Japanese Journal of Cardiovascular Surgery Vol.44, No5

Preface

• Medical Specialist and Quality of Medical Care　T. Miyata

Original

• Surgical Treatment for Acute Pulmonary Embolism　K. Ishida et al.…249
  Surgical Treatment for Acute Pulmonary Embolism
  
  

  Keiichi Ishida	Hideki Ueda	Hiroki Kohno
  Yusaku Tamura	Shinichiro Abe	Kazuyoshi Fukazawa
  Yuichi Inage	Masahisa Masuda	Goro Matsumiya

  
  

  （Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Japan, and Department of Cardiovascular Surgery, Chiba Medical Center＊, Chiba, Japan）
  

  Background:Acute massive pulmonary embolism is a life-threatening disease. It is often treated with thrombolytic therapy, however, the mortality rates are unsatisfactorily high in patients who developed shock and subsequent cardiac arrest. Surgical pulmonary embolectomy is a last resort for patients with hemodynamic instability. We studied the outcomes of our patients who underwent pulmonary embolectomy for acute pulmonary embolism. Methods:Eight patients who underwent pulmonary embolectomy between January 2011 and December 2014 were studied. Our surgical indications were as follows. Patients who experienced cardiac arrest and treated with PCPS, and those in persistent vital shock, with contraindications of thrombolytic therapy, or with right heart floating thrombus. However, patients with ischemic encephalopathy or acute exacerbation of chronic thromboembolic pulmonary hypertension, and those who had already been treated with thrombolytic therapy were excluded. Preoperative ECMO was indicated for those in sustained shock. Pulmonary embolectomy was performed through median sternotomy and with cardiopulmonary bypass. After antegrade cardiac arrest, all clots were removed with forceps under direct vision through incisions in the bilateral main pulmonary arteries. IVC filter（Gu¨nther Tulip）was placed through the right atrial appendage. In our early cases, IVC filter（Neuhaus Protect）was placed after chest closure. Anticoagulation was not administered until hemostasis was achieved. Results:Seven patients underwent pulmonary embolectomy for massive pulmonary embolism, and in one patient pulmonary embolectomy was indicated for right heart floating thrombi although the pulmonary embolism was submassive. Three patients underwent cardiopulmonary resuscitation and were treated with ECMO. Other 3 patients in sustained shock vital were electively treated with ECMO. The other patient developed cardiopulmonary arrest shortly after anesthetic induction and intubation, and suffered disturbance of consciousness postoperatively. All patients were successfully weaned from cardiopulmonary bypass and underwent IVC filter placement（5 Neuhaus Protect, and 3 GProtec Tulip). One patient died due to a vascular complication associated with catheter insertion（retroperitoneal hematoma). No patients developed residual pulmonary hypertension. There were postoperative complications including pneumonia in 5 patients, tracheostomy in 2 patients, atrial fibrillation in 3 patients, and pericardial effusion in 1 patient. One patient who suffered disturbance of consciousness died 2.4 months after the surgery. Other patients had not developed any thrombotic and hemorrhagic complications during a median follow-up of 13.1 months. Conclusions:Pulmonary embolectomy is an effective treatment of acute massive pulmonary embolism. We believe that our strategy is useful, consisting of preoperative hemodynamic stability by an institution of ECMO, complete removal of clots by bilateral main pulmonary incisions, and prevention of recurrence by IVC filter placement.　
  　　

  Jpn. J. Cardiovasc. Surg. 44:249-255（2015）

  Keywords：acute pulmonary embolism;pulmonary embolectomy;surgery
  

  
  

Case Reports

• Endovascular Treatment for Pararenal Abdominal Aortic Aneurysm Using the Chimney Technique for Bilateral Renal Arteries　Y. Souma et al.…256
  Endovascular Treatment for Pararenal Abdominal Aortic Aneurysm Using the Chimney Technique for Bilateral Renal Arteries
  
  

  Yusuke Souma

  Takayuki Tatebayashi

  Sakashi Noji

  
  

  （Department of Cardiovascular Surgery, Higashiyamato Hospital, Higashiyamato, Japan）
  

  Endovascular aneurysm repair（EVAR）of pararenal abdominal aortic aneurysm（pararenal AAA）includes fenestrated or branched endografts, and the chimney technique. However, fenestrated and branched endografts are not currently available. An 82-year-old man, who underwent EVAR two years previously, was admitted to our hospital because of pararenal AAA measuring 56mm. He underwent endovascular treatment with the chimney technique for bilateral renal arteries. We used a self-expanding and balloon-expandable uncovered-stent in renal arteries. Postoperatively he had slight renal dysfunction and acute pancreatitis, but was discharged 14 days after surgery. EVAR with the chimney technique for bilateral renal arteries was thought to be useful in high risk patients with pararenal AAA.

  Jpn. J. Cardiovasc. Surg. 44:256-260（2015）

  Keywords：pararenal abdominal aortic aneurysm;chimney method;endovascular surgery;stent-graft
  
  

  
  
• Total Arch Replacement for Acute Type A Aortic Dissection 5 Years after Aortic Valve-Sparing Operation in a 14-Year-Old Boy with Loeys-Dietz Syndrome　K. Yamana et al.…261
  Total Arch Replacement for Acute Type A Aortic Dissection 5 Years after Aortic Valve-Sparing Operation in a 14-Year-Old Boy with Loeys-Dietz Syndrome
  
  

  Koji Yamana	Hajime Sakurai	Toshimichi Nonaka
  Takahisa Sakurai	Tetsuyoshi Taneichi	Ryohei Otsuka
  Takuya Osawa

  
  

  （Department of Cardiovascular Surgery, Chukyo Children’s Heart Center, Nagoya, Japan）
  

  A 14-year-old boy who underwent aortic valve-sparing operation for annuloaortic ectasia at the age of 9 was referred to our service with a diagnosis of acute type A aortic dissection. Emergency total arch replacement with the elephant trunk technique was done successfully and the postoperative course was uneventful. However, computed tomography（CT）2 weeks after the operation showed a new dissection and enlargement in left subclavian artery and folded elephant trunk. Dilatation in coronary buttons were also seen since the time of surgery. No residual dissection was found in the aorta. Careful follow up is necessary for this case due to multiple aneurysmal changes and a new dissection lesion in a short period. Loeys-Dietz syndrome（LDS）is characterized by vascular findings（aortic aneurysm and dissection）and skeletal manifestations. Due to aortic dissection occurring in smaller diameter aortas in LDS patients than in Marfan syndrome, early and aggressive surgery is recommended for patients with LDS.

   

  Jpn. J. Cardiovasc. Surg. 44:261-265（2015）

  Keywords：Loeys-Dietz syndrome;acute aortic dissection;total arch replacement
  
  

  
  
• A Case of Ascending Aorta Replacement for Chronic Aortic Dissection by Minimally Invasive Cardiac Surgery　Y. Endo et al.…266
  A Case of Ascending Aorta Replacement for Chronic Aortic Dissection by Minimally Invasive Cardiac Surgery
  
  

  Yoshiki Endo	Keita Kikuchi	Kotaro Suzuki
  Takayoshi Matsuyama	Dai Une	Yasuhisa Fukada
  Atsushi Kurata

  
  

  （Department of Cardiovascular Surgery, Yamato Seiwa Hospital, Yamato, Japan, and Division of Cardiovascular Surgery＊, Yamagata Prefectural Central Hospital, Yamagata, Japan）
  

  The number of surgical treatments for acute aortic dissection in octogenarians is increasing. They should return to their daily life as soon as possible after the operation without any complications. Some literature reported that minimally invasive cardiac surgery（MICS）helps quick recovery for the patients. We report a case of minimally invasive ascending aorta replacement for Stanford type A chronic thrombosed aortic dissection in an octogenarian to help quick recovery. An 81-year-old man was admitted in our hospital suffering from chest and back pain. Enhanced CT scan showed Stanford type A acute thrombosed aortic dissection. The diameter of ascending aorta was 45mm and the diameter of false lumen was 7mm. Therefore we decided on medical treatment for this patient according to the guideline. After four weeks medical treatment, ascending aorta was dilated to 49mm and the false lumen also expanded to 9mm. He underwent minimally invasive ascending aorta replacement to help quick recovery considering his age. He was discharged 11 days postoperatively without any complications. MICS offers a better cosmetic result, less blood loss, less pain, better respiratory function and quick recovery. Thus, minimally invasive operation for the elderly is also very satisfactory.

   

  Jpn. J. Cardiovasc. Surg. 44:266-270（2015）

  Keywords：minimally invasive cardiac surgery（MICS）;chronic aortic dissection;ascending aorta replacement;type A acute thrombosed aortic dissection

  
  
• Valve-Sparing Root Replacement for Syphilitic Aortic Arch Aneurysm with Aortic Regurgitation　Y. Kawai et al.…271
  Valve-Sparing Root Replacement for Syphilitic Aortic Arch Aneurysm with Aortic Regurgitation
  
  

  Yujiro Kawai	Mitsutaka Nakao	Hirokazu Niitsu
  Yasuyuki Toyoda	Yasutoshi Tsuda	Kazuaki Shiratori
  Takahiro Takemura

  
  

  （Department of Cardiovascular Surgery, Advanced Care Center, Saku Central Hospital, Saku, Japan）
  

  Syphilitic aortic aneurysm became rare after the discovery of penicillin. Syphilitic aortitis involves the ascending aorta and dilates the aortic annulus, causing aortic valve regurgitation. We report a case of syphilitic aortic aneurysm with severe aortic valve regurgitation, which was successfully treated with the replacement of the valve-sparing root and the total arch. A 55-year-old man, admitted earlier to another hospital for colon diverticulum, was found to have an aortic arch aneurysm. Enhanced computed tomography revealed the aneurysm of the ascending aorta to the transverse arch aorta with the maximum short diameter of the aneurysm at 68mm. He also had a saccular aneurysm in the ascending aorta. Although he had never had a history of syphilis, a routine laboratory test for syphilis was positive. That said, we looked upon this case as a syphilitic aortic aneurysm. In preoperative cardiac echography, the aortic regurgitation was severe with mild valve stenosis and mainly due to dilation of the aortic root. We thought the native valve could be spared and replaced both the valve-sparing root and the total arch. He was discharged on the 11th postoperative day without any complications.

   

  Jpn. J. Cardiovasc. Surg. 44:271-274（2015）

  Keywords：syphilitic aortic aneurysm;aortic regurgitation;valve-sparing root replacement
  

  
  
• A Case of Hemolytic Anemia Caused by a Kinked Graft after Operation for Aortic Dissection　M. Ueno et al.…275
  A Case of Hemolytic Anemia Caused by a Kinked Graft after Operation for Aortic Dissection
  
  

  Masahiro Ueno	Hironori Inoue	Keisuke Yamamoto
  Yasuo Morishita

  
  

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

  A 62-year-old woman was referred to our hospital for treatment of hemolytic anemia 10 years after total arch replacement for acute aortic dissection. The cause of hemolysis was confirmed to be mechanical damage of red blood cells at the kinked graft. Because aortic valve regurgitation and occlusion of the left subclavian artery were also found, resection of the kinked graft, aortic valve replacement and reconstruction of the left subclavian artery were carried out concomitantly at reoperation. Her postoperative course was uneventful, and hemolysis resolved soon after the operation.

   

  Jpn. J. Cardiovasc. Surg. 44:275-278（2015）

  Keywords：acute aotic dissection;hemolytic anemia;kinked graft

  
  
• Total Arch and Descending Aortic Replacement for a Kommerell Diverticulum and Right-Sided Aortic Arch with Aberrant Left Subclavian Artery　S. Hattori et al.…279
  Total Arch and Descending Aortic Replacement for a Kommerell Diverticulum and Right-Sided Aortic Arch with Aberrant Left Subclavian Artery
  
  

  Shigeru Hattori	Keiji Yunoki	Naoya Sakoda
  Atsushi Tateishi	Yasufumi Fujita	Kunikazu Hisamochi
  Hideo Yoshida

  
  

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

  A 74-year-old woman was referred to our unit with a chief complaint of dysphagia. Enhanced CT showed a Kommerell diverticulum with a maximum diameter of 46mm, associated with a right-sided aortic arch and aberrant left subclavian artery. We performed two-staged operations:left subclavian-common carotid artery bypass followed by total arch, and descending aortic replacement by an antero-lateral thoracotomy with partial sternotomy（ALPS). The postoperative course was uneventful. Total arch and descending aortic replacement for a Kommerell diverticulum by an ALPS approach is rare. ALPS approach for Kommerell diverticulum achieves safe surgery with good exposure.

   

  Jpn. J. Cardiovasc. Surg. 44:279-282（2015）

  Keywords：Kommerell diverticulum;right-sided aortic arch;total arch and descending aortic replacement;anterolateral thoracotomy with partial sternotomy
  
  

  
  
• A Case of Early Limb Stenosis after Endovascular Abdominal Aneurysm Repair with the Endurant Stent Graft System　T. Yamamoto et al.…283
  A Case of Early Limb Stenosis after Endovascular Abdominal Aneurysm Repair with the Endurant Stent Graft System
  
  

  Tsunehisa Yamamoto	Katsuhiko Oka	Osamu Sakai
  Hidetake Kawajiri	Sachiko Yamazaki	Taiji Watanabe
  Keiichi Kanda	Hitoshi Yaku

  
  

  （Department of Cardiovascular Surgery＊, and Department of Minimally Invasive Cardiovascular Surgery＊＊, Kyoto Prefectural University of Medicine, Kyoto, Japan）
  

  An 81-year-old man who had a saccular abdominal aortic aneurysm（AAA）with a narrow terminal aorta underwent endovascular aortic aneurysm repair（EVAR）with the Medtronic Endurant●R stent graft system. After 4 days, computed tomography（CT）showed stenosis of the stent graft left limb, which was pressed flat against the right limb at the narrow terminal aorta. We performed re-intervention to dilate the narrow terminal aorta and bilateral limbs with kissing stenting using Express Vascular LD●R（Boston Scientific). After operation his ankle brachial pressure index rose from 0.88 to 0.99 and there was no evidence of stenotic limbs at CT image. We need to be careful about the stenotic limb after EVAR with Medtronic Endurant stentgraft system for AAA with a narrow terminal aorta.　

   

  Jpn. J. Cardiovasc. Surg. 44:283-287（2015）

  Keywords：EVAR;limb stenosis;narrow terminal aorta;kissing stent

  
  
• A Case of Transvalvular Removal of Subvalvular Pannus beneath the Monocusp Tilting-Disk Mechanical Valve at the Aortic Position Using CUSA　R. Izubuchi et al.…288
  A Case of Transvalvular Removal of Subvalvular Pannus beneath the Monocusp Tilting-Disk Mechanical Valve at the Aortic Position Using CUSA
  
  

  Ryo Izubuchi	Shigehiko Tokunaga	Tomoki Cho
  Shota Yasuda	Yukihisa Isomatsu	Munetaka Masuda

  
  

  （Department of Cardiovascular Surgery, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan, Department of Cardiovascular Center, Yokohama City University Medical Center＊, Yokohama, Japan, and Department of Surgery, Yokohama City University Hospital＊＊, Yokohama, Japan）
  

  We describe our surgical treatment in a patient with subvalvular aortic stenosis due to pannus formation beneath a monocusp mechanical valve. In this case, transvalvular removal of subvalvular pannus using a CUSA（Cavitron ultrasonic surgical aspirator）was performed successfully. A 77-year-old woman underwent aortic valve replacement with a monocusp tilting-disk mechanical valve（Bjo¨rk-Shiley, 23mm）30 years previously. Reoperation for severe aortic stenosis due to calcified subvalvular pannus formation was required. Intraoperative findings revealed no limitation of leaflet motion of the valve but presence of left ventricular outflow tract obstruction caused by subvalvular pannus formation under the major orifice of the prosthesis. Because of difficulty of exposure of the prosthetic valve due to severely calcified valsalva sinus wall, simple re-do aortic valve replacement seemed to be almost impossible. Therefore, we tried transvalvular removal of the pannus. A scalpel could not be applied due to severe calcification of the pannus. Then we used CUSA and removed the pannus successfully. Finally, subvalvular stenosis（LVOTO）was ameliorated and a decrease of trans-aortic valve velocity was recognized. She is doing well without recurrence 1.5 years after the surgery.

   

  Jpn. J. Cardiovasc. Surg. 44:288-291（2015）

  Keywords：pannus resection;post aortic valve replacement;monocusp mechanical valve;CUSA
  

  
  
• A Case Report of Aortic Valve Replacement for a Patient with von Willebrand Disease　K. Nakashima…292
  A Case Report of Aortic Valve Replacement for a Patient with von Willebrand Disease
  
  

  Kazue Nakashima	Yukihiro Yoshimura	Shuji Toyama
  Yoshiyuki Maekawa	adanori Minagawa	Mitsuaki Sadahiro

  
  

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

  We report a 30-year-old patient with von Willebrand disease who received AVR under cardio-pulmonary bypass. AR was diagnosed at the age of 13, and von Willebrand disease was revealed after cardiac catheterization because of a bleeding episode. His von Willebrand factor（vWF）activity was significantly low, 43% of normal. Infusion of vWF concentrates（Confact F●R）was administered before surgery. AVR was safely performed and no bleeding complications occurred during the perioperative period. Blood transfusion was unnecessary, vWF infusion was considered to be very useful.

   

  Jpn. J. Cardiovasc. Surg. 44:292-295（2015）

  Keywords：Von Willebrand’s disease;aortic valve replacement;vWF infusion
  
  

  
  
• True Coronary Aneurysms after the Bentall Procedure in a Patient with Marfan Syndrome　S. Oyama et al.…296
  True Coronary Aneurysms after the Bentall Procedure in a Patient with Marfan Syndrome
  
  

  Shogo Oyama

  Shingo Ohuchi

  Hitoshi Okabayashi

  
  

  （Department of Cardiovascular Surgery, Nakadori General Hospital, Akita, Japan, and Department of Cardiovascular Surgery＊, Iwate Medical University Memorial Heart Center, Morioka, Japan）
  

  A 55-year-old woman underwent a Bentall operation and total arch replacement 18 years previously, because of chronic aortic dissection（CAD), annuloaortic ectasia（AAE), aortic valve insufficiency（AI), and Marfan syndrome. In 1996, at age 37 years, she was admitted to our hospital with diagnoses of CAD, AAE, AI, and Marfan syndrome. That same year, we performed the Bentall operation and total arch replacement（Carbomedics, 25mm;Hemashield, 28mm). She then underwent Y-graft replacement for an abdominal aortic aneurysm in 2003, descending aorta replacement for a thoracic aortic aneurysm in 2007, and thoracoabdominal aorta replacement for thoracoabdominal aortic aneurysm in 2010. Afterward, both coronary arteries gradually dilated. The diameter of the left coronary artery was 17mm, while that of the right coronary artery was 25mm. Accordingly, in 2014, we surgically replaced both coronary aneurysms with the great saphenous vein. Pathological analysis showed that both coronary aneurysms were true aneurysms because the three-layered structure was preserved. We confirmed that the great saphenous vein grafts were patent by three-dimensional computed tomography. She was discharged 17 days postoperatively once her condition stabilized. We report a case of Marfan syndrome with both coronary true aneurysms, because we think this kind of report is very rare.

   

  Jpn. J. Cardiovasc. Surg. 44:296-298（2015）

  Keywords：Marfan syndrome;true coronary aneurysm;Bentall operation
  

  
  

Editor’s Post Script

• G. Matsumiya