Japanese Journal of Cardiovascular Surgery Vol.44, No3

Preface

  • Future of the Japanese Board of Cardiovascular Surgery　K. Hashimoto

Case Reports

  • Left Chest Wall Necrosis Following Harvesting the Left Internal Thoracic Artery　K. Murayama et al.…121
    Left Chest Wall Necrosis Following Harvesting the Left Internal Thoracic Artery

    Koh Murayama Fumitaka Isobe Hirotaka Watanuki and Yasuhiro Futamura

    （Department of Cardiovascular Surgery, Aichi Medical University, Aichi, Japan）

    A 53-year-old man who complained of chest pain was admitted. He had been on hemodialysis for chronic renal failure since age 34 and suffered from painful abdominal skin ulcer of unknown etiology when he was 49 years old. His coronary angiography showed severe coronary stenosis on the left main trunk and triple vessels. Preoperative CT revealed severe systemic vascular calcification. He underwent coronary artery bypass grafting using the left internal thoracic artery and saphenous vein grafts. Postoperatively, his left anterior chest wall changed into the painful necrosis. On the 43rd postoperative day, VAC therapy was started after the debridement of necrotizing tissue. Histological examination confirmed that it was ischemic necrosis due to stenosis of the vascular lumen with medial calcification and intimal hyperplasia resembling “calciphylaxis”. Performing the sternal excision and skin grafting for the sternal dehiscence, he was discharged on the 148th postoperative day with perfect healing of the chest wall. The calciphylaxis was suspected to be the cause of this rare complication. Therefore, we should consider this matter carefully whenever we harvest the internal thoracic artery for patients who undergo coronary bypass grafting and who require hemodialysis for chronic renal failure.

     

    Jpn. J. Cardiovasc. Surg. 44:121-124（2015）

    Keywords：coronary artery bypass grafting;chest wall necrosis;calciphylaxis


  • Ventricular Septal Perforation Repair Carried out on a Jehovah’s Witness　Y. Morita et al.…125
    Ventricular Septal Perforation Repair Carried out on a Jehovah’s Witness

    Yuichi Morita Tadashi Tashiro Masahiro Ohsumi
    Yuta Sukehiro Shinji Kamiya Mau Amako
    Noritoshi Minematsu Hitoshi Matsumura Masaru Nishimi and Hideichi Wada

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

    In a 63-year-old male patient Jehovah’s witness, IABP was introduced due to acute myocardial infarction and cardiogenic shock, and PCI（BMS）was carried out to CAG #7 100%. Stent placement was carried out and his hemodynamics stabilized. A left-to-right shunt was observed upon carrying out LVG, so the patient was referred to our hospital for surgery purposes due to a diagnosis of ventricular septal perforation（VSP). Upon transferring the patient to hospital, his PA pressure elevated to 53mmHg although the blood pressure was maintained, and no findings of right heart failure were observed. His respiratory condition was stable. Emergency surgery was considered, but the patient was taking Clopidogrel following PCI, and so VSP repair（extended endocardial repair）was carried out following 4 days discontinuation of Clopidogrel. Preoperative anemia was not observed;however, postoperative hemorrhagic anemia improved due to iron preparation administration, and the patient was discharged from hospital 22 days following surgery without blood transfusion.　

    Jpn. J. Cardiovasc. Surg. 44:125-129（2015）

    Keywords：no blood transfusion;Jehovah’s witnesses;ventricular septum perforation;extended endocardial repair


  • A Papillary Fibroelastoma in the Left Ventricle　Y. Ikeno et al.…130
    A Papillary Fibroelastoma in the Left Ventricle

    Yuki Ikeno Akitoshi Yamada Kunio Gan and Tatsuro Asada

    （Department of Cardiovascular Surgery, Kitaharima Medical Center, Kobe, Japan）

    A 75-year old woman inwhom a left ventricular tumor had been detected by echocardiography 2 years before referral to our hospital, presented with blurry vison for one month. Acute cerebral infarction was diagnosed. We suspected that the infarction was occurred by an embolus from the intraventricular tumor, and resected it through left atrial incision. The resected tumor was 10 mm in size and it resembled a sea anemone. The tumor was pathologically diagnosed as papillary fibroelastoma. The postoperative course was good, with no recurrence for the last 18 months.

     

    Jpn. J. Cardiovasc. Surg. 44:130-132（2015）

    Keywords：papillary fibroelastoma;left ventricular tumor;primary cardiac tumor;surgical indications;surgical approach


  • Repair of Stent Graft-Induced Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair　A. Katayama et al.…133
    Repair of Stent Graft-Induced Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair

    Akira Katayama Jun Kawamoto Hitoshi Tachibana
    Miwa Arakawa and Junya Kitaura

    （Division of Cardiovascular Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan）

    An 80-year-old woman presented with dilatation of the distal aortic arch due to chronic type B aortic dissection. She underwent thoracic endovascular aortic repair（TEVAR）in zone 2 with GORE TAG thoracic endoprostheses（40mm-15cm and 34mm-20cm）for closure of the entry site at the proximal descending aorta. TEVAR was successfully performed and blood flow in the false lumen stopped. Two months after TEVAR, she was admitted to our hospital owing to syncope. A CT scan revealed type A aortic dissection, and emergency surgery was performed. The entry was proximal to the stent graft, and we performed total arch replacement with preservation of the stent graft. Retrograde type A aortic dissection is a rare but lethal complication of TEVAR. Careful consideration of the device selection is needed, and attention should be paid to the placement of the stent graft.

     

    Jpn. J. Cardiovasc. Surg. 44:133-136（2015）

    Keywords：acute aortic dissection;TEVAR;total arch replacement


  • Successful Treatment of Prosthetic Graft Infection 7 Years after Ascending Aorta Replacement and Aortic Root Replacement with a Freestyle Stentless Valve　J. Sakai et al.…137
    Successful Treatment of Prosthetic Graft Infection 7 Years after Ascending Aorta Replacement and Aortic Root Replacement with a Freestyle Stentless Valve

    Jiro Sakai Tatsuhiko Komiya Hiroshi Tsuneyoshi and Takeshi Shimamoto

    （Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan）

    A 62 year-old man presented with severe septic shock complicated by prosthetic graft infection, 7 years after aortic root replacement with a Freestyle stentless valve and graft replacement of the ascending aorta. We initially managed the patient with antimicrobial therapy for 2 months and subsequently surgery was performed, replacing the infected aortic graft with rifampicin-bonded prostheses, and added omentopexy. The infection was cured and has not recurred.

     

    Jpn. J. Cardiovasc. Surg. 44:137-140（2015）

    Keywords：aortic root replacement;prosthetic graft infection;rifampicin-bonded prostheses;omentopexy


  • Right Pulmonary Artery Communication to a Left Atrium　T. Suzuki et al.…141
    Right Pulmonary Artery Communication to a Left Atrium

    Toshihiko Suzuki Kunikazu Hisamochi Hideo Yoshida
    Keiji Yunoki Yasufumi Fujita Atsushi Tateishi and Tomoya Inoue

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

    PA-LA communication is a rare congenital heart disease consisting of direct communication between a branch of the PA and LA through an aneurysmal structure. This disease reveals the central cyanosis with clubbed fingers and surgical repair is needed when symptoms are apparent. Computed tomography is highly recommended for definitive diagnosis. Angiographic catheterization is also recommended to support the diagnosis and decide on the treatment. PA-LA communication is categorized into 4 types. Two types do not need cardiopulmonary bypass（CPB）when treated surgically, but the others need CPB. A 16-year-old girl with clubbed fingers was found to have PA-LA communication by 3DCT. She underwent surgery and was discharged in good condition. The surgical procedure was done through median sternotomy without CPB. The anomalous aneurysmal fistula was doubly ligated. No communication was found after ligation by TEE.

    Jpn. J. Cardiovasc. Surg. 44:141-143（2015）

    Keywords：PA-LA communication;clubbed fingers;central cyanosis


  • Acute Heart Failure due to Noncoronary Sinus of Valsalva Aneurysm with Rupture into the Right Atrium　T. Samura et al.…144
    Acute Heart Failure due to Noncoronary Sinus of Valsalva Aneurysm with Rupture into the Right Atrium

    Takaaki Samura Yasushi Tsutsumi Osamu Monta
    Satoshi Numata Sachiko Yamazaki Hisazumi Uenaka
    Takashi Shirakawa Syusaku Maeda and Hirokazu Ohashi

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

    A 65-year-old woman was referred for progressive dyspnea and leg edema. Physical examination revealed a continuous murmur along the right sternal border. Enhanced computed tomography showed an aneurysm that extended to the right atrium. Aortic angiography confirmed the rupture of the valsalva aneurysm into the right atrium. The patient underwent emergency surgery to close the aneurysm ostium and suture closure of the right atrial fistula. The patient’s postoperative course was uneventful.

     

    Jpn. J. Cardiovasc. Surg. 44:144-147（2015）

    Keywords：valsalva aneurysm;acute heart failure;patch closure


  • Cardiac Tamponade due to Detachment of the Aortic Valve Commissure　H. Uesugi et al.…148
    Cardiac Tamponade due to Detachment of the Aortic Valve Commissure

    Hideyuki Uesugi Touitsu Hirayama Shoichiro Hagiwara
    Ichiro Ideta Takashi Oshitomi Kentaro Takaji
    Yukihiro Katayama Toshiharu Sassa Kazufumi Omori and Hidetaka Murata

    （Department of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, Kumamoto, Japan）

    A 68-year-old man was taken to our hospital by ambulance due to syncope. He was in shock with cardiac tamponade. Pericardial drainage was performed. Aortic valve regurgitation gradually increased and surgery was performed at 25 days after onset. Surgical finding showed that there was a detachment of the commissure between the right and non coronary cusps of the aortic valve. An intimal tear was detected in the same place and aortic root replacement was required. The patient had a good recovery and he was discharged 14 days after surgery.

     

    Jpn. J. Cardiovasc. Surg. 44:148-150（2015）

    Keywords：intimal tear;aortic valve regurgitation;detachment of the aortic valve commissure;aortic root replacement


  • A Case of Long-Term Antifungal Therapy after Tricuspid Valve Replacement for Aspergillus Infective Endocarditis　H. Tsuchiya et al.…151
    A Case of Long-Term Antifungal Therapy after Tricuspid Valve Replacement for Aspergillus Infective Endocarditis

    Hiroshi Tsuchiya Mio Noma Yoshifumi Nishino
    Yusuke Inaba Hidehito Endo and Hiroshi Kubota

    （Department of Cardiovascular Surgery, Kyorin University, Tokyo, Japan）

    Aspergillus infective endocarditis（ASIE）is a very rare disease that carries an extremely poor prognosis. We report a case of ASIE successfully treated by a tricuspid valve replacement and administration of an antifungal drugs. The patient was a 69-year-old man who was taking steroids for an autoimmune disease and was admitted to our hospital because of a persistent fever of 39℃. As chest CT showed infiltrative shadows in both lung fields and the aspergillus antigen was detected in the blood, we diagnosed invasive pulmonary aspergillosis（IPA), and initiated administration of micafungin sodium（MCFG). Later, the patient’s heart failure worsened, and echocardiography revealed vegetation measuring 8mm in diameter in the anterior cusp of the tricuspid valve. As this indicated a definitive diagnosis of ASIE, administration of voriconazole（VRCZ）was initiated. However, the vegetation grew into a movable wart measuring 20mm in diameter within a week, based on which a diagnosis of drug-resistant ASIE was made, and surgery was considered indicated. Very large vegetations were found in the anterior cusp of the tricuspid valve, anterior papillary muscle, the tendinous chord of the medial papillary muscle and the trabeculae carneae of the right ventricle. Based on the findings, it was judged that tricuspid annuloplasty was impossible and tricuspid valve replacement was performed using a biological valve. As to the antifungal medication, long-term administration of VRCZ and MCFG was continued. The patient followed a favorable course and was discharged from the hospital on the 220th day. The patient aking lifelong VRCZ and has shown no evidence of recurrence of the ASIE. To improve the prognosis of ASIE, rapid and radical surgical resection of the vegetations and appropriate administration of antifungal drugs are important.

     

    Jpn. J. Cardiovasc. Surg. 44:151-154（2015）

    Keywords：aspergillosis;mycotic endocarditis;tricuspid valve insufficiency


  • A Case of Spontaneous Aortic Root Rupture　M. Hara et al.…155
    A Case of Spontaneous Aortic Root Rupture

    Masanori Hara Tomohiro Imazuru Shigefumi Matsuyama
    Naomi Ozawa Masateru Uchiyama Tsukasa Ikeda and Tomoki Shimokawa

    （Department of Cardiovascular Surgery, Teikyo University School of Medicine, Tokyo, Japan）

    The patient was a 74-year-old man who was brought to the emergency room with severe chest pain and shock. Transthoracic echocardiography showed moderate pericardial effusion, and contrast-enhanced computed tomography（CT）showed a dilated ascending aorta with hematoma. However, no evidence of an intimal flap in the aorta was found. Bloody pericardial effusion was suggested by the CT attenuation value;therefore, type A aortic dissection was highly suspected. At surgery, an extramural hematoma was observed on the ascending aorta. An 8-mm dehiscence that had penetrated the adventitia was identified just above the commissure between the right and left coronary cusps of the aortic valve, without dissection in the ascending aorta, and thus spontaneous aortic root rupture was diagnosed. The dehiscence was closed directly with a mattress suture from outside of the sinus, and the dilated ascending aorta was replaced. The patient’s postoperative course was unremarkable, and he was discharged 14 days after surgery.

     

    Jpn. J. Cardiovasc. Surg. 44:155-158（2015）

    Keywords：spontaneous aortic root rupture;dehiscence of the aortic valve commissure


  • Successful Treatment of a Rapidly-Expanding Infected Thoracic Aortic Aneurysm with Streptococcus pneumonia　M. Hamaishi et al.…159
    Successful Treatment of a Rapidly-Expanding Infected Thoracic Aortic Aneurysm with Streptococcus pneumonia

    Makoto Hamaishi Kenji Okada Shinji Hirai and Norimasa Mitsui

    （Department of Cardiovascular and Respiratory Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan）

    An 83-year-old woman who had an attack of fever, fatigue, and lumbar pain was hospitalized as an emergency. Detailed investigations revealed that she had urinary infection, infectious spondylitis, and bacteremia with Streptococcus pneumonia, for which she received antimicrobial therapy. After 12 days in hospital, enhanced computed tomography showed that the aortic arch had expanded, with fluid collection. Though there had been no imaging findings by computed tomography scan on admission. We thought this was an infected thoracic aortic aneurysm with Streptococcus pneumonia, and continued to administer the antibiotic drugs for infection control. After 14 days in hospital, she developed hoarseness and complained of severe back pain. Emergency computed tomography scan showed that the aortic arch had further expanded to 66 mm in size and that much more fluid had collected. We decided it was an impending rupture of the rapidly-expanding infected thoracic aortic aneurysm, and we then performed an emergency operation. The infected portion of the thoracic aorta was resected. The ascending, arch, and descending portions of the aorta were replaced with rifampicin-bonded synthetic graft, and then omental wrapping was performed. Antimicrobial administration was continued after surgery. The postoperative course was uneventful. The infection was successfully controlled. She was discharged without complications. No signs of recurrent infection have been observed for 1 year and 6 months after operation.

     

    Jpn. J. Cardiovasc. Surg. 44:159-164（2015）

    Keywords：infected aortic aneurysm;thoracic aortic aneurysm;Streptococcus pneumonia


  • Microembolization of the Sigmoid Colon after Endovascular Aneurysmal Repair （EVAR）　T. Furuyama et al.…165
    Microembolization of the Sigmoid Colon after Endovascular Aneurysmal Repair（EVAR）

    Tadashi Furuyama Tomokazu Ohno and Toshihiro Onohara

    （Department of Vascular Surgery, Kyushu Medical Center, Fukuoka, Japan）

    We report a 90-year-old man with intestinal necrosis of the sigmoid colon after EVAR. His abdominal aortic aneurysm was 7.3cm in diameter, and mural thrombus was present from the abdominal aortic aneurysm to the proximal common iliac arteries. Because type Ib endoleakage from the right distal edge of the stent graft was present, extension to the iliac bifurcation was performed using an additional leg device. The external iliac artery was severely calcified and tortuous;thus, insertion of the leg device was technically difficult. Immediately after the operation, abdominal distention, right trash foot, and a small amount of rectal bleeding were observed. The patient was managed conservatively, and the symptoms resolved within a few days. Oral intake was started on postoperative day 5. However, 4 days after the initiation of oral intake, the patient suffered from abdominal pain and fever. Free air was observed by chest X-ray and computed tomography. Emergency laparoscopic examination revealed intestinal necrosis and perforation of the sigmoid colon. Therefore, the sigmoid colon was resected, and a transverse colostomy was performed. The patient recovered relatively well, with oral food intake beginning on day 6 and rehabilitation on day 8. He was discharged in good condition with unaided ambulation 5 weeks after bowel resection. Pathological examination demonstrated ischemic colitis due to cholesterol emboli.

     

    Jpn. J. Cardiovasc. Surg. 44:165-169（2015）

    Keywords：EVAR;ischemic colitis;microembolization


  • A Rare Complication after Tricuspid Annuloplasty　M. Sunada et al.…170
    A Rare Complication after Tricuspid Annuloplasty

    Masatoshi Sunada Hisao Suda Takuya Nakayama
    Toshiyuki Yamada Yosuke Miyata and Tatsuhito Ogawa  

    （Department of Cardiovascular Surgery, Nagoya City East Medical Center, Nagoya, Japan）

    We report a rare case of severe aortic regurgitation after mitral valve replacement（MVR）and tricuspid annuloplasty（TAP). An 83-year-old woman underwent MVR and TAP for mitral regurgitation and secondary tricuspid regurgitation. The early postoperative course was not eventful until 6 days after surgery. However, 7 days after surgery, she suffered from acute heart failure and transthoracic echocardiography showed severe aortic regurgitation. We performed a second operation 13 days after the first surgery. Intraoperatively, we found the annulus suture of the TAP just under the NCC-RCC commissure of the aortic valve. We speculated that the suture pulled the aortic valve annulus, resulting in severe aortic regurgitation. We removed the suture and replaced the aortic valve with bioprosthetic artificial valve. Postoperative recovery was uneventful, and she was discharged 22 days after the second surgical procedure.

     

    Jpn. J. Cardiovasc. Surg. 44:170-172（2015）

    Keywords：aortic valve regurgitation;tricuspid valve annuloplasty;mitral valve replacement


  • A Chronic Aortic Dissection with Aberrant Right Subclavian Artery and Kommerell’s Diverticulum　M. Sakaguchi et al.…173
    A Chronic Aortic Dissection with Aberrant Right Subclavian Artery and Kommerell’s Diverticulum

    Masanori Sakaguchi Tadahiro Murakami Takumi Ishikawa and Hirokazu Minamimura

    （Department of Cardiovascular Surgery, Bell Land General Hospital, Sakai, Japan）

    A 65-year-old woman suffered from left-side paralysis and dysarthria after sudden chest pain, and we diagnosed cerebral infarction caused by type A acute aortic dissection in the Stanford classification. At that time, the aberrant right subclavian artery with Kommerell’s diverticulum was found on enhanced computed tomography. The acute aortic dissection with closed false lumen was treated conservatively. Because the ulcer-like projection（ULP）expanded during the course, we performed surgery. Ascending aorta and arch replacement, patch closure of Kommerell’s diverticulum and reconstruction of right subclavian artery were performed simultaneously. The postoperative course was good.

     

    Jpn. J. Cardiovasc. Surg. 44:173-176（2015）

    Keywords：aberrant right subclavian artery;Kommerell’s diverticulum;chronic aortic dissection


  • Surgical Treatment for a Case of Intracardiac Foreign Body　K. Kojima et al.…177
    Surgical Treatment for a Case of Intracardiac Foreign Body

    Kazushi Kojima Takahiro Hayase Katsuhiko Niina
    Atsuko Yokota Eisaku Nakamura and Kunihide Nakamura

    （Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan, Department of Cardiovascular Surgery, Miyazaki Medical Association Hospital＊, Miyazaki, Japan, and Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki＊＊, Miyazaki, Japan）

    We describe a case of an intracardiac foreign body that was treated by surgery. A 27-year-old man sustained a neck injury by a nail fired from a pneumatic nail gun, and was admitted to a hospital. Chest radiography did not show any abnormality, and his injury healed after 1week. A radiography performed during a routine medical checkup after 2 months indicated that a nail was located within the heart. He was subsequently admitted to our hospital for further examinations. Chest computed tomography（CT）revealed the presence of a nail-like foreign body in the right ventricle. We diagnosed the patient with an intracardiac foreign body that was related to the injury sustained 2 months previously, although the underlying mechanism was unknown. He underwent emergency surgery, and the foreign body was removed under cardiopulmonary bypass without any complications. When a rigid substance impacts the body at high speeds, we should consider that some fragments could remain embedded in the body. CT scans are very useful for the diagnosis and identification of foreign bodies.

     

    Jpn. J. Cardiovasc. Surg. 44:177-180（2015）

    Keywords：intracardiac forein body;nail, operation;chest CT


Editor’s Post Script

  • H. Takemura