|Ryosuke Kowatari＊||Yasuyuki Suzuki＊||Kazuyuki Daitoku＊|
（Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine＊, Hirosaki, Japan）
A five-year-old boy with a univentricular heart, inferior vena cava interruption, and azygos connection was admitted to our hospital to undergo a staged Fontan-type procedure. Pectus excavatum had developed after he underwent total cavopulmonary shunt at the age of three years. Computed tomography revealed that the hepatic vein was just behind the recessed sternum. We performed simultaneous Nuss and Fontan-type procedures because we were afraid of the compression of the Fontan pathway from the hepatic vein to the pulmonary artery by the recessed sternum. A cardiopulmonary bypass was established and the hepatic vein and pulmonary artery were bypassed with a 16-mm expanded polytetrafluoroethylene graft. After removing the cardiopulmonary bypass, the Nuss procedure was performed. Although the bilateral thoracic cavities were diffusely and densely adhered, adhesiotomy was safely performed under direct visualization. The postoperative course was uneventful. Postoperative computed tomography showed that the pectus excavatum was well repaired and the Fontan pathway was not compressed by the sternum. Although there are few reports of Fontan-type and Nuss procedures being simultaneously performed, this method is useful for securing the space of the Fontan pathway and for preserving good Fontan circulation in the long term.
Jpn. J. Cardiovasc. Surg. 46:273-276（2017）
Keywords：pectus excavatum;congenital heart disease;Fontan;simultaneous surgery
|Yuuki Kou＊||Hajime Matsue＊||Tetsuya Kajiyama＊|
|Masaru Ishida＊||Hisashi Satoh＊||Hikaru Matsuda＊|
（Department of Cardiovascular Surgery, Higashitakarazuka Satoh Hospital＊, Takarazuka, Japan）
It is reported that myasthenia gravis（MG）with thymoma occupy 20% of all MG and extended thymectomy is recommended. After having operation, it is rare, but cases of recurrence of thymoma and, what is worse, thymic cancer from residual thymus tissue are reported. A 69-year-old man came to our hospital to have his dyspnea level examined. He had a past history of MG with thymoma and he had undergone extended thymectomy 17 years previously. Enhanced CT showed pericardial thickening and many tumors in the epicardium. Catheterization study showed dip and plateau pattern of left ventricular pressure. We therefore diagnosed constrictive pericarditis（CP). We performed pericardiectomy under cardiopulmonary bypass. He was discharged ambulatorily on postoperative day 24. Histological findings of the tumor and the pericardium showed that they were dissemination of thymic cancer. It was considered that thymic cancer caused CP and it was an extremely rare case. We think this is the first report to the best of our knowledge.
Jpn. J. Cardiovasc. Surg. 46:277-281（2017）
Keywords：constrictive pericarditis;thymic cancer;myasthenia gravis
|Koji Akasu＊||Tomofumi Fukuda＊||Kosuke Saku＊|
|Keishi Hashimoto＊||Satoshi Kikusaki＊||Koichi Arinaga＊|
（Department of Surgery, Kurume University School of Medicine, Kurume, Japan）
The durability of the Starr-Edwards（SE）mitral caged-disk valve, model 6520, is not clearly known. We reported that SE mitral caged-disk valves implanted ＞20 years previously should be carefully followed up, and that SE caged-disk valves implanted ＞30 years previously should be electively replaced with modern prosthetic valves in our experience. We found the removed valve 39 years after implantation, which seemed minimal structural deterioration. The patient was discharged on the 10th postoperative day without any complications.
Jpn. J. Cardiovasc. Surg. 46:282-284（2017）
Keywords：caged-disk valve;structural valve deterioration;reoperation
|Masataka Hirata＊||Takanori Suezawa＊||Shu Yamamoto＊|
（Department of Cardiovascular Surgery, Kagawa Prefectural Hospital＊, Takamatsu, Japan）
Churg-Strauss syndrome is a rare form of systemic vasculitis that has been reported to involve the heart. However, co-existing involvement of cardiac valves and the conduction system is extremely rare. We present a patient with aortic regurgitation, mitral stenosis and complete heart block secondary to Churg-Strauss syndrome.
Jpn. J. Cardiovasc. Surg. 46:285-287（2017）
Keywords：Churg-Strauss syndrome;aortic valve regurgitation;mitral valve stenosis;heart block
|Kenta Zaikokuji＊||Masaru Sawazaki＊||Shiro Tomari＊|
（Department of Cardiovascular Surgery, Heart Valve Center, Komaki City Hospital＊, Komaki, Japan）
Systolic anterior motion（SAM）is a common complication of mitral valve repair surgery and occasionally requires further treatment. A 56-year-old woman with severe mitral regurgitation accompanied by posterior leaflet prolapse underwent mitral valve plasty including hour-glass-shaped resection, chordal replacement, and interrupted commissural band annuloplasty. The mitral valve was exposed via a right-sided left atriotomy. We found a large thick P2-3 scallop（27mm in height）with ruptured and elongated chordae. After repair, transesophageal echocardiography（TEE）revealed SAM of the anterior mitral leaflet and severe mitral regurgitation upon weaning from the cardiopulmonary bypass. Although catecholamine was discontinued and volume loading applied, the SAM did not improve. We decided to revise the mitral plasty. Therefore, although the height of the P3 scallop after resection remained 17mm, neochordae were placed once more on the basal side of the posterior leaflet, and the leaflet was shortened by placing a continuous suture near the annulus. This reduced the height of the posterior leaflet and moved the co-aptation line posteriorly. After this repair, TEE showed that the SAM had disappeared. Thus, repositioning the neochordae and shortening the posterior leaflet by applying a continuous suture effectively and rapidly eliminated the problem.
Jpn. J. Cardiovasc. Surg. 46:288-291（2017）
Keywords：systolic anterior motion;mitral valve regurgitation;mitral valve plasty
|Yuki Arakawa＊||Eiji Murakami＊||Kenichiro Azuma＊|
（Department of Cardiovascular Surgery, Gifu Municipal Hospital＊, Gifu, Japan, and General and Cardiothoracic Surgery, Graduate School of Medicine, Gifu University＊＊, Gifu, Japan）
A 66-year-old man presented to a local doctor with a chief complaints of episodes of dizziness lasting several seconds. Electrocardiographic findings were suggestive of arrhythmia and old myocardial infarction, and the patient was therefore referred to our hospital. Left ventriculography showed an aneurysm at the posteroinferior wall of the left ventricle, while coronary angiography showed chronic total occlusion of the left circumflex branch（segment 13）and a coronary-pulmonary artery fistula with a coronary aneurysm. On computed tomography, the orifice of the ventricular aneurysm was small, measuring approximately 10 mm. Magnetic resonance imaging showed wall thinning and mural thrombus in the ventricular aneurysm, with aneurysmal dilatation during systole. Suspecting a ventricular false aneurysm resulting from old myocardial infarction, left ventricular reconstructive surgery and resection of the coronary artery aneurysm were performed. Intraoperatively, myocardial necrosis of the posteroinferior wall accompanied by the ventricular aneurysm was seen. There was no pericardial adhesion to the ventricular aneurysm, and the diameter of the orifice of the aneurysm was approximately 10 mm. The ventricular aneurysm was cut open and then closed using a direct suture combined with patch repair. As for the coronary artery aneurysm, the inflow and outflow arteries were each clipped before the wound was closed. The patient had a favorable postoperative course and was discharged from the hospital on the 15th day after surgery. The pathological examination showed residual cardiomyocytes within the aneurysmal wall, thereby establishing the diagnosis of a pseudo-false aneurysm. Our experience with this rare case is reported.
Jpn. J. Cardiovasc. Surg. 46:292-295（2017）
Keywords：pseudo-false aneurysm;old myocardial infarction
|Saori Nagura＊||Kazuaki Fukahara＊||Mari Sakai＊|
|Toshio Doi＊||Shigeki Yokoyama＊||Kimimasa Sakata＊|
|Hayato Obi＊||Naoki Yoshimura＊|
（First Department of Surgery, University of Toyama＊, Toyama, Japan）
A 64-year-old man with congenital factor V deficiency and hereditary spherocytosis was attending our hospital for type II diabetes and stage 4 diabetic nephropathy. Coronary angiography performed to assess chest pain revealed severe triple-vessel disease, including total occlusion of the right coronary artery. The patient required surgical coronary revascularization. In the preoperative examination, the activated partial thromboplastin time（APTT）and prothrombin time-international normalized ratio（PT-INR）were high（89.5s and 1.95）and factor V activity was low（6%;normal range, 70-135%). Hemodialysis was performed on the day of the operation, and 6 units of fresh frozen plasma（FFP）were administered, which reduced immediately the preoperative PT-INR to 1.33. We performed off-pump coronary artery bypass grafting（OPCAB）and perioperatively administered 6 units of FFP with 4 units of red blood cells（RBC）transfusion. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 22. Here we report the case of a patient with a very rare disease of congenital factor V deficiency and hereditary spherocytosis complicated with stage 4 diabetic nephropathy who required OPCAB.
Jpn. J. Cardiovasc. Surg. 46:296-300（2017）
Keywords：factor V deficiency;hereditary spherocytosis;diabetic nephropathy;off pump coronary artery bypass grafting
|Hiroharu Shinjo＊||Koki Takahashi＊||Masahiro Tanji＊|
（Department of Cardiovascular Surgery, Ohta Nishinouchi Hospital＊, Fukushima, Japan）
A 25-year-old woman with a history of atopic dermatitis was admitted to hospital with shortness of breath, high fever, cough, and bloody sputum. Chest X-ray showed a diffuse infiltrative shadow. We diagnosed pneumonia, and antibacterial therapy was started;however, the treatment was ineffective. Echocardiography showed tricuspid endocarditis, and she was thus transferred to our hospital. We selected medical treatment because the case was complicated with severe lung abscesses and pulmonary failure. As a result of appropriate antibacterial medication for 4 weeks, her symptoms and lung abscesses were improved;however, tricuspid regurgitation and right heart failure continued to worsen. Therefore, the patient underwent vegetectomy and tricuspid valve plasty. No perioperative pulmonary complication was observed. She continued to receive the same antibacterial treatment after 2 weeks. In preceding antibacterial treatment before surgical treatment, it is effective for tricuspid endocarditis complicated with severe lung abscess.
Jpn. J. Cardiovasc. Surg. 46:301-304（2017）
Keywords：endocarditis;lung abscess;tricuspid valve plasty
|Yuki Yoshioka＊||Ryusuke Suzuki＊||Tomoya Miyamoto＊|
|Kenta Uekihara＊||Takeshi Sakaguchi＊||Mai Matsukawa＊|
|Ryo Hirayama＊||Masamichi Nakajima＊|
（Department of Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital＊, Kumamoto, Japan）
A 66-year-old man with an unknown medical history developed chest pain and a diagnosis of acute myocardial infarction（AMI）was given by his physician. Percutaneous coronary intervention was performed in the left anterior descending artery. Echocardiography revealed ventricular septal perforation（VSP);therefore, the patient was transferred to our hospital. After admission, his platelet count dropped rapidly during heparin administration, and left ventricular thrombosis and deep vein thrombosis were noted, raising a suspicion of heparin-induced thrombocytopenia（HIT). To establish cardiopulmonary bypass, argatroban alone was insufficient to prolong the Powered by Editorial Manager●R and ProduXion Manager●R from the Aries Systems Corporation activated clotting time（ACT);thus, nafamostat mesilate was also used for coronary artery bypass grafting and surgical repair of VSP. It took many hours to normalize the ACT, requiring re-exploration for excessive bleeding. On the 37th postoperative day, the patient was transferred to another hospital. We performed cardiac surgical procedures using argatroban in a patient who developed HIT during the course of VSP following AMI;however, we had difficulty in controlling the ACT. Since, to the best of our knowledge, there are no previous studies reporting surgical case of VSP complicated by HIT, we present this case with a review of the relevant literature.
Jpn. J. Cardiovasc. Surg. 46:305-310（2017）
Keywords：Heparin-induced thrombocytopenia;ventricular septal perforation;Argatroban;Nafamostat mesilate
|Masami Sotokawa＊||Tetsuyuki Ueda＊||Shota Nakagaki＊|
|Kazuhiro Tani＊||Shingo Otaka＊||Akira Murata＊|
（Department of Cardiovascular Surgery, Toyama Prefectural Central Hospital＊, Toyama, Japan）
A 74-year-old male who had a medical history of thoracic endovascular aortic repair（TEVAR）was referred to us for endoleakage. A total of 21 years ago, he underwent emergent descending aortic grafting for aortic aneurysm rupture at his age of 53. After that, 19 years ago, he underwent TEVAR with Matsui-Kitamura stent graft（MKSG）due to pseudoaneurysm formation at the proximal anastomotic site at the age of 55. CT revealed type III endoleakage due to fracture of MKSG and graft. We proceeded to perform TEVAR with Relay Plus successfully, and his endoleakage disappeared. His postoperative course was uneventful. He was discharged from our hospital on the 9th day after the operation, and is now doing well.
Jpn. J. Cardiovasc. Surg. 46:311-315（2017）
Keywords：Matsui-Kitamura stent graft;stent graft fracture;type III endoleakage;long-term
|Masahiro Inagaki＊||Toshiya Tokui＊||Yasumi Maze＊|
|Kouji Hirono＊||Taro Fujii＊|
（Department of Cardiovascular Surgery, Ise Red Cross Hospital＊, Ise, Japan）
A-54-year-old man with an extensive dissecting thoracic aortic aneurysm underwent staged surgery which consisted of preceding total aortic arch replacement with the frozen elephant trunk technique using J Graft Open Stent Graft, followed by open descending aorta repair. During the second operation, a Dacron graft was anastomosed directly to the stent graft and the true lumen thus, the true lumen could be preserved around the stent graft. We herein discuss our approach in this case, focusing on prevention of bleeding from the elephant trunk.
Jpn. J. Cardiovasc. Surg. 46:316-319（2017）
Keywords：frozen elephant trunk technique;replacement of the descending aorta;chronic dissecting thoracic aortic aneurysm
|Kentaro Sawada＊,＊＊||Yukio Hosokawa＊＊||Hinako Sakurai＊＊|
|Ryo Kanamoto＊＊||Shinichi Imai＊＊||Yusuke Shintani＊＊|
|Shinichi Nata＊＊||Shinichi Hiromatsu＊＊||Hidetoshi Akashi＊＊|
（Department of Surgery, Saiseikai Futsukaichi General Hospital＊, Fukuoka, Japan, and Department of Surgery, Kurume University School of Medicine＊＊, Kurume, Japan）
We herein report on a case in which we conducted bypass surgery for occlusion of a left axillary artery aneurysm with ischemic symptoms 21 years after the contraction of Kawasaki disease and achieved symptomatic improvement. The case involved a 22-year-old man who had been suffering from Kawasaki disease since the age of one. He had been undergoing antiplatelet therapy for bilateral axillary artery aneurysms by orally taking aspirin for 20 years. He suffered from symptoms of upper limb ischemia 21 years after receiving a diagnosis of peripheral aneurysms and occlusion of a left axillary artery aneurysm upon 3DCTA. We conducted aneurysmotomy, plication, and bypass surgery between the axillary and brachial arteries via the autologous vein. Pathological examination revealed due to the formation of atheroma in the tunica intima and disarrangement of the layer structure in the tunica media:thickening of the tunica media was partially observed. His fatigue upon exertion of his left upper extremity remarkably improved following surgery. Although peripheral aneurysms associated with Kawasaki disease are rare, as seen in this case, peripheral arterial disease remains and progresses even after long periods of time. It is believed necessary to carry out long term follow-up and examine the approaches to therapy including surgery in accordance with the site and degree of the disease.
Jpn. J. Cardiovasc. Surg. 46:320-324（2017）
Keywords：Kawasaki disease;axillary artery aneurysm;peripheral arterial aneurysm;upper extremity bypass;finger clubbing
|Mari Chiyoya＊||Satoshi Taniguchi＊||Ryousuke Kowatari＊|
|Tomonori Kawamura＊||Norihiro Kondo＊||Masahito Minakawa＊|
（Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine＊, Aomori, Japan）
A 75-year-old man with underlying arteriosclerosis obliterans presented with acute heart failure secondary to rest pain of the right lower extremity. Echocardiogram showed severe mitral regurgitation, moderate tricuspid regurgitation and a low cardiac function（ejection fraction:27%). Right toe gangrene developed in association with continuous acute heart failure. He underwent mitral valve replacement, tricuspid annuloplasty, right common femoral artery-posterior tibial artery bypass and amputation of the right toes in single-stage surgery. There were no major complications during his hospital stay. After surgery, his symptoms significantly improved.
Jpn. J. Cardiovasc. Surg. 46:325-329（2017）
Keywords：mitral valve replacement;tricuspid annuloplasty;critical limb ischemia;distal bypass;arteriosclerosis obliteration
|Satoko Funata＊,＊＊||Tetsuro Uchida＊||Azumi Hamasaki＊|
|Atsushi Yamashita＊||Jun Hayashi＊||Ai Takahashi＊|
（Second Department of Surgery, Yamagata University School of Medicine＊, Yamagata, Japan, and Department of Cardiovascular Surgery, Kyorin University Hospital＊＊, Tokyo, Japan）
After vascular surgical procedures, complications of the wounds in the groin region may sometimes lead to prosthetic graft infections or prolonged hospital stays. While some wounds heal completely during re-suture and VAC therapy, healing of other wounds that involve refractory graft infection, lymphorrhea, or a dead space, is extremely difficult. We performed tissue coverage using a Sartorius muscle flap for such difficult cases. The muscle is twisted onto itself to fill the dead space with some blood supply. Tissue coverage using a Sartorius muscle flap with adequate blood flow was effective in improving lymphorrhea and infection. We report four such cases where complications in the groin region were managed using a Sartorius muscle flap for wounded coverage.
Jpn. J. Cardiovasc. Surg. 46:330-333（2017）
Keywords：Sartorius muscle flap;wound healing failure
|Ryo Kanamoto＊||Takahiro Shojima＊||Kanako Sakurai＊|
|Mau Amako＊||Hiroyuki Otsuka＊||Satoru Tobinaga＊|
|Seiji Onitsuka＊||Shinichi Hiromatsu＊||Hidetoshi Akashi＊|
（Department of Surgery, Kurume University School of Medicine＊, Kurume, Japan）
We report a case of chronic mesenteric ischemia associated with severe aortic valve regurgitation and stenosis（ASR). The patient was a 76-year-old man who had been given a diagnosis of ASR in his 40s. He gradually developed heart failure and chronic kidney disorder due to deterioration of ASR. He had started hemodialysis 1 year before admission and had complained of abdominal pain after meals and weight loss during that period. He was admitted to the Department of Cardiology in our hospital for evaluation of ASR. Severe ASR with low output syndrome（C. I. 2.00 L/min/m2）were confirmed by cardiac catheter examination. In addition, abdominal angiography revealed total occlusion of the superior mesenteric artery（SMA）and severe stenosis of the celiac artery（CA). We considered that low cardiac output due to severe ASR had exacerbated the mesenteric ischemia. We performed AVR and abdominal aorta-SMA bypass at the same time to prevent acute mesenteric ischemia in the perioperative period. The combination of valvular disease and CMI is very rare. This is the first report in Japan of simultaneous valve replacement and mesenteric artery revascularization.
Jpn. J. Cardiovasc. Surg. 46:334-338（2017）
Keywords：chronic mesenteric ischemia;abdominal angina;aortic valve replacement;aorta-SMA bypass;low output syndrome