Japanese Journal of Cardiovascular Surgery Vol.41, No.6

Preface

• M. Kawasuji

Case Reports

• A Case of Minimally Invasive Cardiac Surgery by the Small Right Intercostal Thoracotomy for Left Atrial Myxoma after Substernal Reconstruction of the Esophagus T. Yamabe et al.…285
  A Case of Minimally Invasive Cardiac Surgery by the Small Right Intercostal Thoracotomy for Left Atrial Myxoma after Substernal Reconstruction of the Esophagus

  (Department of Cardiovascular Surgery, Iwaki Kyouritsu Hospital, Iwaki, Japan, and Department of Cardiovascular Surgery, Fukushima Medical University*, Fukushima, Japan)

  Tsuyoshi Yamabe	Shunich Kondo	Jun Hirota
  Hitoshi Yokoyama*

  We report a case of minimally invasive cardiac surgery treated by small right intercostal thoracotomy for left atrial myxoma after substernal reconstruction of the esophagus using gastric interposition. This technique could not only alleviated risk at the second median sternotomy, but was also minimally invasive. A 63-year old man was admitted to our hospital for complaints of right upper limb asthenia and slight fever. Computed tomography showed cerebral infarction. Moreover, cardiac ultrasonography showed a giant myxoma in the left atrium. We thought that it was impossible to reperform median sternotomy, because there was high risk of injury to the reconstructed esophagus using a gastric duct behind the sternum. The patient underwent excision of the myxoma by the right intercostal thoracotomy approach, and did well. He was discharged from the hospital without any complications.
    Jpn. J. Cardiovasc. Surg. 41:285-288（2012）
  
  Keywords：minimally invasive cardiac surgery, left atrial myxoma, substernal reconstruction of the esophagus
• Acute Upper Extremity Ischemia Caused by a Tumor Embolism Y. Yamashita et al.…289
  Acute Upper Extremity Ischemia Caused by a Tumor Embolism

  (Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan)

  Yoshiyuki Yamashita	Sosei Kuma	Atsushi Guntani
  Ryota Fukunaga	Jin Okazaki

  A 52-year-old woman had undergone colectomy and adjuvant chemotherapy for stage IV cecal cancer with peritoneal dissemination and multiple metastases to the lung and liver. After two years of follow-up, she suddenly had right upper limb pain and was reffered to our hospital for treatment of acute upper limb ischemia. Enhanced CT revealed obstruction of the right brachial artery and metastatic lung cancer with pulmonary vein invasion. We performed emergency embolectomy with local anesthesia. The patient’s perioperative course was uneventful. Pathological findings of the removed embolus revealed that it contained adenocarcinoma cells. We concluded that the embolus had originated from the metastatic lung cancer with pulmonary vein invasion.
    Jpn. J. Cardiovasc. Surg. 41:289-292（2012）
  
  Keywords：tumor embolism, acute limb ischemia, colon cancer
• Rupture of Posterior Tibial Artery Aneurysm in a Patient with von Recklinghausen’s Disease M. Inouchi et al.…293
  Rupture of Posterior Tibial Artery Aneurysm in a Patient with von Recklinghausen’s Disease

  (Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Japan)

  Mikito Inouchi	Yu Shomura	Michihiro Nasu
  Yukikatsu Okada

  A 53-year-old woman with von Recklinghausen’s disease was admitted with severe pain and acute right leg swelling. The physical examination revealed neurofibromas and café-au-lait spots, typical of patients with von Recklinghausen’s disease. Computed tomography and ultrasonography showed a rupture of a posterior tibial artery pseudoaneurysm. Since her complaint of pain was severe and because of the rapid progression of pseudoaneurysm, we performed an emergency operation. Under general anesthesia with the pneumatic tourniquet technique, both of the proximal and distal sides of the posterior tibial artery were ligated, and the pseudoaneurysm was resected. The postoperative course was uneventful. She was given an ambulatory discharge 26 days after operation. Histological examination revealed spindle-shaped cells infiltrating the aneurysmal wall. We diagnosed this is a vascular lesion of von Recklinghausen’s disease.
    Jpn. J. Cardiovasc. Surg. 41:293-295（2012）
  
  Keywords：von Recklinghausen disease, peripheral arterial aneurysm, neurofibroma
• A Case of Venous Thromboembolism in Which a Tubular Thrombus Was Trapped in a Foramen Ovale K. Inoue et al.…296
  A Case of Venous Thromboembolism in Which a Tubular Thrombus Was Trapped in a Foramen Ovale

  （Department of Cardiovascular Surgery, Mie General Medical Center, Mie, Japan）

  Kentarou Inoue	Chiaki Kondou	Ryo Maeshiro
  Hitoshi Suzuki

  A 37-year-old man had been hospitalized at another hospital where he was being treated for encephalitis. Early one morning, the patient had sudden precordial chest pain and dyspnea, so he was examined further. Contrast-enhanced CT revealed filling defects in both pulmonary arteries and in the right and left atria, indicating acute pulmonary embolism. Cardiac ultrasound revealed thrombi floating in the right and left atria, and the patient displayed pulmonary hypertension（estimated pressure:50mmHg). Since scattering of thrombi in the left atrium carried the risk of arterial embolism, emergency surgery was performed at this hospital. An incision was made in the right atrium with the heart stopped, revealing a tubular thrombus trapped in the foramen ovale. The trapped thrombus was completely removed, and the patient’s life was saved since arterial embolism, e.g. paradoxical cerebral embolism, did not occur. This case involved a rare pathology and is thus reported here together with a discussion of the literature.
    Jpn. J. Cardiovasc. Surg. 41:296-298（2012）
  
  Keywords：acute pulmonary embolism, foramen ovale, encephalitis
• Mitral Valve Replacement for Recurrent and Multiple Cerebral Embolisms Caused by Mitral Annular Calcification M. Sugano et al.…299
  Mitral Valve Replacement for Recurrent and Multiple Cerebral Embolisms Caused by Mitral Annular Calcification

  （Department of Cardiovascular Surgery, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan）

  Mikio Sugano	Tatsuo Motoki	Hirotsugu Kurobe
  Homare Yoshida	Taisuke Nakayama	Hajime Kinoshita
  Tamotsu Kanbara	Eiki Fujimoto	Takashi Kitaichi
  Tetsuya Kitagawa

  A 69-year-old woman had syncope and aphasia. Magnetic resonance imaging showed multiple cerebral infarctions in both hemispheres. Cardiogenic embolisms were suspected, but no arrhythmic causes were shown. Transesophageal echocardiography revealed a highly calcified mitral annulus（MAC）with a rough intraluminal surface and mild mitral regurgitation, but no thrombus or tumor in the left heart system. However, recurrent multiple cerebral embolisms occurred in spite of strict anticoagulation therapy. We speculated that spontaneous rupture of the MAC was the cause of the scattered cerebral embolisms, and we therefore planned to remove the MAC as safely as possible and to endothelialize the deficit of MAC with autologous pericardium. Operative findings revealed that the MAC in P2-P3 had ruptured longitudinally and the ostium of the left atrium was connected to the ostium of the left ventricle as an inter-atrioventricular tunnel beneath the posterior mitral annulus with a fragile calcified wall. The finding suggested that calcified particles that had peeled away from the MAC by normal heart beating resulted in the cerebral infarctions. Therefore, she underwent resection of the MAC and mitral valve replacement with reinforcement of the decalcified posterior mitral annulus between the posterior left ventricular wall and the left atrial wall using autologous pericardium, which enabled both appropriate insertion of a mechanical prosthetic valve and endothelial continuity covering the surface of the residual MAC. No systemic embolism has occurred for two and a half years after surgery. This is the first case report of cerebral embolism caused by a spontaneously ruptured MAC.
    Jpn. J. Cardiovasc. Surg. 41:299-303（2012）
  
  Keywords：mitral annular calcification, multiple cerebral infarctions, cardiogenic embolism
• Laparotomy for Acute Cholecystitis after Extracorporeal Left Ventricular Assisted System Implantation S. Matsuyama et al.…304
  Laparotomy for Acute Cholecystitis after Extracorporeal Left Ventricular Assisted System Implantation

  （Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University, Fukuoka, Japan）

  Sho Matsuyama	Hiromichi Sonoda	Yuuta Yamaki
  Yasuhisa Oishi	Yoshihisa Tanoue	Takahiro Nishida
  Atsuhiro Nakashima	Yuichi Shiokawa	Ryuji Tominaga

  A 37-year-old man presented with extensive myocardial infarction due to total occlusion of the left main trunk, complicated with near-fatal heart failure. An extracorporeal left ventricular assisted system LVAS（NIPRO-Toyobo LVAS）was implanted in our hospital. Although his postoperative course was relatively good, acute cholecystitis occurred on the 31stpostoperative day, and emergeney cholecystectomy was indicated. His PT-INR was 4.13 because of taking Warfarin orally, and the cannulas of LVAS passed through his skin at the subxiphoid region. Therefore, we preoperatively transfused fresh frozen plasma quickly to reverse the PT-INR（approximately 2.0）and performed open cholecystectomy via the right side of the para-rectus abdominal muscle. His postoperative course was uneventful, and he is waiting for heart transplantation in our hospital.
    Jpn. J. Cardiovasc. Surg. 41:304-307（2012）
  
  Keywords：extracorporeal LVAS, cholecystectomy, anticoagulation, fresh frozen plasma
• Aortic and Mitral Valve Replacements in a Patient with Extensive Calcification of Intervalvular Fibrous Body M. Funamoto et al.…308
  Aortic and Mitral Valve Replacements in a Patient with Extensive Calcification of Intervalvular Fibrous Body

  （Department of Cardiovascular Surgery, Kyoto University Hospital, Kyoto, Japan）

  Masaki Funamoto	Kenji Minakata	Kazuhiro Yamazaki
  Senri Miwa	Akira Marui	Hiroyuki Muranaka
  Fumie Takai	Motonori Kumagai	Takahiro Nakahara
  Ryuzo Sakata

  Extensive calcification of the mitral annulus presents a formidable technical challenge to surgeons and increases the risk of serious complications such as intractable hemorrhage, atrioventricular disruption, and ventricular rupture during mitral valve surgery. We present a case of aortic and mitral valve replacements for a patient with extensive calcification of an intervalvular fibrous body. A 76-year-old woman was admitted with dyspnea on effort, leg edema and syncope. Transthoracic echocardiography showed severe aortic stenosis, and mitral stenosis with regurgitation, and extensive mitral annular calcification. Decalcification was performed with CUSA and we selected a trans-aortic-valve approach for decalcification of the intervalvular fibrous body. The calcification was left to a certain extent in order to preserve annular strength. Postoperative echocardiography showed no perivalvular leakage from either prostheses. The patient was transferred to a local hospital for further rehabilitation.
    Jpn. J. Cardiovasc. Surg. 41:308-311（2012）
  
  Keywords：mitral annular calcification, intervalvular fibrous body, cavitron ultrasonic surgical aspirator, trans-aortic-valve approach, mitral valve replacement
• A Case Report of Mycotic Aneurysm Following Intravesical Bacillus Calmette-Gue´rin Instillation Therapy for Bladder Cancer Y. Kioka et al.…312
  A Case Report of Mycotic Aneurysm Following Intravesical Bacillus Calmette-Gue´rin Instillation Therapy for Bladder Cancer

  （Department of Cardiovascular Surgery Fukuyama City Hospital, Fukuyama, Japan）

  Yukio Kioka

  Atsushi Tanabe

  Mitsuhito Kuriyama

  Bacillus Calmette-Guérin（BCG）intravesical instillation therapy for bladder cancer is accepted as an effective treatment, and infectious complications are rare. We present a case report on a patient with a common iliac pseudoaneurysm and a recurrent mycotic thoracoabdominal aortic aneurysm, who had a history of previous BCG therapy for bladder cancer. A 64-year-old man underwent emergency graft interposition of the right common iliac artery due to a ruptured pseudoaneurysm. Nine months after initial surgery, a biopsy of the pelvic retroperitoneal collection revealed epithelioid granuloma with caseous necrosis. Ziehl-Neelsen stain and mycobacterial culture were positive for acid-fast bacilli, which was identified as BCG（Tokyo 172). Diagnosis of BCG infection was delayed because of lack of clear clinical evidence of persistent infection. After 6 months of antituberculous chemotherapy the patient underwent resection of the mycotic thoracoabdominal aortic aneurysm and in situ reconstruction with a branched Dacron graft soaked in rifampicin because of its rapid growth. The pathological diagnosis was infectious aneurysm with sclerosis and epithelioid granuloma, however, acid-fast stain and culture were negative. Nine months later CT showed no recurrence of infectious aneurysm. Because the clinical presentation of BCG mycotic aneurysm is different from bacterial or fungal mycotic aneurysm, diagnosis by means of medical history checking and clinical presentation, in addition to surgical and medical combined treatment are important for its management.
    Jpn. J. Cardiovasc. Surg. 41:312-315（2012）
  
  Keywords：infectious aneurysm, bladder cancer, BCG
• A Case of Loeys-Dietz Syndrome That Caused Rapid Enlargement of the Distal Aortic Arch Following Aortic Surgery for Acute Type A Aortic Dissection T. Yoshinaga et al.…316
  A Case of Loeys-Dietz Syndrome That Caused Rapid Enlargement of the Distal Aortic Arch Following Aortic Surgery for Acute Type A Aortic Dissection

  （Department of Cardiovascular Surgery, International University of Health and Welfare Hospital, Nasushiobara, Japan, Department of Cardiovascular Surgery, Kumamoto Rosai Hospital*, Yatsushiro, Japan, and Department of Cardiovascular Surgery, Kumamoto University Hospital**, Kumamoto, Japan）

  Takashi Yoshinaga	Ryuji Kunitomo	Shuji Moriyama*
  Ken Okamoto**	Hisashi Sakaguchi**	Hirokazu Tazume**
  Michio Kawasuji**

  Loeys-Dietz syndrome（LDS）is characterized by vascular findings（aortic aneurysms and dissections）and skeletal manifestations. Since aortic dissection occurs at smaller aortic diameters than observed in Marfan syndrome, early and aggressive surgery is recommended for patients with LDS. A 45-year-old man who underwent aortic valve replacement for aortic regurgitation at the age of 33 was transferred to our hospital with the diagnosis of acute aortic dissection. We performed emergeny ascending aortic replacement, and suspected LDS because of his specific physical characteristics after surgery. His postoperative course was uneventful, however, computed tomography（CT）performed at 2 weeks after operation showed the new entry at the distal anastomotic site, patent false lumen of the descending aorta and rapid enlargement of the distal aortic arch. Therefore, we performed total arch replacement with the elephant trunk method at 3 weeks after the emergency operation. Mutation of the TGFBR2 gene was found and we finally diagnosed LDS. One year after, complete thrombosis of the false lumen of the descending aorta and decrease in size of the distal aortic arch was observed by CT.
    Jpn. J. Cardiovasc. Surg. 41:316-319（2012）
  
  Keywords：Loeys-Dietz syndrome, acute aortic dissection, gene mutation analysis
• A Case of Redo Aortic Valve Replacement by Right Minithoracotomy Approach with Port Access for Aortic Valve Stenosis after Coronary Artery Bypass Grafting T. Tokuda et al.…320
  A Case of Redo Aortic Valve Replacement by Right Minithoracotomy Approach with Port Access for Aortic Valve Stenosis after Coronary Artery Bypass Grafting

  （Department of Cardivascular Surgery, Iwakuni Clinical Center, Iwakuni, Japan, and Department of Cardiovascular Surgery, Kameda Medical Center*, Kamogawa, Japan）

  Takanori Tokuda	Takashi Murakami*	Yuki Yamada
  Takashi Yamamoto	Satoru Oya

  We report a case of redo aortic valve replacement by right minithoracotomy approach for aortic stenosis after coronary artery bypass grafting（CABG). An 81-year-old man was followed-up once a year for 9 years after CABG. He complained of increasing respiratory distress, showed narrowing of the aortic valve area, elevation of the aortic valve pressure gradient, and tricuspid valve regurgitation by echocardiography. He was admitted for surgery. We considered minimally invasive operation would be better for him and performed aortic valve replacement（Carpentier-Edwards Perimaunt valve 19mm）by a right minithoracotomy approach because graft injury could occur by median sternotomy after CABG, and he had the risks of advanced age, low activities of daily living, and mild dementia. His postoperative course was uneventful. On echocardiography performed at postoperative days 9, the ejection fraction recovered to 75% from 53% before surgery and the mean aortic valve pressure gradient was 8mmHg. He was discharged on postoperative day 12. Right minithoracotomy approach with port access is a good option for redo operation for aortic valve stenosis after CABG.
    Jpn. J. Cardiovasc. Surg. 41:320-322（2012）
  
  Keywords：aortic valve replacement, right thoracotomy, post CABG, aortic valvular stenosis, minimally invasive surgery
• A Case of Successful Hybrid Treatment for Chronic Type B Dissection in a Patient with Bilateral Occlusion of Iliac Arteries Y. Kishimoto et al.…323
  A Case of Successful Hybrid Treatment for Chronic Type B Dissection in a Patient with Bilateral Occlusion of Iliac Arteries

  （Division of Organ Regeneration Surgery, Department of Surgery, Tottori University School of Medicine, Yonago, Japan）

  Yuichiro Kishimoto	Munehiro Saiki	Yoshinobu Nakamura
  Yoshikazu Fujiwara	Suguru Shiraya	Takeshi Oonohara
  Yuki Ohtsuki	Satoru Kishimoto	Motonobu Nishimura

  Hybrid techniques to enable endovascular treatment of complex aortic pathology have been previously described. A staged endograft repair of a complex, chronic Stanford type B aortic dissection with atherosclerotic occlusion of bilateral iliac arteries is reported in a 66-year-old man. The patient also had chronic obstructive lung disease as well as chronic renal dysfunction. The aneurysmal portion of the dissection extended from the distal arch to the entire thoracic aorta. Bilateral femoral arteries were bypassed from the abdominal aorta using open techniques. Then, total arch replacement with a frozen elephant trunk was performed through median sternotomy. Finally, the aneurysmal portion was completely covered with an endograft from the frozen elephant trunk to the upper abdominal aorta, just proximal to the celiac trunk. The patient had no neurologic complications. This case report illustrates the feasibility of the hybrid technique in selected high-risk patients when confronted with complex aortic pathology.
    Jpn. J. Cardiovasc. Surg. 41:323-326（2012）
  
  Keywords：chronic dissection, endovascular treatment, hybrid treatment

Editor’s Postscript

• G.Matsumiya