Japanese Journal of Cardiovascular Surgery Vol.44, No4

President Lecture

Case Reports

  • An Inflammatory Pseudotumor Arising from the Mitral Valve　S. Miyasaka et al.…184
    An Inflammatory Pseudotumor Arising from the Mitral Valve

    Shigeto Miyasaka Keisuke Morimoto Kengo Nishimura
    Yoshikazu Fujiwara

    （Department of Cardiovascular Surgery, Tottori Prefectural Central Hospital, Tottori, Japan, and Department of Cardiovascular Surgery, Tottori Kousei Hospital＊, Kurayoshi, Japan）

    We herein report a rare case of an inflammatory pseudotumor arising from the mitral valve. A 58-year-old man who was undergoing maintenance dialysis was referred to us due to the presence of a tumor mass attached to the mitral valve. It was asymptomatic and had been coincidentally found by echocardiography. The tumor mass was a sphere measuring about 1 cm in size, and it arose from the posterior mitral leaflet. A myxoma of the left atrium was suspected, and the tumor mass was resected along with part of the posterior leaflet by means of a right minithoracotomy（MICS). The tumor was postoperatively diagnosed to be an inflammatory pseudotumor based on the findings of a histopathological examination. During the follow-up period of 1 year and 2 months after surgery, there was no recurrence. An inflammatory pseudotumor is a tumorous lesion characterized by the infiltration of inflammatory cells and the growth of myofibroblasts. This tumor occurs most frequently in the lung, and the greatest number of intracardiac cases have been reported in small children. There are few reports of inflammatory pseudotumors occurring in adults, and only 4 cases originating in the mitral valve has so far been reported, which means that such tumors are extremely rare. For this reason, we reported the findings of this case, while adding a bibliographical survey.　

    Jpn. J. Cardiovasc. Surg. 44:184-187（2015）

    Keywords：inflammatory pseudotumor;mitral valve;cardiac tumor


  • Multiple Infected Aneurysms of the Aortic Arch and Thoraco-abdominal Aorta Caused by Bacteroides fragilis　Y. Yamashita et al.…188
    Multiple Infected Aneurysms of the Aortic Arch and Thoraco-abdominal Aorta Caused by Bacteroides fragilis

    Yoichi Yamashita Sayako Nakagawa Kosuke Sakamoto
    Taiko Horii    

    （Department of Cardiovascular Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan）

    A 67-year-old man who had undergone robot-assisted laparoscopic radical prostatectomy 16 days before suffered from high fever. A screening CT showed an aortic arch aneurysm was 40mm in diameter, and Bacteroides fragilis was identified from blood culture. A few days after the first CT, the size of the aneurysm increased rapidly to 50mm in diameter, subsequently an urgent procedure of total arch replacement using rifampicin-soaked Dacron graft was performed. Although the postoperative course was unremarkable, pyrexia recurred on the ninth post operative day. The third CT showed a new aneurysm in the thoraco-abdominal aorta just below the celiac artery. The second urgent procedure of graft replacement of the thoraco-abdominal aorta with the reconstruction of the celiac artery was performed. Preoperative FDG-PET/CT was useful to decide the level of the resection and the suture. The intravenous administration of the antibiotics continued for six weeks after surgery. The patient is doing well without any signs of infection on oral antibiotics at 7 months after the second surgery.

    Jpn. J. Cardiovasc. Surg. 44:188-192（2015）

    Keywords：infected aneurysm;Bacteroides;thoracic aorta;thoraco-abdominal aorta


  • Successful Recovery from Possible Transfusion-Related Acute Lung Injury Following a Redo Aortic Valve Replacement　S. Sakaguchi et al.…193
    HLA
    Successful Recovery from Possible Transfusion-Related Acute Lung Injury Following a Redo Aortic Valve Replacement

    Shuhei Sakaguchi Koji Furukawa Eisaku Nakamura
    Mitsuhiro Yano Kunihide Nakamura  

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

    A 73-year-old man who underwent redo aortic valve replacement due to dysfunction of tissue heart valve developed hypoxemia with bilateral infiltrates on frontal chest radiograph and hypotension shortly after his operation. Due to the presence of progressive hypotension and hypoxemia, we inserted an intra-aortic balloon pump and, furthermore, provided percutaneous cardiopulmonary support. We ruled out cardiogenic pulmonary edema based on information from various examinations, including echocardiography, and subsequently diagnosed possible transfusion-related acute lung injury（possible TRALI). The patient was treated by mechanical ventilation and circulatory support under close supervision, showing a trend of improvement from postoperative day 2 and discontinuing mechanical ventilation on postoperative day 11. The patient made an uneventful recovery and was discharged on postoperative day 50. Cardiac surgery patients are at particular risk for TRALI, so physicians should consider TRALI whenever a patient develops hypoxemia during or shortly after transfusion. Rapid diagnosis and appropriate treatment of TRALI are especially important in cardiac surgery patients.

     

    Jpn. J. Cardiovasc. Surg. 44:193-197（2015）

    Keywords：transfusion-related acute lung injury;transfusion;cardiac surgery;hypoxemia;human leukocyte antigen


  • Ruptured Coronary Aneurysm with a Congenital Coronary Arteriovenous Fistula　S. Kanki et al.…198
    Ruptured Coronary Aneurysm with a Congenital Coronary Arteriovenous Fistula

    Sachiko Kanki Mari Kakita Eiki Woo
    Tomoyasu Sasaki Masahiro Daimon Takahiro Katsumata

    （Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Osaka, Japan）

    An 83-year-old man was transferred to our hospital with cardiac tamponade and suspected cardiac tumor detected by enhanced CT. Coronary angiography showed a coronary aneurysm of 50 mm ID on the left circumflex artery. An emergency surgery was performed to excise the aneurysm, and a fresh thrombus occupying the efferent artery was observed. Both the afferent and efferent vessels were closed by suture. The patient made an otherwise uneventful recovery. This case featured a fresh red thrombus formed in fistulous outflow of the coronary aneurysm that seemed a direct cause of rupture.

     

    Jpn. J. Cardiovasc. Surg. 44:198-202（2015）

    Keywords：coronary aneurysm;congenital coronary arteriovenous fistula;cardiac tamponade


  • A Rare Case of Leiomyosarcoma Originating from the Abdominal Aorta　K. Nakashima et al.…203
    A Rare Case of Leiomyosarcoma Originating from the Abdominal Aorta

    Kazue Nakashima Yukihiro Yoshimura Shuji Toyama
    Yoshiyuki Maekawa Tadanori Minagawa Tetsuro Uchida
    Mitsuaki Sadahiro

    （Department of Cardiovascular, Thoracic and Pediatric Surgery, School of Medicine, Yamagata University, Yamagata, Japan）

    We report an extremely rare case of leiomyosarcoma originating from the abdominal aorta. The patient was a 57-year-old man who had palpable abdominal mass with pain. The symptoms were consistent, and urgent operation was done due to impending rupture of the abdominal aortic aneurysm. The intraoperative findings showed that the mass was a primary tumor of the abdominal aorta, and the histological diagnosis was leiomyosarcoma. It is reported that its prognosis is very poor, but he survived 7.5 years after diagnosis by reason of aggressive management including surgical treatment, chemotherapy and radiotherapy.

     

    Jpn. J. Cardiovasc. Surg. 44:203-207（2015）

    Keywords：leiomyosarcoma originating from aorta;surgical treatment;chemotherapy;radiotherapy


  • A Surgical Case of Fourth Reoperation Using a Unique Technique of Cardioplegia　T. Honda et al.…208
    A Surgical Case of Fourth Reoperation Using a Unique Technique of Cardioplegia

    Takeshi Honda Noriaki Kuwada Hiroki Takiuchi
    Takahiko Yamasawa Yoshiko Watanabe Hiroshi Furukawa
    Yasuhiro Yunoki Atushi Tabuchi Hisao Masaki
    Kazuo Tanemoto

    （Department of Cardiovascular Surgery, Kawasaki Medical School, Kawasaki, Japan）

    The method of cardioplegic myocardial protection is often controversial for re-cardiotomy after a coronary artery bypass grafting（CABG). A 69-year-old woman with a history of three previous surgeries consisting of closed mitral commissurotomy（CMC), dual valve replacement（DVR), and CABG underwent mitral valve replacement（MVR）and CABG for perivalvular leakage（PVL). As a result, the bilateral coronary ostium and the bypass graft to the right coronary artery（RCA）were totally occluded. The left internal thoracic artery（LITA）graft to the left anterior descending（LAD）coronary artery was the only inflow to the left coronary artery system and the right coronary artery system developed collateral inflow. Cardioplegia was carried out by performing a temporary anastomosis graft on the saphenous vein graft（SVG）in the left anterior descending coronary artery and a new bypass graft in the RCA was used for the administration of cardioplegic solution with no complications. There are various strategies for cardioplegic myocardial protection. The best method should be selected depending on the patient characteristics and condition.

     

    Jpn. J. Cardiovasc. Surg. 44:208-211（2015）

    Keywords：cardioplegic myocardial protection;reoperation


  • Two Cases of Graft Replacement of the Infrarenal Abdominal Aorta for Shaggy Aorta Syndrome　Y. Ikeno et al.…212
    Two Cases of Graft Replacement of the Infrarenal Abdominal Aorta for Shaggy Aorta Syndrome

    Yuki Ikeno Akitoshi Yamada Kunio Gan
    Tatsuro Asada

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

    The optimal strategy for shaggy aorta syndrome has not been established, however, several case reports are published with the increase of the aged population. We report two men with shaggy aorta syndrome. The one was 75 years old with acute limb ischemia at the left popliteal artery due to the macroembolism from infrarenal Shaggy Aorta. The other was 76 years old with kidney dialysis, who had suffered from blue toe syndrome due to microembolism from the mobile plaque adhering to the infrarenal aortic wall. We successfully performed graft replacement of the abdominal aorta in order to prevent the recurrence of atheromatous embolization from the Shaggy Aorta. They have been free from any embolic event for the last 1 year. The ultrasonogram was useful for preoperative diagnosis and intraoperative management.

     

    Jpn. J. Cardiovasc. Surg. 44:212-216（2015）

    Keywords：Shaggy Aorta Syndrome;abdominal aortic replacement;aortic ultrasonography


  • The Third Surgical Intervention for a Case of Recurrent Undifferentiated Pleomorphic Sarcoma of the Left Atrium　K. Yokoyama et al.…217
    The Third Surgical Intervention for a Case of Recurrent Undifferentiated Pleomorphic Sarcoma of the Left Atrium

    Kenji Yokoyama Kazunobu Hirooka Dai Tasaki
    Masahiro Ohnuki

    （Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan, and Department of Cardiovascular Surgery, Musashino Red Cross Hospital＊, Musashino, Japan）

    We report a rare case of primary cardiac undifferentiated pleomorphic sarcoma with invasion to the posterior mediastinum, for which partial resection of the tumor in the left atrium had already been carried out twice. After remission for about three years, recurrence in the atrial wall involving the mitral valve posterior leaflet required a third surgical resection following mitral valve replacement.

     

    Jpn. J. Cardiovasc. Surg. 44:217-220（2015）

    Keywords：primary cardiac malignant tumor;undifferentiated pleomorphic sarcoma;invasion to mediastinum;reoperation


  • Surgery for Bilateral Atrial Thromboses Detected in a Cancer Patient with Cerebral Infarction　N. Yamamoto et al.…221
    Surgery for Bilateral Atrial Thromboses Detected in a Cancer Patient with Cerebral Infarction

    Nobuyuki Yamamoto Masaki Nie Akihiro Sasahara
    Kuniyoshi Ohara

    （Department of Cardiovascular Surgery, Ebina General Hospital, Ebina, Japan）

    A 74-year-old man had been taking warfarin for atrial fibrillation, but warfarin was discontinued due to upper gastrointestinal bleeding. One week later, left hemiplegia occurred, and cranial magnetic resonance imaging revealed multiple cerebral infarctions. Systemic examination revealed thrombi in both atria as well as duodenal cancer. Because all of the thrombi in both atria were larger than 30 mm in diameter, the risk of embolism or sudden death was assumed to be high. Although the use of cardiopulmonary bypass for cancer patients is controversial, bilateral atrial thrombectomy was performed 4 weeks after cerebral infarction onset because reasonable survival duration was expected with surgery for duodenal cancer after thrombectomy and further treatment. The timing of and indications for surgery in this case are discussed.

     

    Jpn. J. Cardiovasc. Surg. 44:221-223（2015）

    Keywords：bilateral atrial thromboses;cerebral infarction;cancer;cardiopulmonary bypass;atrial fibrillation


  • A Case of Off-Pump Coronary Artery Bypass Grafting for Coronary Aneurysm after Drug-Eluting Stent Implantation　M. Ueno et al.…224
    A Case of Off-Pump Coronary Artery Bypass Grafting for Coronary Aneurysm after Drug-Eluting Stent Implantation

    Masahiro Ueno Hironori Inoue Keisuke Yamamoto
    Yasuo Morishita

    （Department of Cardiovascular Surgery, Tenyoukai Central Hospital, Kagoshima, Japan）

    A 77-year-old woman underwent percutaneous coronary intervention（PCI）for chronic total occlusion of the left anterior descending artery using a drug-eluting stent（DES). Re-stenosis, stent fracture, and aneurysm were found on follow-up coronary angiography（CAG), and thus implantation of multiple DESs was required. Surgery was indicated because CAG 48 months after first DES implantation revealed enlargement of the aneurysm with other new lesions. She successfully underwent off-pump coronary artery bypass grafting and resection of the aneurysm.

     

    Jpn. J. Cardiovasc. Surg. 44:224-227（2015）

    Keywords：drug-eluting stent;coronary aneurysm;coronary artery bypass grafting


  • A Case of Urgent Thoracic Endovascular Aortic Repair with the Double-Chimney Graft Technique for a Ruptured Thoracic Aortic Aneurysm　K. Shukuzawa et al.…228
    A Case of Urgent Thoracic Endovascular Aortic Repair with the Double-Chimney Graft Technique for a Ruptured Thoracic Aortic Aneurysm

    Kota Shukuzawa Naoki Toya Yasutake Momokawa
    Soichiro Fukushima Tadashi Akiba Takao Ohki

    （Department of Surgery, Jikei University Kashiwa Hospital, Kashiwa, Japan, and Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine＊, Tokyo, Japan）

    A 73-year-old woman suffered from ruptured aortic arch aneurysm into mediastinum. The patient was treated by thoracic endovascular aortic repair with the double-chimney graft technique. Three days later, computed tomography（CT）revealed type 1a endoleak（EL）between the chimney grafts. Ten days later, the patient was treated by coil embolization of the aneurysm from the left subclavian artery. The patient recovered, and was without aortic aneurysm events during six months of follow up.　

     

    Jpn. J. Cardiovasc. Surg. 44:228-231（2015）

    Keywords：ruptured thoracic aortic aneurysm;TEVAR;chimney technique;endoleak;coil embolization


  • A Case of Giant Pseudoaneurysm Following Island-Fashion Arch Reconstruction　R. Matsuura et al.…232
    A Case of Giant Pseudoaneurysm Following Island-Fashion Arch Reconstruction

    Ryohei Matsuura Yasushi Tsutsumi Osamu Monta
    Hisazumi Uenaka Satoshi Taniguchi Kenji Tanaka
    Takaaki Samura Hirokazu Ohashi

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

    We report the rare case of a 68-year-old man, who was admitted to our hospital with a diagnosis of aortic arch anastomotic pseudoaneurysm, with concomintant aortic root enlargement and coronary artery stenosis. Eleven years previously, at age 56, he underwent total arch replacement with island reconstruction for chronic aortic dissection. We performed redo total arch replacement, aortic root replacement and coronary artery bypass, making use of a cardiopulmonary bypass with cannulation through the right subclavian artery, femoral artery and femoral vein before resternotomy. We also used selective cerebral perfusion. Postoperatively, the patient temporarily required reintubation;however, he was discharged in good condition on the 50th post-operative day. The case suggests that island reconstruction has the potential to cause an aortic arch pseudoaneurysm, particularly after a long postoperative period of time. Therefore, thorough postoperative care strategy is required. We also need to consider surgical reconstructive techniques which eliminate vascular lesions as much as possible at the time of the primary surgery, particularly in cases of chronic aortic dissection.

     

    Jpn. J. Cardiovasc. Surg. 44:232-236（2015）

    Keywords：island reconstruction;pseudoaneurysm;arch replacement


  • A Rare Case of Extracardiac Growing Angiomyolipoma Originating from the Interatrial Septum　J. Yanagisawa et al.…237
    A Rare Case of Extracardiac Growing Angiomyolipoma Originating from the Interatrial Septum

    Junji Yanagisawa Atsuo Maekawa Sadanari Sawaki
    Satoshi Hosino Yasunari Hayashi Masayoshi Tokoro
    Toshiaki Ito

    （Department of Cardiovascular Surgery, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan）

    A 58-year-old man was admitted with a complaint of exertional chest discomfort. A mass, 53×55×66mm in size, was detected in the transverse sinus of the pericardium, just cranial to the inter-atrial septum with enhanced chest CT. We performed resection of the tumor under cardiopulmonary bypass. Histopathological findings showed that the tumor was angiomyolipoma originated from the heart. Angiomyolipoma is a benign tumor, most frequently found in the kidney or liver and usually associated with tuberous sclerosis. Extra-cardiac growth of the cardiac angiomyolipoma is extremely rare, and only few have been reported previously.

     

    Jpn. J. Cardiovasc. Surg. 44:237-240（2015）

    Keywords：cardiac tumor;angiomyolipoma;HMB45


  • Ankylosing Spondylitis with Complete Atrioventricular Block and Aortic Regurgitation　S. Fukui et al.…241
    Ankylosing Spondylitis with Complete Atrioventricular Block and Aortic Regurgitation

    Shinya Fukui Masataka Mitsuno Mitsuhiro Yamamura
    Hiroe Tanaka Masaaki Ryomoto Tetsuya Kajiyama
    Ayaka Satoh Yuji Miyamoto

    （Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan）

    Ankylosing spondylitis is chronic, progressive, inflammatory disease involving the spine, peripheral joints, and periarticular structures. Cardiac abnormalities associated with ankylosing spondylitis are well recognized, but a case with DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for aortic regurgitation has not been previously reported. We report a case of a 66-year-old man with ankylosing spondylitis who was successfully treated by DDD pacemaker implantation for complete atrioventricular block and aortic valve replacement for severe aortic regurgitation.

     

    Jpn. J. Cardiovasc. Surg. 44:241-244（2015）

    Keywords：ankylosing spondylitis;aortic valve replacement;DDD pacemaker implantation


  • Endovascular Aneurysm Repair（EVAR）in a Patient with an Aortocaval Fistula　Y. Hari et al.…245
    Endovascular Aneurysm Repair（EVAR）in a Patient with an Aortocaval Fistula

    Yosuke Hari Naoji Hanayama

    Department of Cardiovascular Surgery, Kanto Rosai Hospital, Kawasaki, Japan）

    We report a case of endovascular aneurysm repair（EVAR）in a patient with an aortocaval fistula（ACF）who presented with congestive heart failure due to left-to-right shunting. The patient was an 80-year-old man who complained of sudden respiratory discomfort and lower leg edema, and was admitted to the emergency department. The initial diagnosis on admission was acute heart failure. Because the inferior vena cava was visualized by angiography in the arterial phase due to the fistula from the abdominal aorta, after admission, we rediagnosed this case as ACF. As medical treatment did not improve the patient’s symptoms, emergency surgery was decided upon. Because preoperative evaluation was able to rule out the existence of an aortic aneurysm, ACF closure was performed by EVAR. The postoperative course was uneventful and the patient was discharged 15 days after surgery. ACF without aortic aneurysm is uncommon and is not easily diagnosed. This case demonstrated that EVAR can be an effective treatment option for ACF.

     

    Jpn. J. Cardiovasc. Surg. 44:245-248（2015）

    Keywords：aorto-caval fistula;high output cardiac failure;endovascular aneurysm repair（EVAR）


Editor’s Post Script

  • K. Yamazaki