|Yoshiya Shigehisa＊||Tomoyuki Matsuba＊||Hideaki Kanda＊|
|Yuki Ogata＊||Yutaka Imoto＊|
（Department of Cardiovascular and Gastroenterological Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan）
When mitral valve dysfunction occurs in infants and mitral valve repair is difficult, mitral valve replacement（MVR）is required. However, commercially available prosthetic heart valves can be too large to implant in infants with a small annulus. In these children, the technique of supra-annular MVR is useful. Here we report two cases of supra-annular MVR, which were performed using an expanded polytetrafluoroethylene（ePTFE）graft as a skirt for a prosthetic valve. This method has been previously reported by Sung et al. The first case was a 16-month-old, 6.7-kg male infant who suffered from Shone● syndrome, mitral stenosis（MS）with a parachute mitral valve, coarctation of the aorta（CoA), and ventricular septal defect（VSD). MS progressed after CoA repair and VSD closure and a supra-annular MVR was performed. The second case was a 5-month-old, 4.9-kg female infant who suffered from polysplenia, intermediate atrioventricular septal defect（AVSD), and severe left atrioventricular valve regurgitation. AVSD repair was performed at the age of 3 months. However, valve stenosis and regurgitation gradually progressed postoperatively and consequently, a supra-annular MVR was performed. Postoperative prosthetic valve function was good in both cases. We believe that this method of performing supra-annular MVR is useful for infants with a small annulus.
Jpn. J. Cardiovasc. Surg. 47:157-161（2018）
Keywords：supra-annular mitral valve replacement;small annulus;infant;Shone complex
|Daisuke Sakamoto＊||Yasuhiro Nagayoshi＊||Shigeru Sakamoto＊|
（Department of Cardiovascular Surgery, Kanazawa Medical University, Kanazawa, Japan）
A 68-year-old man presented to the emergency department with a high fever of 39.0 degrees Celsius. His past surgical history was significant, including mitral valve replacement and, tricuspid valve annuloplasty in 2012. On echocardiography, multiple vegetation with a maximum diameter of 20mm was identified on the leaflet of the prosthetic valve. The vegetations were large, multiple, and appeared floating. Moreover, advanced prosthesis valve regurgitation was observed. Candida grablata was detected in the blood culture, suggesting a high probability of PVE due to fungal infection. Emergency surgery was performed to prevent deterioration of his condition. Multiple large vegetations were noted attached to the prosthetic valve, resulting in damage to the valve leaflets and subsequent stenosis. The operation was concluded following removal of the last prosthetic valve and re-enforcement of the MVR. After surgery, antibiotic therapy with amphotericin B liposome was administered. Given that there were no signs of infection, the patient was discharged from the hospital on the 50th day after surgery. Although the vegetation was deemed large with a likelihood of patient deterioration, we believe that the degree of destruction to the leaflets prevented fatality. Existing literature reported cases whereby patients were discharged despite having such large vegetation on the valve. In cases of fungal infective endocarditis（Fungal IE), regardless of whether the valve was natural or prosthetic, the optimal treatment is to combine infected tissue debridement with thorough lesion removal, valve replacement surgery or valve annuloplasty, supplemented with a long-term antifungal agent. We believe this to be an effective treatment, especially if intervention is implemented early.
Jpn. J. Cardiovasc. Surg. 47:162-165（2018）
Keywords：infective endocarditis;giant vegetation;fungus
|Daisuke Yano＊||Fumiaki Kuwabara＊||Shinji Yamada＊|
|Shinichi Ashida＊||Yuichi Hirate＊|
（Cardiovascular Surgery, Nagoya Ekisaikai Hospital＊, Nagoya, Japan）
A 69-year-old woman with a medical history of mitral valve replacement for infective endocarditis 14 years previously was recently admitted after being given a diagnosis with multiple cerebral infarction along with headache and speech disturbance. After emergency admission, both transthoracic and transesophageal echocardiographies revealed multiple, extensive vegetation on the mitral prosthetic valve. Based on these findings, we diagnosed prosthetic valve endocarditis with cerebral septic embolization;and immediate mitral valve re-replacement surgery was performed. During the operation, a complication occurred when the left ventricular posterior wall ruptured during withdrawal from the cardiopulmonary bypass after mitral valve re-replacement. After a second cross-clamp and resection of the mitral prosthetic valve, we repaired the myocardial laceration and repeated the mitral valve re-replacement. We selected the following two methods from different approaches to repair the left ventricular rupture:(ａ) exclusion of the myocardial laceration using a bovine pericardial patch（intracardiac approach）;and (ｂ) direct suturing of the bleeding epicardium（extracardiac approach). Seven days after the surgery, computed tomography（CT）revealed a pseudoaneurysm in the left ventricular posterior wall. Several follow-up examinations using CT and echocardiography revealed gradual enlargement of the pseudoaneurysm. At 112 days after previous surgery, we successfully repaired the pseudoaneurysm through left lateral thoracotomy using the femorofemoral bypass with hypothermia. In the final surgery, we closed the orifice of the pseudoaneurysm using bovine pericardium. This case highlighted that left thoracotomy using a femorofemoral bypass with hypothermia could be a useful approach to address a left ventricular posterior wall pseudoaneurysm.
Jpn. J. Cardiovasc. Surg. 47:166-169（2018）
Keywords：left ventricular pseudoaneurysm;left ventricular rupture;prosthetic valve endocarditis;mitral valve re-replacement;patch closure
|Koji Kawago＊,＊＊||Takehito Mishima＊||Takashi Wakabayashi＊|
|Yuko Tosaka＊||Satoshi Nakazawa＊|
（Department of Cardiovascular Surgery, Niigata City General Hospital＊, Niigata, Japan, and Department of Cardiovascular Surgery, Tokyo Medical University Hospital＊＊, Tokyo, Japan）
Here, we report a patient who underwent surgery for acute aortic regurgitation（AR）due to rupture of an aortic valve commissure. The patient was a 51-year-old man who had undergone ascending aorta replacement for acute type A aortic dissection 6 years previously. He presented with a 2-day-history of headache and insomnia. Echocardiography showed only AR initially. However, 2 days later, a vegetation-like mass was noted at the aortic valve commissure on transesophageal echocardiography. We diagnosed AR associated with infective endocarditis, and decided to perform aortic valve replacement immediately. During surgery, we found that the cause of AR was rupture of the aortic valve commissure without infection. The cause of rupture in this case was suspected to be traumatic or myxomatous degeneration.
Jpn. J. Cardiovasc. Surg. 47:170-173（2018）
Keywords：rupture of an aortic valve commissure;acute aortic regurgitation;myxomatous degeneration;aortic valve replacement
|Daisuke Hiraoka＊||Susumu Manabe＊||Daiki Hirayama＊|
|Takashi Yasukawa＊||Sotaro Katsui＊||Hidetoshi Uchiyama＊|
|Masahiro Onuki＊||Kazunobu Hirooka＊|
（Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital＊, Tsuchiura, Japan）
Surgical stress is closely associated with the activity of the thyroid hormone. Although many patients undergoing cardiac surgery revealed markedly low triiodothyronine（T3), few patients showed symptomatic hypothyroidism. This condition is generally recognized as “non thyroidal illness（NTI）” which is characterized by a low T3 level, despite the normal function of hypothalamus-pituitary-thyroid system. NTI is generally considered as one of the biological defense mechanisms rather than a pathological condition, eliminating the requirement of medical intervention. Even if low T3 is observed in blood biochemical examination after open heart surgery, a cautious interpretation is required. We report an elderly case presenting severe fatigue and mild disorientation accompanied by significantly low thyroid hormone after aortic valve replacement. The morbidity was remarkably improved with medical treatment, suggesting hypothyroidism after cardiac surgery.
Jpn. J. Cardiovasc. Surg. 47:174-177（2018）
Keywords：non thyroidal illness;aortic valve replacement;octogenarian
|Kimihiro Yoshimoto＊||Masakazu Kawasaki＊||Hideyuki Kunishige＊|
|Nozomu Inoue＊||Yoshimitsu Ishibashi＊|
（Department of Cardiovascular Surgery, National Hospital Organization, Hokkaido Medical Center＊, Sapporo, Japan）
A 67-year-old man was admitted to our hospital with a complaint of heart failure. He had a 12-year history of chronic renal failure and hemodialysis. Coronary angiography confirmed the presence of a saccular aneurysm originating from the calcificated left main trunk with coronary artery stenosis. The aneurysm was successfully treated by saphenous vein patch repair of the orifice and coronary revascularization of the left anterior descending and circumflex arteries. A histological examination of the aneurysm wall demonstrated coronary artery dissection. Postoperative coronary angiography 2 weeks after surgery revealed no evidence of residual aneurysm and showed patent bypass grafts.
Jpn. J. Cardiovasc. Surg. 47:178-182（2018）
Keywords：coronary artery saccular aneurysm;left main trunk;vein patch coronary angioplasty;atherosclerosis;coronary artery dissection
|Kouki Jinnouchi＊||Kazuhisa Rikitake＊||Takahiro Miho＊|
（Department of Cardiovascular Surgery, Ureshino Medical Center＊, Ureshino, Japan）
Four-channel aortic dissection is quite rare, and is a highly life-threatening situation predisposing to aortic rupture. We report the case of a 70-year-old woman with non-Marfan syndrome. She was evaluated at our hospital for the diagnosis of another disease. She had no symptoms. Enhanced CT revealed an ascending aortic aneurysm, 68mm in diameter with four-channel dissection. Because of the high risk of rupture, we performed ascending aortic replacement under deep hypothermia. The cardio-pulmonary bypass（CPB）was not discontinued due to right ventricle failure. Coronary arterial bypass grafting（CABG）to the right coronary artery using the great saphenous vein was added. Even after additional CABG, CPB was not discontinued. The surgery finished under percutaneous cardiopulmonary support（PCPS). PCPS was removed on the third postoperative day. Her postoperative course was uneventful, and she was discharged without any abnormal condition. Four-channel aortic dissection has a high risk of rupture, suggesting the need for early surgical treatment.
Jpn. J. Cardiovasc. Surg. 47:183-186（2018）
Keywords：aortic dissection;Marfan syndrome;four channel aortic dissection
|Nobuyuki Hirose＊||Hideaki Nishimori＊||Takashi Fukutomi＊|
|Masaki Yamamoto＊||Kazuki Kihara＊||Miwa Tashiro＊|
（Department of Surgery II, Kochi University Faculty of Medicine＊, Nankoku, Japan）
An 83-year-old man who had undergone aortic arch repair using the elephant trunk technique in addition to abdominal aorta repair required surgical intervention for a pseudoaneurysm at the distal anastomosis of the aortic arch graft. Due to marked adhesion around the aneurysm, aortic cross-clamping was not feasible. Thus, under femoro-femoral partial bypass, the arch prosthesis was endoclamped using an aortic occlusion balloon inserted through the left femoral artery into the aortic arch graft and through the elephant trunk, guided by fluoroscopy and transesophageal echocardiography. This allowed descending aorta replacement with minimal bleeding. His postoperative course was uneventful. This technique enabled safe and bloodless clamping of the proximal portion of the aortic arch graft.
Jpn. J. Cardiovasc. Surg. 47:187-191（2018）
Keywords：occlusion balloon;total arch replacement;pseudoaneurysm;descending aortic replacement
|Hiroki Uchiyama＊||Toshiro Ito＊||Toshitaka Watanabe＊|
|Naomi Yasuda＊||Junji Nakazawa＊||Yosuke Kuroda＊|
|Ryo Harada＊||Nobuyoshi Kawaharada|
（Department of Cardiovascular Surgery, Sapporo Medical University＊, Sapporo, Japan）
A 76-year-old man with a history of total esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer was transferred to our hospital because of consciousness disorder. It became an emergency operation on diagnosis of Stanford type A acute aortic dissection on enhanced CT. Because CT showed the retrosternal gastric tube ran along the right side of the body of the sternum through the back side of the manubrium, we opted for skin and the suprasternal incision on the left side from center. We could perform total aortic arch replacement without the damage of the gastric tube except that the right side of the operative view was slightly poor. We did not recognize digestive organ symptoms such as postoperative passage disorders nor mediastinitis. The patient was discharged from our hospital on postoperative day 24.
Jpn. J. Cardiovasc. Surg. 47:192-195（2018）
Keywords：postoperative esophageal cancer;retrosternal gastric tube reconstruction;median sternotomy;Stanford type A acute aortic dissection;total aortic arch replacement
|Yuki Yoshioka＊||Kentaro Tamura＊＊||Yuki Otsuki＊＊|
|Atsuhisa Ishida＊＊＊||Genta Chikazawa＊＊＊||Arudo Hiraoka＊＊|
|Toshinori Totsugawa＊＊||Ryusuke Suzuki＊||Hidenori Yoshitaka＊＊|
（Department of Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital＊, Kumamoto, Japan, Department of Cardiovascular Surgery＊＊, and Department of Peripheral Vascular Surgery＊＊＊, The Sakakibara Heart Institute of Okayama, Okayama, Japan）
Pulmonary thromboembolism（PTE）is a life-threatening disease, and in severe cases is required surgical treatment. Emergency pulmonary embolectomy using retrograde pulmonary perfusion（RPP）as an adjunct was successfully performed in 2 patients suffering from massive acute PTE. After removal of the pulmonary thrombus via incision of the pulmonary artery trunk, RPP via the right upper pulmonary vein was performed, which enabled the removal of residual thrombotic material and air from the peripheral branches of pulmonary arteries.
Jpn. J. Cardiovasc. Surg. 47:196-200（2018）
Keywords：retrograde pulmonary perfusion;pulmonary embolectomy;acute pulmonary thromboembolism
|Masashi Hattori＊||Shigeyuki Aomi＊||Masaki Saso＊|
|Shizuya Shintomi＊||Takuma Miyamoto＊||Hiroshi Niinami＊|
（Department of Cardiovascular Surgery, The Heart Institute of Japan＊, Tokyo Women’s Medical University, Tokyo, Japan）
A 69-year-old man was referred to our hospital because of a right upper mediastinal mass observed on chest roentgenogram. Computed tomography showed a dissecting aneurysm of the right subclavian artery and dissection of the ascending aorta. Furthermore, the ascending aorta was dilated. We subsequently reconstructed the right subclavian artery with a bypass graft and replaced the ascending aorta. Two-thirds of the aortic arch was placed in deep hypothermic circulatory arrest with retrograde cerebral perfusion. His postoperative course was uneventful with no neurological complications. While subclavian artery aneurysms are relatively rare in comparison to other peripheral artery aneurysms, subclavian artery aneurysms with aortic dissections are even rarer. The most important concerns during subclavian artery aneurysm repair are the method of surgical approach and the maintenance of sufficient cerebral flow. We suggested that deep hypothermic circulatory arrest with retrograde cerebral perfusion might prove useful in cases involving an intramural thrombus adherent to cerebral vessels. Therefore, patients with subclavian artery aneurysms must undergo extensive preoperative evaluation.
Jpn. J. Cardiovasc. Surg. 47:201-205（2018）
Keywords：subclavian artery aneurysm with dissection;subclavian artery bypass grafting;partial arch replacement;deep hypothermic circulatory arrest with retrograde cerebral perfusion