Japanese Journal of Cardiovascular Surgery Vol.48, No.1

Preface

• Readiness of Cardiovascular Surgeon　K. Miyaji
  Readiness of Cardiovascular Surgeon
  Kagami Miyaji
  

Invited Review

• Current Status of Cardiovascular Surgery in Japan:Analysis of Data from Japan Cardiovascular Surgery Database in 2015, 2016
• 1. Congenital Heart Surgery　Y. Hirata et al.…1
  Current Status of Cardiovascular Surgery in Japan:Analysis of Data from Japan Cardiovascular Surgery Database in 2015, 2016. 1. Congenital Heart Surgery
  

  Yasutaka Hirata＊1	Norimichi Hirahara2	Arata Murakami3
  Noboru Motomura4	Hiroaki Miyata2	Shinichi Takamoto2

  
  

  （Department of Cardiac Surgery, The University of Tokyo School of Medicine1, Tokyo, Japan, Department of Health Policy and Management, School of Medicine, Keio University2, Tokyo, Japan, and Kanazawa Cardiovascular Hospital3, Kanazawa, Japan, and Department of Cardiovascular Surgery, Toho University Sakura Medical Center4, Sakura, Japan）
  

  Methods:We collated the nationwide data on congenital heart operations performed between January 2015 and December 2016 from the Japan Cardiovascular Surgery Database（JCVSD). The mortality and morbidity data for the 20 most-frequently performed procedures were analyzed. We also classified the surgical centers into three groups, according to the number of cardiopulmonary cases over a year and estimated the institution-wise distribution of major operations. Results:The mortality rate of the ASD and VSD repair procedures was ＜1%, while the mortality rate of procedures including TOF repair, complete AVSD repair, Rastelli operation, CoA complex repair, bidirectional Glenn and TCPC was found to be between 2-3%. The mortality rate of surgeries such as the Norwood procedure and TAPVC repair was comparably higher（＞10%). These complicated procedures were mainly performed at the surgical institutes handling a large volume of cases. Conclusion:Using the JCVSD, the nationwide data of congenital heart surgery, including postoperative complications, were analyzed.

   

  Jpn. J. Cardiovasc. Surg. 48:1-5（2019）

  Keywords：the Japan Cardiovascular Surgery Database（JCVSD）;congenital heart surgery

  
  
• 2. Isolated Coronary Artery Bypass Surgery　A. Saito et al.…6
  Current Status of Cardiovascular Surgery in Japan:Analysis of Data from Japan Cardiovascular Surgery Database in 2015, 2016. 2. Isolated Coronary Artery Bypass Surgery
  

  Aya Saito1	Norimichi Hirahara2	Noboru Motomura1
  Hiroaki Miyata2	Shinichi Takamoto2

  
  

  （Department of Cardiovascular Surgery, Toho University Sakura Medical Center1, Sakura, Japan, and Department of Health Policy and Management, School of Medicine, Keio University2, Tokyo, Japan）
  

  We reviewed the data of the isolated coronary artery bypass grafting（CABG）procedures performed in 2015 and 2016, as registered in the Japan Cardiovascular Surgery Database, for preoperative characteristics, surgical outcomes, and the choice of graft material used for the left anterior descending artery（LAD). Isolated CABG was performed off-pump in 55.0%（n＝16,173）of all CABG cases（n＝29,392). The left internal thoracic artery and the right internal thoracic artery were used as the graft materials in 72.1 and 17.4% cases respectively. The operative mortality rates remained unchanged since the last report, with 1.7% for elective cases, 8.8% for emergency cases, and 3.0% overall. In elective cases, the operative mortality rate was 1.1% for off-pump CABG（OPCAB）compared with 2.5% for on-pump CABG. The morbidity rates for all OPCAB cases were significantly better except for those falling in the ‘readmission ＜30 days’ group.
  　　

  Jpn. J. Cardiovasc. Surg. 48:6-10（2019）

  Keywords：coronary artery bypass grafting;graft choice;off-pump coronary artery bypass grafting;on-pump coronary artery bypass grafting
  
  

• 3. Valvular Heart Surgery　T. Abe et al.…11
  Current Status of Cardiovascular Surgery in Japan:Analysis of Data from Japan Cardiovascular Surgery Database in 2015, 2016. 3. Valvular Heart Surgery
  

  Tomonobu Abe＊1	Kiyoharu Nakano2	Norimichi Hirahara3
  Noboru Motomura4	Hiroaki Miyata3	Shinichi Takamoto3

  
  

  （Division of Cardiovascular Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University1, Maebashi, Japan, Harajuku Rehabilitation Hospital2, Tokyo, Japan, Department of Health Policy and Management, School of Medicine, Keio University3, Tokyo, Japan, and Department of Cardiovascular Surgery, Toho University Sakura Medical Center4, Sakura, Japan）
  

  Objectives:Data of valvular heart surgeries from the Japan Cardiovascular Surgery Database in 2015 and 2016 were analyzed to demonstrate the associated mortality and morbidity rates and choice of surgical procedures. Methods:We used the Japan Cardiovascular Surgery Database to extract data of cardiac valve replacement procedures performed in 2015 and 2016. The cases were further evaluated depending upon the type of procedure, and prosthesis used at each site. The rate of bio-prosthesis usage was derived for each valve position and age groups. The rates of operative mortality and morbidity were calculated for each valve position and type of procedures. Results:In total, 26,054 aortic valve replacements were performed in 2015 and 2016, showing a slight increase in number since the last report(2013-2014). A total of 3,305 transcatheter aortic valve replacements, 5,652 mitral valve replacements, and 12,024 mitral valve repair procedures were performed. The rate of bio-prosthesis usage in aortic valve replacement was 96.5%, 92.7% and 63.5% for patients in their 80s, 70s and 60s, respectively, demonstrating an increase in usage since 2013-2014. Mechanical valves were preferred in patients on chronic hemodialysis. The mortality rates of aortic valve replacement, mitral valve replacement, mitral valve repair, and tricuspid valve replacement procedures were 4.1%, 7.1%, 2.2%, and 10.5%, respectively. Conclusion:We evaluated recent trends in valvular heart surgery in Japan with respect to the type of procedure and prosthesis preferred and the postoperative outcomes. We found that bio-prosthesis usage was the most common.

   

  Jpn. J. Cardiovasc. Surg. 48:11-17（2019）

  Keywords：prosthetic valve selection;mechanical valve;bioprosthesis;hemodialysis;surgery

  
  
• 4. Thoracic Aortic Surgery　H. Shimizu et al.…18
  Current Status of Cardiovascular Surgery in Japan:Analysis of Data from Japan Cardiovascular Surgery Database in 2015, 2016. 4. Thoracic Aortic Surgery
  

  Hideyuki Shimizu＊1	Norimichi Hirahara2	Noboru Motomura3
  Hiroaki Miyata2	Shinichi Takamoto2

  
  

  （Department of Cardiovascular Surgery, School of Medicine, Keio University1, Tokyo, Japan, Department of Health Policy and Management, School of Medicine, Keio University2, Tokyo, Japan, and Department of Cardiovascular Surgery, Toho University Sakura Medical Center3, Sakura, Japan）
  

  Background:Thoracic and thoracoabdominal aortic diseases are treated using operative procedures like open aortic repair（OAR), thoracic endovascular aortic repair（TEVAR）or even hybrid aortic repair（HAR), a combination of OAR and TEVAR. The surgical approach to aortic repair is evolving over the decades. The purpose of this study was to examine the current trends in treatment. Methods:We extracted the nationwide data of aortic repair procedures performed between 2015 and 2016 from the Japan Cardiovascular Surgery Database（JCVSD). In addition to estimating the number of cases, we also classified the cases based on various criteria such as operative mortality, associated major morbidities（e.g. stroke, spinal cord insufficiency, renal failure), disease pathology（e.g. acute dissection, chronic dissection, ruptured aneurysm, unruptured aneurysm), site of operative repair（e.g. aortic root, ascending aorta, aortic root to arch, aortic arch, descending aorta, thoracoabdominal aorta）and the preferred surgical approach（i.e. OAR, HAR or TEVAR). Results:The total number of cases studied was 35,427, with an overall operative mortality rate of 7.3%. Among the 3 procedures, 64% of patients were treated with OAR. In comparison to the data in our previous report（also derived from the JCVSD in 2013 and 2014), the total number of cases and numbers of OAR, HAR, and TEVAR have increased by 17.0%, 2.4%, 126.1% and 34.9%, respectively. While the overall stroke rates following aortic arch surgical repair with HAR, OAR, and TEVAR were 10.1%, 8.4%, and 7.3% respectively. OAR was found to have the lowest stroke rate when limited to cases presenting with a non-dissected/unruptured aorta. The incidence rates of paraplegia following descending/thoracoabdominal aortic surgical repair using HAR, OAR, and TEVAR were 6.3%/10.4%, 4.3%/8.9% and 3.4%/4.6%, respectively. TEVAR was found to be associated with the lowest incidence of postoperative renal failure. Conclusions The number of operated thoracic and thoracoabdominal aortic diseases has increased, though the rate of operations using an OAR approach has decreased. While TEVAR showed the lowest mortality and morbidity rates, OAR demonstrated the lowest postoperative stroke rate for non-dissecting aortic arch aneurysms.

   

  Jpn. J. Cardiovasc. Surg. 48:18-24（2019）

  Keywords：the Japan Cardiovascular Surgery Database（JCVSD）;aortic aneurysm;aortic dissection;stroke;paraplegia;renal failure

  
  

Review

• “De-airing” in Open Heart Surgery―Report on a Nation-Wide Survey Prior to a CVSAP:Symposium and Literature Review　K. Orihashi et al.…25
  “De-airing” in Open Heart Surgery―Report on a Nation-Wide Survey Prior to a CVSAP:Symposium and Literature Review
  

  Kazumasa Orihashi＊

  Toshihiko Ueda＊＊

  
  

  （Second Department of Surgery, Kochi Medical School＊, Nankoku, Japan, and Division of Cardiovascular Surgery, Tokai University Hachioji Hospital＊＊, Hachioji, Tokyo, Japan）
  

  Since the beginning of cardiac surgery, retained intracardiac air has been one of the important problems to be solved. While transesophageal echocardiography enabled visualization of the air, and de-airing procedures have been routinely carried out, they appear to vary much among institutions and are not necessarily based on firm scientific evidence. Thus, “de-airing” was chosen as the theme of the 2016 CVSAP（Cardiovascular surgery and Anesthesia and Perfusion）Symposium and a nation-wide questionnaire survey was carried out prior to it. This paper reports the results of this survey and illustrates “the best de-airing” at present, based on the literature review. The collection rate of the questionnaire survey was high:77.9%（278/357）and 83.3%（85/102）from major institutions of surgeons and anesthesiologists, respectively, indicating a high level of interest. More than 90% of both considered de-airing as important since adverse events related to air embolism were actually encountered, including some critical ones. Most routinely performed de-airing procedures are posture change, lung inflation and aspiration through the vent cannulae. Direct aspiration of air is carried out in only one-third of institutions. Carbon dioxide insufflation is performed in 82.5% of institutions, mostly at a rate of 2～3L/min. However, not a few surgeons are skeptical of its significance. While many surgeons are grateful for collaboration by anesthesiologists, some expect more information sharing between them. They also expect better comprehension of “de-airing” and timely manipulation of extracorporeal circulation system by clinical engineers to avoid undesirable events. Some surgeons expressed a wish for a convenient device for de-airing. Furthermore, some questions to be solved in the future were raised, including how meticulously the bubbles should be removed or how efficient carbon dioxide insufflation is.

   

  Jpn. J. Cardiovasc. Surg. 48:25-34（2019）

  Keywords：cardiac surgery;retained air;air embolism

  
  

Case Reports

• ［Congenital Heart Disease］Staged Repair of Unilateral Absence of the Right Proximal Pulmonary Artery Using Autologous Azygos Vein Graft Interposition　T. Kawahito et al.…35
  Staged Repair of Unilateral Absence of the Right Proximal Pulmonary Artery Using Autologous Azygos Vein Graft Interposition
  

  Tomohisa Kawahito＊	Yoshiyasu Egawa＊	Yuta Hosoya＊,＊＊
  Yasushi Shimoe＊＊＊	Homare Yoshida＊＊＊

  
  

  （Department of Pediatric Cardiovascular Surgery＊, Department of Education and Training＊＊, and Department of Cardiovascular Surgery＊＊＊, National Hospital Organization Shikoku Medical Center for Children and Adults, Zentsuji, Japan）
  

  The isolated unilateral absence of a proximal pulmonary artery is a rare congenital lesion that presents various symptoms. Although some reports have shown one-stage reconstruction of the pulmonary circulation in infants, the two-stage approach is required in the situation of pulmonary arterial hypoplasia. In these cases, the usual approach is systemic pulmonary shunting for the first operation, to obtain growth of the pulmonary vascular bed, and then connecting bilateral pulmonary arteries for the second operation. Moreover, in the majority of patients without a right proximal pulmonary artery, some material is required for reconstructive surgery that corresponds to the patient’s growth. A girl aged 2 years and 10 months with absent right proximal pulmonary artery, underwent modified Blalock-Taussig shunting with a free autograft of the azygos vein. The shunt was banded to prevent excessive pulmonary blood flow. Reconstructive surgery was performed 10 months after the first operation. At the second operation, growth of the right distal pulmonary artery and azygos autograft was satisfactory. Therefore, we used this autograft as an interposed graft of the right and main pulmonary arteries. Her postoperative course was uneventful. We advocate the usefulness of the azygos vein for graft material possessing the possibility of growth. This autograft is useful for pulmonary arterial reconstruction, such as the present case, and also may be useful for a systemic-pulmonary shunt, while growth is anticipated for more complex heart diseases.

   

  Jpn.J. Cardiovasc. Surg. 48:35-38（2019）

  Keywords：proximal pulmonary artery;azygos vein autograft;Blalock-Taussig shunt
  

  
  
• A Case of Coronary Sinus Type Atrial Septal Defect Treated by 3-Port Totally Endoscopic Surgery　M. Orii…39
  A Case of Coronary Sinus Type Atrial Septal Defect Treated by 3-Port Totally Endoscopic Surgery
  

  Mamoru Orii＊	Toshiaki Ito＊	Atsuo Maekawa＊
  Sadanari Sawaki＊	Jyunji Yanagisawa＊	Masayoshi Tokoro＊
  Takahiro Ozeki＊	Toshiyuki Saiga＊

  
  

  （Department of Cardiovascular Surgery, Japanese Red Cross Nagoya First Hospital＊, Nagoya, Japan）
  

  A 15-year-old boy with coronary sinus type atrial septal defect（CS-ASD）was surgically treated with 3-port totally endoscopic technique. The patient was set in a left semi-lateral position. A 3cm skin incision retracted by a small wound protector, a trocar for the endoscope, and a trocar for left-handed instruments were placed in the right antero-lateral chest. Cardio-pulmonary bypass was established via groin cannulation. After cardioplegic arrest, the CS-ASD was favorably exposed through the left atriotomy, and closed using a bovine pericardial patch. The total operation time was 112 min. The post-operative course was uneventful. Instead of the traditional median sternotomy and right atriotomy, small right thoracotomy and left atriotomy may be a promising alternative for closure of CS-ASD.

   

  Jpn. J. Cardiovasc. Surg. 48:39-42（2019）

  Keywords：coronary sinus atrial septal defect;minimally invasive cardiac surgery;thoracoscope;endoscope;unroofed coronary sinus
  

• ［Acquired Cardiovascular Surgery］A Case of Asymptomatic Thrombus in the Ascending Aorta　Y. Ito et al…43
  A Case of Asymptomatic Thrombus in the Ascending Aorta
  

  Yoshito Ito＊	Toshihiro Funatsu＊	Sokichi Kamata＊
  Toshikatsu Yagihara＊

  
  

  （Department of Cardiovascular Surgery, Rinku General Medical Center＊, Izumisano, Japan）
  

  A 70-year-old man receiving neoadjuvant chemotherapy（5FU＋CDDP）for esophageal cancer was transferred to our hospital for the treatment of asymptomatic thrombus in the ascending aorta. Enhanced computed tomography revealed a low-density mass of 34×16mm in diameter on the posterior surface of the ascending aorta. We performed thrombectomy and suture plication of the aortic intima under hypothermic circulatory arrest. Intraoperative epiaortic echo showed the mass was floating in the aorta. The patient was discharged from the hospital on the 18th postoperative day. Most patients with aortic thrombus are diagnosed under conditions of peripheral embolism. Asymptomatic thrombus in the ascending aorta is extremely rare. We herein report a case of thrombectomy for asymptomatic thrombus in the ascending aorta.

   

  Jpn. J. Cardiovasc. Surg. 48:43-46（2019）

  Keywords：asymptomatic aortic thrombus;thrombectomy;circulatory arrest

  
  
• A Surgical Case of Infective Endocarditis Complicated by Severe Valvulare Regurgitation and Coronary Artery Embolism in Which Cardiogenic Shock Occurred before Surgery　A. Hino et al.…47
  A Surgical Case of Infective Endocarditis Complicated by Severe Valvulare Regurgitation and Coronary Artery Embolism in Which Cardiogenic Shock Occurred before Surgery
  

  Atomu Hino＊	Susumu Hosoda＊	Takeshi Katsube＊
  Akira Shiikawa＊

  
  

  （Department of Cardiovascular Surgery, Sendai Cardio Vascular Center, Sendai, Japan）
  

  A 45-year-old woman with moderate mitral regurgitation due to mitral valve prolapse developed respiratory discomfort after cellulitis and visited our hospital. Electrocardiogram showed ST elevation in V2, V3, V4 and serum creatinine kinase was high. Transthoracic echocardiogram revealed large mitral and aortic vegetation with severe valvular regurgitation and anterior wall motion asynergy. On computed tomography and magnetic resonance imaging, splenic infarction and right renal infarction cerebral infarction on right sided frontal white matter（1cm in diameter）was revealed. These findings led to a diagnosis of acute heart failure due to severe regurgitation and coronary artery embolism with infective endocarditis, thus we performed an emergency cardiothoracic surgery. After general anesthesia, she suffered severe hypotension despite the injection of a high dose of catecholamine, then developed persistent ventricular tachycardia. We started cardiopulmonary resuscitation, and percutaneous cardiopulmonary support. After obtaining stable hemodynamic status, we performed surgery. The intraoperative examination showed vegetation（2cm in diameter）on each aortic cusp, large vegetation on the anterior and posterior mitral leaflet, rupture of the posterior leaflet choreae tendineae, and vegetation on the wall of the left atrium. We performed maximal possible debridement of the infected tissue. Subsequently, we performed mitral valve replacement and aortic valve replacement, tricuspid annuloplasty. We finished surgery without cardiopulmonary support. After tight control, the patient was discharged on the 52nd postoperative day. The patient showed no recurrence of infection during 9 months of follow-up. Cases of coronary embolism with infective endocarditis are rare and have high mortality, and their treatment is still controversial.

   

  Jpn. J. Cardiovasc. Surg. 48:47-50（2019）

  Keywords：infective endocarditis;coronary embolism;cardiogenic shock

  
  
• Surgical Treatment with Fresh Autologous Pericardium for Tricuspid Valve Infective Endocarditis with Ventricle Septal Defect　H. Ogawa…51
  Surgical Treatment with Fresh Autologous Pericardium for Tricuspid Valve Infective Endocarditis with Ventricle Septal Defect
  

  Hironaga Ogawa＊	Yuriko Kiriya＊	Masahiro Seki＊
  Yusuke Takei＊	Kouji Ogata＊	Ikuko Shibasaki＊
  Hirotsugu Fukuda＊

  
  

  （Department of Cardiovascular Surgery, Dokkyo Medical University Hospital＊, Tochigi, Japan）
  

  Right sided infective endocarditis（RSIE）is uncommon. Patients are traditionally treated with antibiotics alone, and indications for operation are not clearly established. A 23-years-old man who developed fever and general fatigue was referred to our hospital on the suspicion of RSIE. A ventricular septal defect（VSD）and untreated dental caries had been previously diagnosed. Transthoracic echocardiography revealed vegetation on the tricuspid valve and severe regurgitation. The tricuspid valve was repaired;the anterosuperior leaflet was partially resected and repaired with fresh autologous pericardium and the use of synthetic chordae. Recurrence of infection and tricuspid valve regurgitation were not observed for 1 year after this operation.

   

  Jpn. J. Cardiovasc. Surg. 48:51-55（2019）

  Keywords：right-sided infective endocarditis;congenital intracardiac shunt;tricuspid valve repair;fresh autologous pericardium

  
  
• A Case of Prosthetic Infective Endocarditis with Acute Myocardial Infarction due to Septic Embolism　S. Oyama et al.…56
  A Case of Prosthetic Infective Endocarditis with Acute Myocardial Infarction due to Septic Embolism
  

  Shogo Oyama＊	Takeshi Osaki＊	Azuma Tabayashi＊
  Tomoyuki Iwase＊	Kazuya Kumagai＊	Junichi Koizumi＊
  Takeshi Kamada＊	Junichi Tsuboi＊	Hajime Kin＊

  
  

  （Department of Cardiovascular Surgery, Iwate Medical University School of Medicine＊, Morioka, Japan）
  

  The patient was a 68-year-old man. In January 2017, he underwent aortic valve replacement（Carpentier-Edwards Perimount Magna, 25mm, Edwards Lifescience Corporation, Irvine, USA）for aortic stenosis and coronary bypass surgery with two saphenous vein grafts（SVG-#7 and SVG-4PD）for asymptomatic myocardial ischemia. He was treated as an outpatient by a local physician for at least a week during November 2017, with a principal complaint of mild fever, but no other significant symptoms. Transthoracic echocardiography suggested prosthetic valve endocarditis, so he was referred to the author’s hospital. The day after admission, he had symptoms of thoracic discomfort, and emergency cardiac catheter examination showed a lesion thought to be due to a thrombus in the left main coronary trunk;so, thrombus aspiration was carried out. However, no improvement in blood flow was achieved, so balloon angioplasty was carried out, with the aim of improving blood flow in the left circumflex artery, where coronary artery bypass grafting had not been performed. Improvement in blood flow was achieved, and a culture was carried out using the aspirated thrombus. Streptococcus pasteurianus was detected in the culture.

   

  Jpn. J. Cardiovasc. Surg. 48:56-59（2019）

  Keywords：prosthetic infective endocarditis;acute myocardial infarction;septic embolism

  
  
• Waffle Procedure via Left Anterolateral Thoracotomy for a Tuberculous Constrictive Pericarditis Patient　C. Teramoto et al.…60
  Waffle Procedure via Left Anterolateral Thoracotomy for a Tuberculous Constrictive Pericarditis Patient
  

  Chikao Teramoto＊	Yoshimori Araki＊	Takafumi Terada＊
  Yasunobu Konishi＊	Osamu Kawaguchi＊

  
  

  （Cardiovascular Surgery, Toyota Kosei Hospital, Toyota, Japan）
  

  We present the case of a 72-year-old man with constrictive pericarditis due to tuberculous pericarditis, who was treated with the waffle procedure via left anterolateral thoracotomy. The preoperative catheterization study showed the dip-and-plateau pattern, and the echocardiographic study shown the thickened pericardium and dilatation impairment. The surgery was able to be performed without cardiopulmonary bypass. The thickened pericardium was abraded with a Harmonic Scalpel. The waffle procedure was effective in this patient. The postoperative course was good, with improvement of NYHA status and cardiac pressure study results. We suggest that this procedure is useful for the patients with constrictive pericarditis.

   

  Jpn. J. Cardiovasc. Surg. 48:60-64（2019）

  Keywords：tuberculous pericarditis;constrictive pericarditis;waffle procedure;left anterior thoracotomy

  
  
• ［Aortic Disease］A Case of Recurrent Acute Inferior Limb Arterial Occlusion Seemingly Caused by Antegrade False Lumen Blood Flow due to Stent Graft-Induced New Entry（SINE）　J. Takaki et al.…65
  A Case of Recurrent Acute Inferior Limb Arterial Occlusion Seemingly Caused by Antegrade False Lumen Blood Flow due to Stent Graft-Induced New Entry（SINE）
  

  Jun Takaki＊	Keiji Kamohara＊	Shugo Koga＊
  Nozomi Yoshida＊

  
  

  （Department of Cardiovascular Surgery, Kouseikai Hospital＊, Nagasaki, Japan）
  

  We report a case of a 53-year-old woman, who was transported as an emergency case to our institution because of type A acute aortic dissection. Total arch replacement and coronary artery bypass grafting（CABG）with open stent graft was performed. After the operation, during rehabilitation for discharge（33 and 38 days after the surgery), she developed acute arterial occlusion of the right lower limb, and we performed thrombectomy. Both thrombi extracted from the right common femoral artery were organized clots. No perioperative arrhythmia was observed, and no obvious left atrial appendage thrombus was observed on CT. We performed angiography to diagnose the cause of the spread of organized clots, and an entry was detected at the distal tip of the open stent graft, and antegrade blood flow in a false lumen was observed. We considered that the thrombus was caused by the antegrade blood flow in a false lumen, TEVAR（c-TAG）was performed to seal the entry 48 days after the surgery. Embolism did not occur afterward, and the patient was discharged for rehabilitation.

   

  Jpn. J. Cardiovasc. Surg. 48:65-68（2019）

  Keywords：stent graft-induced new entry

  
  
• A Case of EVAR for Mycotic Aneurysm Rupture　M. Hirano et al.…69
  A Case of EVAR for Mycotic Aneurysm Rupture
  

  Masahiro Hirano＊	Hiroshi Tsuneyoshi＊	Chikara Ueki＊
  Ken Yamanaka＊	Hirofumi Sato

  
  

  （Department of Cardiovascular Surgery, Shizuoka General Hospital＊, Shizuoka, Japan）
  

  We report a case of mycotic aneurysm treated with endovascular aneurysm repair（EVAR). An 80-year-old man was admitted to a local hospital with high fever and lower back pain. Pyogenic spondylitis and psoas muscle abscess were diagnosed. Klebsiella pneumoniae was confirmed by blood culture. Treatment with intravenous antibiotics was not effective and contrast computed tomography（CT）scan showed an enlargement of the abscess and an abdominal aortic rupture. The patient was immediately transferred to our hospital. Laboratory tests showed an elevated C-reactive protein（12.3mg/dl）and WBC（10,400/μl). Mycotic abdominal aneurysm rupture was diagnosed by CT scan. He underwent an emergency EVAR with an Excluder●R（aorta extender). Intraoperative angiography showed a ruptured abdominal aorta. After operation, he was treated with intravenous minocycline and ampicillin, and the size of the abscess reduced without any endoleak on enhanced CT imaging. After intravenous antibiotics therapy for 4 weeks, we switched to oral antibiotics（minocycline and ciprofloxacin）and continued them for 6 months. As of 2 years after the surgery, there are no signs of infection or recurrence.

   

  Jpn. J. Cardiovasc. Surg. 48:69-72（2019）

  Keywords：mycotic aneurysm;rupture;EVAR;psoas muscle abscess

  
  
• Residual False Lumen Rupture Possibly Triggered by Chest Compression after Reparative Surgery for Type A Aortic Dissection　D. Arima et al.…73
  Residual False Lumen Rupture Possibly Triggered by Chest Compression after Reparative Surgery for Type A Aortic Dissection
  

  Daisuke Arima＊,＊＊

  Akihide Umeki＊

  Tetsufumi Yamamoto＊

  
  

  （Department of Cardiac Surgery, Asahi General Hospital＊, Asahi, Japan, and Present address:Department of Cardiovascular Surgery, Tsukuba Memorial Hospital＊＊, Tsukuba, Japan）
  

  Several complications of cardiopulmonary resuscitation have been reported. Herein we reported a rare case of rupture in a false lumen immediately following chest compressions. A 79-year-old woman underwent a graft replacement surgery of acute Stanford type A aortic dissection. On POD 6 she developed cardiopulmonary arrest from suffocation by phlegm. She was immediately resuscitated with chest compressions, although bloody discharge from the left chest drainage tube increased. A rupture was detected by contrast enhanced computed tomography scan in the false lumen of the descending aorta. There was a risk of post-resuscitative encephalopathy;therefore, conservative treatment, such as blood transfusion, hemostatic administration and therapeutic hypothermia, were performed. After rewarming the patient, she recovered consciousness without any neurological abnormalities. We should bear the possibility in mind that chest compression carries the risk of residual false lumen rupture.

   

  Jpn. J. Cardiovasc. Surg. 48:73-76（2019）

  Keywords：chest compression;acute aortic dissection;rupture in a false lumen

  
  
• Descending Aortic Rupture after Frozen Elephant Trunk Technique for Dissected Aortic Arch Aneurysm　T. Nita…77
  Descending Aortic Rupture after Frozen Elephant Trunk Technique for Dissected Aortic Arch Aneurysm
  

  Tobuhiro Nita＊	Meikun Kano＊	Akira Shiose＊＊
  Masayoshi Umesue＊

  
  

  （Department of Cardiovascular Surgery, Matsuyama Red Cross Hospital＊, Ehime, Japan, and Department of Cardiovascular Surgery, Kyushu University Hospital＊＊, Fukuoka, Japan）
  

  We report a 41-year-old man who presented with a ruptured dissecting aneurysm of the descending aorta. He had undergone aortic root replacement for an acute aortic dissection（Stanford type A）;8 months later, he had undergone total arch replacement with insertion of a frozen elephant trunk（FET）due to enlargement of the chronic dissecting aneurysm of the arch. FET-induced new entry and incomplete thrombosis occurred postoperatively. Three months after FET insertion, he developed an aortic rupture that required emergency replacement of the descending aorta. The patient tolerated the procedure well and was discharged 16 days after the operation.

   

  Jpn. J. Cardiovasc. Surg. 48:77-81（2019）

  Keywords：FET（frozen elephant technique）;dissecting aortic aneurysm;descending aortic rupture;SINE（stent graft induced-new entry）

  
  
• Debranching and Endovascular Repair of a Saccular Aneurysm of the Aortic Arch with Preoperatively Devised, Fenestrated and Branched Stent Grafts（Surgeon-Modified Fenestrated and Retrograde Branched Technique）　S. Kamihira et al.…82
  Debranching and Endovascular Repair of a Saccular Aneurysm of the Aortic Arch with Preoperatively Devised, Fenestrated and Branched Stent Grafts（Surgeon-Modified Fenestrated and Retrograde Branched Technique）
  

  Satoshi Kamihira＊	Kazuma Kanetsuki＊	Tomoki Hanada＊
  Masanobu Yamauchi＊

  
  

  （Department of Cardiovascular Surgery, Shimane Prefectural Central Hospital＊, Izumo, Japan）
  

  An 85-year-old man being treated for idiopathic interstitial pneumonia underwent chest CT 6 months prior to the current admission and was diagnosed as having an expanding saccular aneurysm of the aortic arch. Due to the patient’s advanced age and the anatomical position of the aneurysm, it was difficult to perform total aortic arch replacement or hybrid arch repair with a commercially available device. After ethical approval had been obtained from the institutional review board, a commercially available stent graft（Relay Plus●R）was fenestrated with a 12-mm hole. Under general anesthesia, bypass grafting was performed between the bilateral axillary arteries and the right common carotid artery with a T-shaped ring-supported e-PTFE prosthesis. The fenestrated stent graft was advanced through the left femoral artery and deployed with the device fenestration located at the bifurcation of the brachiocephalic artery. Then, a branched stent graft was deployed through the right common carotid artery in a retrograde manner between the brachiocephalic artery and the ascending aorta through the fenestration to complete the procedure. The patient had an uneventful postoperative course, with no detectable endoleak on postoperative digital subtraction angiography. The current technique，involving the use of an easy-to-make device，is effective for endovascular aneurysm repair, especially when a proximal neck needs to be created in the ascending aorta.

   

  Jpn. J. Cardiovasc. Surg. 48:82-85（2019）

  Keywords：debranching;TEVAR;zone 0 landing;surgeon-modified fenestrated;retrograde branched

  
  
• Two Cases of Valsalva Sinus Aneurysm with Rupture into the Right Atrium　Y. Kanazawa et al.…86
  Two Cases of Valsalva Sinus Aneurysm with Rupture into the Right Atrium
  

  Yuta Kanazawa＊,＊＊	Yasuyuki Yamada＊,＊＊	Ikuko Shibasaki＊
  Koji Ogata＊	Toshiyuki Kuwata＊	Takayuki Hori＊
  Hironaga Ogawa＊	Yusuke Takei＊	Yasuyuki Kanno＊
  Hirotsugu Fukuda＊

  
  

  （Department of Cardiac and Vascular Surgery, Dokkyo Medical University Hospital Heart Center＊, Tochigi, Japan, and Division of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Centre＊＊, Maebashi, Japan）
  

  Valsalva sinus aneurysm（VSA）is a rare disease, especially that of Konno classification Type IV. When VSA ruptures, the patient has uncontrollable congestive heart failure because of massive left-right shunt. We encountered two cases with ruptured VSA of the right atrium. Case 1:A 71-years-old man with a ruptured noncoronary VAS complained of dyspnea on effort. He underwent surgical treatment consisting of aneurysm resection and patch closure with Hemashield after medical treatment for congestive heart failure. He progressed well after operation and was discharged on the 14th postoperative day in stable condition. Case 2:A 41-year-old man had heard systolic murmur. We diagnosed VSA rupture with echocardiography. He was symptomless but his left ventricle diastolic diameter was dilatated and Qp/Qs was 2.0 by blood gas sampling. He underwent elective surgical treatment consisting of aneurysm resection and patch closure with Hemashield. He was discharged on the 14th postoperative day in stable condition.

   

  Jpn. J. Cardiovasc. Surg. 48:86-90（2019）

  Keywords：Valsalva sinus aneurysm

  
  
• ［Peripheral Artery Disease］Successful Surgical Treatment of Tracheo-Innominate Artery Fistula Complicated with Tracheostomy　K. Akabane et al.…91
  Successful Surgical Treatment of Tracheo-Innominate Artery Fistula Complicated with Tracheostomy
  

  Kentaro Akabane＊	Tetsuro Uchida＊	Atsushi Yamashita＊
  Masahiro Mizumoto＊	Yoshinori Kuroda＊	Mitsuaki Sadahiro＊

  
  

  （Second Department of Surgery, Yamagata University Hospital＊, Yamagata, Japan）
  

  Tracheo-innominate artery fistula is a rare complication after tracheostomy, but sometimes presents with fatal bleeding. A 10-year-old girl presented with massive bleeding from a tracheostomy that she underwent for prolonged respiratory failure caused by sequelae of mumps encephalitis. Tracheo-innominate artery fistula, complicated by tracheostomy was diagnosed, and she was transferred to our institution. Under general anesthesia, she underwent transection of the innominate artery to exclude the tracheo-innominate artery fistula via median sternotomy. Her postoperative course was uneventful without recurrent bleeding or infection. Considering the risk of tracheo-innominate artery fistula, careful observation is necessary to prevent catastrophic bleeding in patients with mechanical respiratory support via tracheostomy.

   

  Jpn. J. Cardiovasc. Surg. 48:91-94（2019）

  Keywords：tracheo-innominate artery fistula;innominate artery transection

  
  
• Report of International Congress　S. Oda…95

U-40

• U-40　Surgical Skill Sharing　No.9 A Survey of the Cardioplegia Methods Targeting Under 40 Cardiovascular Surgeons　T. Ito…U1
  A Survey of the Cardioplegia Methods Targeting Under 40 Cardiovascular Surgeons
  

  Takahiro Ito＊

  
  

  （Department of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center＊, Ichihara, Japan）
  

  Cardiovascular surgeons, generally have many strong preferences regarding basic surgical skills. However, those basic skills have not been discussed great detail. The aim of this study is to survey the cardioplegia methods targeting cardiovascular surgeons in Japan aged Under 40, and to share the results of those basic skills.

   

  Jpn. J. Cardiovasc. Surg. 48:U1-U8（2019）

  Keywords：Under Forty;cardioplegia;survey

  
  

Editor’s Post Script

• K. Doi