（Department of Nursing, Department of Infection Control, Kobe City Medical Center General Hospital＊1), Kobe, Japan, Graduate School of Nursing, Nagoya City University＊2), Nagoya, Japan, Department of Clinical Epidemiology, Hyogo College of Medicine＊3), Nishinomiya, Japan, Clinical Research Promotion Center, Department of Research Support, Kobe City Medical Center General Hospital＊3), Kobe, Japan, and Cardiovascular Surgery, Kobe City Medical Center General Hospital＊4), Kobe, Japan）
Objective:Risk factors for SSI after open heart surgeries were evaluated in relation to a bundle of SSI preventive measures. Methods:Research design is a retrospective cohort study. The study population was 1,579 patients who had received open heart surgeries at Kobe City Medical Center General Hospital from January 2008 to December 2010（Period I:when standard infection prevention measures were implemented）and from January 2014 to December 2016（Period II:after a relocation of the hospital to a new campus and enhanced infection prevention measures were implemented). Factors associated with SSI were determined using univariate modelling analysis followed by multi-variate logistic regression analysis. The Center for Disease Control and Prevention definition of SSI was used for case determination. Results:Overall SSI incidence was 4.5%. SSI incidence decreased significantly from 6.6% in Period I to 2.9% in Period II（p＜0.001). Significant improvement in adherence to the recommended preventive measures was observed in Period II in selection of appropriate antibiotics, discontinuation of prophylactic antibiotics within 72h after surgery and glucose control on post-operative Day 1 and 2（p＜0.001). A univariate analysis showed statistical significance in surgical procedure, surgical period, surgical duration, post-operative day 2 morning glucose level, administration of prophylactic antibiotics within 1 h before incision, 100% compliance with the Bundle. Complex surgery（odds ratio 2.5;95%CI 1.3～4.8）were identified as a risk factor by multiple logistic regression. Surgical period（Period II, odds ratio 0.41;95%CI 0.28～30.71）and administration of prophylactic antibiotics within 1h before incision（odds ratio 0.57;95%CI 0.33～0.97）reduced SSI risks. Conclusion:The study demonstrated administration of prophylactic antibiotics within 1h before incision was particularly important for SSI prevention. Higher compliance with SSI bundle and a special attention to patients receiving complex surgery were also warranted.
Jpn. J. Cardiovasc. Surg. 48:161-169（2019）
Keywords：open heart surgery;surgical site infection;risk factor;SSI bundle
（Department of Cardiovascular Surgery, Akita University Graduate School of Medicine＊, Akita, Japan）
Tumor metastasis to the endocardium is rare. The patient was 58-year-old man who was given a diagnosis of a metastatic tumor to the right atrium and right ventricle. The tumor originated from the esophagus, and the patient was at risk of sudden death caused by acute pulmonary embolism. We performed tumorectomy to reduce the risk of sudden death. The postoperative course was satisfactory, and the tumorectomy was followed by chemotherapy. The 5-year survival rate in such cases has been reported to be only approximately 11%. However, resection of tumor mass may be useful for improving postoperative QOL and reducing the risk of sudden death.
Jpn. J. Cardiovasc. Surg. 48:170-172（2019）
Keywords：cardiac tumor;pulmonary tumor embolism;tumor metastasis to the endocardium
（Department of Cardiovascular Surgery, Kumamoto Rosai Hospital＊, Yatsushiro, Japan）
We report a case of constrictive pericarditis with repeated hepatic encephalopathy due to hepatic cirrhosis. A 69-year-old man with exertional dyspnea and leg edema was admitted to our hospital. He had been admitted to our hospital thrice in the past 1 year owing to hepatic encephalopathy. He had hyperammonemia, hyperbilirubinemia, and renal dysfunction. Computed tomography revealed a thick pericardium with calcification and bilateral pleural effusion, and transthoracic echocardiography revealed abnormal early diastolic septal movement and right ventricular restriction. Further, cardiac catheterization identified increased central venous（36mmHg）and a mean pulmonary arterial of 53mmHg and a dip-and-plateau right ventricular pressure curve. We diagnosed constrictive pericarditis. Accordingly, pericardiectomy without extracorporeal circulation was performed. A hypertrophic calcified pericardium was found to be expanded throughout the right atrium to the free wall of the right ventricle. Postoperatively, the patient’s exertional dyspnea and leg edema resolved, and he recovered without any complications.
Jpn. J. Cardiovasc. Surg. 48:173-178（2019）
Keywords：constrictive pericarditis;hepatic encephalopathy;hepatic cirrhosis
（Thoracic, Cardiovascular and General Surgery, Kanazawa University＊, Kanazawa, Japan）
We report two cases with postoperative sternal osteomyelitis after coronary artery bypass graft（CABG), in whom successful two-stage reconstruction was performed via negative pressure wound therapy（NPWT）and pectoralis major myocutaneous flaps. Two patients underwent CABG using bilateral internal thoracic arteries, after which they had surgical site infection（SSI). The intractable wound did not heal with irrigation and NPWT. Then, sternal osteomyelitis was observed via magnetic resonance imaging（MRI), so we planned two-stage reconstruction. The first stage of treatment consisted of complete debridement（including removal of sternal wires and necrosectomy of soft tissue and sequestrum）and application of NPWT until the remission of inflammation. The second stage consisted of wound closure with pectoralis major myocutaneous advancement flaps. After wound closure, the two patients were given 2 months of oral antibiotics, and the postoperative results were good. Two-stage reconstruction with NPWT and pectoralis major myocutaneous flaps results in excellent clinical outcome. In the first stage, the key to the successful management of postoperative sternal osteomyelitis is infection control. This includes surgical debridement and wound-bed preparation with NPWT. The pectoralis major myocutaneous flap technique is brief and does not require a second cutaneous incision or an intact internal thoracic artery. In conclusion, the pectoralis major myocutaneous flap is a useful option in two-stage reconstruction after CABG.
Jpn. J. Cardiovasc. Surg. 48:179-184（2019）
Keywords：sternal osteomyelitis;negative pressure wound therapy;pectoralis major myocutaneous flap
（University of Miyazaki Hospital Cardiovascular Surgery＊, Miyazaki, Japan, and Miyazaki Prefectural Nobeoka Hospital＊＊, Nobeoka, Japan）
A 27-year-old woman who suffered loss of consciousness twice after left femoral pain in the 25th week of gestation was referred to the obstetrics and gynecology department of our hospital. A structure with an attachment on the atrial wall was found in both atria on echocardiography, leading us to suspect impending paradoxical embolism（IPE). Judging from the shape of the thrombus in the atria, we thought that there was a high possibility of further embolism although rescue of the baby was feasible via cesarean section, so we decided to carry out emergency surgery. After delivering the infant by cesarean section, we used a heart-lung machine to incise the right atrium under hypothermia and remove the thrombus. As intraoperative esophageal echocardiography showed embolization in the right pulmonary artery, we cut the right pulmonary artery and removed the emboli. After surgery, a femoral vein thrombus was observed on echocardiography of the lower extremity vein, and we inserted an inferior vena cava filter. The patient was discharged on the 16th postoperative day. The situation whereby a thrombus is trapped in the foramen ovale without embolism of the arterial system is the rare pathological condition known as IPE. As no cases of surgical thrombectomy to treat IPE arising from complications of pregnancy have been reported thus far, the case described herein fittingly augments the literature.
Jpn. J. Cardiovasc. Surg. 48:185-188（2019）
Keywords：impending paradoxical embolism;pregnancy;pulmonary thromboembolism
（Department of Cardiovascular Surgery, Kitaharima Medical Center＊, Ono, Japan）
Pharyngeal perforation is a rare but crucial complication of transesophageal echocardiography during cardiac surgery. We herein report the case of a 72-year-old man with infective endocarditis in the aortic valve, who had a poor performance status due to congestive heart failure and brain infarction. The echo probe of the transesophageal echocardiography was detected in the anterior mediastinum after median sternotomy. Pharyngeal repair after aortic valve replacement with bioprosthetic valve, following omental wrapping was performed simultaneously. The operative course was relatively good, and the patient moved to the general ward 32 days after the surgery.
Jpn. J. Cardiovasc. Surg. 48:189-192（2019）
Keywords：pharyngeal perforation;transesophageal echocardiography;omental wrapping
（Department of Cardiac Surgery＊, and Department of Vascular Surgery＊＊, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan）
A 50-year-old man was admitted to our hospital due to chest pain. He had a history of chronic pancreatitis associated with a pancreatic pseudocyst. Coronary angiography revealed stenotic lesions in left main trunk and right coronary artery coronary artery bypass grafting（RITA-LAD, LITA-OM, SVG-#4PD）were performed. The postoperative course was uneventful without any complications, and he was discharged on the 9th day after surgery. A week later, fatigue and dyspnea appeared. Echocardiography showed a large mount of pericardial fluid and echo-guided pericardiocentesis was performed. One week after the procedure the pericardial fluid reaccumulated. Pericardial drainage resulted in continuous drainage of pericardial fluid. A 7 French plastic stent was placed in the pancreatic pseudocyst, which decompressed the pancreatic pseudocyst, which led to the disappearance of pericardial effusion accumulation. The possible relation between a recurrent pericardial fluid accumulation and a pancreatic pseudocyst was suspected.
Jpn. J. Cardiovasc. Surg. 48:193-196（2019）
Keywords：pericardial effusion;pancreatic pseudocyst
（Department of Cardiovascular Surgery, Niigata City General Hospital＊, Niigata, Japan, Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences＊＊, Niigata, Japan, and Department of Cardiovascular Surgery, Saiseikai Niigata Daini Hospital＊＊＊, Niigata, Japan）
The patient was a 48-year-old woman who had been taking oral steroids for dermatomyositis since age 39. The patient experienced an episode of sudden chest tightness at age 48, and acute myocardial infarction was suspected. Coronary angiography revealed a right coronary artery occlusion;emboli（thrombi）were collected from the same site. Left cardiac ventriculography revealed the presence of a mobile thrombotic mass in the ascending aorta. Although heparin therapy was initiated considering the possibility of thrombosis, no shrinkage of the mass was observed, and surgery was planned as per treatment guidelines. The mass was a rod-shaped thrombus measuring 20mm×7mm×7mm attached to the aortic wall, approximately 2.5cm distal from the entrance to the right coronary artery. Since the aortic wall at the site of the tumor attachment was normal, surgery involved only removal of the mass. A histopathological assessment revealed that the mass was a mixed thrombus containing both white and red thrombotic components. The patient was started on postoperative oral antiplatelet and anticoagulant drug therapy to prevent additional thrombosis, and no recurrence has been noted at 1 year postoperative.
Jpn. J. Cardiovasc. Surg. 48:197-201（2019）
Keywords：ntra-aortic thrombosis;myocardial infarction;embolism;steroid
（Department of Cardiovascular Surgery, Chubu Tokushukai Hospital＊, Okinawa, Japan, Department of Thorac and Cardiovascular Surgery, Graduate School of Medicine, University of The Ryukyus＊＊, Okinawa, Japan, and Division of Cardiovascular Surgery, Nanbu Tokushukai Hospital＊＊＊, Okinawa, Japan）
A 78-year-old woman with abnormal shadows on computed tomography（CT）was given a diagnosis of right-sided aortic arch and Kommerell diverticulum（KD), accompanied by aberrant left subclavian artery. Although no symptoms were observed, the maximum diameter of the aneurysm was 63mm, and surgical intervention was chosen because of the possibility of rupture. At first, a 4-branched blood vessel prosthesis with a side branch was anastomosed to the ascending aorta. Next, after reconstructing the cervical branches, a Conformable GORE●R TAG●R（W.L. Gore and Associates, 34mm×200mm）was inserted from the side branch and expanded in the range of Zones 0 to Th 7. Finally, ALSA coil embolization was performed. She was discharged on postoperative day 36, and at her 2-year follow-up, she was doing well, with shrinkage of Kommerell diverticulum.
Jpn. J. Cardiovasc. Surg. 48:202-205（2019）
Keywords：right aortic arch;Kommerell’s diverticulum;debranching;thoracic endovascular aortic repair（TEVAR）
（Cardiovascular and Gastroenterological Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan）
We describe a rare complication and treatment progression that occurred in a 64-year-old man with an aortic abdominal aneurysm（AAA）that had been treated by endovascular aneurysm repair（EVAR). He had undergone EVAR to treat an infra-renal type AAA 21 months previously and returned to the emergency department with back pain. Contrast-enhanced computed tomography（CT）revealed acute type B aortic dissection, so he was admitted and conservative medical management was started. Acute stomachache and limb pain appeared on hospital day 7, which prevented him from moving his lower limbs. The main body of the stent graft had collapsed, blocking blood flow, and contrast was not found in arteries from the collapsed stent graft portion to the knee level on emergency contrast CT images of the leg. His legs were revascularized by an extra-anatomical right axial-bilateral external iliac bypass. His symptoms disappeared and reperfusion injury was avoided. The collapsed stent graft had retained its original shape at 11 and 18 days after surgery. Furthermore, follow-up CT 4.5 years later showed that the stent graft retained its original form.
Jpn. J. Cardiovasc. Surg. 48:206-209（2019）
Keywords：stent graft collapse;acute aortic dissection;stent graft re-expansion;lower limb ischemia;extra-anatomical bypass
（Thoracic, Cardiovascular and General Surgery, Kanazawa University＊, Kanazawa, Japan）
We report two cases of total arch replacement with open stent graft for the aberrant right subclavian artery（ARSA). Case 1 was a thoracic artery aneurysm with an ARSA. We thought it would be difficult to perform in-situ reconstruction of ARSA via median sternotomy, so we performed total arch replacement with the open stent-grafting technique. Therefore the right axillary artery was reconstructed by extra-anatomical bypass and coil embolization of the ARSA proximal to the vertebral artery to achieve complete thrombosis of the ARSA. The postoperative course was uneventful. Case 2 was a Stanford type A acute aortic dissection involving an ARSA with the entry located near the ARSA. Total arch replacement was performed using the open stent-grafting technique to close the entry site and origin of the ARSA. Then the right axillary artery was reconstructed by extra-anatomical bypass and coil embolization of the ARSA. The postoperative course was uneventful. The open stent-grafting technique might be an effective alternative management of thoracic aortic disease with ARSA.
Jpn. J. Cardiovasc. Surg. 48:210-214（2019）
Keywords：aberrant right subclavian artery;open stent grafting technique
（Department of Cardiovascular Surgery, Akita University Graduate School of Medicine, Akita, Japan）
Basic procedures that cardiovascular surgeons routinely perform are rarely discussed, despite the great variability among facilities. The aim of this study is to survey the current status of internal thoracic artery harvesting in cardiovascular surgeons aged under 40 years old, and to share the results of this questionnaire investigation regarding basic skills.
Jpn. J. Cardiovasc. Surg. 48:U1-U5（2019）
Keywords：Under Forty;survey;internal thoracic artery