JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Vol.49, No.2

Preface

• Something to Be Preserved during Work Style Reform　Y. Hiramatsu

Originals

• Evaluation of Decellularized Arteries Derived from Biological Tissue　A. Yamashita et al.…45
  Evaluation of Decellularized Arteries Derived from Biological Tissue
  

  Akitatsu Yamashita＊	Seiichi Funamoto＊,＊＊	Younguei zhang＊
  Yoshihide Hashimoto＊＊＊	Akio Kishida＊＊＊

  
  

  （Division of Acellular Tissue and Regenerative Medical Material＊, and Division of Biofunctional Molecules＊＊＊, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, Tokyo, Japan, and Department of Biomedical Engineering, Tissue Medical Engineering Laboratory, Osaka Institute of Technology＊＊, Osaka, Japan）
  

  Background:Cardiovascular surgery involves the use of several artificial materials as graft vessels. Although artificial blood vessels of medium and large diameters currently present a satisfactory patency and durability, those of small diameter remain inferior to one’s own vessels to prevent issues such as early thrombosis and vascular stenosis. The present study aimed to investigate the functionality of decellularized tissues that hold structures and growth factors derived from a living body. Methods:Mini pigs were used for the study. The bovine-derived decellularized blood vessels were transplanted into the pigs’ carotid artery, and no anticoagulant or antiplatelet drugs were used after the surgery. The blood vessels were dissected and evaluated for patency and tissue staining. Result:The patency of the blood vessels was confirmed in all cases;however, a thrombus was confirmed in one transplanted vessel. Pathological findings showed maintenance of the blood vessel structure, presenting no issues with collagen or elastin. Conclusion:This study demonstrated that biologically derived decellularized blood vessels are highly functional and present an intact luminal basement membrane, even without antiplatelet therapy. This study suggested that decellularized blood vessels can potentially help in the development of medical devices with higher functionality than that of the existing materials.

   

  Jpn. J. Cardiovasc. Surg. 49:45-51（2020）

  Keywords：vascular graft;decellularized tissue;high-hydrostatic pressure method

  
  
• Efficacy of In Situ Fenestrated Open Stent Technique (FeneOS) for the Surgery of Acute Aortic Dissection Type A Surgery　S. Azuma et al.…52
  Efficacy of In Situ Fenestrated Open Stent Technique（FeneOS）for the Surgery of Acute Aortic Dissection Type A Surgery
  

  Shuhei Azuma＊	Masafumi Morita＊	Sho Mano＊
  Yoshikazu Motohashi＊	Yasuyoshi Yoshii＊＊	Takao Tsuchida＊＊＊

  
  

  （Department of Cardiovascular Surgery, Kyoto Katsura Hospital＊, Kyoto, Japan, Department of thoracic Surgery, Hirakata City Hospital＊＊, Hirakata, Japan, and Department of Cardiovascular Surgery, Shiroyama Hospital＊＊＊, Habikino, Japan）
  

  Background:The surgical repair of acute aortic dissection type A［AAD（A）］by reconstructing the left subclavian artery（LSCA）is sometimes difficult because of the deep surgical field and the occurrence of left recurrent nerve palsy or bleeding. In Japan, since 2014, a commercially available open stent graft（J-graft OPEN STENT）has been used for promoting thrombosis of the false lumen in the descending aorta. This report presents an efficacy evaluation of the surgeon-made in situ Fenestrated Open Stent（FeneOS）for LSCA reconstruction in a patient with AAD（A). Method:We performed surgery with FeneOS using the open stent graft by first deploying it from the entry of the LSCA into the descending aorta and manually making a hole on the LSCA side of the stenting portion;then, the four-branched J graft was anastomosed between the left common carotid（lt. CCA）and SCA（ZONE 2). At our institution, 47 patients with AAD（A）underwent this surgery with FeneOS from 2014 to 2019（FeneOS group）and 97 patients with AAD（A）underwent a normal open-stenting procedure from 2008 to 2014（non-FeneOS group). We analyzed the postoperative results of patients in the FeneOS and non-FeneOS groups. Results:Preoperative characteristics of patients in both groups were similar. Patients in the FeneOS group had an acceptable postoperative course, with no 30-day or in-hospital deaths. The mean operation time, cardiopulmonary bypass time, selective cerebral perfusion time, and open distal anastomosis time were significantly shorter in patients in the FeneOS group（p＜0.01). None of the patients had left recurrent nerve palsy, and postoperative computed tomography or arterial echo showed that the blood flow through the LSCA was intact and revealed no endoleakage. Conclusion:FeneOS is simple, fast, and less invasive for the reconstruction of the LSCA without the risk of left recurrent nerve palsy and can be effective for treating patients with AAD（A).

   

  Jpn. J. Cardiovasc. Surg. 49:52-57（2020）

  Keywords：In Situ Fenestrated Open Stent Technique（FeneOS）;acute aortic dissection type A;reconstruction of the left subclavian artery;left recurrent nerve palsy

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• A Calcified Amorphous Tumor from the Aortic Valve to the Tricuspid Valve withAortic Valve Stenosis　T. Harada et al.…58
  A Calcified Amorphous Tumor from the Aortic Valve to the Tricuspid Valve with Aortic Valve Stenosis
  

  Takashi Harada＊

  Hideki Sasaki＊

  Hiroshi Ishitoya＊

  
  

  （Department of Cardiovascular Surgery, Ehime Prefectural Central Hospital, Matsuyama, Japan）
  

  We report a rare case of a hemodialysis patient with calcified amorphous tumor（CAT）originating from aortic valve cusp that continues to tricuspid valve, which may be related to aortic annular calcification and aortic valve stenosis. A 79-year-old female with chronic kidney disease on hemodialysis for 16 years was transferred to our hospital with loss of consciousness. Echocardiography revealed aortic valve stenosis and presence of tumor on the aortic valve and tricuspid valve. We suspected the presence of a cardiac tumor or vegetation. We underwent tumor resection of tricuspid valve and aortic valve replacement and coronary artery bypass grafting（SVG-RCA). Pathological findings of the tumor was CAT.

   

  Jpn. J. Cardiovasc. Surg. 49:58-61（2020）

  Keywords：hemodialysis;calcified amorphous tumor;aortic valve stenosis

  
  
• Bilateral Re-expansion Pulmonary Edema after Cardiac Surgery Successfully Treated with Venovenous Extracorporeal Membrane Oxygenation　S. Kawatsu et al.…62
  Bilateral Re-expansion Pulmonary Edema after Cardiac Surgery Successfully Treated with Venovenous Extracorporeal Membrane Oxygenation
  

  Satoshi Kawatsu＊	Masayuki Otani＊	Yuka Tabayashi＊
  Koki Ito＊	Katsuhiko Oda＊

  
  

  （Department of Cardiovascular Surgery, Iwate Prefectural Central Hospital＊, Morioka, Japan）
  

  A 57-year-old man was admitted with high fever and chest discomfort associated with aortic valve infective endocarditis. An echocardiogram showed severe aortic valve regurgitation. An emergent operation was performed. The aortic valve was destroyed and an annulus abscess was observed. Aortic valve replacement was performed. There was a large amount of pleural effusion in both chest cavities. Bilateral chest drainage was performed. Cardiopulmonary bypass weaning was performed uneventfully. The operation was finished without any mechanical support required. However, respiratory failure was observed to progress rapidly immediately after the operation. A postoperative X-ray showed bilateral pulmonary edema. Re-expansion pulmonary edema was diagnosed. Because oxygenation was not improved in ventilator settings, venovenous extracorporeal membrane oxygenation（V-V ECMO）was installed. Respiratory support with V-V ECMO was needed for 17 days postoperatively. It took 36 days before the patient was removed from the ventilator. V-V ECMO successfully managed bilateral re-expansion pulmonary edema.

   

  Jpn. J. Cardiovasc. Surg. 49:62-66（2020）

  Keywords：infective pericarditis;re-expansion pulmonary edema;respiratory failure;V-V ECMO

  
  
• A Case of Pneumococcal Endocarditis Complicating Overwhelming Postsplenectomy Infection　H. Hamamoto et al.…67
  A Case of Pneumococcal Endocarditis Complicating Overwhelming Postsplenectomy Infection
  

  Hirotsugu Hamamoto＊

  Kenshi Yoshimura＊

  
  

  （Cardiovascular Surgery, Almeida Memorial Hospital, Oita, Japan）
  

  Postsplenectomy patients are susceptible to severe infections due to encapsulated bacteria such as Streptococcus pneumoniae and Haemophilus influenzae and this condition is widely known as Overwhelming Postsplenectomy Infection（OPSI). OPSI is relatively rare in conditions with rapid progression and high mortality rates. There are very few reports of infective endocarditis from OPSI. A 40-year-old man who underwent splenectomy 20 years before was transported to the emergency room. He had severe heart failure and multiple cerebral embolisms. The echocardiography showed vegetation on the aortic valve and severe regurgitation due to perforation of the non-coronary cusp. We performed aortic valve replacement on an emergent basis. In infected patients after splenectomy, early diagnosis and prompt treatment are desired because of the possibility of rapid progression of sepsis in encapsulated bacteria and poor prognosis.

   

  Jpn. J. Cardiovasc. Surg. 49:67-71（2020）

  Keywords：Overwhelming Postsplenectomy Infection;pneumococcal endocarditis;aortic valve

  
  
• Penetrating Thoracic Trauma with Undetected Left Ventricular Injury Presenting as Sudden Hypotension during Surgery　S. Masuda et al.…72
  Penetrating Thoracic Trauma with Undetected Left Ventricular Injury Presenting as Sudden Hypotension during Surgery
  

  Shinya Masuda＊	Kota Itagaki＊	Keisuke Kanda＊＊
  Masaharu Hatakeyama＊＊＊	Masaaki Naganuma＊	Nobuaki Suzuki＊
  Koichi Nagaya＊

  
  

  （Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital＊, Aomori, Japan, Department of Cardiovascular Surgery, Sendai Kousei Hospital＊＊, Sendai, Japan, and Department of Cardiovascular Surgery, Aomori City Hospital＊＊＊, Aomori, Japan）
  

  A 55-year-old man was brought to our hospital with a knife penetrating his left anterior chest wall following a suicide attempt. Massive left hemothorax was identified on echocardiography;however, there was no evidence of cardiac tamponade. After draining blood from the left thorax, computed tomography（CT）revealed that the tip of the knife had penetrated the left lung and reached the left pulmonary vein. In preparation for cardiopulmonary bypass, an emergency thoracotomy was scheduled with a plan to access the left lung and left pulmonary vein. The patient was transferred to the operating room, and the procedure was started with the patient in the supine position. During dissection of the femoral vessels, the patient suddenly developed hypotension. After surgical access to the heart was achieved via median sternotomy, a pericardiotomy was performed and cardiopulmonary bypass was established. A 50-mm stab wound was identified at the lateral wall of the left ventricle. The knife was removed, and the left ventricular wound was repaired. The lingular segment of the left lung was partially resected. The patient had no postoperative complications and was transferred to the referral hospital on postoperative day 25. This case report emphasizes the importance of taking appropriate measures for thoracotomy and cardiopulmonary bypass in patients with penetrating thoracic trauma with massive hemothorax, even in the absence of cardiac tamponade on imaging. We were able to successfully manage a life-threatening condition by taking appropriate measures.

   

  Jpn. J. Cardiovasc. Surg. 49:72-76（2020）

  Keywords：penetrating thoracic trauma;pericardial effusion;cardiac injury of the left ventricle;hemorrhagic shock

  
  
• ［Aortic Disease］
• A Case of Acute Type B Aortic Dissection Subsequent to Asymptomatic Chronic Type A Aortic Dissection Which Was Difficult to Distinguish from Acute Type A Aortic Dissection　H. Suzuki et al.…77
  A Case of Acute Type B Aortic Dissection Subsequent to Asymptomatic Chronic Type A Aortic Dissection Which Was Difficult to Distinguish from Acute Type A Aortic Dissection
  

  Hitoshi Suzuki＊	Yasuhiro Sawada＊	Kentaro Inoue＊＊
  Masaki Yada＊＊＊	Uhito Yuasa＊＊＊	Chiaki Kondo＊
  Hideto Shimpo＊

  
  

  （Department of Cardiovascular Surgery, Mie Prefectural General Medical Center＊, Yotsukaichi, Japan, Department of Cardiovascular Surgery, Matsusaka Chuo General Hospital＊＊, Matsusaka, Japan, and Department of Cardiovascular Surgery, Kuwana City Medical Center＊＊＊, Kuwana, Japan）
  

  Aortic dissection presents with acute chest or back pain. However, it can be asymptomatic in the acute phase with delayed symptomatic presentation or incidental diagnosis upon chest imaging. We report a case of acute type B aortic dissection subsequent to chronic type A aortic dissection which was difficult to distinguish from acute type A aortic dissection. A 45-year-old man was admitted to a hospital with sudden back pain. An enhanced chest CT revealed a suspected acute type A aortic dissection. The patient was transferred to our hospital and we performed an emergent total arch replacement. Intraoperative findings showed that there were two entries at the origin of the brachiocephalic artery and the left subclavian artery. The ascending aorta presented wall thickening but the descending aorta did not present wall thickening. Histopathologically, the adventitia was obviously thickened with dissection findings in the tunica media. Thus it was diagnosed as acute type B aortic dissection subsequent to chronic type A aortic dissection. Great caution should be taken in asymptomatic chronic aortic dissection.

   

  Jpn. J. Cardiovasc. Surg. 49:77-80（2020）

  Keywords：chronic type A dissection;acute type B dissection;coexisting;asymptomatic aortic dissection

  
  
• Early Abdominal Closure Achieved through Retroperitoneal Hematoma Evacuation after Endovascular Aneurysm Repair and Open Abdominal Management for a Ruptured Aortic Aneurysm　T. Tamura et al.…81
  Early Abdominal Closure Achieved through Retroperitoneal Hematoma Evacuation after Endovascular Aneurysm Repair and Open Abdominal Management for a Ruptured Aortic Aneurysm
  

  Tomoki Tamura＊	Hidetomi Takahashi＊	Rihito Horikoshi＊
  Yusuke Irisawa＊	Tetsuya Horai＊

  
  

  （Department of Cardiovascular Surgery, Central Hospital of the National Center for Global Health and Medicine＊, Tokyo, Japan）
  

  Abdominal compartment syndrome（ACS）is an important postoperative complication of endovascular aneurysm repair（EVAR）for ruptured abdominal aortic aneurysms（rAAA). Open abdominal management（OAM）has been reported to be effective in EVAR;however, only a limited number of reports are available on when and how to close the abdomen. Here we report a case of early abdominal wall closure achieved through the combined use of retroperitoneal hematoma evacuation after EVAR and OAM for rAAA. The patient was a 79-year-old woman who underwent EVAR for rAAA on an emergency basis. She developed ACS after EVAR and underwent OAM. Four days after surgery, a decrease in intraabdominal pressure was confirmed, and subsequent contrast-enhanced computed tomography revealed the absence of an endoleak;retroperitoneal hematoma evacuation was performed, during which the abdominal wall was closed. The postoperative course was good, and the patient was discharged. Early closure of the abdomen may be possible by concomitant retroperitoneal hematoma evacuation after EVAR and OAM for rAAA.

   

  Jpn. J. Cardiovasc. Surg. 49:81-85（2020）

  Keywords：ruptured abdominal aortic aneurysm;abdominal compartment syndrome;open abdominal management;retroperitoneal hematoma evacuation

  
  
• ［Peripheral Artery Disease］
• Use of VIABAHN Stent Graft for Subclavian Artery Injury due to Inadvertent Catheter Placement　S. Kuwauchi et al.…86
  Use of VIABAHN Stent Graft for Subclavian Artery Injury due to Inadvertent Catheter Placement
  

  Shintaro Kuwauchi＊	Nobuya Zempo＊	Hideki Sakashita＊
  Tomohiko Uetsuki＊	Naoki Taniguchi＊	Takayuki Okada＊
  Mitsuharu Hosono＊	Shinya Kanemoto＊	Kohei Kawazoe＊
  Naoki Minato＊

  
  

  （Department of Cardiovascular Surgery, Kansai Medical University Hospital＊, Hirakata, Japan）
  

  A 77-year-old man presenting with uremic acidosis was referred to our department for a misplaced vascular access catheter. Computed tomography revealed the catheter was passing through the subclavian artery and terminating in the ascending aorta. Under angio-fluoroscopic monitoring, a VIABAHN stent graft was deployed immediately after removing the catheter. The patient had no hemorrhagic complication although continuous hemodiafiltration was started just after surgery. His postoperative course was uneventful.

   

  Jpn. J. Cardiovasc. Surg. 49:86-89（2020）

  Keywords：iatrogenic vascular injury;endovascular repair;subclavian artery

  
  

Report of Experience Studying Abroad

• Surgical Fellowship in North America　S. Hosoba…90

U-40

• U-40 Column No.2 How and When Can Cardiovascular Surgeons Get a Day Off ??　K. Wada et al.…U1
  How and When Can Cardiovascular Surgeons Get a Day Off ??
  

  Kumiko Wada＊	Takafumi Abe	Eigo Ikushima
  Katsuya Kawagoe	Tomonori Koga	Shuji Nagatomi
  Hiromitsu Teratani	Takeaki Harada	Shotaro Higa
  Eijiro Nogami	Hirofumi Yamamoto

  
  

  （Department of Cardiovascular Surgery, Our Lady of the Snow Social Medical Corp. St. Mary’s Hospital＊, Kurume, Japan）
  

  We investigated how cardiovascular surgeons get a day off.

   

  Jpn. J. Cardiovasc. Surg. 49（2）:U1-U5（2020）

  Keywords：U-40;Under Forty;work style reform;cardiovascular surgeon

  
  

Editor’s Post Script

• N. Azuma