Japanese Journal of Cardiovascular Surgery Vol.48, No2

Preface

Originals

  • Concomitant Left Atrial Appendage Amputation Using a Stapler during Cardiovascular Surgery　M. Aoki et al.…97
    Concomitant Left Atrial Appendage Amputation Using a Stapler during Cardiovascular Surgery
    Masakazu Aoki＊ Hiroshi Furuhata＊ Toshikazu Shimizu＊
    Riki Sumiyoshi＊ Hiroshi Nagano＊ Hideki Morita＊
    Hiromasa Kawaura＊＊

    （Department of Cardiovascular Surgery, Saitama Red Cross Hospital＊, Saitama, Japan, and Department of Emergency, Saitama Red Cross Hospital＊＊, Saitama, Japan）

    Objective:The objective of this study was to assess the safety and efficacy of left atrial appendage（LAA）amputation during cardiovascular surgery. Methods：Fifty-seven patients underwent LAA amputation using a stapler from 2016 to 2017. The presence of remnant LAA was estimated by transesophageal echocardiography（TEE). Results:All LAA amputations were performed with the heart beating, without collapse. Additional amputation for remnant LAA was required in 14 patients. Sutures were needed to control bleeding in 7 patients. There was one case in which the coronary artery ended up being clamped with the LAA. The average duration for LAA amputation was 6.1±3.2（1.5-15.2）min. There were 25 cases with postoperative atrial fibrillation（POAF), one case of cerebral infarction without POAF and one case of re-exploration for bleeding. Three patients died during hospitalization. Conclusion:LAA amputation using a stapler does not require cardiac arrest, and rarely requires an extended operation time. However, sufficient caution is required as there is the possibility that the coronary artery is obstructed and that remnant LAA is present.

     

    Jpn. J. Cardiovasc. Surg. 48:97-102（2019）

    Keywords：postoperative atrial fibrillation;cardiogenic cerebral embolism;left atrial appendage closure;stapler


  • The Effectiveness of Off-the-Job Training Using a Newly Developed Endoscopic Vessel Harvesting Model　K. Abe et al.…103
    The Effectiveness of Off-the-Job Training Using a Newly Developed Endoscopic Vessel Harvesting Model
    Kohei Abe＊ Yong-Kwang Park＊＊ Kunihiko Yoshino＊
    Hiromi Yanagisawa＊

    （Cardiovascular Center, Division of Cardiovascular Surgery, St.Luke’s International Hospital＊, Tokyo, Japan, and Department of Cardiovascular Surgery, Fukushima Medical University＊＊, Fukushima, Japan）

    Background:Endoscopic vessel harvesting（EVH）is one of the less-invasive graft harvesting techniques for CABG. On the other hand, it needs certain amount of a learning curve to acquire sufficient technique. Inappropriate manipulation will cause damage of the vein, decrease the patency and affect the patient’s long-term survival. Off-the-job training has the potential to shorten the length of the learning curve. In this study we evaluated the effectiveness of a newly developed saphenous vein harvesting model provided by EBM corporation. Purpose:To evaluate the effectiveness of concentrated training with the EVH simulator. Objective and Methods:One novice trainee doctor was recruited for this study. After 20 procedures using the simulator training clinical device, EVH was performed under supervision. This procedure was compared with the last case before the training in terms of setup for the EVH, visualization by endoscope, dissection, division of branches, duration of the procedure, and number required for repair. Results:The duration required to train with the simulator showed a stable average of 10 cases. All the elements in terms of EVH procedure were improved after the simulator training. Discussion:It is important to prepare an appropriate simulator, trainer, and clear purpose for effective training. It was beneficial to enhance the clinical level with the concentrated simulator training. Conclusions:The newly developed EVH model is an effective simulator before performing the initial clinical case.
    　　

    Jpn. J. Cardiovasc. Surg. 48:103-106（2019）

    Keywords：simulator;training;learning curve;endoscopic vein harvesting

Case Reports

  • ［Congenital Heart Disease］ A Severe Aortic Stenosis and Coronary Calcifications in Alkaptonuria　O. Tominaga et al.…107
    A Severe Aortic Stenosis and Coronary Calcifications in Alkaptonuria
    Osamu Tominaga＊ Tatsuhiko Komiya＊ Takeshi Shimamoto＊
    Michihito Nonaka＊ Jiro Sakai＊ Junya Kitaura＊
    Yoshimasa Furuichi＊ Taiyo Jinno＊ Atsushi Sugaya＊

    （Department of Cardiovascular Surgery, Kurashiki Central Hospital＊, Kurashiki, Japan）

    Alkaptonuria is a rare genetic disease, in which amino acids and tyrosine cannot be processed. A 72-year-old man with a history of aortic valve stenosis presented with coronary 3-vessel disease. Intraoperative findings included ochronosis, which is pigmentation caused by the accumulation of homogentistic acids in connective tissues, or on the severely calcified aortic valve, the intima of the aorta, and the coronary arteries. The pigmented region of the coronary arteries had significant stenosis. Aortic valve replacement and coronary artery bypass were performed. From these findings and his past history of arthritis, we diagnosed alkaptonuria. The patient had an uneventful recovery.

     

    Jpn. J. Cardiovasc. Surg. 48:107-110（2019）

    Keywords：alkaptonuria;aortic valve stenosis;ochronosis;coronary artery stenosis;metabolism abnormality


  • ［Acquired Cardiovascular Surgery］ Improvement of the Ischemic Area after Surgical Treatment for Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery　M. Matsuhama et al.…111
    Improvement of the Ischemic Area after Surgical Treatment for Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery
    Minoru Matsuhama＊ Satoshi Arimura＊ Kenichi Sasaki＊＊
    Takashi Kunihara＊＊＊

    （Division of Cardiovascular Surgery, The Cardiovascular Institute＊, Tokyo, Japan, Division of Cardiovascular Surgery, Saitama Sekishinkai Hospital＊＊, Saitama, Japan, and Division of Cardiac Surgery, The Jikei University School of Medicine＊＊＊, Tokyo, Japan）

    Anomalous origin of the right coronary artery from the pulmonary artery（ARCAPA）is a rare congenital coronary anomaly. Although asymptomatic in most cases, with the anomaly only being detected incidentally, surgical correction should be considered before onset of severe myocardial ischemia in such cases. Here, we present a 70-year-old man who was referred to our department due to chest pain on effort and was given a diagnosis of ARCAPA concomitant with mild aortic stenosis. As the symptoms and the degree of aortic stenosis deteriorated during follow-up, the patient underwent direct re-implantation of the right coronary artery into the ascending aorta and aortic valve replacement. The patient’s postoperative course was uneventful, and the symptoms disappeared. Postoperative myocardial perfusion scintigraphy revealed improvement of the myocardial ischemic area.

     

    Jpn. J. Cardiovasc. Surg. 48:111-114（2019）

    Keywords：anomalous origin of the right coronary artery from the pulmonary artery;myocardial perfusion scintigraphy;myocardial ischemia;re-implantation;aortic stenosis


  • Aortic Valve Repair for Infective Endocarditis of an Aortic Valve　K. Zaikokuji et al.…115
    Aortic Valve Repair for Infective Endocarditis of an Aortic Valve
    Kenta Zaikokuji＊ Akihiro Mizuno＊ Tatsuhito Ogawa＊
    Jien Saito＊ Hisao Suda＊＊

    （Department of Cardiovascular Surgery, Nagoya City East Medical Center, Nagoya, Japan, and Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences Medical School＊＊, Nagoya, Japan）

    Infective endocarditis of the aortic valve tends to cause structural damage such as aortic root abscess, and aortic valve replacement is the standard treatment. However, there have been several reports on aortic valve repair for the treatment of infective endocarditis, and it has subsequently emerged as a feasible alternative to aortic valve replacement in selected patients. We report a case of aortic valve repair for infective endocarditis of the aortic valve caused by α-hemolytic Streptococcus. A 50-year-old man was admitted to our hospital with a two-month history of fever of unidentified origin. Transthoracic echocardiography revealed infective endocarditis of the aortic valve. Transesophageal echocardiography confirmed vegetation in the right coronary and non-coronary cusps, and mild aortic regurgitation. Although infection was controlled by approximately one month of antibiotic treatment, there was markedly more severe aortic regurgitation compared to the previous examination. These findings were confirmed on transesophageal echocardiography, and residual vegetation on the right coronary cusp as well as a perforation in the non-coronary cusp were confirmed. Intraoperative findings revealed a perforation in the non-coronary cusp and dehiscence, with vegetation on the right coronary cusp. The vegetation was carefully removed, the non-coronary cusp perforation was repaired with a pericardium patch, and the defect on the right coronary cusp was directly sutured with 6-0 polypropylene. Intraoperative transesophageal echocardiography revealed trivial aortic regurgitation. The postoperative course was uneventful and the patient was discharged 7 days after surgery without any complications. Antibiotics were prescribed for 3 months, and transthoracic echocardiography was performed 5 days, 1 month, and 3 months after surgery. No evidence of recurrence of aortic regurgitation or infection of the aortic valve was observed.

     

    Jpn. J. Cardiovasc. Surg. 48:115-118（2019）

    Keywords：infective endocarditis;aortic valve regurgitation;aortic valve repair


  • Aortic Valve Replacement in a Patient with Primary Antiphospholipid Syndrome and Recurrent Cerebral Infarction　S. Nagura et al.…119
    Aortic Valve Replacement in a Patient with Primary Antiphospholipid Syndrome and Recurrent Cerebral Infarction
    Saori Nagura＊ Kimimasa Sakata＊ Mari Sakai＊
    Kazuaki Fukahara＊＊

    （Department of Cardiovascular Surgery, Minaminagano Medical Center, Shinonoi General Hospital＊, Nagano, Japan, and 1st Department of Surgery, University of Toyama＊＊, Toyama, Japan）

    A 61-year-old woman had a history of deep vein thrombosis of the right leg at the age of 36 years. Primary antiphospholipid syndrome（APS）had been diagnosed at the age of 38 years, and rapidly progressive glomerulonephritis had developed at 54 year. She started hemodialysis one month before presentation due to deterioration of renal function. This time, she presented to the emergency department with paroxysmal nocturnal dyspnea. Echocardiography showed severe combined aortic stenosis and regurgitation（ASR). It was considered that the combination of ASR and construction of an arteriovenous fistula for dialysis had led to congestive heart failure. The patient had also experienced headache and agraphia for several days. Therefore, brain MRI was performed and multiple cerebral infarcts were detected. Early surgery should be considered for ASR, but we planned delayed surgery owing to the complication of acute cerebral infarction. During follow-up observation, a new asymptomatic cerebral infarct was detected. Eventually, aortic valve replacement（AVR）with a biological valve was performed on day 38 of hospitalization. Because she had highly active primary APS, surgery was performed with oral administration of aspirin, followed by continuous systemic heparinization from the early postoperative period. No perioperative thrombosis or bleeding was noted, and the patient was discharged uneventfully on postoperative day 34.

     

    Jpn. J. Cardiovasc. Surg. 48:119-124（2019）

    Keywords：antiphospholipid syndrome;multiple cerebral infarcts;aortic valve replacement;aortic stenosis and regurgitation


  • A Case of Surgical Treatment Applying a Denver Shunt for Intractable Pericardial Effusion　S. Amamoto et al.…125
    A Case of Surgical Treatment Applying a Denver Shunt for Intractable Pericardial Effusion
    Sojiro Amamoto＊ Manabu Sato＊ Hiromitsu Kawasaki＊
    Kozo Naito＊

    （Department of Cardiovascular Surgery, Saga-ken Medical Centre Koseikan, Saga, Janan）

    Surgical management is recommended for a patient with intractable pericardial effusion indicating medical treatment resistance and cardiac tamponade. We report our experience of surgical treatment applying a Denver shunt for intractable pericardial effusion. A 60-year-old woman suffered pericarditis accompanying pericardial effusion complications of systemic lupus erythematosus. She had repeatedly undergone pericardial drainage, however, there was a possibility of increased cardiac tamponade. Surgical treatment consisted of pericardial fenestration with thoracoscopic assist and right pleuro-peritoneal shunt using a Denver shunt. The heart failure symptoms disappeared and pericardial effusion considerably decreased after surgery. The postoperative course was uneventful without recurrence after 1-year of follow up. In the literature, postoperative complications such infection and shunt obstruction have been reported. Careful follow up is mandatory and selection of self-manageable cases is important.

     

    Jpn. J. Cardiovasc. Surg. 48:125-127（2019）

    Keywords：pericardial effusion;Denver shun;pericardial fenestration;pleuro-peritoneal shunt

  • ［Aortic Disease］ Hybrid Repair of Concomitant Descending Thoracic and Abdominal Aortic Aneurysms Using Antegrade Visceral Debranching from the Ascending Aorta　M. Iio et al.…128
    Hybrid Repair of Concomitant Descending Thoracic and Abdominal Aortic Aneurysms Using Antegrade Visceral Debranching from the Ascending Aorta
    Minami Iio＊ Naoki Fujimura＊ Shuichiro Yoshitake＊
    Satoshi Otsubo＊ Takashi Hirotani＊

    （Department of Cardiovascular Surgery, Saiseikai Central Hospital, Tokyo, Japan）

    A 76-year-old man had increasing thoracic and abdominal aortic aneurysms. First, endovascular repair was performed on the thoracic descending aorta, but type Ib endoleak persisted due to severe aortic calcification. Additional treatment was planned since the maximum diameter of the thoracic and abdominal aortic aneurysms had increased to 75 and 70mm, respectively. Due to the fact that aortic calcification was present from the aortic arch to the bilateral iliac arteries, which is sometimes referred to as porcelain aorta, conventional open thoracoabdominal aortic repair or hybrid repair using retrograde debranching seemed impossible. Therefore we performed antegrade visceral debranching from the ascending aorta followed by endovascular thoracoabdominal aortic repair successfully. For the thoracoabdominal aortic aneurysms which present difficulty in performing conventional open surgical repair or hybrid repair with retrograde debranching from the iliac artery. This technique can be an effective alternative strategy, but still needs further investigation, including its indications, due to the high surgical stress associated with the procedure.

     

    Jpn. J. Cardiovasc. Surg. 48:128-133（2019）

    Keywords：thoracoabdominal aortic aneurysm;hybrid repair;ascending aorta


  • A Giant Aortic Arch Aneurysm with Aortopulmonary Fistula　D. Kobayashi et al.…134
    A Giant Aortic Arch Aneurysm with Aortopulmonary Fistula
    Daita Kobayashi＊ Sentaro Nakanishi＊ Seima Oohira＊
    Hayato Ise＊ Natsuya Ishikawa＊ Fumiaki Kimura＊＊
    Hideyuki Harada＊＊ Hiroyuki Kamiya＊

    （Department of Cardiovascular Surgery, Asahikawa Medical University＊, Asahikawa, Japan, and Department of Cardiovascular Surgery, Kushiro Kojinkai Memorial Hospital＊＊, Kushiro, Japan）

    A 69-year-old woman complained of general malaise. Chest X-ray film revealed massive left-sided pleural effusion and CT detected a giant aneurysm of the aortic arch. A diagnosis of ruptured aortic arch aneurysm was made and she underwent total arch replacement as emergency surgery. The intraoperative diagnosis was not a ruptured arch aneurysm but an arch aneurysm penetrating into the left pulmonary artery. The postoperative course was uneventful and the patient was discharged home on the 16th postoperative day.

     

    Jpn. J. Cardiovasc. Surg. 48:134-137（2019）

    Keywords：arch aneurysm;aortopulmonary fistula;total arch replacement


  • Endovascular Repair Prior to Total Aortic Arch Replacement for Stanford A Acute Aortic Dissection with Abdominal Organ Ischemia　Y. Endo et al.…138
    Endovascular Repair Prior to Total Aortic Arch Replacement for Stanford A Acute Aortic Dissection with Abdominal Organ Ischemia
    Yoshiki Endo＊ Yoshihito Irie＊ Tsuyoshi Fujimiya＊
    Akinobu Kitagawa＊

    （Department of Cardiovascular Surgery, Iwaki Kyouritsu Hospital＊, Iwaki, Japan）

    A 47-year-old man was admitted to our hospital complaining of chest and back pain. Enhanced CT scan revealed Stanford type A acute aortic dissection. The celiac artery（CA）was not enhanced and the superior mesenteric artery（SMA）appeared on the delayed phase. There was a small amount of pericardial effusion. Blood gas analysis showed metabolic acidosis. To treat mesenteric malperfusion, we initially performed thoracic endovascular aortic repair（TEVAR）by the PETTICOAT technique and stenting to CA and SMA. The acidosis gradually normalized after TEVAR. We then performed surgical central repair（total arch replacement). He temporarily showed paraplegia after the operation but soon recovered by treatment for spinal ischemia. He was discharged 68 days post operatively without any complication. Surgical central repair is not always effective for treating organ ischemia, so endovascular repair before surgical operation is sometimes taken into consideration.

     

    Jpn. J. Cardiovasc. Surg. 48:138-141（2019）

    Keywords：type A acute aortic dissection;malperfusion;central repair;paraplesia;PETTICOAT technique


  • A Case of Concomitant Extra-Anatomic Bypass to Both Femoral Arteries with Central Repair in a Patient with Aortic Dissection Complicated Ischemia in the Lower Extremities　S. Imai et al.…142
    A Case of Concomitant Extra-Anatomic Bypass to Both Femoral Arteries with Central Repair in a Patient with Aortic Dissection Complicated Ischemia in the Lower Extremities
    Shinichi Imai＊ Masahiro Ueno＊ Keisuke Yamamoto＊
    Hironori Inoue＊ Yasuo Morishita＊

    （Department of Cardiovascular Surgery, Tenyoukai Central Hospital＊, Kagoshima, Japan）

    We report a case of aortic arch replacement and extraanatomic bypass from a branched graft to both bifemoral arteries in a patient with aortic dissection complicated by ischemia in the lower extremities. A 61-year-old woman was found to have thrombosed type II aortic dissection by enhanced computed tomography（CT). Because she had no clinical symptoms, we chose conservative pharmacotherapy. A year later, she suddenly felt severe back pain and dyspnea. CT demonstrated type IIIb aortic dissection. She developed lower extremity ischemia because the true lumen in the abdominal aorta was severely compressed by the false lumen. Two weeks after onset, we planned a bilateral axillo-femoral bypass because the right lower limb ischemia had worsened, with severe pain. However, CT showed ascending aortic dissection. Hence, emergency graft replacement of aortic arch was required. A T-shaped graft was anastomosed to the bilateral femoral arteries, and was used as a delivery line during cardiopulmonary bypass. Although distal anastomosis of the arch was constructed only to the true lumen, leg ischemia persisted. Therefore, the T-shaped graft was connected to the branched graft used for antegrade systemic perfusion. We used INVOS as an indicator of intraoperative lower limb ischemia, which was useful for judging whether or not revascularization of lower extremity was achieved. After the operation, the bypass graft was patent, and ischemia in the lower extremities disappeared.

     

    Jpn. J. Cardiovasc. Surg. 48:142-146（2019）

    Keywords：aortic dissection;lower extremities ischemia;femoral bypass


  • Successful Reversal of Delayed Postoperative Paraplegia Complicating Emergency Total Arch Replacement for Type A Dissection　K. Zaikokuji et al.…147
    Successful Reversal of Delayed Postoperative Paraplegia Complicating Emergency Total Arch Replacement for Type A Dissection
    Kenta Zaikokuji＊ Akihiro Mizuno＊ Tatsuhito Ogawa＊
    Jien Saito＊

    （Department of Cardiovascular Surgery, Nagoya City East Medical Center＊, Nagoya, Japan）

    We report a rare case of paraplegia after emergency total arch replacement for type A acute aortic dissection. A 52-year-old man was referred to our hospital for acute aortic dissection. Contrast-enhanced computed tomography showed a type A aortic dissection extending from the aortic root into the right iliac arteries. The true lumen of the descending and abdominal aorta was collapsed and blood flow to the right lower limb had decreased. Large entry and re-entry tears were revealed in the ascending and distal arch aorta, respectively. His preoperative consciousness was clear, hemodynamics were stable, and there was no evidence of paraplegia or paraparesis. Extracorporeal circulation was established by femoral artery and right atrium cannulation. Total arch replacement was performed under moderate hypothermic circulatory arrest（lowest bladder temperature:21.9℃). The postoperative course was uneventful and he was extubated 6 h postoperatively. Postoperative hemodynamic parameters were stable, the mean blood pressure was maintained at around 70mmHg, and limb movements were confirmed at that time. Although there was no abnormality of lower limb movement until the following morning, paraplegia occurred about 17 h after surgery. While maintaining a mean blood pressure of over 90mmHg, urgent cerebrospinal drainage was immediately performed and combined with steroid treatment and a continuous infusion of naloxone. The neurological defect was resolved immediately after cerebrospinal drainage, and neurological function steadily improved through rehabilitation. He was discharged 20 days after surgery with no neurological defects. Late paraplegia after total replacement for type A acute aortic dissection is a rare complication. From our experience, it is suggested that early diagnosis and treatment are important for improving paraplegia.

     

    Jpn. J. Cardiovasc. Surg. 48:147-151（2019）

    Keywords：acute aortic dissection;total aortic arch replacement;paraplegia;cerebrospinal drainage;spinal ischemia


  • ［Peripheral Artery Disease］ Ureteral Peritonitis after an Abdominal Aortic Aneurysm Repair　S. Nata et al.…152
    Ureteral Peritonitis after an Abdominal Aortic Aneurysm Repair
    Shinichi Nata＊ Kentaro Sawada＊ Takanori Kono＊
    Yusuke Shintani＊ Hiroyuki Ohtsuka＊ Shinichi Hiromatsu＊
    Hiroyuki Tanaka＊

    （Department of Surgery, Kurume Medical University＊, Kurume, Japan）

    An 84-year-old man electively underwent abdominal aortic open repair for an abdominal aortic aneurysm. During the operation, the ureter was not confirmed when manipulating the iliac arteries. Subsequently, intestinal paralysis occurred on the fifth day after surgery and a drainage tube of the intestinal tract was inserted. Liquid retention around the left iliopsoas muscle, and left renal nephropathy were recognized on performing enhanced computed tomography（CT）on postoperative day 11. An initial diagnosis of an iliopsoas abscess was considered. Simple CT imaging was performed on the 13th day after surgery without symptomatic improvement. This scan revealed that the contrast agent had remained in the cavity since the previous CT scan, which had been misdiagnosed as an abscess. Ureteral injury was now suspected. Retrograde ureterography revealed an urinoma caused by left ureter injury. We diagnosed paralytic ileus due to urinoma. For drainage of the urine, a percutaneous renal fistula was constructed. He was discharged from the hospital on the 56th postoperative day, and by six months after the operation, the urinary tract problem had disappeared. In conclusion, we report a case of delayed ureteral injury that occurred after abdominal aortic open repair surgery.

     

    Jpn. J. Cardiovasc. Surg. 48:152-156（2019）

    Keywords：abdominal aortic aneurysm;surgical complication;ureteral injury;urinoma


  • Report of International Congress　J. Aoyama…157
  • Report of Experience Studying Abroad　J. Ito…158

U-40

Editor’s Post Script
  • A. Shiose