JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 53, No. 6, November 2024 CONTENTS

Preface

• Commitment as a Cardiac Surgeon　T. Uchida

Original

• Strategy for Cardiac Surgery in Patients with Antithrombin III Deficiency
  Strategy for Cardiac Surgery in Patients with Antithrombin III Deficiency
  

  Yoshiyuki Nishimura＊	Akio Iwata＊	Syunsuke Fukaya＊
  Hisao Suda＊＊

  
  

  （Department of Cardiovascular Surgery, Mie Heart Center＊, Mie, Japan, and Department of Cardiovascular Surgery, Nagoya City University＊, Nagoya, Japan）
  

  Background: Antithrombin III (AT III) deficiency is a rare disorder and thrombosis can be induced by a minor cause that does not normally lead to thrombosis, such as an external injury and surgery. Therefore, patients with AT III deficiency undergoing cardiac surgery that involves heparinization require careful perioperative management. Objective and Methods: From September 2013 through December 2023, we experienced　8 patients (1.92%) with AT III deficiency who underwent cardiac surgery and were managed with AT III replacement. By administration of AT III concentrate, preoperative AT III activity was maintained at ≥ 120% and postoperative AT III activity at ≥ 80%. Results: All five patients were treated successfully without postoperative complications such as hemorrhage or thrombosis. In a case of aortic valve stenosis in a hemodialysis patient, reoperation was performed 9 months after aortic valve replacement with a bioprosthetic valve. Pathological examination suggested that the deterioration was caused by a large amount of thrombus on the outflow side of the valve leaflet and not by iatrogenic calcification due to dialysis. Conclusions: In patients with AT III deficiency undergoing cardiac surgery, it is important to perform AT III replacement to achieve preoperative AT III activity ≥ 120% and postoperative AT III activity ≥ 80%, while the activated clotting time is maintained at > 400 s during cardiopulmonary bypass. In addition, long-term postoperative anticoagulant therapy is necessary in hereditary AT III deficiency patients with a history of thrombosis.

   

  Jpn. J. Cardiovasc. Surg. 53: 313-317（2024）

  Keywords：antithrombin III deficiency; cardiac surgery; antithrombin III activity

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• A Case of Subaortic Left Ventricular Diverticulum Complicated with Infective Endocarditis A. Otani and H. Takagi　318
  A Case of Subaortic Left Ventricular Diverticulum Complicated with Infective Endocarditis
  

  Atsushi Otani＊

  Hisato Takagi＊

  
  

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

  A 66-year-old man with a history of pyogenic spondylitis a month before was presented with dyspnea. Severe aortic regurgitation due to infective endocarditis was suspected in transthoracic echocardiogram, and emergency surgery was conducted. The aortic valve with three cusps was markedly destroyed with vegetation. After resecting the cusps, there was a cavity just below the commissure between the left and noncoronary cusp （intervalvular fibrous trigon）. In retrospective findings of intraoperative pre-cardiopulmonary bypass transesophageal echocardiogram, a left ventricular diverticulum with paroxysmal movement had been detected at the same place. The diverticulum was left untreated to shorten cardiac arrest time because of low left ventricular function, and aortic valve replacement alone was performed. Cardiopulmonary bypass was weaned with intra-aortic balloon pumping （IABP）. Percutaneous cardiopulmonary support (PCPS) was initiated owing to hypotension in the intensive care unit. The PCPS and IABP were discontinued on postoperative day （POD） 5 and 6, respectively. Torsades de pointes and ventricular fibrillation occurred respectively 2 h after weaning the PCPS and on POD9, but recuperated to sinus rhythm within a minute. A 6-week course of antibiotic infusion was planned, and the patient is now undertaking rehabilitation on POD30 for discharge.

   

  Jpn. J. Cardiovasc. Surg. 53: 318-323（2024）

  Keywords：infective endocarditis; left ventricular diverticulum; subaortic left ventricular diverticulum

  
  
• Cutibacterium Pocket Infection Followed by Intrapericardial Abscess through Internal Lumen of Penetrated Screw-in Pacemaker Lead　M. Inouchi et al. 　324
  Cutibacterium Pocket Infection Followed by Intrapericardial Abscess through Internal Lumen of Penetrated Screw-in Pacemaker Lead
  

  Mikito Inouchi＊	Michihiro Nasu＊	Jin Tanaka＊
  Takeo Nakai＊	Hidetaka Kozai＊

  
  

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

  The case was a 70-year-old man. Nine years after VVI pacemaker implantation with a screw-in electrode, the battery was replaced. One year later, a new electrode was added due to pacing failure, and the old electrode was left in the pocket with silicone cap. Two months later, he was admitted due to fever. Although no infection was recognized, an increase in pericardial effusion was observed and the patient, with a past history of interstitial pneumonia, was positive for anti-ARS antibodies. Therefore, colchicine and aspirin were administered as nonspecific pericarditis, and the pericardial effusion disappeared in 2 weeks. When the dose of aspirin was reduced two months later, the inflammatory reaction flared-up. CT scan showed an abscess between the liver and the right ventricular wall. The electrode, penetrated the right ventricle, was continuous into the abscess cavity. During open heart surgery, it was observed the old electrode firmly adhered to the superior vena cava, right atrium, tricuspid valve, and anterior papillary muscle and successfully dissected and removed without bleeding. The chest was closed after aggressive lavage of the abscess cavity and the pocket. Fluid retention was observed in the pocket, the old electrode internal lumen, and the abscess cavity. Cutibacterium was detected in all of them. It was thought that Cutibacterium pocket infection was transmitted through the internal lumen of the screw-in electrode that penetrated the right ventricular wall and caused intrapericardial abscess. There were no reports about infection transmitted route as in this case.

   

  Jpn. J. Cardiovasc. Surg. 53: 324-328（2024）

  Keywords：intrapericardial abscess; pocket infection; screw-in lead; Cutibacterium infection; route of infection

  
  
• A Case Requiring Tricuspid Valve Replacement during the Extended Sandwich Patch Technique through Right Ventriculotomy for Postinfarction Ventricular Septal Defects S. Komatsu et al. 　329
  A Case Requiring Tricuspid Valve Replacement during the Extended Sandwich Patch Technique through Right Ventriculotomy for Postinfarction Ventricular Septal Defects
  

  Shigeki Komatsu＊	Hiroshi Sato＊	Yukihiko Tamiya＊
  Joji Fukada＊

  
  

  (Department of Cardiovasuclar Surgery, Otaru General Hospital＊, Otaru, Japan)
  

  A 81-year-old-man was diagnosed with the acute myocardial infarction （AMI） and ventricular septal defects （VSD）. He was medically treated under the intra-aortic balloon pumping （IABP） for 2 weeks after the onset of AMI, and underwent the surgical VSD closure by the extended sandwich technique. Surgery was performed with the right ventriculotomy. The infarction was extensive in the ventricular septum and the right ventricular posterior papillary muscle was resected during myectomy of the infarcted septum to prevent the residual shunt. VSD was closed by two patches from the left and right ventricles. Tricuspid valve was completely prolapsed due to the resected papillary muscle and tricuspid valve replacement was required. Postoperative echocardiography showed no residual shunt and normal tricuspid valve function. The patient was discharged 114 days after surgery. The present case suggests the possibility of the right ventricular papillary muscle resection and tricuspid valve treatment during VSD closure by the right ventriculotomy.

   

  Jpn. J. Cardiovasc. Surg. 53: 329-332（2024）

  Keywords：postinfarction ventricular septal defects; extended sandwich patch technique through right ventriculotomy; tricuspid valve replacement

  
  
• A Successful Surgical Case of Severe Aortic Regurgitation Associated with Nonbacterial Thrombotic Endocarditis in the Patient of Cryoglobulinemia　D. Kato et al. 　333
  A Successful Surgical Case of Severe Aortic Regurgitation Associated with Nonbacterial Thrombotic Endocarditis in the Patient of Cryoglobulinemia
  

  Daiki Kato＊	Yosuke Tanaka＊	Makoto Kusakizako＊
  Ryouta Takahashi＊	Koki Yokawa＊	Tomonori Higuma＊
  Hidefumi Obo＊	Hidetaka Wakiyama＊

  
  

  （Department of Cardiovascular Surgery, Kakogawa Central City Hospital＊, Kakogawa, Japan）
  

  A 74-year-old man, with a medical background of cryoglobulinemia, had been undergone nonbacterial thrombotic endocarditis with immunotherapy spanning three months. Following a year and three months, he has presented to our institution experiencing acute decompensated heart failure attributable to severe aortic regurgitation （AR），moderate mitral regurgitation （MR），and severe tricuspid regurgitation （TR）．Transesophageal echocardiography revealed aortic valve cusps destruction and anterior mitral valve leaflet vegetation. The potential complications of leukocytoclastic or necrotizing vasculitis due to hypothermic cardiopulmonary bypass in cryoglobulinemia patients were addressed preemptively through preoperative plasmapheresis. During the procedure, tepid core cooling cardiopulmonary bypass at 33℃ and tepid blood cardioplegia solution at 30℃ were employed to mitigate the risk of vasculitis. Urgent aortic valve replacement, mitral vegetation resection, and tricuspid annuloplasty were performed, and the patient was discharged on the 23rd postoperative day without any untoward events.

   

  Jpn. J. Cardiovasc. Surg. 53: 333-338（2024）

  Keywords：cryoglobulinemia; preoperative plasmapheresis; tepid blood cardioplegia

  
  
• Successful Repair of Ventricular Septal Rupture with Impella Support : A Report of Two Cases　K. Hachiro et al. 　339
  Successful Repair of Ventricular Septal Rupture with Impella Support: A Report of Two Cases
  

  Kohei Hachiro＊	Noriyuki Takashima＊	Kenichi Kamiya＊
  Masahide Enomoto＊	Yasuo Kondo＊	Fumihiro Miyashita＊
  Hodaka Wakisaka＊	Kentaro Matsuoka＊	Komei Kado＊
  Tomoaki Suzuki＊

  
  

  （Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science＊, Otsu, Japan）
  

  Ventricular septal rupture （VSR） is a rare but still possibly catastrophic complication of acute myocardial infarction. We report two successful cases of Impella-assisted VSR. In case 1, a 78-year-old woman was transferred to our hospital with a diagnosis of posterior VSR. After Impella insertion, cardiac output increased from 2.13 to 2.57 and the pulmonary to systemic output ratio decreased from 2.92 to 1.78. Two days after insertion of Impella, she underwent surgery. In case 2, an 89-year-old woman was transferred to our hospital with a diagnosis of anterior VSR. After Impella insertion, cardiac output increased from 2.29 to 2.85, but the pulmonary to systemic output ratio changed little from 3.79 to 3.81. Three days after insertion of Impella, she underwent surgery. Neither patient experience hemodynamic deterioration preoperatively. Postoperative echocardiography showed no residual shunt in either case. Impella for VSR seemed effective in stabilizing hemodynamics preoperatively and postoperatively.

   

  Jpn. J. Cardiovasc. Surg. 53: 339-342（2024）

  Keywords：ventricular septal rupture; impella

  
  
• A Case of Direct Oral Anticoagulant (DOAC) as Anticoagulant after Mitral Valvuloplasty in a Patient with Warfarin-Resistance　S. Wada et al.　343
  A Case of Direct Oral Anticoagulant （DOAC） as Anticoagulant after Mitral Valvuloplasty in a Patient with Warfarin-Resistance
  

  Shunsuke Wada＊	Takashi Hashimoto＊	Koh Kajiyama＊
  Keizo Tanaka＊

  
  

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

  Warfarin is commonly used as an anticoagulant after mitral valvuloplasty （MVP）. The efficacy of warfarin varies widely from patient to patient, and sometimes optimal prolongation of PT-INR cannot be achieved even with high doses of warfarin. In the present case, PT-INR was not prolonged to the target value even after 9 mg of warfarin and 300 mg of Bucolome due to warfarin resistance, and a direct oral anticoagulant （DOAC） was administered as an alternative drug. The patient was a 57-year-old male who became aware of easy fatigue and visited a medical institution for a heart murmur. Transthoracic echocardiography revealed a severe mitral regurgitation （MR） due to thickening of the anterior mitral leaflet and prolapse of the posterior leaflet. Postoperative echocardiography showed no MR, good valve mobility, an effective valve opening area of 2.0 cm2, and an improved blood flow velocity of 0.9 m/s. Warfarin was started on the day after surgery, but the dose was gradually increased because PT-INR was not prolonged. The PT-INR was less than 1 even with 6 mg of warfarin, and the patient was started on Bucolome. The PT-INR was 1.27 after 9 mg of warfarin and 300 mg of Bucolome. The patient was diagnosed as warfarin-resistance and was discharged from the hospital after warfarin was discontinued and dabigatran 300 mg was administered. Dabigatran was discontinued at 3 months after surgery without any embolism or bleeding complications. In some cases, PT-INR prolongation may not be achieved due to warfarin resistance caused by genetic polymorphisms, and in such cases, DOACs can be used as anticoagulants after mitral valvuloplasty.

   

  Jpn. J. Cardiovasc. Surg. 53: 343-347（2024）

  Keywords：warfarin-resistant; PT-INR; mitral valvuloplasty; DOAC

  
  
• ［Aortic Disease］
• Coupling Failure after 4 Years of EVAR with AFX2 Endografts Used in Combination with Aortic Cuffs　R. Ueda et al.　348
  Coupling Failure after 4 Years of EVAR with AFX2 Endografts Used in Combination with Aortic Cuffs
  

  Ryoma Ueda＊	Hideki Tsubota＊	Masanori Honda＊
  Masafumi Kudo＊	Hitoshi Okabayashi＊

  
  

  (Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital＊, Kyoto, Japan)
  

  The Endologix AFX is a bifurcated unibody endovascular aortic repair （EVAR） system used for the treatment of abdominal aortic aneurysms （AAA）. It consists of an inner metal endoskeleton with multiple metal struts covered by a polytetrafluoroethylene graft fabric, which is suitable for treating AAA with narrowed abdominal aortic bifurcations. However, the risk of type 3 endoleak （T3EL） has been alerted and it is recommended that a sufficient overlap length be considered when using a cuff device on the central side. We present the case of an 81-year-old man with a 45 mm AAA who underwent EVAR with an AFX2 main body device and AFX proximal cuff extension device, adhering to the recommended overlap length. However, postoperative aneurysm enlargement occurred gradually, and complete uncoupling of the main body and cuff was observed 4 years later. A retrospective review of 4 years of computed tomography （CT） scans revealed potential caudal migration of the main body device and cranial migration of the cuff device, potentially resulting in a type 3a endoleak （T3aEL）. An additional device was deployed to bridge both components, and the patient was discharged without complications. In cases where an AFX2 main body device and a cuff device are used on the central side, even with adequate overlap, careful follow-up is necessary because of the potential for sideways displacement or craniocaudal migration. The observation of device displacement using 3D reconstruction CT imaging is particularly useful.

   

  Jpn. J. Cardiovasc. Surg. 53: 348-353（2024）

  Keywords：endovascular aortic repair （EVAR）; AFX; type 3 endoleak

  
  
• Surgical Management of Chronic Contained Rupture of an Abdominal Aortic Aneurysm Presenting as Right Lower Extremity Pain　N. Ohashi et al.　354
  Surgical Management of Chronic Contained Rupture of an Abdominal Aortic Aneurysm Presenting as Right Lower Extremity Pain
  

  Noburo Ohashi＊	Daisuke Komatsu＊	Shuji Chino＊
  Toru Mikoshiba＊	Haruki Tanaka＊	Hajime Ichimura＊
  Toshihito Gomibuchi＊	Megumi Fuke＊	Yuko Wada＊
  Tatsuichiro Seto＊

  
  

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

  Chronic contained rupture of an abdominal aortic aneurysm （AAA） is a rare condition that can present with atypical symptoms, making diagnosis challenging. We report a case of chronic contained rupture of an AAA with vertebral destruction presenting as right lower extremity pain. A 78-year-old man with a history of mitral valve replacement and pyogenic spondylitis （L2-L3） presented with a two-month history of low back pain and a four-day history of right lower extremity pain and numbness. Computed tomography revealed a 61 mm diameter ruptured AAA with an irregular margin. Magnetic resonance imaging demonstrated vertebral destruction at L4-L5. The patient underwent open surgical repair with a rifampicin-soaked graft and debridement. Intraoperatively, a large defect was found at the posterior aspect of the aneurysm, exposing the destroyed vertebral bodies. Postoperatively, the patient required spinal immobilization for persistent neurological symptoms, which improved and the patient was discharged on postoperative day 55.

   

  Jpn. J. Cardiovasc. Surg. 53: 354-357（2024）

  Keywords：abdominal aortic aneurysm; chronic contained rupture; lower extremity pain

  
  
• ［Peripheral Artery Disease］
• A Case of Bilateral Ureteral Stenosis and Hydronephrosis due to Bilateral Internal Iliac Artery Aneurysm　D. Sato et al. 　358
  A Case of Bilateral Ureteral Stenosis and Hydronephrosis due to Bilateral Internal Iliac Artery Aneurysm
  

  Daiki Sato*

  Yuta Kume*

  Yukihiro Bonkohara*

  
  

  (Department of Cardiovascular Surgery, National Hospital Organization*, Yokohama, Japan)
  

  To our knowledge, there are no previous reports of bilateral internal iliac artery aneurysms with bilateral hydronephrosis. We herein report the successful surgical treatment of bilateral hydronephrosis in a 65-year-old woman. The patient was referred to the urology department of our medical center. CT showed bilateral internal iliac artery aneurysms （right: 30 mm, left: 26 mm） and hydronephrosis,which was caused by ureteral compression by the aneurysms. First, bilateral ureteral stents were placed to improve hydronephrosis. Then we performed open abdominal aortic graft replacement with bilateral internal iliac aneurysmectomy. The patient had no perioperative complications, and the ureteral stents were removed after the patient was discharged from the hospital.

   

  Jpn. J. Cardiovasc. Surg. 53: 358-361（2024）

  Keywords：iliac artery aneurysm; ureteral stenosis; hydronephrosis

  
  

Progress in Cardiovascular Surgery（2023）

• Advances in the Cogenital Heart Disease　N. Oka　362
• Advancement in the Field of MICS in 2023　M. Hashimoto　366

U-40

• U-40 Column
• Strategies for Registering New Specialist Certification System of Cardiovascular Surgery and Pursuing a Training Advisor Position　Y. Yamazaki et al.　U1
  Strategies for Registering New Specialist Certification System of Cardiovascular Surgery and Pursuing a Training Advisor Position
  

  Yuya Yamazaki	Daichi Takagi＊	Ken Niitsuma
  Masaaki Naganuma	Miki Takeda	Yuki Imamura
  Azuma Tabayashi	Keiichi Ishida	Ai Ishizawa
  Ryousuke Kowatari

  
  

  (Department of Cardiovascular, Akita University Hospital＊, Akita, Japan)
  

  The transition to the new specialist certification system has progressed in cardiovascular surgery, enabling many surgeons to obtain specialist certification earlier than before. This study focuses on conditions that are particularly easy to overlook factors in the application process, namely academic activities, surgical experience, and Off-the-Job Training （OJT）. This report summarizes these changes to facilitate efficient specialist certification applications for trainees.

   

  Jpn. J. Cardiovasc. Surg. 53(6): U1-U5 (2024).

  Keywords：the new specialist certification system; cardiovascular surgery; Off the Job Trainig

  
  

Editor’s Post Script

• T. Yamaoka