Japanese Journal of Cardiovascular Surgery Vol.42, No.2

Preface

• T. Tashiro

Original

• The Effectiveness of Left Side Pericardiotomy in Off-Pump Coronary Artery Bypass Grafting A. Aoki et al.…83
  The Effectiveness of Left Side Pericardiotomy in Off-Pump Coronary Artery Bypass Grafting

  （Cardiovascular Surgery, Kagawa Prefectural Central Hospital, Takamatsu, Japan, and Present address:Cardiovascular Surgery, Showa University*, Tokyo, Japan）

  Atsushi Aoki*	Takanori Suezawa	Mitsuhisa Kotani
  Shu Yamamoto	Mamoru Tago

  In off-pump coronary artery bypass grafting（OPCAB), adequate exposure under stable hemodynamic condition is mandatory. We introduced left side pericardiotomy to expose the left anterior descending artery without lifting up the ventricle in 2008. With this pericardiotomy approach, the exposure of the circumflex and right coronary artery territory became easier and OPCAB with left side pericardiotomy was compared with OPCAB with midline pericardiotomy. From 2004 to 2011, 194 elective first time coronary artery bypass grafting（CABG）were performed in our hospital. Before 2008, 62 patients underwent OPCAB with midline pericardiotomy which constituted 61% of the CABG in that period. After 2008, the pericardium was dissected on the left side and a small pericadiotomy was made on the left side of the main pulmonary artery. This incision was then extended to the apex. With this pericardiotomy, only two patients underwent CABG with cardiopulmonary bypass（one patient with 15% left ventricle ejection fraction and one more patient who developed acute coronary syndrome during anesthesia induction). Thus 91 out of 93 patients underwent OPCAB（98%）（Group L). In Group L, old myocardial infarction and unstable angina patients were frequent. The frequency of the patients with left ventricular ejection fraction less than 40% tended to be more in Group L. The operation time was significantly shorter in Group L（Group M 305±71 min, Group L 223±54, p＜0.0001）and the number of distal anastomoses number was significantly more in Group L（Group M 2.3±0.7, Group L 2.8±1.0, p＜0.0001). Blood pressure during left circumflex coronary artery and right coronary artery anastomosis was significantly higher in Group L, and even continuous dopamine infusion requirement was significantly less in Group L（92% in Group M, 13% in Group L, p＜0.001）among the patients with left ventricle ejection fraction less than 60%. There was only 1 hospital death in Group M. Postoperative maximum CK-MB was significantly lower in Group L（Group M 48±107 IU/l, Group L 13±16 IU/l, p＝0.005）and the patients with CK-MB more than 12 IU/l was significantly frequent in Group M（Group M 73%, Group L 33%, p＜0.0001). Postoperative ICU and hospital stay period was significantly shorter in Group L（ICU stay:Group M 3.4±2.3 days, Group L 2.0±1.4 days, p＜0.0001, hospital stay:Group M 27±21 days, Group L 16±7 days, p＜0.0001). The patency of the graft to the left anterior descending artery did not differ significantly（Group M 94%, Group L 99%), however the patencies of the grafts to left circumflex artery and right coronary artery were significantly better in Group L（left circumflex artery:Group M 75%, Group L 98%, p＝0.001, right coronary artery:Group M 81%, Group L 98%, p＝0.014). Left side pericardiotomy seemed to be useful because OPCAB with left side pericardiotomy yielded shorter operation time, less myocardial enzyme release, improved postoperative recovery and better patency of graft to the left circumflex and right coronary artery.
    Jpn. J. Cardiovasc. Surg. 42:83-88（2013）
  
  Keywords：off pump coronary artery bypass grafting, left side pericardiotomy
• Morphological Type and Histological Features of the Dilated Ascending Aorta in Patients with a Bicuspid Aortic Valve Y. Yoshioka et al.…89
  Morphological Type and Histological Features of the Dilated Ascending Aorta in Patients with a Bicuspid Aortic Valve

  （Department of Cardiovascular Surgery, and Department of Surgical Pathology*, Hyogo College of Medicine, Nishinomiya, Japan）

  Yoshiteru Yoshioka	Masataka Mitsuno	Mitsuhiro Yamamura
  Hiroe Tanaka	Masaaki Ryomoto	Shinya Fukui
  Noriko Tsujiya	Tetsuya Kajiyama	Yuji Miyamoto
  Hiroyuki Hao*

  Bicuspid aortic valve（BAV）is one of the more common congenital anomalies. It is well known that the ascending aorta and aortic root sometimes dilate in patients with BAV, even when the valve function is normal. We examined the morphological type and histological features of the dilated ascending aorta in patients with BAV. Of 276 patients who underwent aortic valve replacement（including coronary artery bypass grafting）from 2004 onwards, 60（21.5%）with BAV were included in this study. The type of BAV was defined according to the Sievers classification. Type 1 BAV was the most common, and enlargement of the ascending aorta（≧45mm）was the most common in the L/R type of BAV（48%). The morphology of the dilated ascending aortic wall was evaluated using three-dimensional CT angiography. The majority of dilations were asymmetric, but dilation was symmetric in the patient with dilation of the aortic root. Histological examination graded cystic medial necrosis of the ascending aortic walls using the aortic wall score. All patients with BAV had degeneration of the aortic wall, even when there was no dilation. The aortic walls of patients with dilated aortic roots showed advanced degeneration compared with the aortic walls of other patients. Therefore, aggressive root replacement may be appropriate, when the root is mildly dilated in patient with BAV.
    Jpn. J. Cardiovasc. Surg. 42:89-93（2013）
  
  Keywords：bicuspid aortic valve（BAV), dilated ascending aorta, aortic wall score
• Usefulness of JapanSCORE―Comparative Study of the Usefulness of the JapanSCORE and the Logistic EuroSCORE N. Umehara et al.…94
  Usefulness of JapanSCORE―Comparative Study of the Usefulness of the JapanSCORE and the Logistic EuroSCORE

  （Department of Cardiovascular Surgery, Tokyo Wemen’s University, Tokyo, Japan）

  Nobuhiro Umehara	Satoshi Saito	Hiroyuki Tsukui
  Kenji Yamazaki

  Risk analysis models are becoming more important in various aspects of the clinical setting. We have used the logistic EuroSCORE as a risk analysis model, but there is divergence between the model and actual clinical reality in our country. The Japan Score is a risk model based on the Japan Adult Cardiovascular Surgery Database and it is considered to be better reflect from Japanese clinical results. We compared the logistic EuroScore（ES）and Japan Score（JS）and their predictive accuracy, using our clinical results. Between October 2006 and June 2011, 733 operations suitable for evaluation by the Japan Score were performed at our institute. Isolated coronary artery bypass grafting（CABG）was performed in 151 cases, valve surgery（Valve）in 346 cases and aortic surgery（Aorta）in 236 cases. In these cases we calculated 30-day mortality using the EuroSCORE and JapanSCORE and compared the results and prediction accuracy, by calculating the receiver operating characteristic curve（ROC curve）and the area under the ROC curve（AUC). We also calculated 30-day mortality and morbidity by the JapanSCORE and analyzed it by the same method. In the entire group, logistic 30-day mortality by ES and JS was 7.28 and 4.05% respectively. The AUC was 0.740 and 0.806, while 30-day mortality and morbidity calculated by JS was 17.72% and the AUC was 0.646. In the CABG group the 30-day mortality by ES and JS was 5.7 and 3.18% respectively, the AUC was 0.636 and 0.770, the 30-day mortality and morbidity was 13.37% and the AUC was 0.631. In the Valve group 30-day mortality by ES and JS was 6.00 and 3.79% respectively. The AUC was 0.715 and 0.794, 30-day mortality and morbidity was 17.54% and the AUC was 0.606. In the Aorta group 30-day mortality was 10.17 and 4.99% respectively. The AUC was 0.720 and 0.827. The 30-day mortality and morbidity was 20.83% and the AUC was 0.640. The 30-day mortality calculated by JS was significantly lower than that of ES（p＜0.001). The prediction accuracy of both of the ES and the JS was satisfactory but the prediction accuracy of JS was better than that of the ES. The prediction accuracy of the logistic 30-day mortality and morbidity were not as accurate as 30-day mortality. JS was a good risk analysis model not only for prediction of surgical results but also for improving surgical outcome.
    Jpn. J. Cardiovasc. Surg. 42:94-102（2013）
  
  Keywords：JapanSCORE, EuroSCORE, risk analysis model
• Early and Mid-term Outcomes of Endoscopic Saphenous Vein Harvesting in Coronary Artery Bypass Grafting S. Matsuyama et al.…103
  Early and Mid-term Outcomes of Endoscopic Saphenous Vein Harvesting in Coronary Artery Bypass Grafting

  （Department of Cardiovascular Surgery, Teikyo University Hospital, Tokyo, Japan, and Department of Cardiovascular Surgery, Sakakibara Heart Institute*, Tokyo, Japan）

  Shigefumi Matsuyama	Toshihiro Fukui*	Minoru Tabata*
  Nobuhiko Hiraiwa*	Akihito Matsushita*	Kenichi Sasaki*
  Shuichiro Takanashi*

  In this study, we report early and mid-term outcomes of endoscopic saphenous vein（SV）harvesting（EVH）for coronary artery bypass grafting. EVH is expected to have superior cosmetic results and fewer wound complications than conventional open techniques. EVH was performed in 262 patients from April 2008 to December 2010. From September 2010, we have administered heparin before EVH to prevent intraluminal SV clot formation. The mean age of the patients was 70±7.3 years, and 178（67.9%）patients were men. The success rate of EVH was 97.3%. Hospital mortality was 1.2%. Postoperative wound complications occurred in only 7（2.8%）patients. The early and mid-term patency was 95.8%（276/288）and 74.2%（187/252), respectively, as evaluated by postoperative angiography or computed tomography. Comparing the mid-term patency rate between the groups with or without systemic heparinization before EVH, statistical significance was not observed, but the mid-term patency was good in the group with systemic heparinization（82.5% vs. 73.6%，p＝0.16). Actuarial 1-year and 3-year survival were 93.9% and 79%. Actuarial 1-year and 3-year major adverse cardiac event-free rates were 92.2% and 77.5%. In 10 patients who had SV graft occlusion during the observation period, percutaneous coronary intervention was required for the native coronary artery. EVH has great cosmetic advantages and has a good early patency. However, the mid-term patency is not satisfactory. Thus, systemic heparinization before EVH, improvement of the device and further clinical experience and techniques are required to improve the mid-term and late patency.
    Jpn. J. Cardiovasc. Surg. 42:103-107（2013）
  
  Keywords：great saphenous vein, endoscopic graft harvesting, graft patency rate, wound complications
• The Risk Factors of Surgical Site Infection after Valvular Heart Surgery N. Shinkai et al.…108
  The Risk Factors of Surgical Site Infection after Valvular Heart Surgery

  （Department of Nursing, and Department of Cardiovascular Surgery*, Kobe City Medical Center General Hospital, Kobe, Japan, and Aichi Medical University, College of Nursing**, Nagakute, Japan）

  Noriko Shinkai	Yu Shomura*	Yukikatsu Okada*
  Matsuko Doi**

  Surgical Site Infection（SSI）is one of the most serious post-operative complications and therefore its prevention is extremely important. SSI risk factors were evaluated in 337 cardiac valvular surgical cases without concomitant CABG or the thoracic great vessels interventions which had been performed in our center between January 2008 and December 2010. The Center for Disease Control and Prevention definition of SSI was used for case determination. The SSI incidence was 4.7%（16 cases). Univariate analysis found statistical significance in history of cardiac surgery, LVEF, surgical procedures, operative time and morning glucose level on post-operative days（POD）1 and 2. POD 1 morning glucose level higher than 150mg/dl（odds ratio 4.2;95% confidence interval 1.3-13.7）and operative time（odds ratio 2.0;95% CI 1.2-3.5）were identified as independent factors by multiple logistic regression. According to SSI rate comparison by glucose-level, the incidence was higher when POD 2 morning glucose level exceeded 150mg/dl as in the case of POD 1（p＜0.02). Longer operative time represented higher SSI rates in interquartile range-based comparison. This study suggested values of reducing surgical time and controlling POD 1 morning glucose level within 150mg/dl.
    Jpn. J. Cardiovasc. Surg. 42:108-113（2013）
  
  Keywords：cardiac valvular surgery, surgical site infection, risk factor, post-operative glucose level
• Effect of a Renal Protection Protocol on the Renal Function after Endovascular Aortic Aneurysm Repair A. Aoki et al.…114
  Effect of a Renal Protection Protocol on the Renal Function after Endovascular Aortic Aneurysm Repair

  （Department of Cardiovascular Surgery, and Department of Radiology*, Kagawa Prefectural Central Hospital, Takamatsu, Japan, and Present address:Cardiovascular Surgery, Showa University**, Tokyo, Japan）

  Atsushi Aoki**	Takanori Suezawa	Mitsuhisa Kotani
  Shu Yamamoto	Jun Sakurai*

  Endovascular aortic aneurysm repair using stent graft（SG）for both thoracic and abdominal aortic aneurysms（SG therapy）rapidly became widespread in Japan because of its relatively low invasiveness. Pre- and postoperative contrast enhanced CT are mandatory in SG therapy and angiography is required during SG therapy. Therefore contrast induced nephropathy（CIN）might occur after SG therapy. In our hospital, a renal protection protocol（oral N-acetylcysteine, perioperative normal saline infusion and bicarbonate infusion during SG therapy）was introduced in June 2010. In this report, the effect of the renal protection protocol on renal function after SG therapy was evaluated. During May 2008 and March 2012, 229 patients underwent SG therapy in our hospital. Serum creatinine（CRTN）was higher than 1.5 mg/dl and estimated glomerular filtration rate（eGFR）was less than 50ml/min/1.73m²in 26 patients. In these 26 patients, the renal protection protocol was applied in 15 patients（group P）and group P was compared with the 11 patients without renal protection protocol（group N). Also the relationship between CIN occurrence and preoperative renal function was evaluated in 192 patients who did not receive the renal protection protocol. CIN was defined as more than 25% or 0.5mg/dl increase of CRTN based on the European Guidelines. As renal protection protocol, N-acetylcysteine（600mg）was given 4 times every 12 h. Normal saline infusion was started on the evening of the day before surgery at the rate of 50ml/h and was continued until 1h before surgery. Sodium bicarbonate solution（151mEq/l）was started 1 h before surgery at the rate of 180ml/h and the infusion rate was decreased to 60ml/h during surgery. After surgery, 1,000ml of normal saline was given at a rate of 60ml/h. In group N, CRTN increased 1 and 3 days after SG therapy and returned to baseline level 6 days after SG therapy. On the other hand, CRTN was lower than baseline after SG therapy in group P. At 3 days after SG therapy, the percent change of CRTN component with baseline level was significantly lower in group P（14.5±19.1% in group N, －3.7±15.8% in group P, p＝0.014). CIN occurrence tended to be more in group N（45% in group N, 7% in group P, p＝0.054). Among the 192 patients without the renal protection protocol, CIN occurred in 16 patients（29.1%）out of 55 patients with preoperative CRTN≧1.0mg/dl and eGFR≦50ml/min/1.73m², however CIN occurred in only 1 patient（0.7%）among 137 patients with preoperative renal function out of this range（p＜0.001). Renal protection protocol seemed to be effective to prevent CIN after SG therapy. Renal protection might be useful for patients with a CRTN≧1.0mg/dl and eGFR≦50ml/min/1.73m².
    Jpn. J. Cardiovasc. Surg. 42:114-119（2013）
  
  Keywords：endovascular surgery, stent graft, contrast media, kidney failure, renal function

Case Reports

• Successful Repair of Tricuspid Valve Endocarditis in a Drug Abuser H. Uchida et al.…120
  Successful Repair of Tricuspid Valve Endocarditis in a Drug Abuser

  （Depatrment of Cardiovascular Surgery, Osaka Medical College Hospital, Takatsuki, Japan）

  Hiroaki Uchida	Hayato Konishi	Yoshikazu Motohashi
  Mari Kakita	Eiki Woo	Tomoyasu Sasaki
  Shigetoshi Mieno	Masahiro Daimon	Hideki Ozawa
  Takahiro Katsumata

  This case report describes a 20-year-old man, who was a drug abuser, and was treated surgically for tricuspid valve endocarditis. He presented with fever, caused by tricuspid valve endocarditis with a lung abscess. Blood culture detected Staphylococcus aureus and cardiac ultrasonography showed tricuspid insufficiency and tricuspid valve vegetation. He was treated with intravenous antibacterial agents, but the inflammation signs did not improve. He had a large number of puncture scars, as a consequence of self-injection of drugs in his lower arm. He underwent tricuspid valve plasty, and recovered successfully. He was discharged 2 weeks after surgery, and we instructed him to return for follow-up examination in our hospital. However, he did not return to our hospital because he was arrested for drug possession. In such cases, it is necessary to consider the operative method relative to reuse of drugs in the postoperative management of medication.
    Jpn. J. Cardiovasc. Surg. 42:120-123（2013）
  
  Keywords：tricuspid valve endocarditis, drug abuser, tricuspid valve annuloplasty
• Collagen Gel Droplet-Embedded Culture Drug Sensitivity Test（CD-DST）for a Leiomyosarcoma Originating in the Inferior Vena Cava N. Kondo et al.…124
  Collagen Gel Droplet-Embedded Culture Drug Sensitivity Test（CD-DST） for a Leiomyosarcoma Originating in the Inferior Vena Cava

  （Department of Surgery II, Kochi Medical School, Nangoku, Japan）

  Nobuo Kondo	Masaki Yamamoto	Hideaki Nishimori
  Takashi Fukutomi	Seiichiro Wariishi	Kazuki Kihara
  Miwa Tashiro	Kazumasa Orihashi

  The collagen gel droplet-embedded culture drug sensitivity test（CD-DST）identifies effective anticancer drug using resected tumor specimen, enabling tailor-made chemotherapy for a rare tumor. We report a case of the patient with leiomyosarcoma originating in the inferior vena cava, to which CD-DST was applied. This application has not been previously reported to the best of our knowledge. A 61-year-old woman consulted a nearby hospital because of abdominal pain. Computed tomography revealed an inferior vena cava tumor. The tumor was resected with the inferior vena cava, which was reconstructed with a 16mm ePTFE graft. The tumor was diagnosed as leiomyosarcoma histopathologically. CDDP, VP-16, ADR, and VDS were CD-DST showed the tumor to be sensitive. Her postoperative course has been good without recurrence of tumor for 6 months, and the results of CD-DST may be helpful for chemotherapy strategy in case of recurrence.
    Jpn. J. Cardiovasc. Surg. 42:124-127（2013）
  
  Keywords：leiomyosarcoma in the inferior Vena cava, CD-DST, reconstruction of inferior Vena cava, anticancer drug sensitive test
• A Case of Ruptured Cryopreserved Homograft 7 Months after Implantation Y. Inoue et al.…128
  A Case of Ruptured Cryopreserved Homograft 7 Months after Implantation

  （Department of Cardiovascular Surgery, Teinekeijinkai Hospital, Sapporo, Japan）

  Yosuke Inoue	Ryoshi Maruyama	Yukio Hasegawa
  Eiichiro Hata	Akira Yamada	Katsuhiko Nakanishi
  Keisuke Sakai

  Infectious abdominal aortic aneurysm is a relatively rare disease, and there is no consensus regarding its surgical treatment. Medical infectious control should be concerned comparison with surgical treatment if there is sepsis, however we sometimes have no other choice but emergency operation for uncontrollable cases. In many reports, cryopreserved homografts were used as in-situ alternative grafts for infectious aortic aneurysms because they had some merits such as anti-infectious effects, suitability and so on. However the number of in-situ cryopreserved homograft replacement cases are few, and the long term result is unclear. We encountered a ruptured cropreserved homograft case 7 months after urgent in-situ cryopreserved homograft replacement. We report the case and refer to the relevans literature.
    Jpn. J. Cardiovasc. Surg. 42:128-131（2013）
  
  Keywords：cryopreserved homograft, infectious aortic aneurysm
• A Case of Thoracic Endovascular Aortic Repair with Fenestrated Stentgraft for Ulcer-like Projection of the Proximal Anastomosis after Total Arch Replacement for Acute Type A Aortic Dissection after Open Heart Surgery S. Yamamoto et al.…132
  A Case of Thoracic Endovascular Aortic Repair with Fenestrated Stentgraft for Ulcer-like Projection of the Proximal Anastomosis after Total Arch Replacement for Acute Type A Aortic Dissection after Open Heart Surgery

  （Department of Cardiovascular Surgery, and Department of Radiology*, Kagawa Prefectural Central Hospital, Takamatsu, Japan）

  Shu Yamamoto	Atsushi Aoki	Takanori Suezawa
  Mitsuhisa Kotani	Mamoru Tago	Jun Sakurai*

  We report a case of thoracic endovascular aortic repair（TEVAR）with a fenestrated stent graft for ulcer-like projection（ULP）of the proximal anastomosis after total arch replacement（TAR）for acute type A aortic dissection（DAA). A 73-year-old woman with a history of surgical resection of a left atrial myxoma in January 2009 underwent TAR for DAA in November 2011. The contrast enhanced CT（CE-CT）72 days after TAR revealed two ULPs anterior and posterior to the proximal anastomosis. Surgical repair would be difficult because of the history of cardiac and aortic surgery, therefore TEVAR with a fenestrated stent graft was performed. The postoperative course was uneventful and she was discharged on the 8th postoperative day. The CE-CT 3 months after TEVAR showed almost completely thrombosed ULPs. Endovascular repair with fenestrated stent graft for the proximal anastomotic ULP can be a useful and effective treatment.
    Jpn. J. Cardiovasc. Surg. 42:132-136（2013）
  
  Keywords：type A aortic dissection, ulcer-like projection, thoracic endovascular aortic repair, fenestrated stent graft
• A Case of Tricuspid Leaflet Augmentation for Severe Secondary Tricuspid Regurgitation K. Ono and H. Kuroda…137
  A Case of Tricuspid Leaflet Augmentation for Severe Secondary Tricuspid Regurgitation

  （Department of Cardiovascular Surgery, San-in Rousai Hospital, Yonago, Japan）

  Kimiyo Ono

  Hiroaki Kuroda

  A 71-year old woman, who underwent direct closure of an atrial septal defect with mild tricuspid regurgitation（TR）18 years previously, suffered terminal cardiac failure with extreme cardiomegaly, mitral regurgitation and severe TR. Medical treatment gradually became ineffectual and we decided to perform surgical therapy. Mitral annuloplasty with a prosthetic ring, tricuspid valve repair, plications of extended bilateral atrium walls and epicardial ventricular pacemaker implantation were performed. In tricuspid valve repair, anterior tricuspid leaflet was augmented by use of glutaraldehyde-preserved autologus pericardial patch and tricuspid annuloplasty with addition of a slightly larger prosthetic ring. Atrio-ventricular regurgitations disappeared and she was discharged 63 days after the operation. Valve extension is a very effective technique to treat severe secondary TR, and long term follow-up is necessary.
    Jpn. J. Cardiovasc. Surg. 42:137-140（2013）
  
  Keywords：tricuspid regurgitation, leaflet augmentation, autologus pericardial patch, ring annuloplasty, tricuspid valve repair
• A Giant Celiac Aneurysm with Acute Aortic Dissection and Idiopathic Thrombocytonenic Purpura Y. Toyoda et al.…141
  A Giant Celiac Aneurysm with Acute Aortic Dissection and Idiopathic Thrombocytonenic Purpura

  （Department of Cardiovascular Surgery, Saiseikai Maebashi Hospital, Maebashi, Japan, and Department of Cardiovascular Surgery, Tokyo Wemen’s Medical University*, Tokyo, Japan）

  Yasuyuki Toyoda	Kenji Suzuki	Takuya Maeda
  Masakuni Ishiyama	Shigeyuki Aomi*

  We report a rare case of a giant celiac aneurysm complicated with nosocomial acute aortic dissection and idiopathic thrombocytonenic purpura（ITP). A 75-year-old man with ITP complained of abdominal swelling. Enhanced computed tomography（CT）showed a giant celiac aneurysm 72mm in size. Surgery repair was scheduled and platelet count increased by intravenous administration of immunoglobulin. After admission, he complained of back pain. CT showed aortic dissection（DeBakey classification:IIIb）and a celiac aneurysm enlarged to 78mm. He underwent surgical repair for a giant celiac aneurysm and splenectomy after management with medial therapy.
    Jpn. J. Cardiovasc. Surg. 42:141-144（2013）
  
  Keywords：giant celiac aneurysm, acute aortic dissection, idiopathic thrombocytonenic purpura
• Lung Metastasis of Renal Cell Carcinoma Extended into the Left Atrium S. Nakaji…145
  Lung Metastasis of Renal Cell Carcinoma Extended into the Left Atrium

  （Department of Cardiovascular Surgery, Nagasaki University Hospital, Nagasaki, Japan, and Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences*, Nagasaki, Japan）

  Shun Nakaji	Koji Hashizume	Tsuneo Ariyoshi
  Yoichi Hisada	Kazuyoshi Tanigawa	Takashi Miura
  Seiji Matsukuma	Mizuki Sumi	Toshiyuki Nakayama*
  Kiyoyuki Eishi

  We report an extremely rare case of renal cell carcinoma（RCC）extending into the left atrium through the pulmonary vein next to lung metastasis. The patient was a 76-year-old man. Extirpation of the RCC in the right kidney was carried out. Metastasis to the lungs, mediastinal lymph nodes and the pubis were diagnosed and 4 years later, a myxoma-like tumor was formed in the left atrium by echocardiography. We extirpated of the tumor. During surgery, continuity with the metastatic lesion in the right lung, right inferior pulmonary vein and the left atrium was suggested. Histopathologic examination showed the same histopathology as seen in the RCC.
    Jpn. J. Cardiovasc. Surg. 42:145-147（2013）
  
  Keywords：left atrium tumor, renal cell carcinoma, pulmonary vein, left atrium myxoma
• A Case of Aortic Valve Papillary Fibroelastoma with Atrial Septal Defect H. Kanda…148
  Lung Metastasis of Renal Cell Carcinoma Extended into the Left Atrium

  （Department of Cardiovascular Surgery, Nagasaki University Hospital, Nagasaki, Japan, and Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences*, Nagasaki, Japan）

  Shun Nakaji	Koji Hashizume	Tsuneo Ariyoshi
  Yoichi Hisada	Kazuyoshi Tanigawa	Takashi Miura
  Seiji Matsukuma	Mizuki Sumi	Toshiyuki Nakayama*
  Kiyoyuki Eishi

  We report an extremely rare case of renal cell carcinoma（RCC）extending into the left atrium through the pulmonary vein next to lung metastasis. The patient was a 76-year-old man. Extirpation of the RCC in the right kidney was carried out. Metastasis to the lungs, mediastinal lymph nodes and the pubis were diagnosed and 4 years later, a myxoma-like tumor was formed in the left atrium by echocardiography. We extirpated of the tumor. During surgery, continuity with the metastatic lesion in the right lung, right inferior pulmonary vein and the left atrium was suggested. Histopathologic examination showed the same histopathology as seen in the RCC.
    Jpn. J. Cardiovasc. Surg. 42:145-147（2013）
  
  Keywords：left atrium tumor, renal cell carcinoma, pulmonary vein, left atrium myxoma
• Endovascular Repair with a Fenestrated Stent Graft for Kommerell’s Diverticulum with a Right Aortic Arch Y. Tamiya et al.…151
  Endovascular Repair with a Fenestrated Stent Graft for Kommerell’s Diverticulum with a Right Aortic Arch

  （Department of Cardiovascular Surgery, Otaru Municipal Medical Center, Otaru, Japan, and Department of Emergency Medicine, Sapporo Medical University*, Sapporo, Japan）

  Yukihiko Tamiya	Johji Fukada	Yasuaki Fuzisawa
  Yosihiko Kurimoto*

  A 77-year-old man with an abnormal shadow on chest x-ray film, was found to have Kommerell’s diverticulum associated with a right aortic arch 2 years previously. During the period of follow-up, the Kommerell’s diverticulum was expanded to 5.3cm in diameter. CT revealed a right aortic arch with mirror-image branching and Kommerell’s diverticulum. To eliminate the risk of rupture, the Kommerell’s diverticulum was excluded by deployment of a handmade fenestrated stent-graft using the brachial wire traction technique via the right femoral artery and left brachial artery. At 30-months of follow-up the patient is doing well, with no signs of endoleak or migration. Endovascular repair of Kommerell’s diverticulum with a right aortic arch is feasible, safe and effective. This is a rare case of a right aortic arch with Kommerell’s diverticulum and without left aberrant subclavian artery.
    Jpn. J. Cardiovasc. Surg. 42:151-154（2013）
  
  Keywords：right aortic arch, Kommerell’s diverticulum, endovascular repair using a fenestrated stent-graft
• A Case Report of Atrio-Esophageal Fistula Caused by Percutaneous Transcatheter Ablation of Atrial Fibrillation S. Nakayama et al.…155
  A Case Report of Atrio-Esophageal Fistula Caused by Percutaneous Transcatheter Ablation of Atrial Fibrillation

  （Department of Cardiovascular Surgery, Osaka Red Cross Hospital, Osaka, Japan）

  Shogo Nakayama

  Kazuhisa Sakamoto

  Megumi Ito

  A 66-year-old man underwent percutaneous transcatheter ablation of the myocardium to treat chronic atrial fibrillation. Fifteen days after the procedure, he visited our hospital with a chief complaint of hematemesis. At that time, upper gastrointestinal endoscopy led to a diagnosis of esophageal ulcer. Oral food intake was suspended for approximately 1 month. Subsequently, 4 days after resumption of oral intake, he developed multiple cerebral infarcts. Moreover, massive hematemesis occurred, with resultant shock and cardiopulmonary arrest. At this point, a definitive diagnosis of left atrio-esophageal fistula resulting from the injury relating to the transcatheter ablation was made. Cardiopulmonary resuscitation was carried out, followed by emergency surgery. The operation was performed via median sternotomy and was done under cardiac arrest using complete extracorporeal bypass, and the fistula in the posterior left atrial wall and the middle esophagus were directly sutured for closure. Unfortunately, 3 days after this open heart surgery, the patient died from low cardiac output syndrome and multiple organ failure. Although rare, this complication may be fatal when it develops then its prevention is important. Once atrio-esophageal fistula develops after percutaneous transcatheter ablation, immediate surgical intervention seems essential.　
    Jpn. J. Cardiovasc. Surg. 42:155-158（2013）
  
  Keywords：percutaneous transcatheter ablation, left atrio-esophageal fistula, complication, hematemesis
• Stanford Type A Acute Aortic Dissection Case Caused by Blunt Chest Trauma H. Saisho et al.…159
  Stanford Type A Acute Aortic Dissection Case Caused by Blunt Chest Trauma

  （Department of Surgery, Kurume University Medical School, Kurume, Japan）

  Hiroyuki Saisho	Satoru Tobinaga	Yuichiro Hirata
  Kumiko Wada	Ryusuke Mori	Tomokazu Ohno
  Atsuhisa Tanaka	Shinichi Hiromatsu	Hidetoshi Akashi
  Hiroyuki Tanaka

  A 31-year-old man fell into syncope caused by compression by a machine in his factory. He was taken to the nearest hospital at once for treatment. His chest X-ray seemed normal and his general condition improved. He received no medical treatment and was allowed to return home. Two days later, he went to the hospital for further investigation, and contrast-enhanced chest computed tomography（CT）was performed. Chest CT showed aortic dissection from the ascending aorta to the aortic arch. Therefore, he was admitted for bed rest with antihypertensive therapy. He was discharged on the 35th day after the accident. However, the diameter of the ascending aorta was found to have become dilated, and so he underwent ascending aorta and hemiarch replacement at our hospital. His postoperative course was uneventful, and he was discharged on the 16th postoperative day. We report a rare case of an acute aortic dissection caused by blunt chest trauma.
    Jpn. J. Cardiovasc. Surg. 42:159-162（2013）
  
  Keywords：blunt chest trauma，traumatic aortic dissection，Stanford Type A
• A Case of Double Valve Replacement due to Prosthetic Valve Dysfunction after Infective Endocarditis A. Kagoshima and S. Takahashi…163
  A Case of Double Valve Replacement due to Prosthetic Valve Dysfunction after Infective Endocarditis

  （Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan, and Department of Cardiovascular Surgery, Hoshi General Hospital*, Koriyama, Japan）

  Akihito Kagoshima

  Shoichi Takahashi*

  A 56-year-old woman was admitted due to a cerebral hemorrhage two years after undergoing aortic valve replacement, mitral valve annuloplasty, and tricuspid valve annuloplasty. During treatment, she developed infective endocarditis. Although this was successfully treated conservatively, a surgical approach was subsequently adopted due to progressive mitral stenosis. Echocardiography revealed gradual proliferation of abnormal tissue overhanging the mitral valve around the prosthetic mitral annularring, as well as increased flow velocity in the artificial aortic valve. The cause of the increased flow velocity could not be determined on echocardiography. However, multidetector computed tomography revealed abnormal subprosthetic tissue that obstructed the opening and closing of the prosthetic aortic valve. Resection of the abnormal tissue and double valve replacement were performed. Prosthetic valve dysfunction due to pannus proliferation is relatively rare（around 1-2%), but it should be considered as a potential long-term postoperative complication. Though turbulent flow has been suggested as a potential cause, the exact etiology remains unknown. Furthermore, the disease course may be fulminant or gradual and symptomatic, leading to difficulties with diagnosis. A case of double valve replacement conducted for valve dysfunction due to abnormal tissue proliferation occurring two years after aortic valve replacement, mitral valve annuloplasty, and tricuspid valve annuloplasty followed by infective endocarditis is reported, along with a review of the related literature.
    Jpn. J. Cardiovasc. Surg. 42:163-167（2013）
  
  Keywords：valve obstruction, pannus, infective endocarditis, multi detecter computed tomography
• A Simple Modified Infarct Exclusion Technique for a Patient with Large Ventricular Septal Perforation K. Hisamoto et al.…168
  A Simple Modified Infarct Exclusion Technique for a Patient with Large Ventricular Septal Perforation

  （Department of Cardiovascular Surgery, Kameda Medical Center, Chiba, Japan）

  Kazuhiro Hisamoto	Masaaki Toyama	Masanori Katoh
  Yuji Kato	Yukiharu Sugimura

  A 79 year-old woman was given a diagnosis of acute myocardial infarction and was immediately transferred to our hospital by a helicopter. Cardiologists successfully revascularized the occluded left anterior descending artery which was considered to be the care of this case. After that, they detected a large ventricular septal perforation by transthoracic echocardiography. We performed repair of the ventricular septal perforation 4 days later, with a modified infarct exclusion technique. Residual shunt flow was not seen by echocardiography after the operation. This patient recovered uneventfully and was discharged on postoperative day 55.
    Jpn. J. Cardiovasc. Surg. 42:168-171（2013）
  
  Keywords：ventricular septal perforation, VSP, modified infarct exclusion technique

Editor's Postscript

• M. Ono