hisaya Mori＊	Hisato Takagi＊	Yosuke Hari＊
  Noritsugu Naito＊

  
  

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

  A 63-year-old female suddenly suffered right hemiplegia. Multiple cerebral infarctions in the nucleus basalis and the frontal and temporal lobes perfused by the left middle cerebral artery were diagnosed. A left atrial myxoma probably causing the cerebral infarctions was identified. The patient underwent anticoagulation therapy with heparin to prevent recurrent cerebral infarctions while waiting for surgical resection of the myxoma. Motor aphasia, however, occurred on the 8th day after the onset of the cerebral infarctions. Extensive hemorrhagic cerebral infarctions involving the left temporal and frontal lobes with a midline shift occurred, and accordingly the anticoagulation therapy was discontinued. After a 6-week interval from the hemorrhagic cerebral infarctions, the left atrial myxoma was successfully resected, and the patient was discharged from the hospital without any new neurological complications. Even if left atrial myxoma complicates extensive hemorrhagic cerebral infarctions, surgical resection may be safely performed allowing a sufficient interval. Anticoagulation therapy to prevent recurrent cerebral infarctions while waiting for surgery after cerebral infarctions should be avoided because of the risk of hemorrhagic cerebral infarctions, and early surgery should be considered.

   

  Jpn. J. Cardiovasc. Surg. 53: 259-262（2024）

  Keywords：left atrial myxoma; hemorrhagic cerebral infarction; midline shift

  
  
• Superior Mediastinum Lymphatic Vessel Injury Diagnosed and Treated by Lymphangiography after Coronary Artery Bypass Grafting　T. Shimada and T. Ariyoshi　263
  Superior Mediastinum Lymphatic Vessel Injury Diagnosed and Treated by Lymphangiography after Coronary Artery Bypass Grafting
  

  Takashi Shimada＊	Tsuneo Ariyoshi＊

  
  

  （Division of Cardiovascular Surgery of Nagasaki Medical Center＊, Nagasaki, Japan）
  

  A 66-year-old female patient was diagnosed with unstable angina and atrial fibrillation, and underwent coronary artery bypass grafting, pulmonary vein isolation, and left atrial appendage closure. After the surgery, only a small amount of pale blood drainage was observed from the drain, which is a normal occurrence following surgery. However, approximately 15 h after surgery, the drain discharged 300 ml of serous fluid per 4 h. A large amount of fluid continued to be drained, amounting to 500-900 ml per day. It continued to be serous even after resuming oral intake, differing from the typical course of lymphorrhea accompanied by chylothorax. Based on a biochemical test result and characteristics of the drainage fluid, lymphorrhea was suspected; therefore, we started a fat-restricted diet and subcutaneous injections of octreotide, as in the case of chylothorax. However, drainage continued. Finally, lymphangiography using Lipiodol was performed for diagnostic and therapeutic purposes, and the lymphorrhoea improved.

   

  Jpn. J. Cardiovasc. Surg. 53: 263-266（2024）

  Keywords：cardiovascular surgery; Chylothorax; lymphoangiography

  
  
• ［Aortic Disease］
• A Case of Acute Type A Aortic Dissection with Liver Injury of Unknown Cause　H. Yamauchi et al.　267
  A Case of Acute Type A Aortic Dissection with Liver Injury of Unknown Cause
  

  Hirotaka Yamauchi＊	Takeki Ohashi＊	Soichiro Kageyama＊
  Akinori Kojima＊	Hideo Morita＊	Takanori Hishikawa＊
  Hirofumi Sogabe＊

  
  

  (Department of Cardiovascular Surgery, Nagoya Tokushukai General Hospital＊, Kasugai, Japan)
  

  AAAD （Acute type A aortic dissection） may cause trauma, due to a fall down with LOC （loss of consciousness）, which can be missed when the disturbance of consciousness is prolonged. Intraoperative heparinization may result in persistent bleeding, and trauma due to a fall with LOC associated with acute aortic dissection should always be kept in mind. An 81-year-old woman underwent emergency surgery for ruptured AAAD with LOC. Preoperative hemodynamics were unstable and low blood pressure persistent even after release of the cardiac tamponade. The partial arch replacement with brachiocephalic artery reconstruction was performed. Before the chest was closed, a large amount of bloody ascites was noted in abdomen and multiple traumas of the liver were found, resulting in a diagnosis of traumatic liver injury due to a fall with LOC. The patient had liver cirrhosis and coagulation abnormality, and hemostasis was difficult to achieve. The operation was finished with gauze packing and placed ABTHERAⓇ was placed for open abdominal wounds. The abdomen was closed in the second stages. The patient’s postoperative course was good, and the patient was transferred for continued rehabilitation.

   

  Jpn. J. Cardiovasc. Surg. 53: 267-269（2024）

  Keywords：acute type A aortic dissection; liver injury; trauma

  
  
• A Case of Sudden Death due to Massive Intraluminal Continuous Thrombosis from a Thoracic Stent Graft to Bilateral Femoral Arteries　H. Mori and H. Takagi　 270
  A Case of Sudden Death due to Massive Intraluminal Continuous Thrombosis from a Thoracic Stent Graft to Bilateral Femoral Arteries
  

  Hisaya Mori＊	Hisato Takagi＊

  
  

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

  A woman aged 87 underwent root replacement with a mechanical valve and ascending/arch replacement for annuloaortic ectasia with aortic regurgitation and ascending/arch aneurysm 10 years before and thoracic endovascular aortic repair for thoracic descending aneurysm 5 years before. She had been doing well but suffered sudden chest/back pain and bilateral lower-limb paralysis. Contrast-enhanced CT scans revealed filling defects initiating from the distal end of the thoracic stent graft and continuing to the bilateral femoral arteries. Massive thrombosis from the thoracic stent graft to the bilateral femoral arteries was diagnosed. The entire circumference of the thrombus was enhanced, and the thrombus was conceivable not attached to the aortic/arterial inner wall. Although the patient took warfarin orally for the replaced mechanical valve, anticoagulation with heparin was added. Her general condition promptly deteriorated and she died deceased 6 hours after the onset. Thrombosis continuing distally from the thoracic stent graft is extremely rare.

   

  Jpn. J. Cardiovasc. Surg. 53: 270-273（2024)

  Keywords：intra-endograft thrombosis; intra-aortic thrombosis; thoracic endovascular aortic repair

  
  
• Revascularization of Left Internal Carotid Artery for Acute Aortic Dissection Type A with Cerebral Malperfusion　M. Ikematsu et al.　274
  Revascularization of Left Internal Carotid Artery for Acute Aortic Dissection Type A with Cerebral Malperfusion
  

  Makoto Ikematsu＊	Tomoyuki Minami＊＊	Naoto Yabu＊
  Aya Tateishi＊	Ichiya Yamazaki＊	Aya Saito＊＊

  
  

  (Department of Cardiovascular Surgery, Fujisawa City Hospital＊, Fujisawa, Japan, and Department of Surgery, Yokohama City University＊＊, Yokohama, Japan)
  

  Cerebral malperfusion is a serious complication of acute aortic dissection type A（AADA），and the best strategy for its management remains unclear. A 71-year-old woman was brought to our hospital because of consciousness disorder and right hemiplegia. Contrast-enhanced CT showed AADA and occlusion of the left common carotid artery. As the symptoms gradually improved and CT showed flow in the left distal carotid artery, we prioritized central repair by total arch replacement and Frozen Elephant Trunk with deep hypothermia and antegrade cerebral perfusion （ACP）．Although the ACP cannula did not go into the left common carotid artery and we eventually had to do a left intra-carotid bypass, she was discharged home without any symptoms. It is acceptable that we give the priority to central repair over direct carotid artery re-perfusion when her symptoms improve. Besides we have to perform carotid bypass if the malperfusion is remains.

   

  Jpn. J. Cardiovasc. Surg. 53: 274-277（2024）

  Keywords：acute aortic dissection type A; cerebral malperfusion; carotid artery bypass

  
  
• A Case of Preoperative DIC and Carotid Artery Occlusion due to Type A Acute Aortic Dissection　R. Hatayama et al.　278
  A Case of Preoperative DIC and Carotid Artery Occlusion due to Type A Acute Aortic Dissection
  

  Rei Hatayama＊	Aya Saito＊＊	Keiji Uchida＊
  Shota Yasuda＊	Tomoki Cho＊	Ryo Izubuchi＊
  Shotaro Kaneko ＊	Atsushi Matsumoto＊	Makoto Ikematsu＊
  Sho Kakuta＊

  
  

  (Cardiovascular Center, Yokohama City University Medical Center＊, Yokohama, Japan, and Department of Surgery, Yokohama City University Hospital＊＊, Yokohama, Japan)
  

  A 61-year-old male presented to another hospital with sudden chest and back pain, and CT revealed a diagnosis of type A acute aortic dissection with patent false lumen. The ascending aortic diameter was 45 mm and the right common carotid artery was occluded. There were no neurological abnormalities, no pericardial effusion, and only mild AR. Eight hours after onset, the patient was transferred to our hospital. The laboratory data showed severe DIC with fibrinogen <50 mg/dl, so that medical DIC treatment was given first because of the high risk of bleeding. Twenty-two hours after the onset, DIC improved and surgery was initiated. The right common carotid artery was ligated for fear of thrombus dispersion at the periphery of the occlusion site. An ascending arch replacement was then performed. Postoperative hemostasis was good, and no new neurological abnormalities were observed. Usually, type A acute aortic dissection is indicated for emergency surgery, but in this case, DIC treatment took precedence. We report here a rare experience.

   

  Jpn. J. Cardiovasc. Surg. 53: 278-282（2024）

  Keywords：type A acute aortic dissection; DIC; right common carotid occlusion

  
  
• A Case of Infected Endograft Explanation Following Thoracic Endovascular Aortic Repair for Distal Anastomotic Infectious Pseudoaneurysm after Total Arch Replacement　H. Mori et al.　283
  A Case of Infected Endograft Explanation Following Thoracic Endovascular Aortic Repair for Distal Anastomotic Infectious Pseudoaneurysm after Total Arch Replacement
  

  Hisaya Mori＊	Hisato Takagi＊	Yosuke Hari＊
  Noritsugu Naito＊

  
  

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

  We report a case of semi-urgent infected endograft explanation following thoracic endovascular aortic repair （TEVAR） for distal anastomotic （DA） infectious pseudoaneurysm after total arch replacement （TAR）. A 70-year-old male underwent TAR for distal arch saccular aneurysm 10 years before and open bifurcated graft replacement for an abdominal aortic aneurysm 5 years before. The patient was admitted 3 years before because of repeated pyrexia of 40℃. Contrast-enhanced CT scans revealed suspected vegetation and infectious pseudoaneurysm at the DA of the TAR, and semi-urgent TEVAR was performed on the next day. Antibiotic therapy was initiated for Staphylococcus capitis detected in a blood culture, and the patient was discharged after a negative blood culture. At this time, he was admitted owing to face and below-knee edema and dyspnea. Because a blood culture identified Methicillin-resistant Staphylococcus capitis and antibiotic therapy uncontrolled infection, we performed explanation of the infected endograft and distal end of the TAR graft and replacement of the descending thoracic aorta with a rifampicin-bonded graft under moderate hypothermic circulatory arrest with retrograde cerebral perfusion via the 4th intercostal posterolateral thoracotomy. Postoperative 6-week antibiotic therapy was continued and the patient was discharged in good condition after a negative blood culture on postoperative day 46.

   

  Jpn. J. Cardiovasc. Surg. 53: 283-289（2024）

  Keywords： infected endograft; thoracic endovascular aortic repair; anastomotic infectious pseudoaneurysm; total arch replacement

  
  
• A Case of Hemolytic Anemia Caused by Felt Strips in the Proximal Anastomosis Site after Acute Aortic Dissection Surgery　Y. Gunji et al.　290
  A Case of Hemolytic Anemia Caused by Felt Strips in the Proximal Anastomosis Site after Acute Aortic Dissection Surgery
  

  Yusuke Gunji＊	Daisuke Hama＊	Motoki Nagatsuka＊
  Kenichiro Noguchi＊	Tohru Asai＊

  
  

  (Shonan Kamakura General Hospital＊, Kamakura, Japan)
  

  The patient was a 49-year-old male who had undergone total arch replacement with Elephant trunk procedure for acute aortic dissection Stanford type A at another institution. Eight months post-surgery, he presented with hematuria and jaundice. Mechanical hemolysis by grafts was considered, and he was referred to our hospital. Subsequently, we conducted transesophageal echocardiography, which revealed the inversion of felt strips at the proximal anastomosis site, accompanied by blood turbulence at the same site. Consequently, we established a diagnosis of mechanical hemolysis attributed to the inversion of the inner felt strip within the anastomosis, prompting a redo surgery. The utilization of felt strips for reinforcing the anastomosis has become a prevalent technique in ascending aortic replacement for acute aortic dissection. This technique serves to mitigate hemorrhage from the anastomosis and counteract the formation of pseudoaneurysms. In this study, we report an uncommon complication caused by the presence of felt strips within the anastomosis.

   

  Jpn. J. Cardiovasc. Surg. 53: 290-293（2024）

  Keywords：acute aortic dissection; teflon felt strip; hemolytic anemia

  
  
• A Surviving Case of Root and Ascending Replacement for Ruptured Type-A Acute Aortic Dissection with Root Ectasia Following Aortic Valve Replacement　H. Mori and H. Takagi　294
  A Surviving Case of Root and Ascending Replacement for Ruptured Type-A Acute Aortic Dissection with Root Ectasia Following Aortic Valve Replacement
  

  Hisaya Mori＊	Hisato Takagi＊

  
  

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

  A 77-year-old man suffered sudden chest oppression in driving. The patient had undergone aortic valve replacement with a mechanical valve for unknown valvular heart disease 17 years before. On arrival, the symptom was improved and hemodynamics were stable. Contrast-enhanced CT scans revealed remarkable pear-shaped dilatation of the aortic root （76 mm in maximum diameter）, ascending aortic dissection, and extravasation from the posterior wall of the dissecting aorta with mediastinal hematoma compressing the left atrium. Ruptured type A acute aortic dissection with root ectasia （following aortic valve replacement） was diagnosed and urgent root and ascending aortic replacement was performed preserving the replaced mechanical valve. Initially, surgery not under hypothermic circulatory arrest but under normothermic aortic cross clamp was planned. Although sudden massive bleeding from the rupture site （dorsal to the ascending aorta） occurred during exposure of the ascending aorta （just proximal to the origin of the brachiocephalic artery）, the procedure could be continued under bleeding control by the surgeon’s fingers. The patient underwent re-sternotomy for hemostasis and undertook rehabilitation for discharge on the postoperative day 30. Mortality of ruptured type A acute aortic dissection is extremely high, and no surgical surviving case has been reported in the Japanese language.

   

  Jpn. J. Cardiovasc. Surg. 53: 294-298（2024）

  Keywords：type A acute aortic dissection; rupture; aortic root ectasia; root and ascending aortic replacement

  
  
• ［Peripheral Artery Disease］
• A Patient with the LEAD-Complicated Mid-Aortic Syndrome with Bilateral External Iliac Artery Hypoplasia Underwent Bilateral Common Iliac-Common Femoral Artery Bypass Surgery　D. Ito et al.　299
  A Patient with the LEAD-Complicated Mid-Aortic Syndrome with Bilateral External Iliac Artery Hypoplasia Underwent Bilateral Common Iliac-Common Femoral Artery Bypass Surgery
  

  Daichi Ito＊	Jun Okadome＊	Hiroyuki Ito＊

  
  

  (Department of Vascular Surgery, Saiseikai Fukuoka General Hospital＊, Fukuoka, Japan)
  

  A 27-year-old woman developed circulatory failure 4 days after birth and was diagnosed with mid-aortic syndrome （MAS） 10 days after birth. Despite repeated endovascular treatments, restenosis recurred, and descending aorta-abdominal aorta bypass surgery was performed at the age of 6. Since the age of 14, bilateral external iliac artery occlusion has been observed, but no ischemic symptoms were observed in the lower extremities, and the patient was followed up. From around the age of 26, significant claudication appeared in both lower extremities, and it was determined that surgical intervention was required. Bilateral common iliac artery-common femoral artery bypass surgery was performed. The bilateral common iliac arteries were used as the central anastomosis, and the common femoral artery just above the bifurcation of the bilateral superficial and deep femoral arteries was used as the peripheral anastomosis. No ischemic symptoms in the lower extremities have been observed up to now （2 years after the operation）. Bilateral common iliac artery-common femoral artery bypass surgery was performed for abdominal aortic stenosis with hypoplasia of the bilateral external iliac arteries and lower extremity artery disease （LEAD）. Since we experienced the case with favorable results, we will add a review of the literature and report it.

   

  Jpn. J. Cardiovasc. Surg. 53: 299-303（2024)

  Keywords：mid-aortic syndrome; congenital; external iliac artery hypoplasia; LEAD; bypass surgery

  
  

Progress in Cardiovascular Surgery（2023）

• Advances in the Myocardial Protection in 2023　R. Bessho and M. Fujii　304
• Progress in Coronary in 2023　K. Honda　308

U-40

• U-40 Column
• The Reform of Work Has Begun－Young Cardiovascular Surgeons Now　H. Hidaka et al.　U1
  The Reform of Work Has Begun－Young Cardiovascular Surgeons Now
  

  Hideaki Hidaka＊	Keisuke Iwahashi	Shogo Niizaki
  Masato Hayama	Takehiro Kishigami	Kazuya Terazono
  Kousuke Mori	Shunsuke Taguchi	Takafumi Abe
  Yuichi Koga

  
  

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

  The reform of the way physicians work was started from April 2024. Restrictions on doctors' working hours is expected to be difficult to achieve the level required by the government. U40 Kyushu-Okinawa Branch conducted a questionnaire survey of young cardiovascular surgeons nationwide on their working conditions. While some institutions have taken measures such as streamlining doctors' work and shifting tasks, others seem to have made a few change to their previous work content. The reform of work styles of cardiovascular surgeons requires not only individual improvement of work styles, but also efforts by cardiovascular surgeons as a one team, including department heads and facility directors, and requires the involvement of academic societies and governments.

   

  Jpn. J. Cardiovasc. Surg. 53(5): U1-U6 (2024)

  Keywords：work style reform; young cardiovascular surgeons; questionnaire survey

  
  

Editor’s Post Script

• Y. Yoshikawa