|Munehiro Saiki＊,＊＊||Yoshinobu Nakamura＊||Suguru Shiraya＊|
|Shingo Harada＊||Yuichiro Kishimoto＊||Takeshi Ohnohara＊|
|Tomohiro Kurashiki＊||Satoru Kishimoto＊||Hiromu Horie＊|
（Division of Organ Regeneration Surgery, School of Medicine, Tottori University＊, Tottori, Japan, Present address:Department of Endovascular Treatment for Structural Heart and Aortic Disease, Hiroshima City Hiroshima Citizens Hospital＊＊, Hiroshima, Japan）
Background:Endovascular treatment of the thoracic aorta（TEVAR）for type B aortic dissection is reported to be effective if the interval between the onset and the procedure is relatively short. However, the optimal timing for TEVAR is still controversial. Method:From December 2008 to April 2015, we experienced 46 TEVARs for type B aortic dissection. The interval between onset and TEVAR was within 3 months in 15 cases（Group A), from 3 months to 1 year in 10 cases（Group B), and more than 1 year in 21 cases（Group C). Result:Primary success was obtained in all cases, and no new intimal tear was formed during the procedure. There was no hospital death. At the time of discharge, disappearance of ULP or thrombosed thoracic false lumen occurred significantly more frequently in Group A（93%）than in Group B（50%）and Group C（43%）（p＜0.05). At 6 months, the rate of the patients with reduced aneurysm diameter more than 5mm was significantly higher in Group A（87%）and Group B（70%）than in Group C（19%）（p＜0.05). Three cases of Group C had enlargement of the aneurysm despite of TEVAR, and graft replacement of thoracoabdominal aorta was performed in one of the cases. Conclusion:For type B aortic dissection, TEVAR is more effective if performed within 3 months from the onset.
Jpn. J. Cardiovasc. Surg. 45:101-106（2016）
Keywords：stent graft;type B aortic dissection;timing of the intervention
|Mizuki Sumi＊,＊＊||Koji Hashizume＊,＊＊||Tsuneo Ariyoshi＊|
|Seiji Matsukuma＊||Shun Nakaji＊||Kiyoyuki Eishi＊|
（Department of Cardiovascular Surgery, Graduate School of Medicine, Nagasaki University＊, Nagasaki, Japan, Department of Cardiovascular Surgery, Nagasaki Harbor Medical Center City Hospital＊＊, Nagasaki, Japan）
We report a case of percutaneous transluminal angioplasty（PTA）treatment for low cardiac output syndrome due to superior vena cava（SVC）stenosis with venous return anomaly. A 69-year-old man was referred to our hospital for surgical treatment of tricuspid valve infective endocarditis due to infected pacemaker leads, which had been implanted for sick sinus syndrome. Preoperative computed tomography indicated polysplenia syndrome-related absence of the hepatic segment of the inferior vena cava（IVC). Preoperative coronary angiography showed a 99% stenosis in the left anterior descending artery and a total occlusion in the right coronary artery. We therefore performed pacemaker system removal, tricuspid valve plasty, coronary artery bypass surgery, and a new pacemaker implantation（epicardial leads). However, over the postoperative course we noted low cardiac output syndrome due to SVC syndrome, which appeared to be aggravated by venous return anomaly from the patient’s absent IVC hepatic segment. Eight days after the surgery we conducted PTA for SVC syndrome, which notably improved the patient’s hemodynamics. The patient recovered and was transferred to a rehabilitation facility 34 days after the surgery.
Jpn. J. Cardiovasc. Surg. 45:107-111（2016）
Keywords：polysplenia syndrome;anomalous inferior vena cava with azygos connection;pacemaker lead endocarditis;superior vena cava syndrome;percutaneous transluminal angioplasty
|Shunsuke Sakamoto＊||Kenichiro Fujii＊||Yasuhiro Sawada＊|
|Yu Shomura＊||Jin Tanaka＊||Toru Mizumoto＊|
（Department of Cardiovascular and Respiratory Surgery, Anjo Kosei Hospital＊, Anjo, Japan）
Primary cardiac malignant tumors are relatively rare, and their prognosis is poor. We report a patient with sarcoma causing severe mitral regurgitation and stenosis due to rapid and specific infiltration into the mitral valve.
Jpn. J. Cardiovasc. Surg. 45:112-114（2016）
|Masato Suzuki＊||Fumikazu Nomura＊||Yohei Ohkawa＊|
|Akira Adachi＊||Kisyu Fujita＊||Takemi Ohno＊|
（Department of Cardiovascular Surgery, Hokkaido Ohno Hospital＊, Sapporo, Japan）
A 52-year old man was referred to our hospital for atrial fibrillation ablation therapy. A multislice computed tomography study demonstrated a giant coronary artery aneurysm situated just proximal to the left anterior descending（LAD), LAD stenosis and coronary-pulmonary artery fistula. The fistula was ligated and the aneurysm was resected under cardiopulmonary bypass. The left internal thoracic artery was used as a bypass graft to the LAD as well as a patch for closure of the LAD orifice to avoid left circumflex artery stenosis. We report a rare case of giant LAD aneurysm with coronary-pulmonary artery fistula.
Jpn. J. Cardiovasc. Surg. 45:115-120（2016）
Keywords：giant coronary artery aneurysm;coronary-pulmonary artery fistula;internal thoracic artery patch
|Keisuke Nonoyama＊||Takayuki Saito＊||Yukihide Numata＊|
（Department of Cardiovascular Surgery, Kariya Toyota General Hospital, Kariya, Japan）
An 80-year-old man was referred to our hospital due to anorexia and loss of body weight. Blood examination showed a severe inflammatory reaction and Streptococcus oralis was detected in his blood culture. Echocardiogram demonstrated severe aortic valve regurgitation and vegetation located on the valve. Although we diagnosed infective endocarditis（IE）and started to treat with antibiotics, the patient refused treatment and was discharged. Ten days later, he was readmitted to our hospital because of chest pain. Electrocardiogram demonstrated an anteroseptal acute myocardial infarction and an emergency coronary angiogram revealed complete obstruction of the left anterior descending coronary artery（LAD). He was successfully treated with thrombus aspiration using a catheter device. Pathological examination of the thrombus revealed that the coronary embolism was caused by infective endocarditis（IE). To prevent re-embolization, we performed aortic valve replacement 8 days after the intervention and CABG was also carried out for residual stenosis on the LAD. Coronary embolism caused by IE is a rare problem. We reported a case of AMI associated with IE that was initially treated with thrombus aspiration which was followed by aortic valve replacement.
Jpn. J. Cardiovasc. Surg. 45:121-125（2016）
Keywords：infective endocarditis;acute myocardial infarction;vegetation
|Soichiro Kageyama＊||Takeki Ohashi＊||Koji Iida＊|
|Masao Tadakoshi＊||Haruo Suzuki＊||Masato Furui＊|
|Akinori Kojima＊||Noriko Kodani＊|
（Department of Cardiovascular Surgery, Nagoya Tokushukai General Hospital＊, Kasugai, Japan）
Fulminant myocarditis is known as a disastrous disease that requires intensive care with mechanical cardiopulmonary support. Percutaneous cardiopulmonary bypass（PCPS), which is referred to as extracorporeal membrane oxygenation, is usually used for fulminant myocarditis. However, in some cases, PCPS may be ineffective because of circulatory insufficiency and could be associated with various severe complications such as multiple organ failure or leg ischemia. In such cases, placement of a ventricular assist device（VAD）is required. A 46-year-old man with fever and severe fatigue was admitted to a local hospital and diagnosed as having fulminant myocarditis. Although an intra-aortic balloon pump and PCPS were introduced, cardiac function was not recovered, causing multiple organ failure and leg ischemia. Hence, he was transferred to our hospital for further mechanical support. Transesophageal echocardiography（TEE）revealed severe biventricular cardiac dysfunction, and radiography showed pulmonary edema. His total bilirubin level was 6.9mg/dl and platelet level was 3,300/μl. Thus, we implanted a biventricular assist device（BiVAD). At 12 days after the implantation, TEE revealed improvement of cardiac function, and blood biochemical examination revealed recovery of multiple organ function. Thereafter, the patient was weaned from the BiVAD successfully. After the operation, the patient underwent a long rehabilitation. He was discharged 51 days after the operation, without any neurological or cardiac complication.
Jpn. J. Cardiovasc. Surg. 45:126-130（2016）
Keywords：fulminant myocarditis;adult BiVAD
|Yosuke Tanaka＊||Kazuhiro Mizoguchi＊||Nobuhiro Tanimura＊＊|
|Hidetaka Wakiyama＊＊＊||Keiji Ataka＊|
（Department of Cardiovascular Surgery, Sumitomo Hospital＊, Osaka, Japan, Department of Vascular Surgery, Soryukai Inoue Hospital＊＊, Osaka, Japan, Department of Cardiovascular Surgery, Kakogawa East City Hospital＊＊＊, Kakogawa, Japan）
A 28-year-old woman with patent foramen ovale who developed tricuspid valve infective endocarditis with complications of multiple infarctions and abscesses was treated surgically. The patient was transferred to our institution because of fever and joint pain. Echocardiography revealed a large vegetation（25mm）on the tricuspid valve and a patent foramen ovale. Computed tomography and magnetic resonance imaging showed cerebral infarctions, multiple lung abscesses, and vertebral osteomyelitis. Staphylococcus epidermidis was identified in blood cultures. After treatment with adequate antibiotics for 5 weeks, the patient underwent surgical resection of the vegetation followed by tricuspid valve repair and direct closure of the patent foramen ovale. Antibiotic therapy was continued postoperatively, and the patient was discharged 7 weeks after the operation. No further endocarditis or embolism has occurred. In cases of right-sided endocarditis with systemic embolism and abscesses, the presence of a patent foramen ovale should be considered, and appropriate timing of the operation should be determined to prevent further systemic embolization of the vegetation.
Jpn. J. Cardiovasc. Surg. 45:131-134（2016）
Keywords：infective endocarditis;patent foramen ovale;tricuspid valve surgery
|Daigo Suzuki＊||Shun-Ichiro Sakamoto＊||Masafumi Shibata＊|
|Hiroyasu Kawase＊||Yasuo Miyagi＊||Yosuke Ishii＊|
|Tetsuro Morota＊||Takashi Nitta＊|
（Department of Cardiovascular Surgery, Nippon Medical School＊, Tokyo, Japan）
Treating a thoracic aortic aneurysm（TAA）after coronary artery bypass graft（CABG）surgery requires an appropriate surgical procedure to preserve the functional graft. We present a case of hybrid procedure of thoracic endovascular aortic repair combined with a redo off-pump CABG via median sternotomy. The patient was a 76-year-old man with a history of CABG and abdominal aortic replacement in a different country. Chest computed tomography revealed a saccular-shaped aortic aneurysm in the distal aortic arch with diameter of 5.6 cm. Coronary angiography revealed theLIMA graft was patent but anastomosed to the diagonal branch and the left anterior descending artery（LAD）was totally occluded and was opacified through the right coronary artery. Significant ischemic change in the anteroseptal wall suggested a requirement of surgical revascularization of LAD. The chest was opened via re-midsternotomy. Then the 3 arch vessels were reconstructed with a trifurcated artificial graft attached to the ascending aorta and coronary artery bypass grafting was performed on the beating heart. Finally, the aneurysm was excluded by introducing a stent graft through the graft to zone 0. The patient’s postoperative course was uneventful and he was discharged on postoperative day 16. A hybrid procedure via median sternotomy was useful in the surgery for TAA with the functional LIMA after CABG.
Jpn. J. Cardiovasc. Surg. 45:135-138（2016）
Keywords：thoracic aortic aneurysm;hybrid operation;redo-CABG
|Isamu Yoshitake＊||Mitsumasa Hata＊＊||Tsutomu Hattori＊|
（Department of Cardiovascular Surgery, Sagamiharakyodo Hospital＊, Sagamihara, Japan, Department of Cardiovascular Surgery, Nihon University Hospital＊＊, Tokyo, Japan）
A 76-year-old man with hypertension had an enlarged distal aortic arch aneurysm with a maximum dimension of 55mm. Coronary computed tomography angiogram showed none of stenosis in a coronary artery, but penetrating atherosclerotic ulcer at ascending aorta. We performed open surgical repair combination of ascending aortic replacement and less invasive quick open stenting（LIQS）to reduce operative risk, because of his advanced age. The operation was carried out without any complications（Operation time:242min, Cardiopulmonary bypass time:154min, Aortic cross clamp time:71min). The patient’s postoperative course was unremarkable, and he was discharged 19 days after surgery. LIQS is effective to reduce operative risk for high-risk patients, and it can be easily combined with other procedures.
Jpn. J. Cardiovasc. Surg. 45:139-143（2016）
Keywords：open stent graft;frozen elephant trunk;penetrating atherosclerotic ulcer;distal arch aortic aneurysm;minimally invasive sugery
|Shigeki Koizumi＊||Kenji Minakata＊||Hisashi Sakaguchi＊|
|Kentaro Watanabe＊||Tomohiro Nakata＊||Kazuhiro Yamasaki＊|
|Tadashi Ikeda＊||Ryuzo Sakata＊|
（Department of Cardiovascular Surgery, Kyoto University Hospital＊, Kyoto, Japan）
We report a case of 76 year-old woman who had previously undergone coronary artery bypass grafting（CABG）with the right internal thoracic artery（RITA）bypassed to the left anterior descending artery. Six years after CABG, she developed acute type A aortic dissection, and she was medically treated because the false lumen was thrombosed and it was considered that surgical intervention would be high risk for the patent RITA graft crossing between the sternum and the ascending aorta. During follow-up, her aortic aneurysm enlarged to 57mm in diameter, and finally she was referred to our hospital for surgical intervention. In this case, preservation of the patent RITA graft was thought to be critical because the RITA graft was the only blood source for the left anterior descending artery. Prior to re-median sternotomy, we performed a right anterior minithoracotomy to make sufficient space between the sternum and the RITA graft, and then instituted peripheral cardiopulmonary bypass to decompress the heart. After re-sternotomy, we ensured minimum dissection of the RITA graft, and we successfully accomplished graft replacement of the ascending aorta to the aortic arch without injuring the patent RITA graft. In cases with a patent RITA graft and an ascending aortic aneurysm close to the sternum, our strategy is considered to be efficient for re-median sternotomy.
Jpn. J. Cardiovasc. Surg. 45:144-147（2016）
Keywords：coronary artery bypass grafting;internal thoracic artery;re-sternotomy;aortic surgery;graft design