（Cardiovascular and Gastrointestinal Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan）
Due to the increasing number of patients with repaired tetralogy of Fallot（TOF), the amount of subsequent sequelae has also increased along with the need for further surgical interventions. This case report described a patient who underwent multiple reoperations for late sequelae over a period of 48 years after repair of TOF. The patient was a 58-year-old man who underwent a reparative operation for TOF at the age of 9 years. At the age of 30, he underwent patch closure of residual VSD and reconstruction of right ventricular outflow tract（RVOT）with a mono-cusped trans-annular patch combined with aortic valve replacement. At the age of 47, he underwent aortic root replacement for aneurysmal dilatation of the Valsalva sinus, and he was implanted with a pacemaker for bradycardia atrial fibrillation at the age of 51. By the age of 58, he required pulmonary valve replacement and tricuspid valve annuloplasty for right ventricular dysfunction resulting from regurgitation of the pulmonary and tricuspid valves as 4th midline sternotomy surgery. His status improved to NYHA functional class III to II after the most recent procedures, although he still needed strict medical control. A proactive approach during long-term follow-up after TOF repair is important for timely and appropriate surgical intervention in the event of late sequelae.
Jpn. J. Cardiovasc. Surg. 47:95-99（2018）
Keywords：tetralogy of Fallot;reoperation;pulmonary valve regurgitation;right-sided cardiac failure
（Department of Cardiovascular Surgery, Dokkyo Medical University Saitama Medical Center＊, Koshigaya, Japan, and Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine＊＊, Chiba, Japan）
A 46-year-old man who had been hospitalized for treatment of pneumonia was referred to our hospital with a diagnosis of acute pulmonary thromboembolism. Multi-detector row computed tomography revealed massive thrombi in the bilateral main pulmonary arteries. Transthoracic echocardiography showed dilated right heart chambers and a large floating thrombus in the right atrium. Emergency thromboembolectomy was performed. Although fresh thrombi were removed from the right atrium and left main pulmonary artery, organized old thrombi were present in the bilateral pulmonary arteries, leading to a diagnosis of chronic thromboembolic pulmonary hypertension. Because no instruments were available for pulmonary endarterectomy, the surgery was terminated with percutaneous cardiopulmonary support. Five days postoperatively, pulmonary endarterectomy was performed under deep hypothermic circulatory arrest. The postoperative course was uneventful, and the patient returned to his preoperative lifestyle without the need for oxygen support.
Jpn. J. Cardiovasc. Surg. 47:100-104（2018）
Keywords：chronic thromboembolic pulmonary hypertension;acute pulmonary thromboembolism;pulmonary endarterectomy
（Division of Cardiovascular Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Toho University＊, Tokyo, Japan）
We report a case of a 64-year-old woman who presented with symptoms for the common cold, for a medical examination. The chest X-ray showed enlargement of the heart, and echocardiography detected a mobile mass suggestive of a tumor 21×14mm in the left ventricle. Because there was a risk of embolism, we decided to perform an operation. The tumor was elastic and soft and had a stalk arising from the wall of the left ventricle. We considered that it would be difficult to observe and expose the left ventricular tumor by direct vision. Therefore, we chose to perform a complete endoscopic resection. The tumor was determined histopathologically to be a papillary fibroelastoma. Here, we report the relatively rare benign tumor, a papillary fibroelastoma, and include a discussion of the literature.
Jpn. J. Cardiovasc. Surg. 47:105-108（2018）
Keywords：cardiac papillary fibroelastoma;endoscopic resection;cardiac tumor
（Department of Cardiovascular Surgery, Iida Municipal Hospital＊, Iida, Japan, and Department of Cardiovascular Surgery, Nagano Red Cross Hospital＊＊, Nagano, Japan）
A 62-year-old man was admitted to our hospital complaining of high fever and clouding of consciousness. His initial diagnosis was infective vegetative endocarditis involving the mitral valve with multiple hemorrhagic cerebral infarctions. We chose medical therapy because of cerebral hemorrhage and scheduled surgery two weeks after the hospital admission. During medical therapy, echocardiography showed rapid growth of the vegetation on the 6th hospital day, suggesting cardiac tumor. Surgery was performed on the 16th hospital day. We found an infected myxoma with vegetation on the mitral valve and annular abscess extending to the left ventricle. The myxoma was resected and the abscess carefully debrided. We replaced the mitral valve after the mitral annulus was reinforced with autologous pericardium. The patient underwent antibiotic therapy for 6 weeks after the surgery. He was discharged from the hospital with no sign of recurrence.
Jpn. J. Cardiovasc. Surg. 47:109-112（2018）
Keywords：infected myxoma;rapidly growing;endocarditis
（Division of Cardiovascular Surgery, Koto Memorial Hospital＊, Higashiomi, Japan, and Division of Cardiovascular Surgery, Shiga University of Medical Science＊＊, Otsu, Japan）
Some 50% of patients who undergo cardiac surgery will have heparin-induced thrombocytopenia（HIT）antibodies, only 1% will develop typical clinical HIT. Especially delayed-onset HIT is not well-known and extremely rare. A 83-year-old man underwent aortic valve replacement（AVR）with a bioprosthetic valve（Mitroflow 21mm）and pulmonary vein isolation（PVI). Intravenous unfractionated heparin（8,000I.U./day）was administered for 5 days after surgery. He had a good recovery and was discharged to home with a platelet count of 100,600/μl on POD 15 on warfarin. On POD 18, he was readmitted to our hospital due to cerebral infarction with hemiparesis. As MRI revealed a multiple left hemispheric infarction, the presence of cardiogenic cerebral infarction was suspected. Continuous intravenous administration of unfractionated heparin（15,000I.U./day）was started. On POD 24, the platelet count fell to 27,000/μl, and a contrast CT scan revealed a giant thrombus in the aortic arch. He was found to have HIT antibodies, supporting a diagnosis of HIT. After cessation of heparin therapy and administration of vitamin K antagonist, argatroban was administered. He recovered neurologically and was discharged on POD 58. He remains well at 3 years follow up. If a patient has an unexplained and severe thrombocytopenia after cardiovascular surgery, delayed-onset HIT should be taken into consideration.
Jpn. J. Cardiovasc. Surg. 47:113-117（2018）
（Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Japan）
Triple-vessel disease of coronary artery was recognized in the examination of a 78-year-old man when hemodialysis was introduced for diabetic nephropathy. Percutaneous coronary intervention（PCI）was performed as initial treatment for the lesion of the right coronary artery. Contrast CT was performed because of persistent fever from the first day after the PCI. Since the tumor occupying the inside of the left atrium which was not found before PCI we were concerned about the failure of the hemodynamics and decided to treat it surgically. Surgery was performed with off-pump coronary artery bypass grafting, followed by left atrial mass removal surgery under cardiac arrest using cardio-pulmonary bypass. When examining the interior of the left atrium with a right lateral incision of the left atrium, the tumor was found to be on the posterior wall. This surface was smooth, and there was no endometriosis or hematoma. After incising the left atrial adventitia, old hematoma was found in the inside of the left atrium muscle layer, and it was removed as much as possible. The left atrial tumor was actually an intramural hematoma, based on image findings and macroscopic findings. Searching for the cause retrospectively, it was thought that the wire which was displaced during PCI was the cause of bleeding. We confirmed that there was no recurrence of left atrial intramural hematoma on an outpatient visit on the 113th postoperative day. We report a rare case of removing left atrial intramural hematoma under cardiac arrest which appeared after PCI.
Jpn. J. Cardiovasc. Surg. 47:118-122（2018）
Keywords：left arterial intramural hematoma;percutaneous coronary intervention;off-pump coronary artery bypass grafting;diabetic kidney disease
（Department of Thoracic and Cardiovascular Surgery, Sapporo General City Hospital＊, Sapporo, Japan, and Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University＊＊, Sapporo, Japan）
A 48-year old man consulted a doctor at a nearby medical clinic due to dyspnea and increased body mass which he began to experience in October, 2011. Further evaluation revealed the presence of three-vessel severe coronary artery disease, poor left ventricular function, and mitral valve regurgitation. Transthoracic echocardiography showed anterior wall asynergy and left ventricular enlargement. Reconstruction of the left ventricle was contemplated during the preoperative evaluation. The patient underwent hemodialysis for chronic renal failure prior to admission. Generally, delayed gadolinium-enhanced MRI is used for cardiac viability assessment. However, gadolinium is contraindicated in a patient with chronic renal failure owing to the risk of development of nephrogenic systemic fibrosis. Thus, gadolinium-enhanced MRI is contraindicated in the patient. Instead, we used fluorodeoxyglucose-positron emission tomography（FDG-PET）computed tomography（CT）to assess myocardial viability. Consequently, viability was assessed except for a part of the apical electrode in the left anterior descending artery territory. Subsequently, revascularization and mitral valve annuloplasty with coronary artery bypass grafting of five vessels were performed in January, 2012 without left ventricular reconstruction. A left ventricular assist device was used postoperatively, from which he was later weaned. The outcome was good because post-operative left ventriculography revealed improvement in left ventricular wall motion. This case is presented including bibliographical comments on the effectiveness of FDG PET-CT for assessment of myocardial viability.
Jpn. J. Cardiovasc. Surg. 47:123-127（2018）
Keywords：myocardial viability;hemodialysis;FDG PET-CT;left ventricular plasty
（Department of Surgery II, Faculty of Medicine, University of Yamanashi＊, Chuo, Japan）
A 62-year-old man was referred to our hospital because of dyspnea. Electrocardiogram showed chronic atrial fibrillation and echocardiogram revealed severe tricuspid regurgitation. His history included a motorbike accident at age 17, and a heart murmur was pointed out in the following year. He developed paroxysmal atrial fibrillation when he was 45 years old. Heart failure was not controlled by medication and tricuspid valve repair was indicated. At surgery, the anterior leaflet of tricuspid valve was widely prolapsed due to chordal rupture. We performed chordal reconstruction with 4 expanded polytetrafluoroethylene（CV-5●R）sutures, and ring annuloplasty. Furthermore, a small fenestration at the tricuspid annulus was noticed and was closed with a direct suture. The biatrial modified Maze procedure was performed subsequently. The patient is doing well without TR recurrence, and restored sinus rhythm is maintained. We report successful repair of traumatic tricuspid regurgitation.
Jpn. J. Cardiovasc. Surg. 47:128-132（2018）
Keywords：traumatic tricuspid regurgitation;tricuspid valvuloplasty;blunt chest trauma
（Department of Cardiovascular Surgery Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan）
Patients with Beh●et disease often develop postoperative valve detachment and pseudoaneurysm as a potentially fatal complication following aortic valve surgery, necessitating re-operation in a few cases. A 37-year-old man underwent 5 aortic valve and aortic root surgeries for the management of valve detachment after initial aortic valve replacement. Evaluation during the course of his disease revealed incomplete Beh●et disease. He presented with high fever and Staphylococcus epidermidis bacteremia during the introduction of immunosuppressive therapy with infliximab. Contrast computed tomography revealed a pseudoaneurysm around the aortic root, and an aortic root replacement was performed using an aortic homograft after administration of a 6-week course of vancomycin. The patient is being observed at our outpatient clinic and has demonstrated no complications after 5 years from his last surgery.
Jpn. J. Cardiovasc. Surg. 47:133-137（2018）
Keywords：Beh●et disease;homograft;infectious endocarditis;pseudoaneurysm;aortic root surgery
（Department of Cardiovascular Surgery, Southern Tohoku General Hospital, Koriyama, Japan）
We report a case of operations using a hybrid technique for repeated extensive aortic aneurysm. A 71-year-old man had extensives aneurysms of the aortic arch and descending aorta. In the first operation, he had undergone thoracoabdominal aortic replacement with island repair for thoracoabdominal aortic aneurysm（Crawford type 3）at age 64. Six years later, computed tomography showed an aortic aneurysm around the region of the island repair and penetrating atherosclerotic ulcer（PAU). Therefore, he underwent abdominal debranching and thoracic endovascular aortic repair（TEVAR）at 70 years old. At the same time, he had an extensive aortic arch aneurysm. Considering the complicated surgical history and the affected region, we judged that conventional graft replacement was difficult. So, in the third operation, we performed TEVAR for the descending aorta at 71 years old. One month later, total arch replacement（TAR）with a frozen elephant trunk（FET）was performed（4th operation). The patient was discharged home 22 days after the 4th operation. This strategy of operations using hybrid techniques for extensive aortic aneurysm may be useful in high risk cases of surgical procedures and postoperative complications.
Jpn. J. Cardiovasc. Surg. 47:138-141（2018）
Keywords：extensive aortic aneurysm;frozen elephant trunk;debranching TEVAR;hybrid technique;thoracoabdominal aortic aneurysm
（Department of Cardiovascular Surgery, Akita University Graduate School of Medicine＊ Akita, Japan, and Central Laboratory Division, Akita University Hospital＊＊, Akita, Japan）
A 77-year-old man presented with fever and back pain. Computed tomography revealed a distal arch aneurysm. Bacteroides fragilis was found in a blood culture, and we diagnosed a thoracic infected aneurysm. Because of the rapid enlargement of the aneurysm and his frailty, a TEVAR procedure was urgently performed. He left the hospital after antibiotic treatment with meropenem. However, he was re-hospitalized due to recurrence of the infection. The infection was well-controlled by treatment with intravenous meropenem, and the subsequent oral administration of metronidazole（MNZ). He was re-hospitalized again 7 weeks after discharge due to unsteady gait and articulatory disorder. MNZ-induced encephalopathy（MIE）was diagnosed because FLAIR brain magnetic resonance imaging revealed an area of high signal intensity in the bilateral basal dentate nuclei. These symptoms improved after MNZ was changed to AMPC/CVA. Fifteen months later, the patient was doing well and had no recurrence of the infection. We performed TEVAR for a patient with a thoracic aneurysm infected by B. fragilis. The recurrence of the infection was controlled by adequate antibiotic therapy, which included the administration of MNZ. However, patients who are treated with MNZ should be carefully observed to detect the development of neurological signs, as MNZ may induce encephalopathy. The early detection and withdrawal of metronidazole is important for the improvement of MIE.
Jpn. J. Cardiovasc. Surg. 47:142-147（2018）
Keywords：Bacteroides fragilis;infected aneurysm;Metronidazole;encephalopathy;TEVAR
（Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan）
Today, syphilitic aortic aneurysm is rarely diagnosed due to widespread use of penicillin for early syphilis. Large aneurysms can be symptomatic by compressing on adjacent organs. We report a case of a huge syphilitic aneurysm of the thoracic aorta complicated with airway obstruction and superior vena cava syndrome. A 62-year-old man presented with acute severe dyspnea and distention of superficial veins. Contrast-enhanced computed tomography revealed an aneurysm of the ascending aorta extending to the transverse arch the diameter of which was 90mm. The aneurysm compressed the bilateral main bronchi and superior vena cava. We performed an emergency operation because respiratory failure persisted despite the support of a ventilator. Since the aneurysm eroded the sternum, median sternotomy was performed under hypothermic circulatory arrest. Dissecting the aneurysm was complicated due to dense adhesion. Ascending aorta and partial arch replacement with reconstruction of the brachiocephalic trunk was successfully performed with antegrade cerebral perfusion. Postoperative computed tomography demonstrated that compression of the bilateral main bronchi was released. The result of preoperative syphilitic serologic test was strongly positive, and pathological findings of the aneurysm wall specimen was compatible with syphilitic aneurysm. Following treatment with benzyl penicillin for 14 days, the patient was discharged on the 19th postoperative day without specific complications.
Jpn. J. Cardiovasc. Surg. 47:148-152（2018）
Keywords：syphilitic aortic aneurysm;airway obstruction;superior vena cava syndrome;main bronchus compression
（Cardiovascular Surgery, NTT East Sapporo Hospital＊, Sapporo, Japan）
A 39-year-old man was found to have left iliac artery rupture, and was transferred to our department. Emergency surgical repair was done, however, his intra- and postoperative condition precluded primary abdominal closure. On the 8th postoperative day, temporary abdominal closure（TAC）was performed using Composix Mesh TM and negative pressure wound therapy（NPWT). On the 19th day after the first surgery, an emergency reoperation was needed because of the rupture of the common hepatic artery aneurysm, of which there was no finding on admission. After the reoperation of the hepatic artery aneurysm, TAC was again performed using new Composix Mesh. On the 43rd day after the first surgery, the abdominal wall reconstruction without Composix Mesh was done using components separation and the anterior rectus abdominis sheath turnover flap method. On the 106th day after the first surgery, he had recovered well and was discharged. The genetic testing revealed COL3A1 mutation, which is specific for vascular type Ehlers-Danlos syndrome. When long-term open abdominal management is necessary after the abdominal aortic surgery, TAC with Composix Mesh and NPWT may be a useful alternative. Artery rupture in young people is a finding that should be considered suspicious for vascular type Ehlers-Danlos syndrome, which is difficult to treat.
Jpn. J. Cardiovasc. Surg. 47:153-156（2018）
Keywords：temporary abdominal closure;rupture of the iliac artery;Ehlers-Danlos syndrome