|Hirofumi Midorikawa＊||Megumu Kanno＊||Yuusuke Suzuki＊|
|Masatoshi Sunada＊||Takashi Takano＊||Takashi Ono＊|
（Department of Cardiovascular Surgery, Southern Tohoku General Hospital＊, Kooriyama, Japan）
Objective:We examined the utility of distal perfusion（DP）in open stent grafting（OSG）for the treatment of thoracic aortic aneurysm. Methods:Fifty patients who underwent OSG were categorized into two groups（the Non-DP group and the DP group）based on the presence or absence of distal perfusion in OSG. There was no statistically significant difference between the two groups with regard to patient characteristics. Results:There was no statistically significant difference between the two groups with regard to operation time, but, cardiopulmonary bypass time（178±22 min vs. 193±18 min;p＜0.01）and aortic cross clamp time（84±23 min vs. 106±19 min;p＜0.01）were significantly longer in the DP group. Lower-body circulatory arrest time（46±11 min vs. 20±5 min;p＜0.001）was significantly longer in the Non-DP group. Postoperative paraplegia and paraparesis occurred in one case each in the Non-DP group, whereas permanent spinal cord ischemia did not occur in the DP group. Postoperative intubation time（72.6±40.1 h vs. 40.1±34.7 h;p＜0.05）was significantly longer in the Non-DP group. There were two in-hospital deaths due to stroke and respiratory failure in the Non-DP group, and one in-hospital death due to respiratory failure in the DP group. The postoperative maximum value of BUN（38.5±15.6mg/dl vs. 30.8±9.8mg/dl;p＜0.05）and s-Cr（1.9±1.0mg/dl vs. 1.3±0.4mg/dl;p＜0.01）were significantly higher in the Non-DP group. Conclusion:DP in OSG was an effective method for prevention of spinal cord ischemia, and for protection of respiratory and renal function.
Jpn. J. Cardiovasc. Surg. 45:149-153（2016）
Keywords：open stent grafting;distal perfusion;spinal cord ischemia
|Yuta Kume＊||Takeshi Hiramatsu＊||Mitsugi Nagashima＊|
|Gouki Matsumura＊||Kenji Yamazaki＊|
（Department of Cardiovascular Surgery, Tokyo Women’s Medical University＊, Tokyo, Japan）
Background:There has been no ideal valve prosthesis for children from the point of view of thromboembolism and size mismatch, and the surgical repair of native mitral valve has always been our first priority in children. However, valve replacement becomes the inevitable surgical option if repair is impossible. The purpose of this study was to assess the long-term results of mitral valvuloplasty（MVP）and mitral valve replacement（MVR）for isolated mitral valve diseases in children under 15 years old. Patients and Methods:From 1981 to 2010, 30 patients underwent a total of MVPs（P group）and 26 consecutive patients underwent a total of MVRs（R group). The median age was 4.6 years（4 months to 16 years）in group P and 6.2 years（4 months to 13.7 years）in group R, and the median body weight was 13.4kg（6 to 35.5kg）in group P and 16.4kg（4.8 to 50.7kg）in group R. The etiology was congenital in 55（98%）patients, and due to endocarditis in 1（2%）patient. Isolated mitral regurgitation was present in 41（73%）patients（group iMR), and isolated mitral stenosis was present in 15（27%）patients（group iMS). Mechanical valves（bileaflet disc, n＝26）were used in all initial MVR patients. Results:Overall hospital mortality was 0%. The median follow-up time was 9.3±7.8 years（4 months to 27.7 years). There were 6 reoperations in P group and 5 explants due to size mismatch in R group with patient growth, and no explant due to structural valve deterioration. Survival rates at 10 years were 100% in the P group and 88.0% in the R group, and there was a significant difference（p＝0.043). Freedom from reoperation at 10 years was 77.6% in P group and 77.0% in R group. Freedom rate from cerebral events at 10 years were 100% in both groups, respectively, and there were no significant differences. Survival rates at 10 years were 100% in the iMR group and 53.3% in the iMS group, respectively, and there was a significant difference between the groups（p＜0.001). Freedom rates from reoperation at 10 years were 77.1% in the iMR group and 64.3% in the iMS group, respectively, there being no significant difference. Conclusions:The long-term results of pediatric mitral surgery were acceptable. Mitral valvuloplasty for patients with isolated mitral regurgitation were excellent. Mitral valve replacement can be performed with low initial mortality but should be reserved for medical and reconstruction failure because reoperation and late mortality are high, particularly for patients with isolated mitral stenosis.
Jpn. J. Cardiovasc. Surg. 45:154-160（2016）
Keywords：congenital mitral valve disease;mitral valvuloplasty;mitral valve replacement
|Takao Miki＊||Toru Takahashi＊||Jun Mohara＊|
|Masanori Koike＊||Izumi Takeyoshi＊|
（Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan）
A 55-year-old man presented with exertional dyspnea. He was found to have an incomplete atrioventricular septal defect（AVSD), mitral regurgitation, a patent foramen ovale（PFO), atrial fibrillation, and pectus excavatum. A one-stage operation including thoracoplasty in addition to the intracardiac repair was preferred in order to obtain a good view of the operative field and control the postoperative hemodynamics. Therefore, we performed autologous pericardial patch closure of the AVSD, mitral valve plasty with closure of the mitral cleft, direct closure of the PFO, and a modified maze procedure, followed by sternal elevation（modified Ravitch procedure）during chest closure. Postoperatively, his respiratory status on a respirator improved slowly and he was extubated on the 17th postoperative day. Dysphagia developed because of the prolonged intubation, but improved with deglutition rehabilitation. The subsequent postoperative course was uneventful and he was discharged on the 59th postoperative day. We performed a modified Ravitch procedure, instead of sternal turnover, because the latter requires exfoliating a broad area, which could increase the total blood loss and the risk of infection, and make it difficult to maintain the blood flow of the plastron. We obtained a good view of the operative field and stable hemodynamics postoperatively with sternal elevation in pectus excavatum accompanied by heart disease.
Jpn. J. Cardiovasc. Surg. 45:161-165（2016）
Keywords：incomplete AVSD;pectus excavatum;sternal elevation;one-stage operation
|Yasuyuki Toyoda＊||Takahiro Takemura＊||Kazuaki Shiratori＊|
|Yasutoshi Tsuda＊||Gentaku Hama＊||Hirokazu Niitsu＊|
|Yujiro Kawai＊||Hiroo Kinami＊||Takahito Yokoyama＊|
（Department of Cardiovascular Surgery, Saku Central Hospital Advanced Care Center＊, Saku, Japan）
The efficacy of minimally invasive cardiac surgery（MICS）has often been reported. However, in Japan most of these procedures are supported with robotic systems, which are expensive. We report the technique of atrial septum defect（ASD）closure by MICS and a three-dimensional endoscope without the aid of a robotic system. From March 2012 to April 2015, we performed ASD closure using this method in 7 patients. The use of a three-dimensional endoscope enables cardiac surgery to be performed through smaller incisions（●5cm in width). We have adopted this method of ASD closure with the Maze procedure for patients complicated by atrial fibrillation. The operation time will decrease as we improve our surgical technique. Our current practice is to attempt ASD closure with totally endoscopic support.
Jpn. J. Cardiovasc. Surg. 45:166-169（2016）
Keywords：MICS;ASD;three dimensional endoscope
|Takehiro Kubota＊||Satoru Wakasa＊＊||Yasushige Shingu＊＊|
（Department of Cardiovascular Surgery, National Hakodate General Hospital＊, Hakodate, Japan, Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine＊＊, Sapporo, Japan）
Congenital coronary artery-pulmonary artery fistula is rare and occurs concomitantly with various disease conditions, including myocardial ischemia symptoms and aneurisms. Such a fistula complicated by continuity to a systemic blood vessel is even rarer. The patient was a healthy 75-year-old man who had lost consciousness for several tens of seconds at home. An examination performed at a nearby neurosurgical clinic showed no abnormalities, and he was referred to our cardiovascular department for detailed examination for suspected cardiogenic syncope. Sick sinus syndrome was diagnosed based on Holter monitoring. Pulmonary artery-bilateral coronary artery fistula with coronary artery stenosis was diagnosed on coronary arteriography. It was difficult to determine whether coronary bypass surgery was indicated because of the presence of a fistula. Based on the overall evaluation of coronary fractional flow reserve, coronary artery ultrasound, and stress myocardial scintigraphy in addition to usual coronary arteriography, triple-vessel bypass surgery was indicated. Preoperative CT angiography showed a left common carotid artery/bronchial artery-pulmonary artery fistula, with a communication at a bilateral coronary artery-pulmonary artery fistula. Coronary artery bypass surgery was performed in addition to coronary artery-pulmonary artery fistula ligation, left common carotid artery-pulmonary artery fistula closure, bronchial artery-pulmonary artery fistula closure, and pacemaker implantation. Preoperative CT angiography and perioperative surface echocardiography were useful for locating fistula openings. The abnormal blood vessels that allowed blood flow from the left common carotid and bronchial arteries, and into the fistula vessel opening were ligated previously. When cardioplegic solution was injected, the fistula opening was directly pressed, which facilitated the solution to spread over the cardiac muscle, contributing to full cardiac arrest. Postoperative CT angiography showed disappearance of the pulmonary artery-bilateral coronary artery fistula and left common carotid artery/bronchial artery-pulmonary artery fistula. To our knowledge, there are no reports describing the surgical treatment of left common carotid artery/bronchial artery-pulmonary artery fistula and bilateral coronary artery-pulmonary artery fistula. Here we report this rare case with a review of the relevant literature.
Jpn. J. Cardiovasc. Surg. 45:170-175（2016）
Keywords：congenital systemic-pulmonary artery fistulas;congenital pulmonary-coronary fistula
|Shigeharu Sawa＊||Susumu Fujii＊||Kazuma Shimura＊|
|Chihiro Kashiwamura＊||Kentaro Yamabe＊|
（Department of Cardiovascular Surgery, Ogikubo Hospital＊, Tokyo, Japan）
We report a case of severe aortic regurgitation due to deformation of the right coronary cusp which remained in a double-folded shape. A 76-year-old woman was admitted in August 2015 for the evaluation and treatment of dyspnea. She had no history of rheumatic fever, syphilis, endocarditis, or chest trauma. During physical examination, a grade IV/VI diastolic murmur was noted along the left sternal border. Her chest x-ray film showed marked cardiomegaly with interlobular pleural effusion（Vanishing tumor). An aortography revealed abnormally dilated proximal part of right coronary artery as well as severe aortic regurgitation. At operation, the ascending aorta was exposed through median sternotomy with the patient on total cardiopulmonary bypass. The left and non-coronary cusps were easily identified and noted to be normal. The right coronary cusp was recognized to be turned inside out and stayed in a double-folded shape, which made mal-coaptation of cusps and caused aortic regurgitation. The size of the right coronary cusp was larger than other two cusps. A very large right coronary ostium which occupied almost all of the sinus of Valsalva was confirmed. The aortic valve was excised and reconstructed with glutaraldehyde-treated autologous pericardium. She had an uneventful recovery and was discharged on POD 32. The mechanism of how right coronary cusp became disfigured was discussed. We think that the lesions of the sinus of Valsalva and proximal part of the RCA may have caused the double-folded right coronary cusp abnormality.
Jpn. J. Cardiovasc. Surg. 45:176-179（2016）
Keywords：aortic regurgitation;abnormally dilated RCA;double-folded cusp
|Hirokazu Minamimura＊||Shinsuke Kotani＊||Tadahiro Murakami＊|
（Department of Cardiovascular Surgery, Bell Land General Hospital＊, Sakai, Japan）
The onset mechanism of takotsubo cardiomyopathy is unkown. The reported cases of takotsubo cardiomyopathy that happened after cardiac surgical operation were very few. We describe one case of takotsubo cardiomyopathy with left ventricular outflow tract obstruction（LVOTO）that occurred after having undergone mitral valve replacement（MVR）for combined valvular disease. The patient was an 82-year-old woman who was hospitalized with congestive heart failure in our hospital. She had diagnosis of rheumatic valvular disease（i.e. severe mitral regurgitation and mild mitral stenosis, secondary tricuspid regurgitation), atrial fibrillation and pulmonary hypertension. She had a sigmoid septum pointed out by cardiac ultrasonography. Preoperative coronary angiography was normal. After general anesthesia induction, bradycardia and hypotension developed. Therefore epinephrine and norepinephrine were administered. The rheumatic mitral valve was replaced using a 27mm-size mitral pericardial bioprosthesis, preserving the posterior mitral leaflet. DeVega tricuspid annuloplasty and maze surgery were also performed at the same time. We did not recognize wall motion abnormalities by the transesophageal echocardiographic examination during the operation. On postoperative day 1, she was extubated and became hypotensive immediately. Takotsubo cardiomyopathy was diagnosed from characteristic views（an apical ballooning and a preserved basal contraction of the left ventricle）by transthoracic echocardiography（TTE). This echocardiogram showed also LVOTO of pressure gradient 38mmHg. Blood transfusion and discontinuation of epinephrine infusion improved LVOTO. TTE showed a gradual recovery of the left ventricle to normal systolic function, on postoperative day 34. The postoperative coronary angiogram was normal. We presumed that LVOTO was important in the onset and severity of takotsubo cardiomyopathy. In this report, we showed also the pathological significance of the sigmoid septum.
Jpn. J. Cardiovasc. Surg. 45:180-186（2016）
Keywords：takotsubo cardiomyopathy;mitral valve replacement;left ventricular outflow tract obstruction（LVOTO）;sigmoid septum
|Takahiro Shigaki＊||Tohru Takaseya＊||Satoshi Kikusaki＊|
|Takahiro Syojima＊||Kumiko Wada＊||Kouji Akasu＊|
|Kouichi Arinaga＊||Hiroyuki Tanaka＊|
（Department of Surgery, Kurume University School of Medicine＊, Kurume, Japan）
A 69-year-old woman was given a diagnosis of moderate aortic stenosis（AS）associated with congenital bicuspid valve in 2011. In 2014, surgery was indicated because of progression of AS and dilatation of the sinus of Valsalva and ascending aorta. Preoperative contrast-enhanced CT and echocardiography showed the saccular space（2×2cm）located at the left ventricular outflow tract just below the aortic annulus. At surgery, the saccular aneurysm was located just below the aortic annulus of the noncoronary cusp. We resected the aneurysm and closed the orifice with interrupted sutures from the inside of the LV and the outside. Aortic subannular left ventricular aneurysm is a very rare malformation with only 25 reported cases and its natural course is largely unknown. Rupture of aneurysms, infection, thrombus formation, arrhythmia, and heart failure etc. has been reported as complications. We reported a case of aortic subannular left ventricular aneurysm with bicuspid aortic valve stenosis with a literature review.
Jpn. J. Cardiovasc. Surg. 45:187-191（2016）
Keywords：aortic subannular aneurysm;bicuspid aortic valve;fibrous cardiac diverticulum
|Satoru Otani＊||Tsuyoshi Yamamoto＊||Yuki Yamada＊|
（Department of Cardiovascular Surgery, Iwakuni Clinical Center＊, Iwakuni, Japan）
An 89-year-old woman had undergone a medical examination and treatment due to exertional dyspnea symptom and cardiac enlargement, but her symptoms had not improved. According to images from a computed tomography scan, a huge intrapercardial mass excluding the heart was detected, and the patient was referred to our department for surgical treatment. Because of cardiac failure due to the mass excluding the heart, we planned to excise the tumor for cure and also for diagnosis. We did not distinguish the tumor before operation as is often the case with cardiac tumor. The tumor arose from the epicardium of the left ventricular（LV）anterior wall, and was attached to the LV wall with a broad stalk（approximately 3×10 cm）along the left anterior descending coronary artery（LAD). We had to operate under cardiopulmonary bypass and cardiac arrest, since the tumor involved the LAD, so we underwent resection of a part of the LAD. The patient was discharged uneventfully on postoperative day 37. On histopathology, the tumor was diagnosed as a solitary fibrous tumor（SFT）of the epicardium. Cardiac SFTs are rare. Above all, SFTs arising from LV epicardium are very rare. We report this case with some literature review.
Jpn. J. Cardiovasc. Surg. 45:192-195（2016）
Keywords：solitary fibrous tumor;SFT;pericardial tumor;cardiac tumor
|Junzo Inamura＊,＊＊||Masafumi Akita＊||Daisuke Shiomi＊|
|Haruhiko Sugimori＊||Masakazu Aoki＊||Tatsuya Nakao＊|
（Department of Cardiovascular Surgery, New Tokyo Hospital＊, Matsudo, Japan, Present address:Shinmatsudo Central General Hospital＊＊, Matsudo, Japan）
Primary cardiac tumors are rare. Myxoma is the most common type of benign cardiac tumor and papillary fibroelastoma（PFE）is the second most common. We report a case of coexisting left atrial myxoma and aortic valve PFE. A 77-year-old Japanese woman with a left atrial mass was referred to our hospital for further diagnostic evaluation and surgical treatment. The mass was detected by coronary computed tomography, which was performed by her general practitioner. Investigation with an echocardiogram revealed a mass on the fossa ovalis, extending into the left atrium. Intraoperative transesophageal echocardiography（TEE）showed another mass attached between the left coronary cusp（LCC）and the right coronary cusp of the aortic valve. After cardiopulmonary bypass and cardioplegic arrest, we performed an aortotomy, and observed the aortic valve. We found a mobile mass on the LCC and resected it. After left atriotomy, a left atrial myxoma was identified and resected, together with its margin. Postoperatively, sinus bradycardia, sinus pauses, and atrial fibrillation tachycardia were identified. Therefore, we implanted a permanent pacemaker on the 29th postoperative day. The patient was discharged on the 38th postoperative day. Simultaneous existence of two different primary cardiac tumors is rare. We believe that preoperative and intraoperative TEE in patients with cardiac tumors is important.
Jpn. J. Cardiovasc. Surg. 45:196-199（2016）
Keywords：myxoma;papillary fibroelastoma;cardiac tumor
|Hirokazu Niitsu＊||Takahito Yokoyama＊||Hiroo Kinami＊|
|Yujiro Kawai＊||Yasuyuki Toyoda＊||Yasutoshi Tsuda＊|
|Kazuaki Shiratori＊||Takahiro Takemura＊||Takashi Hachiya＊＊|
（Department of Cardiovascular Surgery, Saku Central Hospital Advanced Care Center＊, Saku, Japan, Department of Cardiovascular Surgery, Kawasaki Municipal Hospital＊＊, Kawasaki, Japan）
We report a case of ruptured chronic type B aortic dissecting aneurysm that was successfully treated with the Candy plug technique to exclude a false lumen. A 57-year-old man had undergone abdominal fenestration for complicated acute type B aortic dissection previously. He then underwent debranching TEVAR for an impending rupture because of a dilated thoracic aortic dissecting aneurysm in 2014. After one year, the aneurysm was ruptured because of continuous distal flow of the false lumen. We performed TEVAR using the Candy plug technique, and he was discharged on the 11th postoperative day. The false lumen diameter was reduced. TEVAR using the Candy plug technique for chronic type B aortic dissection was thought to be useful in high-risk patients, but we need more careful observation.
Jpn. J. Cardiovasc. Surg. 45:200-204（2016）
Keywords：chronic type B aortic dissection;thoracic endovascular aneurysm repair;Candy plug technique;false lumen exclusion
|Takao Tsuchida＊||Masataka Yoshida＊||Kentaro Yano＊|
（Department of Cardiovascular Surgery, Shiroyama Hospital Cardiovascular Center＊, Habikino, Japan）
Case:A 75-year-old man was brought to our hospital by ambulance with dorsal pain. Contrast-enhanced computed tomography（CT）revealed acute communicating aortic dissection（Stanford type B）complicated by an aberrant right subclavian artery（ARSCA). Under a diagnosis of type B dissection, conservative treatment by hypotensive therapy and resting was performed. One month after onset, contrast-enhanced CT showed the expansion of the false lumen, and intermittent abdominal pain persisted. To close the entry of the distal arch and reconstruct the ARSCA route, right common carotid artery-right axillary artery bypass, thoracic endovascular aortic repair（TEVAR), and coil embolization of the ARSCA were performed. Five days after surgery, contrast-enhanced CT revealed the expansion of a false abdominal lumen. Abdominal endovascular aortic repair（EVAR）was additionally conducted, leading to the disappearance of false lumen blood flow. ARSCA is a congenital arch vessel abnormality. It may cause obstruction of the esophagus/trachea, aortic aneurysm/dissection of an adjacent area, or aneurysmal changes/rupture of the ARSCA. Various techniques have been reported;reconstruction of the ARSCA route and closure of the false lumen by de-branch TEVAR may be effective for acute communicating aortic dissection with an ARSCA.
Jpn. J. Cardiovasc. Surg. 45:205-210（2016）
Keywords：Stanford type B aortic dissection;aberrant right subclavian artery;TEVAR