Japanese Journal of Cardiovascular Surgery Vol.45, No1



  • Extensive Left Ventricular Myectomy Surgery for Hypertrophic Obstructive Cardiomyopathy H. Doi et al.…1
    Extensive Left Ventricular Myectomy Surgery for Hypertrophic Obstructive Cardiomyopathy

    Hirosato Doi Azusa Furugen Ryuji Koshima
    Satoshi Sumino Keijiro Mitsube Makoto Hashimoto

    Department of Cardiovascular Surgery* and Department of Cardiology**, Sapporo Cardiovascular Clinic, Sapporo, Japan)

    [Background]Surgical septal myectomy is the gold-standard therapy for hypertrophic obstructive cardiomyopathy(HOCM)in Europe and America. However, few cases underwent surgical septal myectomy in Japan. We have performed the surgical transaortic extended left ventricular myectomy(LV myectomy)as a first choice in HOCM patients unresponsive to pharmacologic therapy. We report the short and medium term clinical outcomes. Methods:From May 2012 to September 2014, 9 patients underwent extended LV myectomy without other accompanying procedures. All cases were symptomatic and peak left ventricular outflow tract pressure gradients(LVOTG)were 50 mmHg or more. We assessed clinical and echocardiographic outcomes at the short and medium term, intra-operative findings and cardiomyocyte pathological findings. Results:All patients(mean age 64.3 years, 56% female)underwent transaortic LV myectomy with no obvious complications. Postoperative LVOTG were controlled within 10 mmHg or less. SAM disappeared completely in all patients and MR decreased to mild or less. LVOTG sustained good control of 10 mmHg or less under low-dose dobutamine stress echocardiography at the medium term. Conclusion:Our transaortic extended LV myectomy procedure is effective in decreasing LVOTG, SAM and MR with low operative morbidity and mortality. 

    Jpn. J. Cardiovasc. Surg. 45:1-7(2016)

    Keywords:hypertrophic obstructive cardiomyopathy(HOCM);myectomy;left ventricular outflow tract(LVOT);mitral SAM;abnormal muscle bundle

Invited Commentary

  • Continuous Suture Technique for Aortic Valve Replacement in Patients with Severe Aortic Valve Stenosis M. Matsuhama and Mohd. Azhari Yakub, FRCS…10
    Continuous Suture Technique for Aortic Valve Replacement in Patients with Severe Aortic Valve Stenosis

    Minoru Matsuhama Mohd. Azhari Yakub, FRCS

    (Department of Cardiovascular Surgery, Dai-ni Okamoto General Hospital*, Uji, Japan, and Department of Cardiothoracic Surgery, National Heart Institute**, Kuala Lumpur, Malaysia)

    Objective:The aim of the present study is to show the continuous suture technique in which the aortic valve replacement can be safely performed to insert prosthetic valves of an appropriate size in patients with aortic stenosis associated with a small annulus. Patients and Methods:Thirteen patients with severe aortic valve stenosis(aortic valve area <1.0cm2)underwent aortic valve replacement with the continuous suture technique using three 2/0 non-absorbable monofilament polypropylene sutures. Transthoracic echocardiogram was performed before and after surgery in all patients to determine how large a prosthetic valve could be used compared to the preoperative annular size. Results:The mean size of the prosthetic valve implanted was 23.3mm, while the preoperative mean value of aortic annulus was 21.7mm. The 19mm size prosthetic valves were never used even when the preoperative aortic annular diameter was less than 19mm(in 2 patients). The duration of procedure time was adequate and the post-operative echocardiography showed excellent results with good prosthetic valve function and no adverse events. Conclusions:Using our continuous suture technique, prosthetic valves of an appropriate size can be safely and effectively inserted at an aortic position in patients with severe aortic stenosis.


    Jpn. J. Cardiovasc. Surg. 45:10-15(2016)

    Keywords:aortic valve replacement;continuous suture technique;paravalvular leakage;minimally invasive;prosthesis-patient mismatch

  • Unilateral Selective Cerebral Perfusion during Aortic Valve Replacement in Patients with a Compromised Aorta K. Zaikokuji et al.…16
    Unilateral Selective Cerebral Perfusion during Aortic Valve Replacement in Patients with a Compromised Aorta

    Kenta Zaikokuji Masaru Sawazaki Shiro Tomari
    Yusuke Imaeda

    (Department of Cardiovascular Surgery, Heart Valve Center, Komaki City Hospital*, Komaki, Japan)

    Background:Aortic valve stenosis may be complicated by atherosclerotic lesions in the ascending aorta, which may cause cerebral infarction due to intraoperative dispersion of atheromas. We describe herein a safe aortic cross-clamping technique after removal of the sclerotic lesion in the ascending aorta during short-term unilateral selective cerebral perfusion and mild hypothermic circulatory arrest. Methods:From January 2006 to March 2014, a total of 144 patients underwent aortic valve replacement(AVR)for treatment of aortic valve stenosis. Patients who required ascending aorta replacement surgery, had infective endocarditis, or required emergency surgery were excluded. Five patients underwent AVR using unilateral selective cerebral perfusion and mild hypothermic circulatory arrest due to the presence of atherosclerotic plaques or severe calcification of the ascending aorta(Compromised Aorta group), and 139 patients underwent AVR using ascending aortic perfusion and clamping(Control group). Cardiopulmonary bypass using the right axillary and femoral arteries was started and cooled to a pharyngeal temperature of 34℃ in the Compromised Aorta group. During hypothermic circulatory arrest, the brachiocephalic artery was clamped and unilateral selective cerebral perfusion was administered from the right axillary artery. The perfusion volume was adjusted to 500 to 800 ml while using the cerebral oxygen saturation monitor. After transection of the ascending aorta, the atheroma and suture line calcification were removed. A suitable site for cross-clamping was identified under direct vision, and the aorta was carefully cross-clamped. Results:The patients in the Compromised Aorta group required a mean circulatory arrest period of 3.8min(range, 3.0-5.5 min). The mean minimum value of the left-side cerebral oxygen saturation was 52.0%(range, 45-58%). No patients in the Compromised Aorta group died or developed cerebral complications(95% confidence interval(CI)0.000-0.522). Complications in the Control group included in-hospital mortality(3/140, 2.2%;95%CI:0.003-0.046;p=0.899), stroke(2/139, 1.4%;p=0.932), transient neurologic deficits(4/139, 2.9%;p=0.867), and total cerebral complications(6/139, 4.3%;95%CI:0.009-0.077;p=0.806). Additionally, there were no significant differences between the Compromised Aorta and Control groups in the operative time(345.8±71.8 vs. 333.6±85.4 min, respectively;p=0.754), cardiopulmonary bypass time(196.4±63.6 vs. 199.2±50.0min, respectively;p=0.902), and aortic cross-clamp time(132.0±44.1 vs. 124.8±36.3 min, respectively;p=0.666). Conclusion:Short-term unilateral selective cerebral perfusion and mild hypothermic circulatory arrest is a safe strategy in patients undergoing AVR with a severely atherosclerotic aorta. The outcomes of this strategy were equivalent to those in the Control group, which had fewer atherosclerotic lesions in the ascending aorta.


    Jpn. J. Cardiovasc. Surg. 45:16-20(2016)

    Keywords:aortic valve replacement;aortic valve stenosis;Compromised Aorta;selective cerebral perfusion;hypothermic circulatory arrest

Case Reports

  • [Congenital Heart Disease] Bentall Procedure for Aortic Root Dilatation in a Patient with Turner Syndrome H. Nakagawa et al.…21
    Bentall Procedure for Aortic Root Dilatation in a Patient with Turner Syndrome

    Hirofumi Nakagawa Akihiro Nabuchi Masahiro Terada
    Takuya Miyazaki Hiroshi Okuyama Masahiro Endo

    (Department of Cardiovascular Surgery, Tokyo Heart Center*, Tokyo, Japan)

    A 30-year-old woman who had no specific symptom was diagnosed with Turner syndrome at the age of 6 years. Subsequently, she was followed up at a hospital. However, she stopped going to the hospital when she was 18 years old. At 30 years of age, she underwent examinations involving echocardiography and enhanced chest CT at a hospital, which revealed severe aortic valve regurgitation and extreme dilatation of the aortic root. We performed the Bentall procedure through a median sternotomy following which she had an uncomplicated postoperative course. Aortic root enlargement increases the risk of aortic dissection in patients with Turner syndrome. However, no aortic events occurred before the surgery in this case. We considered the reason was related to the mosaic karyotype of this case.

    Jpn. J. Cardiovasc. Surg. 45:21-25(2016)

    Keywords:Turner syndrome;aortic root dilatation;Bentall procedure;acute aortic dissection;bicuspid aortic valve

  • Modified Right Ventricular Obliteration Technique for Fontan Candidates with Non-functional Right Ventricle H. Asai et al.…26
    Modified Right Ventricular Obliteration Technique for Fontan Candidates with Non-functional Right Ventricle

    Hidetsugu Asai Tsuyoshi Tachibana Yasushige Shingu
    Satoru Wakasa Tomonori Oooka Yoshiro Matsui

    (Department of Cardiovascular and Thoracic Surgery, Hokkaido University Hospital*, Sapporo, Japan)

    Introduction:Right atrial(RA)and right ventricular(RV)dilatation that are associated with severe tricuspid regurgitation, and severe high RV pressure that is associated with pulmonary atresia and intact ventricular septum cause left ventricular(LV)dysfunction and hypoplastic lung. We have applied a modified RV obliteration technique that excludes non-functional enlarged RV for these diseases. Objectives:To evaluate the efficacy of our procedure. Methods and Results:Five patients(six operations)underwent the procedure without complications. Cardiothoracic ratio significantly decreased from 71±10% to 61±5%(p=0.017), and fractional shortening ended to increase from 27±17% to 37±5%(p=0.071). All of them achieved Fontan completion finally. One patient who underwent this procedure as a neonate experienced RV re-dilation 19months later. He additionally received the same procedure in a Fontan operation, and then RV reduced again and good LV function was maintained. Conclusion:The application of modified RV obliteration technique is effective for Fontan candidates with nonfunctional RV.


    Jpn. J. Cardiovasc. Surg. 45:26-31(2016)

    Keywords:modified right ventricular obliteration technique;Fontan;nonfunctional right ventricle

  • Staged Repair for a Patient with Infracardiac Total Anomalous Pulmonary Venous Connection Complicated by Hypoplastic Left Heart Complex T. Nakata et al.…32
    Staged Repair for a Patient with Infracardiac Total Anomalous Pulmonary Venous Connection Complicated by Hypoplastic Left Heart Complex

    Tomohiro Nakata Tadashi Ikeda Kenji Minakata
    Kazuhiro Yamazaki Hisashi Sakaguchi Kyokun Uehara
    Kazuhisa Sakamoto Taro Nakatsu Daisuke Heima
    Ryuzo Sakata

    (Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine*, Kyoto, Japan)

    Total anomalous pulmonary venous connection(TAPVC)is rarely associated with remarkably small left heart structures. In these types of cases, the hemodynamics resembles that of hypoplastic left heart syndrome, and the treatment strategy is controversial. We present the case of a 1-day-old girl with infracardiac TAPVC, small left heart structures(hypoplastic left heart complex), bilateral superior vena cava, and aberrant origin of the right subclavian artery. We performed a semi-emergent first-stage open palliation for repair of TAPVC, because of pulmonary venous obstruction. We concomitantly performed atrial septal defect(ASD)enlargement and bilateral pulmonary artery banding(BPAB). The postoperative course was uneventful and the left heart structures did not grow, so we performed the Norwood procedure and placed a right ventricle-pulmonary artery shunt with a 5.0mm artificial graft. Subsequently, the left heart structures were not suitable for biventricular repair, so we chose univentricular repair. The patient underwent a bilateral bidirectional Glenn operation and Fontan completion at 6 and 23 months of age, respectively. TAPVC repair, BPAB, and ASD enlargement are reasonable surgical options for a patient with borderline small left heart structures and TAPVC, as they enable us to wait for growth in the left heart structures and to determine whether univentricular or biventricular repair is suitable.


    Jpn. J. Cardiovasc. Surg. 45:32-36(2016)

    Keywords:infracardiac total anomalous pulmonary venous connection;hypoplastic left heart complex;bilateral pulmonary artery banding

  • [Acquired Cardiovascular Surgery] Successful Surgical Intervention for Infected Mitral Endocarditis in a Patient Complicated with Multiple Cerebral Infarction and Hemorrhage J. Yokota et al.…37
    Successful Surgical Intervention for Infected Mitral Endocarditis in a Patient Complicated with Multiple Cerebral Infarction and Hemorrhage

    Junki Yokota Hiroyuki Nishi Naosumi Sekiya
    Mitsutomo Yamada Toshiki Takahashi  

    (Department of Cardiovascular Surgery, Osaka Police Hospital*, Osaka, Japan)

    The optimal timing of cardiac surgery for infective endocarditis in patients with severe brain complication remains unclear. We present here the successful surgical treatment of a case of infected mitral endocarditis with intractable heart failure, disseminated intravascular coagulation(DIC), and cerebral infarction with hemorrhage. A 37 year-old woman who received chemotherapy for breast cancer developed mitral infective endocarditis perhaps caused by infection of the implanted central venous access device and was referred to our hospital for an emergency operation. On admission, she had a mild fever and showed motor aphasia and right-sided hemiplegia. Brain CT scan findings revealed a cerebral infarction in the area of the left middle cerebral artery and a cerebral hemorrhage in the right occipital lobe. Echocardiography showed severe mitral regurgitation with huge mobile vegetation. Chest X-ray revealed severe pulmonary congestion and laboratory data showed DIC. After the mitral valve replacement with a bioprosthetic valve following complete excision of infected tissue, she was extubated on the first postoperative day with dramatic improvement of infectious signs and heart failure. Postoperative brain CT showed a new small brain hemorrhage, but no aggravation of the preoperative cerebral lesion. After she underwent surgical drainage for brain abscess on the 15th postoperative day, her postoperative course was uneventful. Even though this report is limited to a single case, only aggressive and prompt surgical intervention could relieve the intractable conditions in such a patient with extremely high risk.


    Jpn. J. Cardiovasc. Surg. 45:37-40(2016)

    Keywords:infective endocarditis;cerebral infarction;cerebral hemorrhage;surgical intervention

  • Simple Excision for Cardiac Fibroelastomas Arising from Three Leaflets of the Aortic Valve Y. Hirata et al.…41
    Simple Excision for Cardiac Fibroelastomas Arising from Three Leaflets of the Aortic Valve

    Yuichiro Hirata Keiichiro Tayama Koichiro Shimoishi
    Yusuke Shintani Hidetsugu Hori Teiji Okazaki
    Kenichi Kosuga

    (Department of Cardiovascular Surgery, Munakata Suikokai General Hospital*, Fukutsu, Japan)

    Cardiac papillary fibroelastomas are rare but are still the second most common benign cardiac tumor;after myxoma. While cardiac papillary fibroelastomas are benign, there is the potential for severe complications related to embolism. Consequently, a surgical treatment approach is generally recommended. Nevertheless, from the risk of the recurrence of tumor and the valve insufficiency, the excision range is still controversial, particularly with tumors arising from the valve. We report the case of a 66-year-old woman who underwent resection of cardiac papillary fibroelastomas arising from three leaflets of the aortic valves. We performed simple excision without valve surgery and obtained an uneventful prognosis. At 18 months after surgery, no recurrence of tumors was recognized. We consider that it is possible to resect cardiac papillary fibroelastomas without performing valve repair or replacement if they are removed carefully even if the tumors arise from three leaflets of an aortic valve.


    Jpn. J. Cardiovasc. Surg. 45:41-44(2016)

    Keywords:cardiac papillary fibroelastoma;aortic valve tumor;cardiac tumor

  • [Aortic Disease] Delayed-Onset Paraplegia after Type A Dissection Repair K. Furukawa et al.…45
    Delayed-Onset Paraplegia after Type A Dissection Repair

    Koji Furukawa Shuhei Sakaguchi Katsuya Kawagoe
    Masakazu Matsuyama Mitsuhiro Yano

    (Department of Cardiovascular Surgery, Miyazaki Medical Association Hospital*, Miyazaki, Japan)

    We present the case of a 53-year-old man who developed delayed-onset paraplegia after type A dissection repair. He was referred to our hospital with a diagnosis of type A dissection, for which we performed total arch replacement. Although the patient started walking on postoperative day 4, on postoperative day 5, he developed lower limb paraplegia without any precipitating episodes. Computed tomography showed that the false lumen was thrombosed in the upper descending thoracic aorta and hypoperfused in the lower descending thoracic aorta. The cerebrospinal fluid was immediately drained to maintain the spinal pressure at 14 cm H2O for four days. Although the patient began to move his legs immediately after treatment, he remained paraparetic, and was transferred to another rehabilitation hospital on postoperative day 40.


    Jpn. J. Cardiovasc. Surg. 45:45-48(2016)

    Keywords:delayed-onset paraplegia;after type A dissection repair

  • A Case of Giant Unruptured Left Coronary Sinus of Valsalva Aneurysm F. Asami et al.…49
    A Case of Giant Unruptured Left Coronary Sinus of Valsalva Aneurysm

    Fuyuki Asami Kazuo Yamamoto Tsutomu Sugimoto
    Yuuki Okamoto Mitsuhiro Kimura Ayako Nagasawa
    Satoru Shiraiwa Shinpei Yoshii  

    (Department of Cardiovascular Surgery, Tachikawa General Hospital, Tachikawa Medical Center*, Nagaoka, Japan)

    A 40-year old man with chest pain was admitted to our hospital. A three-dimensional CT revealed an unruptured left coronary sinus of Valsalva aneurysm and mild stenosis of the left main trunk. An echocardiogram revealed severe aortic regurgitation. He was operated on with an aortic root replacement procedure. Though the procedure was itself uneventful, he could not be weaned from cardiopulmonary bypass because of unexpected coronary events;relative stenosis of the RCA and stretched LMT due to a huge aneurysm of the sinus of Valsalva. Additional CABG with LITA to LAD and SVG to RCA led to weaning from cardiopulmonary bypass. Left coronary sinus of Valsalva aneurysm is rare, and it requires early surgical intervention for an increase in the diameter of the aneurysm together with myocardial ischemia due to compression of the coronary artery.


    Jpn. J. Cardiovasc. Surg. 45:49-51(2016)

    Keywords:sinus of Valsalva aneurysm;left coronary cusp;aortic root replacement;CABG

  • A Case of Symptomatic Mural Thrombus in the Ascending Thoracic Aorta M. Suzuki et al.…52
    A Case of Symptomatic Mural Thrombus in the Ascending Thoracic Aorta

    Masato Suzuki Yohei Ohkawa Fumikazu Nomura
    Akira Adachi Kenji Sugiki Takemi Ohno

    (Department of Cardiovascular Surgery, Hokkaido Ohno Hospital*, Sapporo, Japan)

    Fifty-two-year-old man who suffered from headache and left neck pain was brought to a nearby hospital by ambulance. Anisocoria and disorder in the field of view of the left eye were observed. Emergency brain MRA showed obstruction of the left internal carotid artery. The patient was transported to our hospital for emergency surgery for suspected acute type A aortic dissection on CT scan. Operative findings revealed a thrombus attached to the ascending aorta continued to left common carotid artery. Thrombectomy for left carotid artery and partial arch replacement were performed. The patient was discharged in good condition on the 16th postoperative day. We encountered a very rare mural thrombus in the ascending aorta.


    Jpn. J. Cardiovasc. Surg. 45:52-56(2016)

    Keywords:thoracic aorta mural thrombus;occlusion of left carotid artery;partial aortic arch replacement

  • A Case of Type A Acute Aortic Dissection in an Elderly Woman with Immune Thrombocytopenia Who Underwent Replacement of the Ascending Aorta and Aortic Arch and Later Required Aortic Root Replacement for Redissection of the Aortic Root T. Kono et al.…57
    A Case of Type A Acute Aortic Dissection in an Elderly Woman with Immune Thrombocytopenia Who Underwent Replacement of the Ascending Aorta and Aortic Arch and Later Required Aortic Root Replacement for Redissection of the Aortic Root

    Takanori Kono Toru Takaseya Satoshi Kikusaki
    Keishi Hashimoto Yuichiro Hirata Kumiko Wada
    Koji Akasu Satoru Tobinaga Hidetoshi Akashi
    Hiroyuki Tanaka    

    (Department of Surgery, Kurume University School of Medicine*, Kurume, Japan)

    We report a case of type A acute aortic dissection in an elderly woman with immune thrombocytopenia(ITP)who underwent replacement of the ascending aorta and aortic arch and later required aortic root replacement for redissection of the aortic root one month after her initial surgery. She was an 86-year-old woman with severe mitral regurgitation, and surgery was contraindicated because of her age and ITP. In October 2014, the patient presented with back pain. Computed tomography confirmed the diagnosis of her condition as type A acute aortic dissection, and she was immediately transferred to our hospital. Because echocardiography showed severe aortic regurgitation, severe mitral regurgitation, and moderate tricuspid regurgitation, we performed replacement of the ascending aorta and aortic arch, mitral valve repair, and tricuspid annuloplasty. We used Bioglue to fuse the false lumen of the type A acute aortic dissection and used a Teflon felt sandwich for the proximal anastomosis technique. Respiratory support was discontinued 91h after her first operation;however, 30 days after surgery, she developed a to-and-fro murmur-a sign of the progression of heart failure. Echocardiography showed aggravation of aortic regurgitation, and computed tomography showed aortic root redissection;therefore, 39 days after the initial surgery, we performed aortic root replacement. During the operation, we found the entry under the proximal anastomosis with an almost semicircle form at the right coronary cusp to the noncoronary cusp, and the dissection extended close to the right coronary artery;thus, we performed bypass to the right coronary artery. Pathologic findings did not establish a causal association between the redissection and Bioglue, and we believed the fragility of the tissue and the selection of the surgical procedure to be the cause of redissection. The patient was transferred to another hospital when she was able to walk and eat, which was 121 days after her first operation. The patient required 50 units of platelet transfusion during her first and second operations, but her bleeding was easily controlled during surgery. She needed two procedures of pericardium drainage for pericardiac effusion and cardiac tamponade, which may relate to ITP. The diagnosis of redissection of the aortic root was made 30 days after the patient’s first operation, on the basis of exacerbation of the to-and-fro murmur. Here, we emphasize the clinical importance of basic observations over time, such as auscultation, that are liable to be overlooked in the intensive care unit.


    Jpn. J. Cardiovasc. Surg. 45:57-61(2016)

    Keywords:ITP;type A acute aortic dissection;bioglue;very elderly

  • [Peripheral Artery Disease] The Case of a Patient with Femoral Artery Stenosis Caused by Angio-Seal●R Use Treated with Endoarterectomy M. Kawasaki et al.…62
    The Case of a Patient with Femoral Artery Stenosis Caused by Angio-Seal●R Use Treated with Endoarterectomy

    Masakazu Kawasaki Yoshimitsu Ishibashi Kiyotaka Morimoto
    Hideyuki Kunishige Nozomu Inoue

    (Department of Cardiovascular Surgery, National Hospital Organization Hokkaido Medical Center*, Sapporo, Japan)

    In cases of hemostasis of the femoral artery where the sheath is removed after percutaneous catheterization, there is greater improvement in patient condition and shorter duration of hospital stay when arterial puncture closing devices are used rather than standard manual compression because the use of these devices results in shorter hemostasis and rest times. However, some complications due to these devices have also been reported. Here, we report a case of femoral artery stenosis due to Angio-Seal●R use in a 67-year-old woman. Embolization of the basilar artery aneurysm by endovascular treatment was performed at another institution;the percutaneous puncture site was the right femoral artery. When this treatment was provided, hemostasis of the artery was performed with the Angio-Seal●R. About one month after the embolization, right intermittent claudication occurred after a 300-m walk. Echography and computed tomography(CT)angiogram showed 75% stenosis of the right common femoral artery, and therefore endoarterectomy of the artery was performed. The postoperative course was favorable and the ankle brachial index score improved from 0.82 to 1.15. In addition, CT angiogram showed resolution of the stenosis of the right common femoral artery and right intermittent claudication ameliorated. Based on the intraoperative views, it was suggested that the arteriosclerotic lesion had existed at the common femoral artery before the endovascular treatment and it might be the cause of the complication mentioned above. In order to prevent complications due to Angio-Seal●R use, it is important to examine the indications of the use of this device by evaluating the puncture site of the artery with echography and other diagnostic techniques before the insertion of a sheath.


    Jpn. J. Cardiovasc. Surg. 45:62-66(2016)

    Keywords:embolization of basilar artery aneurysm;Angio-Seal●R;endoarterectomy

Editor’s Post Script
  • H. Arai