Japanese Journal of Cardiovascular Surgery Vol.42, No.5

Preface

• Y. Matsui

President Lecture

• The Japanese Society for Cardiovascular Surgery:The Year 2020 Y. Ueda…349

Review

• Hospital Management by the Cardiovascular Surgeon Y. Okamura…356

Originals

• Late Aortic Reoperation Following Routine Transverse Arch Replacement for Type A Acute Aortic Dissection M. Takamatsu et al.…359
  Late Aortic Reoperation Following Routine Transverse Arch Replacement for Type A Acute Aortic Dissection

  （Department of Cardiovascular Surgery, Tokyo Saiseikai Central Hospital, Tokyo, Japan）

  Masanori Takamatsu	Takashi Hirotani	Satoshi Ohtsubo
  Shigeyuki Takeuchi

  We assessed the late aortic reoperation after surgery for type A acute aortic dissection（AAAD). Subjects were 108 consecutive patients with AAAD who underwent surgery by routine aortic arch replacement using geratin-resorcin-formalin-glutaraldehyde（GRF）glue between January 1996 and December 2010. Seven of the 94 patients who were discharged after the initial repair of AAAD required reoperation for the residual aorta. Reoperations included 4 procedures on the distal aorta and 3 procedures on the proximal aorta（aortic root or ascending aorta）at a mean interval of 6.1±3.5（0.9～13.7）years after initial surgery. There were no hospital reoperation-related deaths. Freedom from reoperation was 96% and 89% at 5 and 10 years. In conclusion, the use of GRF glue may influence the risk of reoperation after surgery for AAAD, but our results showed that there were very few of such cases. Furthermore, routine aortic arch replacement for AAAD may reduce late aortic reoperations after surgery by eliminating possible risks of residual tear at the transverse arch.
    Jpn. J. Cardiovasc. Surg. 42:359-363（2013）
  
  Keywords：acute type A dissection, aortic arch grafting, reoperation, geratin-resorcin-formalin-glutaraldehyde glue
• Early Results of Endoscopic Saphenous Vein Harvesting in Coronary Artery Bypass Grafting H. Seo et al.…364
  Early Results of Endoscopic Saphenous Vein Harvesting in Coronary Artery Bypass Grafting

  （Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Fukui, Japan）

  Hiroyuki Seo	Yasushi Tsutsumi	Osamu Monta
  Satoshi Numata	Sachiko Yamazaki	Shohei Yoshida
  Hirokazu Ohashi

  Recently, with the advent of medical devices and minimally invasive operations, endoscopic saphenous vein harvesting（EVH）in coronary artery bypass grafting has been widely accepted. Although EVH has short-term advantages of less wound morbidity and better cosmetic results compared with open vein harvesting（OVH), several studies have demonstrated that the mid- and long-term patency rate of EVH veins is significantly lower than that of OVH veins, therefore the role of EVH is currently controversial. The purpose of this study was to investigate the early results of EVH compared with the OVH group. Between April 2011 and December 2012, 115 consecutive patients underwent coronary artery bypass grafting（CABG）in our institution. Of these, EVH was performed in 62 patients and OVH in 53. In EVH groups, all 50 patients were men, and mean age was 71.3±7.8 years. A total of 211 coronary anastomoses, 109 SVGs anastomoses were assessed for patency postoperatively by angiography or enhanced computed tomography before discharge. The mean vein harvesting time was 26.0±8.1 min, and the mean number of ostial branch tear was 0.34±0.59. The overall SVG patency rates at discharge were 95.4% in EVH and 92% in OVH, respectively（p＝0.24). There was a significant reduction in the incidence of leg wound complications in the EVH group（EVH:1.6%;OVH:13.2%;p＝0.038). In conclusion, the short-term result of EVH was satisfactory. EVH reduces leg wound complications compared with OVH.
    Jpn. J. Cardiovasc. Surg. 42:364-368（2013）
  
  Keywords：CABG, SVG, endoscopic vein harvesting, graft patency rate, wound complication
• Invited Commentary I. Yamanaka…369
• Surgical Results of Valvular Disease in Hemodialysis Patients H. Saisho et al.…371
  Surgical Results of Valvular Disease in Hemodialysis Patients

  （Department of Cardiovascular Surgery, Kurume University, Kurume, Japan）

  Hiroyuki Saisho	Koichi Arinaga	Takahiro Shojima
  Yuichiro Hirata	Takanori Kono	Koji Akasu
  Tomokazu Kosuga	Hiroshi Tomoeda	Hidetoshi Akashi
  Hiroyuki Tanaka

  Background:The Japanese Society for Dialysis Therapy in 2011 reports that the number of hemodialysis patients has been increasing and that there is an increase in long-term hemodialysis patients and the aging of hemodialysis induction. Therefore, it can be expected that the number of valve surgeries in chronic hemodialysis patients will increase. However, there are many problems between chronic hemodialysis and valve surgery. Objectives:To describe the results of valve surgery in chronic hemodialysis patients at our institution and evaluate the selection of prosthetic valve and associated problems. Methods:Between January 2001 and June 2011, a total of 29 patients on chronic hemodialysis including 3 patients for re-operation, underwent valve replacements. The average age was 67.3±9.3 years and 17（65%）were men. The average dialysis duration was 7.9±6.4 years. The etiologies of renal failure were 8 for chronic glomerulonephritis（31%), 8 for nephrosclerosis（31%） and 3 for diabetic nephropathy（12%). Results:There were 2（7.7%）in-hospital deaths, which resulted from ischemia of intestine and multiple organ failure due to heart failure. Twelve（46%）patients died during the follow-up period and the 5-year survival rate after surgery was as poor as another authors have reported previously（30.6%). However, the 5-year survival rate after hemodialysis introduction was 87.1%, which was better than the report of the Japanese Society for Dialysis Therapy in 2011（60%). Average age was significantly higher in bioprosthetic valves than in mechanical valves（p＝0.02). There was no significant difference in survival rate among mechanical and bioprosthetic valves（p＝0.75). There was no significant difference in valve-related complication free rate among mechanical（27.5%） and bioprosthetic valves（23.4%）（p＝0.9). Three patients with mechanical valves had cerebral hemorrhage, and 1 patient with bioprosthetic valve had structural valve deterioration. Conclusions: Surgical result of valvular disease in hemodialysis patients was as poor as another authors reported previously（5-year survival rate:30.6%), but survival rate after hemodialysis introduction was not very poor（87.1%). There was no significant difference in survival rate among mechanical and bioprosthetic valves. Bioprosthetic valve has the risk of reoperation due to early structural valve deterioration, but there was no significant difference in valve-related complication free rates. Therefore, we should select prosthetic valve in consideration of individual cases.
    Jpn. J. Cardiovasc. Surg. 42:371-376（2013）
  
  Keywords：valvular disease, hemodialysis, prosthetic valve
• Preventing Surgical Site Infection in Cardiovascular Surgery:Cooperation between the Infection Control Team and Surgeons Y. Shomura et al.…377
  Preventing Surgical Site Infection in Cardiovascular Surgery:Cooperation between the Infection Control Team and Surgeons

  （Department of Cardiovascular Surgery, and Infection Control Team＊, Kobe City Medical Center General Hospital, Kobe, Japan）

  Yu Shomura	Yukikatsu Okada	Noriko Shinkai＊
  Michihiro Nasu	Hiroshi Fujiwara	Tadaaki Koyama
  Mitsuru Yuzaki	Takashi Murashita	Naoto Fukunaga
  Yasunobu Konishi

  Postoperative infections should be comprehensively controlled in the context of infection control, rather than as activities of individual surgeons. We started a surgical site infection（SSI）surveillance program in 2009 in which prophylactic measures for preventing SSIs were applied. These measures were as follows:1）screening for nasal carriage of methicillin-resistant Staphylococcus aureus;2）dental checks and oral screening;3）antibiotic prophylaxis in the intra- and postoperative period;4）control of glucose levels to ≦160mg/dl in the immediate postoperative period;and 5）early removal of surgical drain. After the introduction of prophylactic measures, we reexamined SSI surveillance and added the following prophylactic measures at the beginning of 2011:6）data concerning SSI and compliance with prophylactic measures for all surgical and ward staff were published monthly, and the Infection Control Team（ICT）and surgeons performed weekly ward visits to assess SSIs;7）recommendations were made for wearing two pairs of gloves and surgical hoods to cover the hair, scalp, ears and neck;and 8）collaboration with diabetologists was implemented to control glucose levels in diabetics. We compared incidences of SSI in cardiovascular surgery from the periods before（469 cases, Group B）and after（118 cases, Group A）introduction of the additional prophylactic measures. Clinical characteristics of patients in each group did not differ significantly. Operative time was significantly shorter in Group A（400±116min）than in Group B（434±145min). Compliance with antibiotic prophylaxis in the intraoperative period improved progressively from 93% in Group B to 99% in Group A. Compliance with control of glucose levels to ≦160mg/dl on postoperative day 1 improved progressively from 71% in Group B to 81% in Group A. Duration of drain placement was significantly shorter in Group A（2.9±1.8days）than in Group B（3.6±2.9days). Incidence of SSI decreased significantly from 6.0% in Group B to 0.8% in Group A. Revision of preventive measures based on the results of surveillance and enhancement of cooperation between the ICT and surgeons could help to decrease the incidence of SSI.
    Jpn. J. Cardiovasc. Surg. 42:377-383（2013）
  
  Keywords：cardiovascular surgery, surgical-site infection, infection control team, surveillance, compliance with SSI prophylactic measures
• Preoperative Assessment of Small Saphenous-Type Varicose Veins by Three-Dimensional CT Venography with Dual-Route Injection K. Sato et al.…384
  Preoperative Assessment of Small Saphenous-Type Varicose Veins by Three-Dimensional CT Venography with Dual-Route Injection

  （Department of Cardiovascular Surgery, National Hospital Organization, Higashi-Hiroshima Medical Center, Higashi-Hiroshima, Japan, Department of Cardiovascular Surgery, Kochi Medical School Hospital＊, Nankoku, Japan, Department of Thorac-Cardiovascular Surgery, Hiroshima Prefectural Hospital＊＊, Hiroshima, Japan, and Department of Cardiovascular Surgery, Hiroshima University Hospital＊＊＊, Hiroshima, Japan）

  Katsutoshi Sato	Kazumasa Orihashi＊	Satoru Morita
  Kenji Okada＊＊	Norimasa Mitsui＊＊	Katsuhiko Imai＊＊＊
  Naomichi Uchida＊＊＊	Taijiro Sueda＊＊＊

  The saphenopopliteal junction（SPJ）is found at various levels and has various patterns compared with the saphenofemoral junction. Although this can cause difficulty in the surgical treatment of varicose veins and affect the outcome, there have been few reports on preoperative assessment of the small saphenous vein（SSV）regarding this point. This study was undertaken to evaluate three-dimensional CT venography with dual-route injection for the preoperative assessment of a small saphenous-type varicose vein. We examined a total of 15 legs in 15 patients with a small saphenous-type varicose vein, which were preoperatively evaluated by CT venography and then surgically treated. The patients included 4 men and 11 women with ages ranging from 50 to 80 years old（mean age, 66 years). The grading of varicose veins according to the CEAP classification was C2, C3, C4, and C5 in 3, 4, 6 and 2 legs, respectively. The CT imaging was performed with contrast medium diluted ten-fold, which was injected into the great and small saphenous veins simultaneously. CT venography clearly visualized the lower extremity veins. Whereas the popliteal vein coursed deep above the level of the femoral intercondylar groove, it followed a shallow course below the level of the knee joint. In 11 legs（74%), the SPJ was located in the shallow portion, whereas it was in the deep portion in 4 legs（26%). Among the former group, the SSV was connected to the great saphenous vein via the Giacomini vein in 2 cases, and the gastrocnemius vein was connected to the SSV before the SPJ in 3 cases. Among the latter group, a localized large venous aneurysm with thrombus before its termination was found in one case. In another case, the SSV showed branched termination in the deep portion. Our three-dimensional CT venography with dual-route injection provides more accurate information on venous anatomy in the lower extremity. The accuracy of images acquired by CT venography with dual-route injection was verified by intraoperative findings. Although Doppler ultrasound is essential for examining the presence of regurgitation in the veins and locating the course of a varicose vein in the surgical field, all 15 cases had scheduled surgery under local anesthesia based on accurate preoperative diagnosis. This study suggests that CT venography with dual-route injection is beneficial in preventing undesired complications during surgery and avoiding additional procedures for recurrent varicose veins.
    Jpn. J. Cardiovasc. Surg. 42:384-390（2013）
  
  Keywords：CT venography, small saphenous vein, saphenopopliteal junction

Case Reports

• Endovascular Repair of a Secondary Aortoenteric Fistula M. Aoki et al.…391
  Endovascular Repair of a Secondary Aortoenteric Fistula

  （Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Japan）

  Masaya Aoki	Masato Yoshida	Hirohisa Murakami
  Soichiro Henmi	Shunsuke Matsushima	Naritomo Nishioka
  Naoto Morimoto	Tasuku Honda	Keitaro Nakagiri
  Nobuhiko Mukohara

  A 71-year-old man who had undergone repair of a ruptured abdominal aortic aneurysm with a tube graft 3 months ago was transferred from another hospital with an Aortoenteric Fistula（AEF）for surgical treatment. Computed tomographic（CT）angiography revealed pseudoaneurysm formation at the proximal anastomotic site. Waiting for the elective operation, he developed massive hematemesis with shock. Endovascular stent-graft repair was emergently performed because of high risk for conventional open surgery. Gastrointestinal bleeding was successfully controlled. The psuedoaneurysm disappeared, which was confirmed by postoperative CT angiography. At 1-year follow-up, he has shown no clinical and radiographic evidence of recurrent infection or bleeding. For the case with shock, Endovascular repair could be a bridge to open surgery because it is fast and minimally invasive. Endovascular repair of AEF is technically feasible and may be the definitive treatment in selected patients without signs of infection and gastrointestinal bleeding.
    Jpn. J. Cardiovasc. Surg. 42:391-394（2013）
  
  Keywords：Aortoenteric Fistula, endovascular aneurysm repair（EVAR), abdominal aortic aneurysm（AAA）
• A Case of Cardiac Angiosarcoma with Superior Vena Cava Syndrome F. Mizuno et al.…395
  A Case of Cardiac Angiosarcoma with Superior Vena Cava Syndrome

  （Department of Cardiovascular Surgery, Kanazawa Medical University, Ishikawa, Japan）

  Fumito Mizuno	Toshiaki Akita	Koichi Morioka
  Naofusa Mikami	Yasuhisa Noguchi	Takashi Kobata
  Hiroo Shikata

  A 31-year-old woman was admitted to our hospital with a sudden onset of chest pain and dyspnea. Echocardiography, chest CT, and chest MRI revealed a huge mass in the right atrium. She underwent pericardial drainage to alleviate cardiac tamponade. Emergency surgery was performed because of superior vena cava syndrome and the risk of tricuspid valve obstruction by the mass. The tumor was resected en bloc, including the right atrial wall and a large segment of the proximal superior vena cava. The right atrium was then reconstructed with a Xenomedica patch and the superior vena cava was reconstructed using an expanded polytetrafluoroethylene（ePTFE）vascular graft. The pathological diagnosis was haemangiosarcoma. Cardiac angiosarcoma is a rare tumor, and its prognosis is very poor. The patient could survive for about 5 months after surgical resection.   Jpn. J. Cardiovasc. Surg. 42:395-398（2013）
  
  Keywords：cardiac angiosarcoma, superior vena cava syndrome, cardiac tamponade
• A Case of Left Ventricular Rupture during Mitral Valve Reconstruction N. Mitsui et al.…399
  A Case of Left Ventricular Rupture during Mitral Valve Reconstruction

  （Department of Cardiovascular and Thoracic Surgery, Hiroshima, Japan）

  Norimasa Mitsui	Yoshiharu Hamanaka	Kenji Okada
  Makoto Hamaishi	Shinji Hirai

  Left ventricular rupture is one of the critical complications that can occur during cardiac surgeries, often during a mitral valve replacement. We report a case in which we encountered a left ventricular rupture during a mitral valve reconstruction after completing use of a cardiopulmonary bypass. A 58-year-old man was found to have a cardiac murmur during a health check-up, and visited a nearby hospital where he was given a diagnosis of severe mitral valve regurgitation due to a prolapsed mitral valve by an echocardiographic examination. Under a median sternotomy, a cardiopulmonary bypass was established, and we reconstructed chordae tendineae with Gore-Tex suture and placed an annuloplasty ring to repair the mitral valve. Weaning from the cardiopulmonary bypass was simple, but bleeding inside the pericardium increased during the following hemostasis and we found an oozing area in the left ventricular posterior wall, which was diagnosed as a left ventricular rupture. The patient was placed back on cardiopulmonary bypass, and we closed the ruptured area by tucking it with felt strips while the heart was beating and reinforced it with a fibrin sheet, PGA sheet, and fibrin glue. We then inserted IABP. The hemodynamic condition was stable afterwards and IABP was removed on the 7th day. The patient developed an atrial flutter on the 13th day, which was drug resistant, and we performed a radiofrequency ablation. The patient fully recovered and was discharged on the 44th postoperative day. Considering factors such as excess resection of papillary muscle, failure of mitral loop due to a resection of papillary muscle, excess resection of annulus tissue, excess traction of papillary muscle, damage to the left ventricular inner wall by suction tubes, or excess load on the left ventricle when removing a cardiopulmonary bypass as possible causes, we think very careful maneuvers are required and important even in a mitral valve reconstruction.
    Jpn. J. Cardiovasc. Surg. 42:399-402（2013）
  
  Keywords：left ventricular rupture, mitral valve reconstruction
• Three Cases of Graft Replacement of Distal Arch Aneurysm after Open-Stent Graft Technique due to Stent Migration and Endoleak N. Masaki et al.…403
  Three Cases of Graft Replacement of Distal Arch Aneurysm after Open-Stent Graft Technique due to Stent Migration and Endoleak

  （Division of Cardiovascular Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan）

  Naoki Masaki	Manabu Fukasawa	Shuji Toyama
  Yu Kawahara	Yuichi Inage

  Exposure of the surgical field and bleeding control are main problems of distal anastomosis during an operation for distal arch aneurysms. The open-stent technique and thoracic endovascular aortic repair（TEVAR）are useful techniques for the resolution of these problems. Recently, TEVAR has progressively expanded in the treatment of various complex thoracic aortic diseases. However, complications such as endoleaks and graft migrations have still remained an issue. Although some patients who have late distal endoleaks can be almost treated successfully with additional TEVAR, some of them cannot. We report 3 cases of graft replacement of descending aorta after open-stent technique due to stent migrations and endoleaks. All of them were previously performed by total arch replacement with open-stent technique for distal aortic arch aneurysms. The follow-up CT after the first operation revealed graft migrations and endoleaks. The open surgical repairs through left lateral thoracotomy were performed, followed by graft replacements. The stent grafts were easily clamped after the incision of the aneurysm. In 2 cases, grafts were directly anastomosed to the descending aorta after the removal of the stent. In 1 case, graft was extended with new graft and then anastomosed to the descending aorta. These procedures were technically successful;there were no trouble to exfoliate aorta, to perform anastomosis and hemostasis, and neither patient developed major complications. These results indicate that open surgical repair of descending aorta could be one of the safety options for the treatment of endoleaks and stent migrations of thoracic aortic stent graft in the era of increasing endovascular therapy.
    Jpn. J. Cardiovasc. Surg. 42:403-407（2013）
  
  Keywords：open stent, endoleak, stent migration, TEVAR
• A Case of Infective Thoracoabdominal Aortic Aneurysm with Rapid Expansion during Steroid Therapy for Retroperitoneal Fibrosis S. Akuzawa et al.…408
  A Case of Infective Thoracoabdominal Aortic Aneurysm with Rapid Expansion during Steroid Therapy for Retroperitoneal Fibrosis

  （Department of Cardiovascular Surgery, Fujieda Municipal General Hospital, Fujieda, Japan）

  Satoshi Akuzawa	Naoyuki Ishigami	Kazuchika Suzuki

  A 66-year-old man who suffered from intermittent abdominal and back pain underwent medical examinations at our hospital. A high value of leukocyte, inflammatory reaction and IgG4 was detected, and computed tomography demonstrated that there was thickened soft tissue around the abdominal aorta which extended to the superior mesenteric artery and the renal arteries. He was given a diagnosis of retroperitoneal fibrosis, and prednisolone（PSL）was administered. Although the decrease in thickness of the soft tissue around the aorta was seen, the enlargement of the aorta mainly near the orifice of the celiac artery was shown. We were consulted on this thoracoabdominal aortic aneurysm（Crawford type IV）at this time, and considered that this aneurismal change had occurred secondary to chronic periaortitis. In a few weeks, the rapid expansion of this aneurysm was occurred, so we planned early surgical treatment after tapering of PSL. He underwent graft replacement of thoracoabdominal aorta with rifampicin-bonded graft, because the infection could not be denied as a cause of this aneurysmal change. Although Streptococcus pneumoniae was detected in the specimens from the periaortic tissue, false lumen and aortic wall in the culture test, he had a good post operative course with prolonged antibiotic therapy.
    Jpn. J. Cardiovasc. Surg. 42:408-411（2013）
  
  Keywords：infective aortic aneurysm, rifampicin-bonded graft, inflammatory aortic aneurysm, chronic periaortitis, retroperitoneal fibrosis
• Aortic Root Replacement with a Valve Sparing Technique for Quadricuspid Aortic Valve K. Yamanaka et al.…412
  Aortic Root Replacement with a Valve Sparing Technique for Quadricuspid Aortic Valve

  （Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan）

  Katsuhiro Yamanaka	Atsushi Omura	Shiori Shirasaka
  Shunsuke Miyahara	Yoshikatsu Nomura	Toshihito Sakamoto
  Takeshi Inoue	Hitoshi Minami	Kenji Okada
  Yutaka Okita

  A 67-year-old man with ascending aortic aneurysm was referred to our hospital. Transthoracic echocardiography showed severe aortic regurgitation with annuloaortic ectasia and transesophageal echocardiography revealed a quadricuspid aortic valve. This patient underwent aortic root replacement with a valve sparing technique. Under deep hypothermic circulatory arrest with retrograde cerebral perfusion, replacement of the ascending aorta was successfully performed. The postoperative course was uneventful. This patient is doing well 6 months after surgery without recurrence of aortic regurgitation.
    Jpn. J. Cardiovasc. Surg. 42:412-415（2013）
  
  Keywords：quadricuspid aortic valve, aortic root replacement with a valve sparing technique, valve repair, annuloaortic ectasia
• A Case Report of Papillary Muscle Rupture after Mitral Valve Replacement with Preservation of Whole Subvalvular Apparatus J. Iemura et al.…416
  A Case Report of Papillary Muscle Rupture after Mitral Valve Replacement with Preservation of Whole Subvalvular Apparatus

  （Department of Cardiovascular Surgery, Okanami General Hospital, Iga, Japan）

  Junzo Iemura	Yoshio Yamamoto	Atushi Kambara
  Kohsuke Fujii

  Preservation of subvalvular mitral apparatus and maintenance of continuity between structures and annulus is recognized, and widely accepted as a significant factor for avoiding impairment to ventricular function and preventing left ventricular rupture during mitral valve replacement. However, we encountered a patient who developed posteromedial papillary muscle rupture following chordal sparing mitral valve replacement. The patient was a 67-year-old man who underwent mitral valve replacement with a porcine bioprosthesis 29M for acute mitral valve insufficiency due to several spontaneous chordal ruptures. The subvalvular apparatus of both leaflets was retained, the center of the anterior leaflet was excised elliptically, and the entire posterior leaflet was preserved. Although his postoperative course was uneventful, the transthoracic echocardiogram showed a floating structure prolapsing through the aortic valve in the left ventricle synchronizing with the cardiac cycle. The severed papillary muscle was removed successfully via an aortotomy through the native aortic valve on the 57th day after the first surgery. The patient recovered with no events. Surgeons should consider avoiding an excessive tension on the preserved chordae and delivering a cardioplegia sufficiently and uniformly during mitral valve replacement.
    Jpn. J. Cardiovasc. Surg. 42:416-419（2013）
  
  Keywords：mitral valve replacement, rupture of papillary muscle, preservation of chordae, chordal sparing mitral valve replacement, subvalvural apparatus
• A Case of Cardiac Angiosarcoma Successfully Treated with Postoperative Conformal Dynamic Arc Radiotherapy T. Masuda et al.…420
  A Case of Cardiac Angiosarcoma Successfully Treated with Postoperative Conformal Dynamic Arc Radiotherapy

  （Asahikawa City Hospital, Asahikawa, Japan）

  Takahiko Masuda	Junichi Oba	Tsukasa Miyatake
  Kimihiro Yoshimoto	Akira Adachi	Atsushi Okuyama
  Hidetoshi Aoki

  Cardiac angiosarcoma is a rare heart malignancy. The prognosis is reported to be very poor. Here, we report a case of cardiac angiosarcoma which was treated by postoperative conformal dynamic arc radiotherapy. The patient has been in good health with no recurrence for 18 months after surgery. The patient was a 71-year-old woman, who presented edema and general malaise. Echocardiography and computed tomography revealed a right atrial mass and massive pericardial effusion, which was thought to be the cause of tamponade. Intraoperatively, we found a large tumor arising from right atrial wall spreading and invading to the inferior vena cava, diaphragm, and right pericardium. We abandoned complete resection of the tumor. We only resected the part of the tumor under cardiopulmonary bypass. The subsequent defect of the right atrial wall was reconstructed with bovine pericardial patch. The pathological diagnosis was consistent with angiosarcoma, and the margin was positive for the tumor. In addition to reduction surgery, we adopted radiotherapy（conformal dynamic arc radiotherapy, 10MV-X-ray, 54Gy/18Fr/4.5week, fractionated radiotherapy). The CT, one month after the radiation, showed a significant reduction in tumor size. Moreover, no tumor could be pointed out by echocardiography 18 months after surgery. Advances in technology and methodology has made tumor control possible without significant side effects. We conclude that reduction surgery accompanied with postoperative radiotherapy is promising in maintaining quality of life and in improving life expectancy.
    Jpn. J. Cardiovasc. Surg. 42:420-424（2013）
  
  Keywords：primary cardiac tumor, cardiac angiosarcoma, postoperative radiotherapy, conformal dynamic arc radiotherapy
• Emergent Redo-Mitral Valve Replacement during Pregnancy at 23 Weeks and 4 Days of Gestation due to Bioprosthetic Valve Deterioration Y. Motomatsu et al.…425
  Emergent Redo-Mitral Valve Replacement during Pregnancy at 23 Weeks and 4 Days of Gestation due to Bioprosthetic Valve Deterioration

  （Department of Cardiovascular Surgery, Kyushu University Hospital, Fukuoka, Japan, and Department of Cardiovascular Surgery, Japan Red Cross Fukuoka Hospital^＊, Fukuoka, Japan）

  Yuma Motomatsu＊	Hiromichi Sonoda	Yasuhisa Oishi
  Yoshihisa Tanoue	Takahiro Nishida	Atsuhiro Nakashima
  Yuichi Shiokawa	Ryuji Tominaga

  We report a case of emergent redo-mitral valve replacement during pregnancy at 23 week and 4 days of gestation. A 23-year-old woman, who underwent mitral valve replacement with a bioprosthetic valve（Carpentier-Edwards Perimount®27mm）for infective endocarditis 5 years ago, was transferred to our hospital due to severe congestive heart failure. Echocardiography revealed structural valve deterioration of the mitral prosthesis and severe mitral stenosis. Emergent redo-mitral valve replacement with a bioprosthetic valve was performed to save the patient with top priority. Cardiopulmonary bypass was operated under normothermic, high flow, high pressure and pulsatile fashion. Fetal heart rate was continuously monitored during the operation. Although her baby was delivered vaginally just after operation weighing only 520g, she was treated by the neonatologists successfully.
    Jpn. J. Cardiovasc. Surg. 42:425-429（2013）
  
  Keywords：pregnancy, redo-mitral valve replacement, structural valve deterioration
• Trans-axillary Aortic Valve Replacement M. Aoki and T. Ito…430
  Trans-axillary Aortic Valve Replacement

  （Department of Cardiovascular Surgery, Matsumoto Kyoritsu Hospital, Nagano, Japan, and Department of Cardiovascular Surgery, Japanese Red Cross Nagoya Daiichi Hospital^＊, Nagoya, Japan）

  Masakazu Aoki	Toshiaki Ito＊

  We have performed trans-axillary aortic valve replacement（TAX AVR）as a new minimally invasive approach in 5 patients with aortic regurgitation since September 2012. The mean age was 63 years（range 25-84 years). TAX AVR was performed through 7 cm skin incision along the right anterior axillary line, and small 4th intercostal thoracotomy. Cardiopulmonary bypass was established through the femoral artery and vein. Intra-thoracic procedures were performed under direct vision, or videoscopic assistance with the aid of minimally invasive surgical apparatus. The mean operative time was 312±44 min, cardiopulmonary bypass 217±38 min, and cross-clamp 139±22min. The mean ventilation time was 4.2±6.1 h, and length of post-operative hospital stay was 14.8±0.9 days. There was no re-operation for bleeding, or conversion to median sternotomy. TAX AVR can avoid sternotomy, transection of rib, and sacrifice of internal thoracic artery. The postoperative wound was unrecognizable unless the right arm was raised. This approach may promise patients’ early rehabilitation and better cosmetic results.
    Jpn. J. Cardiovasc. Surg. 42:430-433（2013）
  
  Keywords：minimally invasive cardiac surgery, aortic valve replacement, endoscopic assistance
• Successful Repair of Critical Air Leakage after Surgery for a Large Thoracoabdominal Aortic Aneurysm H. Matsumura et al.…434
  Successful Repair of Critical Air Leakage after Surgery for a Large Thoracoabdominal Aortic Aneurysm

  （Department of Cardiovascular Surgery, Fukuoka University School of Medicine, Fukuoka, Japan）

  Hitoshi Matsumura	Hideichi Wada	Mitsuru Fujii
  Masahiro Oosumi	Gou Kuwahara	Yuta Sukehiro
  Noritoshi Minematsu	Masaru Nishimi	Tadashi Tashiro

  A 76-year-old woman with a sudden onset of chest and back pain was admitted to our hospital. Computed tomography（CT）showed a giant thoracoabdominal aortic aneurysm. Therefore, the patient underwent emergency operation. Under a left anterolateral thoracotomy and pararectal laparotomy with left heart bypass, we performed graft replacement of the thoracoabdominal aorta and reconstruction of the celiac artery, superior mesenteric artery and renal arteries. The left lung was tightly adhered to the aneurysm because of the contained rupture. Copious pulmonary bleeding and air leakage occurred due to thrombectomy of the aneurysm. During the operation, critical air leakage was repaired using the remaining aneurysmal wall. The postoperative course was uneventful. The patient was discharged 16 days after surgery. Copious air leakage due to lung injury was a potentially life-threating condition in the postoperative course of this case of thoracoabdominal aortic aneurysm. Surgical treatment of critical air leakage due to lung injury is very important in thoracic surgery.
    Jpn. J. Cardiovasc. Surg. 42:434-437（2013）
  
  Keywords：thoracoabdominal aortic aneurysm, copious air leakage, graft replacement
• A Case of Isolated Internal Iliac Artery Aneurysm with Arteriovenous Fistula Y. Shomura et al.…438
  A Case of Isolated Internal Iliac Artery Aneurysm with Arteriovenous Fistula

  （Department of Cardiovascular Surgery, Anjo Kosei Hospital, Anjo, Japan, Department of Cardiovascular Surgery, Toyooka Hospital^＊, Toyooka, Japan, and Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital^＊＊, Kobe, Japan)

  Yu Shomura	Michihiro Nasu＊	Yukikatsu Okada＊＊
  Hiroshi Fujiwara＊＊	Tadaaki Koyama＊＊	Toru Mizumoto

  We report a case of left internal iliac aneurysm that ruptured into the left common iliac vein and formed an arteriovenous fistula. A 79-year-old man who had general fatigue was admitted to our hospital with a diagnosis of left internal iliac artery aneurysm, left hydronephrosis, dehydration and low renal function. After dehydration and low renal function resolved rapidly by medical treatment, an enhanced computed tomography was performed. This demonstrated a 69 by 67 mm diameter left internal iliac artery aneurysm with an arteriovenous fistula. During the operation, left common iliac artery and left external iliac artery were resected and the stumps sutured. External iliac-external iliac artery bypass was performed. An occlusive balloon catheter was inserted from the left femoral vein and the balloon was dilated to patch the fistula before opening the aneurysm. After clamping the proximal artery the aneurysm was opened. Bleeding from the fistula was controlled by this maneuver and digital compression of the left common iliac vein where was proximal side of fistula. An arteriovenous fistula with a 18 by 3mm orifice was found between the left internal iliac artery and left common iliac vein. The fistula was closed from the inside of the aneurysm. His postoperative course was uneventful.
    Jpn. J. Cardiovasc. Surg. 42:438-441（2013）
  
  Keywords：arteriovenous fistula, iliac artery aneurysm, occlusive balloon catheter
• Complete Repair of Truncus Arteriosus and Interrupted Aortic Arch（Arch Reconstruction＋ Rastelli Operation）after Bilateral Pulmonary Artery Banding S. Shiraishi et al.…442
  Complete Repair of Truncus Arteriosus and Interrupted Aortic Arch（Arch Reconstruction＋Rastelli Operation）after Bilateral Pulmonary Artery Banding

  （Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan）

  Shuichi Shiraishi	Masashi Takahashi	Maya Watanabe
  Yuka Okubo	Masanori Tsuchida

  A baby girl delivered at 41 weeks of gestation with persistent truncus arteriosus（PTA）and interrupted aortic arch（IAA）type A was referred to our institute for surgical intervention. Bilateral pulmonary artery banding（BPAB）proceeded through a median sternotomy at the age of 11 days to control excessive pulmonary blood flow. Thereafter, she gained weight under continuous prostaglandin E1（PGE 1）infusion. Definitive repair proceeded at the age of 2 months. Cardiopulmonary bypass was established through a redo-median sternotomy, with two arterial cannulae（brachiocephalic artery and descending aorta). The aortic arch was reconstructed with direct anastomosis. The orifice of the pulmonary artery was removed from the arterial trunk and the defect in the aortic wall was directly closed. A ventricular septal defect was closed under cardioplegic arrest via a right ventriculotomy. The continuity from the right ventricle to the pulmonary artery was made using a hand-made, extended polytetrafluoroethylene（ePTFE）conduit with a bicusp. The sternum was left open at the end of the procedure and the chest was closed on post-operative day（POD）3. She was weaned from mechanical ventilation on POD 4 and the postoperative course was uneventful. She was discharged on POD 49.
    Jpn. J. Cardiovasc. Surg. 42:442-446（2013）
  
  Keywords：truncus arteriosus, interrupted aortic arch, pulmonary artery banding, staged operation
• Successful Treatment of Aneurysm-Associated Disseminated Intravascular Coagulation with Endovascular Aneurysm Repair（EVAR） Y. Matsumura et al.…447
  Successful Treatment of Aneurysm-Associated Disseminated Intravascular Coagulation with Endovascular Aneurysm Repair（EVAR）

  （Department of Cardiovascular Surgery, Nagano Chuo Hospital, Nagano, Japan）

  Yu Matsumura	Yuki Nakayama	Fumitaka Yamaki

  A 80-year-old woman was referred to our hospital for coagulation abnormality and huge abdominal aortic aneurysm（AAA). She had persistent hemorrhage from the surgical wound after the operation for her cubital tunnel syndrome 5 days before. Enhanced computed tomography image revealed AAA with a maximum diameter of 91mm. Laboratory data were compatible with disseminated intravascular coagulation（DIC). Due to the marked hemorrhagic status, we thought the open repair of AAA was an extremely risky procedure. We initiated the medical treatment with gabexate mesilate. However, the hemorrhage continued after 2 weeks of medical therapy. We performed endovascular aneurysm repair（EVAR). DIC improved after the procedure. Postoperative enhanced computed tomography image showed regression of the aneurysm with no endoleak. EVAR might be an acceptable procedure for AAA with DIC.
    Jpn. J. Cardiovasc. Surg. 42:447-451（2013）
  
  Keywords：abdominal aortic aneurysm（AAA), disseminated intravascular coagulation（DIC), endovascular aneurysm repair（EVAR）

Editors’ Post Script

• K. Miyachi