|Hideki Ozawa||Shintaro Nemoto||Ryo Shimada|
|Shinji Fukuhara||Hayato Konishi||Yoshikazu Motohashi|
|Hiroaki Uchida and Takahiro Katsumata|
（Department of Pediatric Cardiovascular Surgery＊, and Department of Cardiovascular Surgery＊＊, Osaka Medical University Hospital, Takatsuki, Japan）
Objectives:Mediastinitis results in significant morbidity in pediatric patients after cardiac surgery. The management of mediastinitis is not well established in the pediatric population. Our strategy for pediatric mediastinitis after cardiac surgery consists of rapid introduction of simple vacuum-assisted drainage system and sternal closure without plombage under aseptic conditions. The efficacy of our strategy was examined. Methods:The records of 7 pediatric patients with mediastinitis after cardiac surgery managed with this drainage system from May 2006 to May 2013 were retrospectively reviewed. The median age of the patients was 20.5 months and median body weight was 9.7kg. Mediastinitis occurred 1-3 weeks after surgery. The mediastinum was re-explored immediately under general anesthesia after the diagnosis was made, and continuous drainage was used after extensive debridement was performed. We developed a simple vacuum-assisted drainage system consisting of conventional polyurethane foam, surgical drape containing povidone-iodine, and 1 to 3 silicone drainage tubes connected to a drain aspirator（－99cmH2O). Patients were allowed oral intake and resumption of daily activity after extubation. The components of the drainage system were exchanged every 2-3 days. The sternum was closed without the use of the omentum or muscle for plombage of the mediastinum after two negative topical swab cultures were obtained. Results:Negative topical swab cultures were obtained in all cases（3-12 days after the drainage commencement）and the sternum was closed 7-19 days after the drainage commencement. The median duration of hospital stay was 31 days（range, 14-47). Although one patient with prenatal infection died of aortic rupture, the remaining six children survived and did not experience recurrence after hospital discharge. Conclusion:The simple vacuum-assisted drainage system enabled rapid control of wound bacterial infection and sternal closure in postoperative pediatric mediastinitis without the need for special, and expensive devices.
Jpn. J. Cardiovasc. Surg. 44:65-69（2015）
Keywords：pediatric cardiac surgery;mediastinitis;negative pressure wound therapy
|Hiroharu Shinjo||Hirono Satokawa||Shinya Takase|
|Yuki Seto||Takashi Igarashi||Akihito Kagoshima|
|Tsuyoshi Fujimiya and Hitoshi Yokoyama|
（Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan）
A 65-year-old man was admitted with subacute myocardial infarction. During medical treatment, the patient lost consciousness as a result of an atrioventricular block and underwent an operation for an emergency percutaneous coronary intervention in the right coronary artery. In a follow-up examination, transthoracic echocardiography and computed tomography showed a left ventricular pseudo-false aneurysm, and therefore another operation was carried out. The operative findings showed that the heart markedly adhered to the pericardium and the aneurysm at the apex. The patient then underwent a double-patch closure of the ruptured point using an equine pericardial patch and a Dacron patch. No perioperative complication was observed. Left ventricular pseudo-false aneurysm is a rare complication following myocardial infarction. Here, we report a successful case of a double-patch closure of a pseudo-false aneurysm.
Jpn. J. Cardiovasc. Surg. 44:70-73（2015）
Keywords：left ventricular pseudo-false aneurysm;subacute myocardial infarction;double-patch closure
|Tomonori Koga||Tatsuhiko Komiya||Hiroshi Tsuneyoshi|
（Division of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, Kumamoto, Japan, and Department of Cardiovascular Surgery, Kurashiki Central Hospital＊, Kurashiki, Japan)
A 75-year-old woman presented with dyspnea, and was admitted urgently on a diagnosis of concurrent acute cardiac insufficiency. Because of her low blood pressure and respiratory failure, care was started in the intensive care unit. A transthoracic echocardiogram（TTE）showed severe tricuspid regurgitation（TR). We concluded that her cardiogenic shock was caused by acute right heart failure with severe TR and therefore carried out emergency surgery. We noted expansion of the tricuspid valve ring and shortening of the tendinous cord, and the leaflet was pulled into the right ventricle side. Initially we attempted a tricuspid annuloplasty（TAP), but it proved difficult to control the TR. We therefore performed a tricuspid valve replacement（TVR). The patient was moved from the intensive care unit to a general ward 10 days after the operation, and to another hospital 26 days later.
Jpn. J. Cardiovasc. Surg. 44:74-78（2015）
Keywords：tricuspid regurgitation;tricuspid valve replacement;acute right heart failure
|Hideya Tanaka||Kojiro Furukawa||Hiroyuki Morokuma|
|Ryo Noguchi||Manabu Itoh||Keiji Kamohara and Shigeki Morita|
（Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, Saga, Japan）
Early surgical resection for cardiac myxoma is necessary because it may frequently cause cerebral infarction. However the optimal surgical timing for the disease is controversial because the acute phase of infarction may induce intracranial hemorrhage. An 82-year-old woman referred to our hospital because of unconsciousness and right hemiparesis. MRI showed infarction in the left middle cerebral artery area and UCG revealed a left atrial mass. The fourth day after the onset, brain CT showed hemorrhagic infarction and MRI showed new infarction. There was no enlargement of the hemorrhagic focus on brain CT and the patient underwent surgery on the fifth day after the onset. The postoperative course was uneventful. Despite the existence of hemorrhagic infarction, open heart surgery may save patients with cerebrovascular event.
Jpn. J. Cardiovasc. Surg. 44:79-81（2015）
Keywords：myxoma;cerebral complication;cardiopulmonary bypass
|Masahiro Ryugo||Hiroshi Imagawa||Hironori Izutani|
|Takumi Yasugi and Yuji Sakashita|
（Department of Cardiothoracic Surgery, Ehime University Hospital, Matsuyama, Japan）
A 34-year-old female patient, who had undergone several operations relating to pulmonary atresia with ventricular septal defect（PA/VAD), was admitted to our hospital for recurrent massive hemoptysis requiring blood transfusion. She had undergone a Potts’ shunt（systemic-pulmonary shunt）at age 3, and undergone intraaortic patch closure for paraanastomotic pseudoaneurysm of occluded Potts’ shunt at age 28. Chest CT scan revealed an enhancement of this aneurysm surrounding ground glass like appearance of left lung lobe which indicated pulmonary bleeding. In order to avoid skeltonization of severe adhesion of mediastinal and left thoracic space due to several prior operations, endovascular repair of this pseudoaneurysm with debranching of left subclavian artery was performed. Postoperative course was uneventful and hemoptysis was disappeared. She was discharged at 8 postoperative day.
Jpn. J. Cardiovasc. Surg. 44:82-86（2015）
|Hitoshi Suhara||Toshiki Takahashi||Takashi Kido and Masaya Kainuma|
（Department of Cardiovascular Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan）
Infective endocarditis in association with pyogenic vertebral osteomyelitis is rarely observed. We report an 80-year-old man with infective endocarditis and pyogenic vertebral osteomyelitis requiring reoperation due to aortic prosthetic valve dysfunction. He suffered from back pain as the initial symptom, and he was admitted to our hospital. On magnetic resonance imaging, vertebral osteomyelitis was revealed, and antibiotics were started. On blood sampling α-streptococcus was identified and infective endocarditis was diagnosed. He responded to the antibiotic treatment. Despite the improvement in his general condition and the inflammatory parameters of blood samples, the aortic prosthetic valve dysfunction progressed. On echocardiography, aortic regurgitation worsened to 4/4, and the ejection fraction decreased from 72 to 46%. As heart failure was apparent, we performed a redo aortic valve replacement. Tears were found in the leaflets of the removed prosthetic valve（Hancock II). The 21-mm Carpentier-Edwards PERIMOUNT valve（CEP Magna Ease TFX）was replaced. His post-operative course was uneventful, and intravenous administration of ampicillin was continued. Oral rifampicin was also continued. On the 69th post-operative day, he was discharged and was ambulatory. Although we have no evidence that the tissue valve deterioration had resulted from bacterial damage, we were able to confirm that the structural valve deterioration involved bacterial contact in this case. Patients with infective endocarditis and pyogenic vertebral osteomyelitis should be treated cautiously regardless of whether or not the inflammation is controlled.
Jpn. J. Cardiovasc. Surg. 44:87-91（2015）
Keywords：vertebral osteomyelitis;infective endocarditis;aortic valve replacement;antibiotics
|Hiroyuki Seo||Hiromichi Fujii||Takanobu Aoyama and Yoshikado Sasako|
(Department of Cardiovascular Surgery, Japan Community Health Care Organization, Osaka Hospital, Osaka, Japan）
A 72-year-old man, in whom hypertrophic cardiomyopathy（HCM）had been treated with medication for 4 years, complained of general fatigue and mild dyspnea on effort. Transthoracic and transesophageal echocardiography revealed diffuse left ventricular（LV）hypertrophy and LV obstruction from the mid-portion to the outflow tract with a peak pressure gradient of 94 mmHg. Additionally, anterior displacement of the abnormal, hypertrophied anterior papillary muscle（PM）and restricted motion of the anterior mitral leaflet, caused by the shortened chordae arising from the abnormal PM, were found. Furthermore, during the systolic phase, the abnormal, hypertrophied anterior PM was shifted to the septal side, causing LV obstruction with systolic anterior motion of the mitral leaflet. The diagnosis was HCM with LV obstruction due to abnormal PM. Mitral valve replacement（MVR）using a mechanical valve and excision of the abnormal PM was performed. His postoperative course was uneventful, and he was discharged on the 14th postoperative day. Postoperative echocardiography revealed no residual obstruction and no pressure gradient in the LV, indicating that complete release of the LV obstruction had been accomplished. In cases of HCM with LV obstruction due to an abnormal mitral subvalvular apparatus, transaortic septal myectomy may not always be an effective procedure. Therefore, we propose that MVR with excision of the PM should be considered one of the useful surgical procedures for such cases.
Jpn. J. Cardiovasc. Surg. 44:92-96（2015）
Keywords：hypertrophic cardiomyopathy;left ventricular outflow tract obstruction;abnormal papillary muscle;systolic anterior motion of the mitral leaflet;mitral valve replacement
|Hiroo Kinami||Kiyozo Morita||Yoshihiro Ko|
|Gen Shinohara and Kazuhiro Hashimoto|
（Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan）
Primary repair of the tetralogy of Fallot with absent pulmonary valve syndrome（TOF/APV）is associated with high mortality rates of 17-33%, especially in neonates. Our standard strategy involves a staged repair with a first palliation, performed during the neonatal period, that includes main pulmonary septation with an ePTFE patch, pulmonary arterioplasty for reduction of vascular dilation, and a modified Blalock-Taussig shunt. We performed successful repairs on two neonates with TOF/APV, one symptomatic and the other non-symptomatic, with this strategy. Case 1:A 7-day-old boy had TOF/APV, with progressively worsening respiratory distress. His left bronchi, superior vena cava and left atrium were compressed by a dilated pulmonary artery, which was repaired by emergency surgery. Decreasing the diameter of the pulmonary artery（PA index from 2,550 to 525）relieved the compressed organs. Case 2:A 16-day-old boy with TOF/APV with a main pulmonary artery that increased in diameter from 8 to 17mm in the course of a single day. He was treated in the same fashion as Case 1. At 1 year of age, an intracardiac repair with tricuspid anuuloplasty was performed successfully. This strategy is much safer than a primary repair and is a good choice for neonatal repair of TOF/APV.
Jpn. J. Cardiovasc. Surg. 44:97-102（2015）
Keywords：tetralogy of Fallot;absent pulmonary valve syndrome;neonatal;staged repair
|Kei Yagami||Hiroomi Murayama||Hiroki Hasegawa and Masanobu Maeda|
（Aichi Children’s Health and Medical Center, Cardiac Surgery, Obu, Japan）
Giant left atrium（LA）in association with mitral valve disease is a significant risk factor for mortality and morbidity. It may cause obstruction of the bronchus, pulmonary artery, inferior vena caval orifice, or left ventricle, and has also required prolonged hospital stay. We describe our experience of left atrial reduction by means of circular LA resection concomitant with mitral valve plasty in 2 children with severe mitral regurgitation（MR）and giant LA. Case 1 was a 1-year-old boy, who had severe MR and giant LA, presenting with left bronchial obstruction. He underwent mitral valve plasty and circular LA resection. His LA volume, which was calculated using enhanced chest CT examination, was decreased by 23% postoperatively, comparing that before the operation. The cardiothoracic ratio on chest X-ray changed from 60% to 49%, and his sequential symptoms from giant LA disappeared. His postoperative course was uneventful and he was discharged on postoperative day 21. Case 2 was a 12-year-old girl with severe MR and giant LA. Her LA together with the sternum and spine compressed the right atrium and caused right heart failure. She underwent mitral valve plasty and circular LA resection. Her LA volume was decreased by preoperative 22%. Cardiothoracic ratio on chest X-ray changed from 63% to 57%. Her sequential symptoms from giant LA disappeared. Her postoperative course was uneventful and she was discharged 28 days after the operation. The circular LA resection technique reduced LA volume effectively, and the patients became free of clinical symptoms. Even in children, this procedure should be indicated in selective cases who presented clinical symptoms caused by the expanded LA.
Jpn. J. Cardiovasc. Surg. 44:103-107（2015）
Keywords：giant LA;mitral valve regurgitation;LA resection;child;mitral valve plasty
|Masanori Sakaguchi||Tadahiro Murakami||Takumi Ishikawa and Hirokazu Minamimura|
（Department of Cardiovascular Surgery, Bell Land General Hospital, Sakai, Japan）
A 69-year-old woman suffered from postprandial abdominal pain and hematochezia. Colonoscopy suggested ischemic colitis, and intestinal angina was diagnosed by multirow-detector computed tomography（CT), which showed occlusion of the superior mesenteric artery（SMA). On enhanced CT, there was extensive calcification on the aortic wall and aortic expansion and several mural thrombi in the thoracoabdominal and abdominal aorta, as well as severe stenoses in the bilateral common iliac arteries. A bypass from the right renal artery, which was the only artery without significant stenosis of the major branches of the abdominal artery, to the SMA, was created using a saphenous vein graft. Postoperatively, the postprandial abdominal pain disappeared, and the patient was discharged after a good postoperative course.
Jpn. J. Cardiovasc. Surg. 44:108-111（2015）
Keywords：intestinal angina;revascularization;saphenous vein graft
|Jun Iida||Manabu Morishima and Koji Ueyama|
（Department of Cardiovascular Surgery, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan）
Primary cardiac myxofibrosarcoma is an extremely rare malignant tumor of the heart, which can be difficult to diagnose. We report such a case, which recurred 7 months after the initial heart surgery. A 63-year-old woman with progressive dyspnea was seen by a physician. A transthoracic echocardiography revealed a large mobile mass in the left atrium, causing severe mitral stenosis. The patient was referred to our hospital for an operation. The tumor, which arose from the anterior mitral annulus, was resected, and mitral and tricuspid annuloplasty were performed. The histopathological diagnosis was myxoma. The postoperative course was uneventful. Seven months later, the patient reported suffering from dyspnea and leg edema. The echocardiography showed multiple recurrences of tumor in the left atrium. A second operation was performed to reduce the mass volume as a palliative treatment because some large fragile tumors occupied the left atrium. The patient died 5 months after the second operation due to metastasis. The final diagnosis by histopathology was myxofibrosarcoma.
Jpn. J. Cardiovasc. Surg. 44:112-116（2015）
Keywords：primary cardiac tumor;cardiac myxofibrosarcoma;recurrence
|Tomohiro Hayashida||Yutaka Yokota||Noriyuki Tokunaga|
|Mikizo Nakai and Masahiro Okada|
（Department of Cardiovascular Surgery, National Hospital Organization, Okayama Medical Center, Okayama, Japan）
Unruptured sinus of Valsalva aneurysm is a rare anomaly which may be acquired or congenital. We describe a case of a 64 year old man with aneurysms（left:31mm, non:21mm）of the coronary sinus. The Bentall operation was successfully performed and his postoperative course was uneventful. The histopathology of the aortic wall showed Takayasu’s arteritis. Bentall surgery is a good choice for multiple aneurysms of the Valsalva sinus with aortitis.
Jpn. J. Cardiovasc. Surg. 44:117-120（2015）
Keywords：Takayasu’s arteritis;unruptured sinus of Valsalva aneurysms;Bentall operation