Japanese Journal of Cardiovascular Surgery Vol.41, No.2

Preface

• F. Yamamoto

Original

• Merits and Demerits of the Reversed Elephant Trunk Technique Based on Experiences with 6 Cases N. Kanemitsu et al.…53
  Merits and Demerits of the Reversed Elephant Trunk Technique Based on Experiences with 6 Cases

  （Department of Cardiovascular Surgery, Japan Red Cross Society Wakayama Medical Center, Wakayama Japan）

  Naoki Kanemitsu

  Masaki Aota

  Shingo Hirao

  We encountered 6 cases of descending or thoracoabdominal aortic aneurysm operation with reversed elephant trunk（R-ET). R-ET was originally developed by Dr. Carrel in order to circumvent the dissection of the proximal anastomotic site from surrounding organs such as the lung, recurrent nerve, phrenic nerve, and esophagus in the future proximal aortic replacement. Three of 6 patients underwent a 2nd operation（total arch replacement). Distal anastomosis was easy and safe. One patient had multiple cerebral infarction and died after the second operation, but no patient suffered from complications derived from injury to the lung, esophagus, recurrent nerve or phrenic nerve. During outpatient follow-up, 1 patient who had suffered from paraparesis after the 1st operation died of repture of an arch aneurysm before the 2nd operation could be. Thrombosis was found between the inside and outside grafts of R-ET in 2 patients, who had been implanted with Gelweave prosthesis. There were no negative events caused by the thrombus. One patient with the thrombus underwent total arch replacement. We removed the fibrin-like thrombus from the R-ET prosthesis under endoscopic visualization without any complication. R-ET is a very easy and useful technique, but one should exert care about the thrombus formation around the R-ET.
    Jpn. J. Cardiovasc. Surg. 41:53-57（2012）
  
  Keywords：reversed elephant trunk technique, multiple thoracic aortic aneurysms
• Surgical Embolectomy for Acute Pulmonary Thromboembolism D. Shiomi et al.…58
  Surgical Embolectomy for Acute Pulmonary Thromboembolism

  （Division of Cardiovascular Surgery, Sekishinkai Sayama Hospital, Sayama, Japan）

  Daisuke Shiomi	Aya Takahashi	Nobuaki Kaki
  Hiroshi Kiyama

  Treatment of acute pulmonary thromboembolism（APTE）in patients with hemodynamic instability still remains controversial. We analyzed the outcome and validity of surgical pulmonary embolectomy for APTE. Between January of 2004 to December of 2010, 15 patients underwent emergency surgical pulmonary embolectomy using cardiopulmonary bypass with beating heart. Our operative indications were;within 7 days from onset, hemodynamic instability, bilateral pulmonary artery obstruction or unilateral obstruction with central clot and right ventricular dysfunction. Ten patients presented in cardiogenic shock, two of whom showed cardiac arrest and required cardiopulmonary resuscitation before operation. One patient required percutaneous cardiopulmonary support. Median follow up period is 33 months（range 3 to 86 months). All patients survived the operation, but 3 patients died in the hospital on post operative day 11（massive cerebral infarction), day 18（brain hypoxia）and day 25（multiorgan failure). Two of them had cardiac arrest and received cardiopulmonary resuscitation before operation. Hospital mortality was 20%. And all patients left the hospital on foot except one patient who had been bedridden by myotonic dystrophy before operation. No patients died or showed symptoms of pulmonary hypertension after discharge. Prompt diagnosis and surgical pulmonary embolectomy before threatening fatal condition improves the outcome of embolectomy.
    Jpn. J. Cardiovasc. Surg. 41:58-62（2012）
  
  Keywords：acute pulmonary thromboembolism, surgical embolectomy, percutaneous cardiopulmonary support
• Survey of Doctors Changed Their Clinical Specialty from Cardiac Surgery S. Gon et al.…63
  Survey of Doctors Changed Their Clinical Specialty from Cardiac Surgery

  （Cardiovascular Surgery, Tsukuba Memorial Hospital, Tsukuba, Japan）

  Shigeyoshi Gon	Tsuyoshi Shimizu	Sei Morizumi
  Yoshihiro Suematsu

  Some doctors change specialty from cardiac surgery to cardiology or peripheral vascular surgery or practice general medicine before retirement age. We carried out a survey to investigate their working conditions and reasons for changing their specialty. We sent questionnaires by mail to 154 doctors of whom 56（36%）answered. The most common reason for changing specialty was taking over their family’s practice, and the second most common reason was a small income. Actually, the annual income of 41 doctors increased after changing from cardiac surgery（75%). Many cardiac surgeons have to work with a years lest self-sacrifice and unpaid overtime work. Of the respordents 65% could not renew their Japanese Board of Cardiovascular Surgery, because of their limited operative numbers. If the current condition continues, the number of cardiac surgeons in Japan will decrease. It is necessary to improve working conditions and the environment so that surgeons can concentrate more on operations.
    Jpn. J. Cardiovasc. Surg. 41:63-66（2012）
  
  Keywords：working conditions, cardiac surgeon, changing specialty
• Clinical Study of Brachial Vein Transposition Fistulas for Hemodialysis H. Urayama…67
  Clinical Study of Brachial Vein Transposition Fistulas for Hemodialysis

  （Department of Thoracic and Vascular Surgery, Kurobe City Hospital, Kurobe, Japan）

  Hiroshi Urayama

  Brachial vein transposition fistulas for hemodialysis are embloyed when the superficial veins in arms are not used. In our hospital, 28 patients have received brachial vein transposition fistula in the past 13 years. Post-operative complications were bleeding at the puncture sites in 2 patients, infection at the puncture site in 1, and aneurysm formation in the transposed vein in 1. Access related hand ischemia and venous hypertension were not recognized. For 3 patients of fistula stenosis, percutaneous catheter dilatation was performed. For 2 of 19 patients with fistula occlusion, surgical thrombectomy was performed. The primary patency rates were 76.8% at 1 year and 55.8% at 4 years. The secondary patency rates were 95.5% at 1 year and 66.3% at 4 years. The brachial vein transposition procedure is useful for long-term continuation of hemodialysis using autologous arm vessels.
    Jpn. J. Cardiovasc. Surg. 41:67-69（2012）
  
  Keywords：brachial vein, brachial artery, blood access, vein transposition, long-term results

Case Reports

• A Case of Partial Aortic Root Remodeling for the Right Sinus of Valsalva Aneurysm with an Anomalous Origin of the Coronary Artery T. Ueno et al.…70
  A Case of Partial Aortic Root Remodeling for the Right Sinus of Valsalva Aneurysm with an Anomalous Origin of the Coronary Artery

  （Department of Cardiovascular Surgery, Kagoshima Medical Center, Kagoshima, Japan）

  Takayuki Ueno	Kazuhisa Matsumoto	Kosuke Mukaihara
  Kenji Toyokawa	Tomoyuki Matsuba	Goichi Yotsumoto
  Yoshihiro Fukumoto	Yoshiya Shigehisa	Hitoshi Toyohira
  Masahumi Yamashita

  A sinus of Valsalva aneurysm is a rare cardiac disorder, and reports of it with an anomalous origin of the coronary artery are scarce. A 35-year-old male was admitted to our department with fatigue and cough. Multi-detector-row computer tomography（MDCT）revealed an isolated extracardiac right sinus of Valsalva aneurysm with an anomalous origin of the left circumflex artery（LCX）and total occlusion of the right coronary artery（RCA). Its diameter was about 70mm. We performed a partial aortic root remodeling procedure with a trimmed J-graft because he had neither aortic regurgitation（AR）nor annuloaortic ectasia（AAE). Concomitantly, coronary artery bypass grafting to the RCA（Seg.3）using a saphenous vein, and reconstruction of the LCX by Piehler’s technique using a saphenous vein were added. The patient’s postoperative course was uneventful, and he was discharged on the 28th postoperative day. Postoperative MDCT revealed that the aneurysm of the right sinus of Valsalva was not enhanced, and the RCA and LCX were patent. This procedure preserved the patient’s own normal aortic valve and sinus of Valsalva and enables him to have more physiologically normal hemodynamics than aortic root reconstruction using a composite graft, e.g. Bentall procedure, Cabrol procedure, although the potential progression of the AR requires careful follow-up.
    Jpn. J. Cardiovasc. Surg. 41:70-75（2012）
  
  Keywords：right sinus of Valsalva aneurysm, extracardiac, anomalous origin of the coronary artery, aortic regurgitation, partial aortic root remodeling
• A Case of Long Term Survival for Left Ventricular Assist Device Related Mediastinitis with Negative Pressure Wound Therapy Y. Hoshino et al.…76
  A Case of Long Term Survival for Left Ventricular Assist Device Related Mediastinitis with Negative Pressure Wound Therapy

  （Graduate School of Medicine, Department of Cardiac Surgery, and Graduate School of Medicine Therapeutic Strategy for Heart Failure*, The University of Tokyo, Tokyo, Japan）

  Yasuhiro Hoshino	Takashi Nishimura*	Mitsuhiro Kawata
  Masahiko Andou	Osamu Kinoshita	Noboru Motomura
  Arata Murakami	Syunei Kyo*	Minoru Ono

  A 44-year-old man who received left ventricular assist device（LVAD）implantation for end-stage heart failure due to dilated cardiomyopathy suffered from mediastinitis. Computed tomography confirmed mediastinitis. His mediastinum was reopened and irrigated. Negative pressure wound therapy（NPWT）was applied to the wound without closing the chest. This system enabled the patient to receive early physical rehabilitation. One year after LVAD implantation, under NPWT, the patient could walk in the general ward, and was waiting for cardiac transplantation. We used some useful materials for NPWT including a coatable non-alcoholic film, flexible sealing sheet, soft exudate absorber, in order to control wound clean, keep air-tight, prevent damage to the skin and to reduce mediastinal instability. LVAD implantation is usually performed as a bridge to transplantation or recovery. One of the most critical complications is intractable mediastinitis. We described a successful infection control of LVAD related mediastinitis with the NPWT.
    Jpn. J. Cardiovasc. Surg. 41:76-79（2012）
  
  Keywords：LVAD，NPWT，mediastinitis
• Aortic Valve Replacement for Severely Calcified Aorta with SCP and Deep Hypotheramic Circulatory Arrest M. Hatakeyama et al.…80
  Aortic Valve Replacement for Severely Calcified Aorta with SCP and Deep Hypotheramic Circulatory Arrest

  （Department of Cardiovascular Surgery, Aomori Rousai Hospital, Hachinohe, Japan, and Cardiovascular Surgery, Hirosaki Central Hospital**, Hirosaki, Japan）

  Masaharu Hatakeyama*	Yuichi Ono	Mamoru Munakata
  Hiroyuki Itaya**

  A 60-year-old man on chronic hemodialysis was found to have severe aortic stenosis causing refractory atrial fibrillation elected to undergo aortic valve replacement. However, chest CT scan revealed a severely calcified ascending aorta which prevented safe aortic cross-clamping. At operation, arterial cannulation of the systemic circulation was performed to a graft anastomosed to the right axillary artery and venous cannulation to the right atrium. Cardiopulmonary bypass was started and the body was cooled. When a rectal temperature of 25℃ was achieved, cardioplegic solution was administered retrogradely to achieve cardiac arrest and circulatory arrest was performed. Immediately, brachiocephalic artery was clamped and a single selective cerebral perfusion（SCP）was started with right axillary perfusion. In addition, a selective cerebral perfusion was added via the left common carotid artery to maintain adequate flow. After anastomosing the tube graft to the distal ascending aorta, cardiopulmonary bypass was restarted, a clamp was placed on the tube graft, and the patient was rewarmed. The aortic valve was excised and a 21-mm SJM-Regent valve was placed in the intra-annular position. The systemic circulatory arrest time was 18min. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without complications. The ascending aorta replacement described here for the treatment of aortic valve disease in a patient with a severely calcified aorta is safer than deep hypothermic circulatory arrest alone, allowing a shorter circulatory arrest period. In addition, selective cerebral perfusion by right axillary artery anastomosed graft is advantageous in that we can start selective cerebral perfusion promptly by clamping the brachiocephalic artery.
    Jpn. J. Cardiovasc. Surg. 41:80-84（2012）
  
  Keywords：severe calcific ascending aorta, hypothermic circulatory arrest, selective cerebral perfusion, AVR
• A Pleomorphic Rhabdomyosarcoma in the Left Atrium K. Sasaki et al.…85
  A Pleomorphic Rhabdomyosarcoma in the Left Atrium

  （Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan）

  Kenichi Sasaki	Toshihiro Fukui	Susumu Manabe
  Minoru Tabata	Shuichiro Takanashi

  A 47-year-old man was referred to our hospital with acute congestive heart failure. Echocardiography and computed tomography revealed a left atrial tumor obstructing blood flow. An emergency operation was performed to relieve the obstruction. The tumor deeply invaded the posterior wall of the left atrium. We did not completely resect the tumor. The patient was discharged 10 days after surgery without complications. The tumor was diagnosed as pleomorphic rhabdomyosarcoma histopathologically. Adjuvant chemotherapy（cyclophosphamide, vincristine, adriamycin and dacarbazine）was started 23 days after surgery. Although partial remission was achieved, the tumor started to grow after chemotherapy was discontinued because of severe adverse effects. The patient died 11 months after surgery. In this patient, even though complete resection was not done, emergency palliative surgery was effective to treat acute heart failure and to establish a pathologic diagnosis of the tumor. We report this rare case and discuss the therapeutic strategy for primary cardiac sarcomas.
    Jpn. J. Cardiovasc. Surg. 41:85-89（2012）
  
  Keywords：sarcoma, pleomorphic rhabdomyosarcoma, rhabdomyosarcoma
• A Thrombus in the Descending Aorta T. Nonaka et al.…90
  A Thrombus in the Descending Aorta

  （Tokyo Metropolitan Tama Medical Center, Tokyo, Japan）

  Takahiro Nonaka	Mikio Ninomiya	Motoyuki Hisagi
  Toshiya Ohtsuka

  A 49-year-old man complaining of nausea and vomiting was admitted to our hospital for the examinations. Blood tests demonstrated anemia due to iron deficiency and slightly elevated D-dimer. Colonoscopy defected early stage sigmoid colon cancer. Enhanced systemic computed tomography revealed that a 5-cm-long mass was growing along the descending aortic lumen and that multi-embolism had occurred in the peripheral arteries. The limited graft replacement of the descending aorta was carried out under cardiopulmonary bypass to prevent recurrent embolism. Histologically, the mass was a blood clot. In addition, the thickened endothelial lining and slight atheromatous degeneration was detected in the resected aortic wall. The patient was discharged after endoscopic mucosal resection for the sigmoid colon cancer. During the two-year follow-up period, despite no anticoagulation, the patient has developed no thrombus in the aorta and suffered no embolic events.
    Jpn. J. Cardiovasc. Surg. 41:90-94（2012）
  
  Keywords：aorta thrombus, iron deficiency anemia, colon cancer
• Waffle Procedure for a Constrictive Pericarditis as an Emerging Manifestation of Hyper-IgG4 Disease K. Yamashita et al.…95
  Waffle Procedure for a Constrictive Pericarditis as an Emerging Manifestation of Hyper-IgG4 Disease

  （Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara, Japan）

  Keigo Yamashita	Takehisa Abe	Nobuoki Tabayashi
  Yoshiro Yoshikawa	Yoshihiro Hayata	Tomoaki Hirose
  Shun Hiraga	Yoichi Kameda	Yinghao Hu
  Shigeki Taniguchi

  A 74-year-old man presenting with general fatigue and dyspnea was admitted to another hospital. He was transferred to our hospital because his symptoms deteriorated and pericardial fluid increased. The symptoms did not improve even after percutaneous pericardial drainage. On a diagnosis of heart failure due to pericardial constriction, he underwent pericardiectomy. No hemodynamics improvement was found despite subtotal pericardiectomy. Multiple longitudinal and transverse incisions like a waffle were made in the thickened epicardium and improved the hemodynamics. The symptoms improved after sugery. Steroid therapy was effective after pathological examination of the excised epicardium that confirmed an emerging manifestation of hyper-IgG4 disease. We report a waffle procedure with good results for a constrictive pericarditis with hyper-IgG4 disease.
    Jpn. J. Cardiovasc. Surg. 41:95-98（2012）
  
  Keywords：constrictive pericarditis, waffle procedure, hyper-IgG4 disease
• Intravenous Infusion of Tranexamic Acid during Aortic Valve Replacement in a Patient with Indiopathic Thrombocytopenic Purpura M. Hamamoto and D. Futagami…99
  Intravenous Infusion of Tranexamic Acid during Aortic Valve Replacement in a Patient with Indiopathic Thrombocytopenic Purpura

  （Department of Cardiovascular Surgery, JA Onomichi Genaral Hospital, Onomichi, Japan）

  Masaki Hamamoto

  Daisuke Futagami

  An 82-year-old woman, who had suffered from idiopathic thrombocytopenic purpura（ITP）treated with oral steroids, was admitted to our hospital with worsening exertional dyspnea. Cardiac examinations revealed severe aortic stenosis with left ventricular dysfunction. High dose intravenous gammaglobulin therapy（400mg/kg/day）for 5 days was conducted to increase the platelet count prior to the operation. However, a decrease was observed in the platelet count from 2.1×104/mm3 on admission to 1.9×10⁴/mm³ before surgery. Without additional therapy, aortic valve replacement using a 19mm bioprosthesis was performed with cardiopulmonary bypass（CPB). Tranexamic acid（20mg/kg/h）was continuously infused from the skin incision to the end of the surgery. Forty units of the platelet concentrates were transfused just after weaning from CPB. The patient had no hemorrhagic complications. We believe that intraoperative administration of tranexamic acid combined with platelet transfusion is effective to reduce perioperative bleeding for a patient with ITP unresponsive to preoperative gammaglobulin therapy.
    Jpn. J. Cardiovasc. Surg. 41:99-102（2012）
  
  Keywords：idiopathic thrombocytopenic purpura, aortic valve replacement, tranexamic acid, high-dose intravenous gammaglobulin therapy
• Aortic Valve Replacement for a Patient with Left Main Coronary Artery Stenting H. Sakaguchi et al.…103
  Aortic Valve Replacement for a Patient with Left Main Coronary Artery Stenting

  （Department of Cardiovascular Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan）

  Hisashi Sakaguchi	Toshiharu Sassa	Shuji Moriyama
  Takashi Yoshinaga	Ken Okamoto	Ryuji Kunitomo
  Michio Kawasuji

  We report a case of aortic valve replacement using a bioprosthesis after coronary artery stenting in the left coronary main trunk of a 76-year-old man with symptoms of heart failure. Pre-operation studies revealed severe aortic valve regurgitation and that the left main coronary stent protruded into the aorta. Cardiac arrest was obtained with retrograde cardioplegia. Careful observation was made to avoid injury to the aortic bioprosthesis. The postoperative course was uneventful and cardiac echo graphy showed good function of the aortic valve.
    Jpn. J. Cardiovasc. Surg. 41:103-106（2012）
  
  Keywords：aortic valve replacement left main trunk, percutaneous coronary intervention