|Atsushi Aoki＊||Tadashi Omoto＊||Kazuto Maruta＊|
|Tomoaki Masuda＊||Yui Horikawa＊|
（Department of Surgery, Division of Cardiovascular Surgery, Showa University School of Medicine＊, Tokyo, Japan）
Purpose:Easy and safe implantability, good post-operative valve function and good long-term durability are required for any bioprosthetic valve implanted in aortic position. The Carpentier Edwards Perimount Magna valve（Magna）was introduced in 2009 and the St. Jude Medical Trifecta valve（Trifecta）was introduced in 2012 to our institution. In this study, we compared implantability, early post-operative valve function and structural valve deterioration（SVD）between these two valves. Patients and Methods:Between January 2009 and December 2019, Magna or Trifecta were electively implanted for 254 patients（Magna 151 patients and Trifecta 103 patients）and these patients were included in this study. Implantability was evaluated by occurrence of intraoperative valve dysfunction. Early post-operative valve function was evaluated by mean pressure gradient（m-PG）and indexed aortic valve area（AVAI）by ultrasonography performed 10 days after surgery. The relationship between indexed bioprosthetic valve orifice area calculated from internal diameter（GOAI）and AVAI was evaluated. If there was a significant relationship between GOAI and AVAI, maximum body surface area（BSA）to obtain AVAI●0.85cm2/m2 was estimated from 99% reliable interval of regression line. Results:Age, gender, and BSA did not differ between the two groups. There was no intraoperative valve dysfunction in Magna;however we experienced one patient with severe aortic regurgitation due to stent distortion by the aortic wall during surgery with the 25 mm Trifecta valve. For this patient, Trifecta was replaced with Magna intra-operatively. In the 19mm valve, AVAI was significantly larger（1.12±0.27cm2/m2 vs. 0.88±0.21cm2/m2, p＜0.001）and m-PG was significantly lower（8.7±2.7mmHg vs. 17.2±6.3mmHg, p＜0.001）in Trifecta. The frequency of AVAI＜0.85cm2/m2（24% vs. 49%, p＝0.036）and the frequency of m-PG●20mmHg（0% vs. 26%, p＝0.006）were significantly less in Trifecta. There was significant relationship between GOAI and AVAI in both valves. Maximum BSA to obtain AVAI ●0.85cm2/m2 was estimated as 1.35m2 in Magna and 1.50m2 in Trifecta. In the 21mm valve, AVAI was significantly larger（1.14±0.23cm2/m2 vs. 0.92±0.22cm2/m2, p＜0.001）and m-PG was significantly lower（7.8±3.2mmHg vs. 14.6±4.7mmHg, p＜0.001）in Trifecta. The frequency of AVAI＜0.85cm2/m2 was significantly less in Trifecta（11% vs. 42%, p＝0.002）;however, the frequency of m-PG●20mmHg did not differ significantly. There was a significant relationship between GOAI and AVAI in Magna and Trifecta. Maximum BSA to obtain AVAI ●0.85cm2/m2 was estimated as 1.49m2 in Magna and 1.70m2 in Trifecta. In the 23 and 25mm valves, AVAI was significantly larger and m-PG was significantly lower in Trifecta. However neither the frequency of AVAI＜0.85cm2/m2 nor m-PG●20mmHg differed between the two valves. There was one early（27 months after surgery）SVD due to leaflet tear in Trifecta and two SVDs due to leaflet calcification more than 10 years after surgery in Magna. Conclusion:For Trifecta implantation, valve size selection seemed to be important and larger valves should be avoided with narrow ST junctions. Selection of 19 and 21mm Magna valves should be limited for the patient with a BSA less than 1.35 and 1.49m2 respectively. In Trifecta, early SVD might occur and careful follow-up is necessary.
Jpn. J. Cardiovasc. Surg. 49:243-252（2020）
Keywords：Carpentier-Edwards Perimount Magna valve;St. Jude Medical Trifecta valve;implantability;valve function;structural valve deterioration
|Honami Mizushima＊||Hiroki Kato＊||Naoki Saito＊|
|Hideyasu Ueda＊||Hironari No＊,＊＊||Shintaro Takago＊|
|Kenji Iino＊||Keiichi Kimura＊||Hirofumi Takemura＊|
（Thoracic, Cardiovascular and General Surgery, Kanazawa University Hospital＊, Kanazawa, Japan, and Ishikawa Prefectural Hospital＊＊, Kanazawa, Japan）
We describe a 50-year-old man who was diagnosed with anomalous aortic origin of the right coronary artery（AAORCA）by coronary angiography and coronary computed tomography performed for chest pain on exertion. Exercise-loaded myocardial scintigraphy revealed inferior wall ischemia, and hence surgery was performed. Intraoperatively, the right coronary artery was seen to run in the aortic wall, and hence, right coronary ostioplasty（unroofing）was performed. Postoperatively, coronary computed tomography revealed that the right coronary artery originated from a normal position, and exercise-loaded myocardial scintigraphy indicated no ischemia.
Jpn. J. Cardiovasc. Surg. 49:253-256（2020）
Keywords：congenital coronary anomalies;anomalous aortic origin of coronary artery:sudden cardiac death;Unroofing
|Shuichi Shiraishi＊||Ai Sugimoto＊||Masanori Tsuchida＊|
（Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences＊, Niigata, Japan）
A 37-year-old male patient who had previously undergone left original Blalock-Taussig shunt, original Glenn shunt, left pulmonary artery patch plasty, and a Bjo¨rk procedure was referred to our hospital due to protein-losing enteropathy. Because he suffered from severe low-cardiac output syndrome immediately after the Bjo¨rk procedure, mechanical circulatory support and construction of the bypass between the right atrial appendage and the innominate vein using an artificial graft were required. We performed a Fontan-revision operation:total cavopulmonary connection with extra-cardiac conduit, right atrial ablation, pacemaker lead implantation, construction of fenestration between the conduit and the atrium, and reconstruction of the left pulmonary artery in front of the ascending aorta successfully. His postoperative course was uneventful and protein-losing enteropathy had not recurred 3 years after the operation.
Jpn. J. Cardiovasc. Surg. 49:257-260（2020）
Keywords：protein-losing enteropathy;TCPC conversion;Bjo¨rk procedure
|Satoshi Okugi＊||Masaaki Koide＊||Kazumasa Watanabe＊|
|Yoshifumi Kunii＊||Minori Tateishi＊||Yosuke Sakurai＊|
|Risa Shimbori＊||Hiroki Moriuchi＊|
（Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital＊, Hamamatsu, Japan）
The patient in this case was a boy aged 2 years and 9 months. The patient was transferred to our hospital with ductal shock, and bilateral pulmonary artery banding was performed on the 9th day after the diagnosis of interruption of the aortic arch, ventricular septal defect, subaortic stenosis, and bicuspid aortic valve. Left ventricular outflow tract stenosis due to aortic annulus diameter and subaortic stenosis after repair was suspected. Damus-Kaye-Stansel（DKS）anastomosis, extended aortic arch anastomosis, and a right modified Blalock-Taussig operation were performed. Preoperative examination of the intracardiac repair showed growth of the aortic annulus and confirmed that biventricular repair was possible after DKS take-down. The patient’s native aortic and pulmonary valves were preserved, and an intracardiac repair was performed without using an extracardiac conduit. The postoperative course was uneventful, and the patient is currently in a good condition at the age of 6 years. Three and a half years after surgical intervention, echocardiography and cardiac catheterization showed improvement of subaortic stenosis and enlargement of the aortic annulus. Our findings indicate that the most appropriate surgical procedure can be selected by detailed examination of the preoperative condition at each stage of the staged operation.
Jpn. J. Cardiovasc. Surg. 49:261-266（2020）
Keywords：congenital heart disease;interruption of the aortic arch;subaortic stenosis;bicuspid aortic valve;biventricular repair
|Kiyotaka Suzuki＊||Hiroshi Tsuneyoshi＊||Takehide Akimoto＊|
|Chikara Ueki＊||Ken Yamanaka＊||Masahiro Hirano＊|
（Department of Cardiovascular Surgery, Shizuoka General Hospital＊, Shizuoka, Japan）
We herein report a case of cardiac tumor resection through a right mini-thoracotomy. A 48-year-old man exhibited no symptoms. A mass was detected incidentally in the right atrium on computed tomography. We performed resection under cardiopulmonary bypass through a right mini-thoracotomy. Histopathological examination confirmed that this tumor was a lipoma. The patient’s postoperative recovery was uneventful. He was discharged on postoperative day 6. As cardiac tumor resection through right mini-thoracotomy is minimally invasive, this approach may be useful for surgery in cases of benign cardiac tumors.
Jpn. J. Cardiovasc. Surg. 49:267-270（2020）
Keywords：right mini-thoracotomy;cardiac tumor;lipoma
|Yasuka Nakanishi＊||Mitsuru Yuzaki＊||Kentaro Honda＊|
|Masahiro Kaneko＊||Takahiro Fujimoto＊||Kota Agematsu＊|
|Mitsugi Nagashima＊||Yoshiharu Nishimura＊|
（Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University＊, Wakayama, Japan）
A 67-year-old man with dyspnea at rest was diagnosed with acute heart failure and admitted to our hospital. Echocardiogram showed severe AR, and CT implied an ascending aortic aneurysm and abnormal space in the aortic root. The patient underwent emergent surgery for suspected acute aortic dissection. Intraoperative findings showed the dehiscence of commissure of the aortic valve, and more, the abnormal space in the aortic root was not due to acute aortic dissection but an aortic subannular left ventricular aneurysm. The aneurysm was sutured and closed, and after that, aortic valve replacement and ascending aortic replacement were performed. Although subannular left ventricular aneurysm is a rare disease, it is important to carry out the preoperative evaluation considering the existence of such diseases.
Jpn. J. Cardiovasc. Surg. 49:271-274（2020）
Keywords：aortic subannular left ventricular aneurysm;bicuspid aortic valve;infectious endocarditis
|Yuto Narumiya＊||Hideo Yoshida＊||Yu Oshima＊|
|Yoshimasa Kishi＊||Shohei Yokoyama＊||Kenji Yoshida＊|
|Munehiro Saiki＊||Atsushi Tateishi＊||Keiji Yunoki＊|
（Department of Cardiovascular Surgery, Hiroshima Citizens Hospital of Hiroshima City Hospital Organization＊, Hiroshima, Japan）
Mitral valve surgeries for cases with mitral annular calcification（MAC）are challenging because of the operative complications. For a case of MS with MAC, we achieved mitral valve plasty by ultrasonic decalcification alone. An 82-year-old male with edema and dyspnea was diagnosed with AS and MS with MAC. MAC was so severe that MVR was challenging. There were calcifications at the anterior commissure and the anterior mitral leaflet（AML), and removal of them was expected to improve the valve function. Therefore, anterior commissurotomy and ultrasonic decalcification of the anterior commissural annulus was performed using cavitron ultrasonic surgical aspiration（CUSA). Following the resection of the aortic valve, we carried out decalcification of the AML through the aortic valve orifice. After AVR, a trans-esophageal echocardiogram showed MS was ameliorated. Two years after surgery, recurrence of MS was not recognized. Some mitral cases with MAC can be treated by only decalcification to avoid risky valve replacement.
Jpn. J. Cardiovasc. Surg. 49:275-279（2020）
|Takehiro Kishigami＊||Sho Matsuyama＊||Toru Yasutsune＊＊|
|Yosuke Nishimura＊＊||Masato Sakamoto＊|
（Department of Cardiovascular Surgery, Kitakyushu Municipal Medical Center＊, Kitakyushu, Japan, and Department of Cardiovascular Surgery, School of Medicine, University of Occupational and Environmental Health, Japan＊＊, Kitakyushu, Japan）
Post-myocardial infarction ventricular septal perforation（VSP）is one of the lethal complications of transmural myocardial infarction. Although the treatment of VSP mostly requires surgical procedures using heterologous pericardium, thromboembolism rarely occurs in patients who undergo VSP repair. Herein we report the case of a patient who died of sudden massive cerebral infarction two weeks after the surgery. The autopsy findings revealed concaved mural LV thrombus in the dissected heart. It is suspected that the patient died of extensive cerebral infarction due to thromboembolic occlusion of the carotid or central cerebral artery. In the postoperative period after VSP repair, several risk factors for thrombus formation may occur, such as postoperative hypercoagulability due to systemic inflammation by the high operative invasiveness, the presence of foreign material in the impaired left ventricle, or pericardial patch suturing methods. Our clinical experience indicates that meticulous postoperative management may be needed, keeping LV thrombus formation in mind after VSP repair.
Jpn. J. Cardiovasc. Surg. 49:280-283（2020）
Keywords：post-myocardial infarction ventricular septal perforation;myocardial infarct exclusion;cardiogenic cerebral infarction
|Ryota Nomura＊||Masanao Nakai＊||Shinji Kawaguchi＊|
|Yuta Miyano＊||Shinnosuke Goto＊||Yasuhiko Terai＊|
|Muneaki Yamada＊||Hiroshi Mitsuoka＊||Fumio Yamazaki＊|
（Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital＊, Shizuoka, Japan）
An 87-year-old man underwent a transcatheter aortic valve implantation（TAVI）for severe aortic stenosis. Approximately 8 months later, he was readmitted to our institution because of a cerebral infarction. Viridans Streptococcus was identified from the blood culture, and transesophageal echocardiography revealed a mobile mass on the leaflet. Prosthetic valve endocarditis（PVE）was diagnosed and we initially administered intravenous antibiotic therapy for 4 weeks, after which the patient underwent surgical aortic valve replacement. Herein, we report on the surgical AVR in the patient using a pericardial valve after successful removal of the infected prosthetic valve, and discuss some issues related to this rare complication after TAVI.
Jpn. J. Cardiovasc. Surg. 49:284-287（2020）
|Yasuyuki Kanno＊||Yasuyuki Kato＊||Hidetaka Yamauchi＊|
|Taiyo Jinno＊||Yusuke Date＊||Kenichi Sasaki＊|
|Atsushi Shimizu＊||Hiroshi Kiyama＊|
（Department of Cardiovascular Surgery, Saitama Sekishinkai Hospital＊, Sayama, Japan）
A 65-year-old man who had been taking warfarin for a mitral mechanical valve, was transported to our hospital for acute heart failure 3 months after switching to edoxaban. The fluoroscopy revealed restriction of the mechanical valve opening, and the catheterization showed an increased pressure gradient of the mechanical valve. The patient was diagnosed with valve thrombosis, and emergency redo mitral valve replacement was performed. The patient recovered well without complication. In cases with mechanical heart valves, sufficient explanation and education about warfarin administration is mandatory for patients’ home doctors as well as patients and their families.
Jpn. J. Cardiovasc. Surg. 49:288-290（2020）
Keywords：direct oral anticoagulants;mechanical valve;valve thrombosis
|Hiroyuki Kawaura＊||Hideki Morita＊||Riki Sumiyoshi＊|
|Takehiro Shirasugi＊||Hiroshi Nagano＊|
（Department of Emergency Medicine＊, and Department of Cardiovascular Surgery＊＊, Saitama Red Cross Hospital, Saitama, Japan）
We encountered a case of aortic root replacement of a prosthesis-patient mismatch（PPM）after performing aortic valve replacement（AVR）with the Bjo¨rk-Shiley Monostrut（BSM）valve. The patient was a 55-year-old female. She underwent AVR with a bioprosthesis for the treatment of congenital aortic stenosis at 20 years of age;AVR was performed again using the BSM valve at 28 years of age. Congestive heart failure gradually worsened, and she was referred to our hospital at 55 years of age, where she was diagnosed with PPM after AVR. Under general anesthesia, standard median resternotomy was performed, and cardiopulmonary bypass was established with right femoral artery and right femoral vein cannulation. Cardiac arrest was achieved with the antegrade application of a cold, crystalloid, cardioplegic solution. The BSM valve was removed, and her annulus was extremely small, measuring less than 19mm. We performed an aortic root replacement with a 21mm mechanical valve composite graft because aortic root enlargement was difficult owing to the fragility of her annulus and very severe adhesion surrounding the ascending aorta. The postoperative course was uneventful. Postoperative ultrasonic echocardiography showed reduced transvalvular mean gradients. Although the BSM valve is durable, non-structural valvular deterioration surrounding the implanted BSM valve may occur and should be monitored.
Jpn. J. Cardiovasc. Surg. 49:291-294（2020）
Keywords：Bjo¨rk-Shiley valve;redone valve replacement;aortic root replacement
|Shinji Abe＊||Yasuhiro Kamikubo＊||Ryo Matsumoto＊|
（Department of Cardiovascular Surgery, Kushiro-City General Hospital＊, Kushiro, Japan）
During aortic arch replacement in response to an aortic arch aneurysm sealed rupture, we experienced a case in which weaning from cardio-pulmonary bypass（CPB）became difficult, and pulmonary artery stenosis developed due to expanded hematoma. A 77-year-old man was raced to our hospital due to subjective symptom of chest/back pain. With a recognition of aortic arch aneurysm and hematoma around the aneurysm, it was diagnosed as an aortic arch aneurysm sealed rupture. Even though an elective aortic arch replacement was implemented using an open stent graft, reduction in blood pressure and poor oxygenation was observed at the process of CPB weaning. As a result of intraoperative pulmonary arteriography, severe stenosis was revealed on both left and right pulmonary arteries. With placement of a self-expanding stent, weaning from CPB was successfully completed. Being transferred to other hospital on day 60 after the surgery in order to continue rehabilitation, the man visits our hospital as an outpatient on his own as of now. As it is considered to be a rare case that weaning from CPB was successfully performed by pulmonary stenting in response to progressed intraoperative pulmonary artery stenosis caused by expanded hematoma after heparin administration, the details are reported here.
Jpn. J. Cardiovasc. Surg. 49:295-299（2020）
Keywords：aortic arch aneurysm;cardio-pulmonary bypass;pulmonary artery stenosis;pulmonary artery stenting
|Kentaro Kasa＊||Shigeru Shinozaki＊||Suguru Watanabe＊|
（Department of Cardiovascular Surgery, Japanese Red Cross Ishinomaki Hospital＊, Ishinomaki, Japan）
A fifty-seven-year-old male farmer with a history of cerebral infarctions twice in the past without any functional disability stopped prescribed antithrombotics and regular medical follow-up. He had sudden left hemiplegia after the work, and was taken to our hospital. A contrast-enhanced computed tomography（CT）scan showed infarction at the right basal ganglia, occlusion of the internal carotid artery and the left vertebral artery, and mural thrombus in the ascending aorta. Mural thrombus in the ascending aorta was suspected to be the causative thrombus of other infarctions. He was started on continuous heparin infusion on the day of presentation, and had ascending aortic replacement surgery on day 24. No perioperative complication was confirmed. He was extubated on postoperative day（POD）1, and was transferred to another rehabilitation hospital with almost no functional disability. No thrombotic event was confirmed as of POD 180.
Jpn. J. Cardiovasc. Surg. 49:300-304（2020）
Keywords：mural thrombosis in the ascending aorta;occlusion of internal carotid artery;occlusion of vertebral artery;ascending aortic replacement
|Satoshi Kikusaki＊||Keiichi Akaiwa＊||Katsuhiko Nakamura＊|
（Department of Cardiovascular Surgery, Omura Municipal Hospital＊, Omura, Japan）
Both aortic dissection and aortic aneurysm are complicated with disseminated intravascular coagulation（DIC）at the rate of four percent. DIC is said to be caused by the imbalance between coagulation and fibrinolysis and is classified into three types:suppressed fibrinolysis, balanced fibrinolysis, and enhanced fibrinolysis. Tranexamic acid has effects on suppressing the fibrinolytic system by inhibiting the mechanism by which plasmin decomposes fibrin. It is generally considered that the use of tranexamic acid for DIC is contraindicated. However, some reports show its effectiveness for non-infective chronic DIC. We illustrate two cases of DIC with enhanced fibrinolysis which are complicated with aortic dissection or aortic aneurysm that were successfully treated with tranexamic acid.
Jpn. J. Cardiovasc. Surg. 49:305-309（2020）
Keywords：tranexamic acid;disseminated intravascular coagulation;aortic dissection;aortic aneurysm
|Keita Hayashi＊1||Takurin Akiyoshi＊2||Kentaro Matsubara＊3|
（Department of Vascular Surgery, Hiratsuka City Hospital＊1, Hiratsuka, Japan, and The Shonan Hiratsuka Varicose Vein Clinic＊2, Hiratsuka, Japan, Department of Surgery, Keio University School of Medicine＊3, Tokyo, Japan, and Department of Vascular Surgery, Shimokitazawa Hospital＊4, Tokyo, Japan）
Popliteal artery entrapment syndrome（PAES）is a rare cause of intermittent claudication. Optimal strategies and management have been debated. We report two cases of PAES that were treated with respective different procedures. Case 1:A 53-year-old male with intermittent claudication was referred to our department with PAES with a decrease in the ankle brachial index（ABI）with plantar flexion. Computed Tomography（CT）and Magnetic Resonance Imaging（MRI）showed medial deviation and compression of the popliteal artery by the medial head of the gastrocnemius muscle. The patient received excision of the medial head of the gastrocnemius muscle and thrombectomy of the popliteal artery. The diagnosis was confirmed as PAES type 2 during the procedure. Case 2:A 37-year-old male presenting intermittent claudication and declining ABI in his left lower extremity was diagnosed with PAES by contrast CT. MRI and CT indicated that a fibrous band was compressing the popliteal artery. The findings of the imaging studies were confirmed during the subsequent surgical procedure and it was diagnosed as PAES type 4. In addition to removal of the band, popliteal artery interposition using a saphenous vein graft was performed due to severe stenosis with intimal hyperplasia. Pathological findings of the excised artery showed intimal hyperplasia and degeneration of elastic fibers in the media due to chronic compression. Although a large volume of retrospective data exists on PAES, recommendation of a particular operative procedure has not yet been derived. Thus, the treatment for PAES should be individually determined based on etiology and status of affected vessels.
Jpn. J. Cardiovasc. Surg. 49:310-316（2020）
Keywords：popliteal artery entrapment syndrome;popliteal artery;intermittent claudication
|Chiharu Tanaka＊||Daichi Takagi＊＊|
（Department of Cardiovascular Surgery, Tokai University Hachioji Hospital＊, Tokyo, Japan, and Akita University Hospital＊＊, Akita, Japan）
Japanese board of cardiovascular surgery is changing to new system. To discuss about future education, the cardiovascular surgeons should know more about the new system. The present article demonstrated the questionnaire survey about the board, and evaluated its outcome. This is the first article of the column series about the board. We hope the article is useful information for the young surgeons, and the surgeons will discuss about better environment for training in new era.
Jpn. J. Cardiovasc. Surg. 49（5）:U1-U5（2020）
Keywords：Japanese board of cardiovascular surgery;young cardiovascular surgeons;questionnaire survey