|Ko Shibata＊||Tomoki Tamura＊||Yuta Tsuchida＊|
（Department of Cardiovascular Surgery, NTT Medical Center Tokyo＊, Tokyo, Japan）
We report a case of minimally invasive cardiac surgery（MICS）for partial anomalous pulmonary venous return（PAPVR）to the high portion of the superior vena cava. A 34-year-old female was referred to our hospital for exertional chest oppression, and was diagnosed with PAPVR and a sinus venosus atrial septal defect. Two pulmonary veins were connected to the superior vena cava（SVC）:one to the SVC-atrial junction and the other to the high SVC adjacent to the azygos connection. We performed an intracardiac repair through a small right axillary incision. The postoperative course was uneventful. MICS may become a useful option for PAPVR repair.
Jpn. J. Cardiovasc. Surg. 47:41-44（2018）
Keywords：minimally invasive cardiac surgery;partial anomalous pulmonary venous return;atrial septal defect
|Yasuhito Nakamura＊||Yositaka Kumada＊||Yuusuke Mizuno＊|
（Department of Cardiovascular Surgery, Matunami General Hospital＊, Kasamatu, Japan）
Primary cardiac angiosarcoma is extremely rare and its prognosis remains poor. We present a 61-year-old woman with angiosarcoma who was admitted with exertional dyspnea and considerable hemodynamic compromise. Computed tomography showed a large tumor in the right atrium and multiple liver metastases. The cardiac tumor invaded from the superior vena cava to the atrial septum. After the cardiac tumor was removed, the right atrium, the atrial septum and the superior vena cava were reconstructed with a bovine pericardial patch. The pathological diagnosis was angiosarcoma, and the cut-end was positive for sarcoma. The patient survived 14 months after surgery with the aid of adjuvant chemotherapy.
Jpn. J. Cardiovasc. Surg. 47:45-48（2018）
Keywords：primary cardiac tumor;angiosarcoma;liver metastasis
|Chiharu Tanaka＊||Toshihiko Ueda＊||Hidekazu Furuya＊|
|Masaomi Yamaguchi＊||Kazuo Kanabuchi＊||Shinichiro Shimura＊＊|
（Tokai University Hachioji Hospital＊, Hachioji, Japan, and Tokai University School of Medicine＊＊, Isehara, Japan）
A 60-year-old man complained of palpitation due to transitory atrial fibrillation. The annulo-aortic ectasia was recognized, and was getting enlarged to 52mm. After an additional examination, membranous ventricular septal aneurysm was revealed. There was no evidence of thrombus, shunt, or infection in the membranous ventricular septal aneurysm. The valve-sparing aortic root replacement（reimplantation）and the patch-closure of the membranous ventricular septal aneurysm were performed. Stabilizing the subannular tissue by a Dacron patch made the reimplantation technique feasible. To secure a subannular suture line, 3 mattress stitches were passed inside-out through the Dacron patch, the fibrous rim of the membranous septum and the prosthetic graft again. He was discharged without any complication 12 days after the operation.
Jpn. J. Cardiovasc. Surg. 47:49-53（2018）
Keywords：membranous ventricular septal aneurysm;annulo-aortic ectasia;valve-sparing aortic root replacement
|Reo Sakakura＊||Tomoaki Suzuki＊||Naoshi Minamidate＊|
|Shinya Terada＊||Takeshi Kinoshita＊||Tohru Asai＊|
（Department of Cardiovascular Surgery, Shiga University of Medical Science＊, Otsu, Japan）
The surgical outcome is worse when VSP is attempted soon after myocardial infarction due to the more poor general condition, preoperative cardiogenic shock, fragile infarcted myocardial tissue. We successfully rescued a 80-year cardiopulmonary arrest patient who was suffering from subacute postinfarcted VSP complicated by the left ventricular aneurysm. The VSP was closed with the sandwich patch technique approached from both ventricles. The left ventricular aneurysm was repaired with endoventricular circular patch plasty.
Jpn. J. Cardiovasc. Surg. 47:54-57（2018）
Keywords：ventricular septal perforation;left ventricular
|Takashi Shuto＊||Hirofumi Anai＊||Tomoyuki Wada＊|
|Hideyuki Tanaka＊||Madoka Kawano＊||Takayuki Kawashima＊|
|Tadashi Umeno＊||Kenji Yoshimura＊||Kaoru Uchida＊|
（Department of Cardiovascular Surgery, Faculty of Medicine, Oita University＊, Yufu, Japan）
The first case was a 67-year-old woman. She had been given a diagnosis of fulminant myocarditis and received a biventricular assist device as a bridge to recovery. A Nipro ventricular assist device（VAD）was implanted into her left heart. She was also found to have moderate aortic insufficiency before the operation, so she received aortic valve replacement（AVR）with a bioprosthetic valve（CEP Magna Ease 21mm）at the same time. Her cardiac function recovered gradually. Therefore, a weaning operation was scheduled for three months after the VAD implantation. However, her left ventricle motion was very poor when she was taken off of the extracorporeal circulation after removing the VAD, and transesophageal echocardiography（TEE）revealed severe bioprosthetic valve stenosis. When her heart was stopped again and the bioprosthetic valve was observed, the leaflets of the bioprosthetic valve were fused. Commissural fusion of bioprosthetic valve was able to be released using forceps, and the punnus extending under the leaflet was removed. In this way, the function of the bioprosthetic valve was restored. Her cardiac motion became good, and removal from extracorporeal circulation was easily achieved. She left the hospital 100 days after weaning from the VAD. The second case was a 68-year-old woman. She also had fulminant myocarditis. She underwent biventricular assist device implantation and AVR（CEP Magna Ease 19 mm). Her cardiac function recovered, and a weaning operation was scheduled on the 73rd-postoperative day. Preoperative TEE before the weaning of VAD showed severe bioprosthetic valve stenosis. The commissural fusion of the bioprosthetic valve was released and the punnus extending under the leaflet removed at the same time as the VAD was removed. Re-valve replacement was not required. We should therefore consider the possibility of bioprosthetic valve stenosis when VAD implantation and AVR with a bioprosthetic valve are performed at the same time in patients with an extremely reduced cardiac function.
Jpn. J. Cardiovasc. Surg. 47:58-61（2018）
Keywords：fulminant myocarditis;Nipro LVAD;aortic valve replacement;bioprosthetic valve stenosis
|Hiromichi Sonoda＊||Tomoki Ushijima＊||Yasuhisa Oishi＊|
|Kazuhiro Hinokiyama＊||Hideki Tatewaki＊||Yoshihisa Tanoue＊|
（Department of Cardiovascular Surgery, Kyushu University Hospital, Fukuoka, Japan）
Bleeding control during aortic surgery is one of the most important issue. The well-known fibrinogen-based hemostat contains the blood product, which means the potential risk of the blood-related infection. Recently, the newly-designed hemostat “Hydrofit”, which is assembled with urethane-based polymer without blood product（Matsudyte:Sanyo-chemical industry, Kyoto, Japan). Hydrofit is applicated for the hemostasis of thoracic aortic surgery. In sealing of the Hydrofit gel to the anastomosis site of aorta, water-contact initiation boosts the chemical change to the forming elastomer and adheres around anastomosis site rapidly. We experienced the extirpation of the Hydrofit which was used over 4 years ago. The patient is 42 year-old female who was operated aortic valve replacement and graft replacement of ascending aorta using a Hydrofit as a hemostat at 4 year 8 months ago due to the aortitis syndrome. Re-sternotomy and re-AVR was performed because of the prosthetic valve dehiscence due to the active aortitis syndrome. Hydrofit left around suture line without infection, and functioned very well as the elastic sealant for the long-term period.
Jpn. J. Cardiovasc. Surg. 47:62-65（2018）
Keywords：Hydrofit;Matsudyte;long-term removal;ascending aortic replacement
|Kenji Yokoyama＊||Kiyotoshi Oishi＊||Dai Tasaki＊|
（Department of Cardiovascular Surgery, Musashino Red Cross Hospital＊, Musashino, Tokyo, Japan）
A 85-year-old man with an abnormal shadow on X-ray was given a diagnosis of aortic arch aneurysm by CT scan. Preoperative additional careful examinations revealed that his dominant vertebral artery was the left one and he had an allergy to metals such as platinum, tin and zinc. He underwent thoracic endovascular aortic repair（TEVAR）after revascularization of left vertebral artery by bypass grafting between bilateral axillary arteries and the left common carotid artery with a T-shape graft. Because of the position of the origin of the left vertebral artery from the left subclavian artery was comparatively proximal part, we made it transposition more distally to occlude the LSA by ligation. We selected conformable GORE●R TAG●R for zone-1 TEVAR because the stent graft, which was not composed of allergic metals, contained only less allergic metals than any other devices commercially available. More than two years have passed since his discharge and he was followed as an outpatient without any allergic symptom and other remarkable complications. Here, we report a rare case of 2 debranching TEVAR for aortic arch aneurysm with metal allergy.
Jpn. J. Cardiovasc. Surg. 47:66-70（2018）
Keywords：metal allergy;debranching;TEVAR;left vertebral artery transposition
|Kayo Sugiyama＊||Katsuhiko Matsuyama＊＊||Nobusato Koizumi＊|
|Keita Maruno＊||Yukio Muromachi＊||Akinari Iwahori＊|
|Satoshi Takahashi＊||Toru Iwahashi＊||Toshiya Nishibe＊|
（Department of Cardiovascular Surgery, Tokyo Medical University Hospital＊, Tokyo, Japan, and Department of Cardiovascular Surgery, Aichi Medical University Hospital＊＊, Aichi, Japan）
We report on a rare case of Marfan syndrome with giant dissecting descending thoracic and abdominal aortic aneurysms associated with poor left ventricular function and severe mitral regurgitation. Before the anesthetic induction, a partial extra-corporeal circulation was established to prevent a collapse of the circulation. Descending aortic graft replacement and following abdominal aortic graft replacement were performed safely using the partial extra-corporeal circulation to relief the afterload for the severely deteriorated left ventricle with severe mitral regurgitation. Intra-aortic balloon pumping was also promptly used to assist the poor circulation in the postoperative period. Despite the admission to a specialized institute, he died from irreversible heart failure with a developing renal failure. Even for a difficult patient with Marfan syndrome with severe left ventricular dysfunction and mitral regurgitation, graft replacement was feasible with meticulous perioperative circulatory management using partial extra-corporeal circulation and intra-aortic balloon pumping. However, a prompt registration for heart transplantation and an aortic surgery concomitant with implantation of left ventricular assisted device should have been considered to save the patient.
Jpn. J. Cardiovasc. Surg. 47:71-77（2018）
Keywords：Marfan syndrome;left ventricular dysfunction;aortic aneurysm;partial extra-corporeal circulation;intra-aortic balloon pumping
|Kazufumi Yoshida＊||Naoto Fukunaga＊||Tadaaki Koyama＊|
（Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital＊, Kobe, Japan）
Vascular Ehlers-Danlos Syndrome（EDS）causes fragility of the blood vessels, skin, and hollow organs, and the most common clinical feature is vascular rupture. We report a surgical case of a spontaneous ruptured dissection of the left common iliac artery（CIA）in a patient with vascular EDS. A 27-year-old man with documented vascular EDS with a mutation of the collagen type III alpha-1［COL3A1］gene, presented with acute left lower abdominal pain. The enhanced computed tomography（CT）scan revealed a ruptured dissection of the left CIA with extravasation, and left iliopsoas hematoma. The enhanced CT performed 1 month previously showed no arterial aneurysm. The left CIA was anastomosed end-to-end using a 7mm heparin-bonded polytetrafluorethylene（PTFE）graft（Fusion, MAQUET Cardiovascular LLC, USA). A PTFE graft was anastmosed end-to-side to the left external iliac artery（EIA). The distal side of the CIA was closed. The postoperative enhanced CT showed aneurysmal formation in the right inferior gluteal artery. The follow-up CT showed enlargement of the left EIA（from 7.5 to 12mm in a diameter), and aneurysm formation in the proper hepatic artery. Therefore, a close follow-up based on noninvasive imagings is mandatory to detect life-threatening vascular complecations in patients with vascular EDS.
Jpn. J. Cardiovasc. Surg. 47:78-81（2018）
Keywords：vascular Ehlers-Danlos Syndrome;aneurysmal formation;surgical repair
|Yu Hohri＊||Takuma Yamasaki＊||Yuichi Matsuzaki＊|
（Department of Cardiovascular Surgery, Kyoto Daini Red Cross Hospital＊, Kyoto, Japan）
A 26-year-old lady with Loeys Dietz syndrome had undergone 5 consecutive operations from 2007 to 2014. Finally, her total aorta was replaced by vascular grafts and stent grafts. The patient was admitted to our hospital with headache and dizziness in 2016. Computed tomography showed a giant pseudoaneurysm at the aortic arch with extravasation from the vascular graft. The proximal flares of thoracic stent grafts caused perforation of thoracic vascular grafts. Cerebral perfusion was not sufficient, because this aneurysm compressed the innominate, left carotid and left subclavian arteries. Decreasing of cerebral perfusion caused headache and dizziness. We performed total arch replacement. We started extracorporeal circulation before median sternotomy but the aneurysm ruptured during median sternotomy. We controlled the bleeding by manual compression and immediately started selective cerebral perfusion and induced cardiac arrest. After opening the distal portion, we cut down the proximal flares of thoracic stent graft and inserted an elephant trunk into the stent graft. We sutured between the new vascular graft and the stent graft and covered the suture line with another short vascular graft. As a result we could protect the vascular graft from the stent graft. Computed tomography demonstrated that the pseudoaneurysm and extravasation disappeared. Cerebral perfusion increased and the patient’s symptoms improved. Postoperatively the patient was discharged from our hospital without any major complications at POD 11.
Jpn. J. Cardiovasc. Surg. 47:82-87（2018）
Keywords：Loeys-Dietz syndrome;total aortic replacement;total arch replacement;non-anastomotic pseudoaneurysm;TEVAR
|Minoru Matsuhama＊||Takuma Kobayashi＊＊||Takashi Kunihara＊|
（Department of Cardiovascular Surgery, The Cardiovascular Institute＊, Tokyo, Japan, and Department of Cardiovascular Surgery, Kyoto Okamoto Memorial Hospital＊＊, Kyoto, Japan）
Immunoglobulin G4（IgG4)-related disease is a chronic disease characterized by fibrotic mass and/or thickened lesions with elevated serum IgG4 concentrations, and infiltrations of IgG4 positive plasma cells. Since it has recently been reported to occur in the cardiovascular system, therapeutic strategy needs to be established. We report a case of IgG4-related thoracic aortic aneurysm（IgG4-R TAA）which was diagnosed postoperatively though suspected as aortic intramural hematoma preoperatively. A 70-year-old man who has medical histories of retroperitoneal fibrosis twice visited our hospital with chief complaints of cough and a CT scan was performed. Though there had been no episodes related to the onset of aortic dissection such as chest pain, an ascending aortic intramural hematoma of 52mm in diameter was suspected and we planned to perform hemi-arch replacement. Intraoperative findings suggested that it was a true aneurysm and there was no sign of dissection. Histopathologically, the adventitia was obviously thickened with infiltrations of IgG4 positive plasma cells without infiltrations and dissection findings in the tunica media. In addition, serum IgG4 exceeded the normal value, thus it was diagnosed as IgG4-R TAA on the basis of the comprehensive diagnostic criteria. Great caution should be taken in IgG4-R TAA because it may show intramural hematoma on imaging and may develop aortic dissection and rupture as well.
Jpn. J. Cardiovasc. Surg. 47:88-92（2018）
Keywords：IgG4-related disease;aortic dissection;intramural hematoma;diagnostic criteria