|Hanae Sasaki＊||Ryosuke Kowatari＊||Yasuyuki Suzuki＊＊|
|Kazuyuki Daitoku＊||Ikuo Fukuda＊|
（Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine＊, Hirosaki, Japan, and Department of Cardiovascular Surgery, Ibaraki Clinical Education and Training Center, University of Tsukuba Hospital＊＊, Kasama, Japan）
The patient was a six-month-old girl with an anomalous origin of the left coronary artery from the pulmonary artery（ALCAPA). She had fever and visited a family physician at 5 months of age. Because of poor oxygenation, she was referred to our pediatric department and intubated soon after hospitalization. Echocardiography showed that the orifice of left coronary artery was just above pulmonary commissure, the left ventricular ejection fraction was 9%, and the level of mitral regurgitation was moderate. Right coronary angiography showed that the left coronary artery contrasted against the collateral arteries. The left coronary artery originated from the left side of the pulmonary trunk. After recovery of the general condition with medical therapy, the patient underwent coronary artery reconstruction by the modified spiral cuff technique on the 21st day of hospitalization. The temporary detachment of pulmonary valve and its commissure for making a margin around the left coronary artery enabled us to make the spiral cuff in almost the usual manner. She was moved to the intensive care unit with the support of extracorporeal membrane oxygenation（VA-ECMO）and was successfully weaned off the VA-ECMO 5 days after the surgery. The postoperative course was good, and she was discharged from our hospital 3 months after the surgery. The echocardiogram one year after the surgery showed a left ventricular ejection fraction of 30%, mild mitral regurgitation, and mild pulmonary regurgitation. Our experience indicates that the spiral cuff technique is a useful coronary reconstruction method for the treatment of ALCAPA, especially in cases presenting a considerable distance between the origin of the left coronary artery and the transplantation site. There are few reports regarding the surgical treatment of infantile ALCAPA showing reduced left ventricular function. Coronary artery reconstruction using the spiral cuff method and planned VA-ECMO are useful surgical procedures in such cases. Our experience also suggests that the establishment of a treatment strategy including mechanical support is essential to improve the results in severe ALCAPA cases.
Jpn. J. Cardiovasc. Surg. 49:325-329（2020）
Keywords：anomalous origin of the left coronary artery from the pulmonary artery;Bland-White-Garland syndrome;spiral cuff technique;detachment of posterior commissure
|Toru Koakutsu＊||Masanao Nakai＊||Daisuke Uchiyama＊|
|Shinji Kawaguchi＊||Yuta Miyano＊||Muneaki Yamada＊|
|Yasuhiko Terai＊||Shinnosuke Goto＊||Fumio Yamazaki＊|
（Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital＊, Shizuoka, Japan）
The patient was a 34-year-old woman who had been routinely monitored after receiving a childhood diagnosis of partial anomalous pulmonary venous connection, but unilaterally discontinued follow-up examinations after the age of 18. At 33 years of age, she was admitted to our hospital after a physical examination revealed an abnormal shadow on a chest X-ray. Transthoracic echocardiography detected an atrial septal defect（ASD), and contrast-enhanced computed tomography showed that the right lower pulmonary vein drained to the inferior vena cava. The patient was diagnosed with scimitar syndrome with ASD. Cardiac catheterization showed a pulmonary/systemic flow ratio（Qp/Qs）of 2.48 and a left-to-right shunt rate of 59.7%. Surgical treatment was deemed to be indicated. The right lower pulmonary vein was anastomosed to the anterolateral wall of the right atrium, and an intra-atrial baffle repair was performed from the orifice within the right atrium to the left atrium through the existing ASD using untreated fresh autologous pericardium. Two years after the operation, good blood flow was maintained within the baffle with no stenosis at the anastomotic site. This report describes a rare case of scimitar syndrome with ASD in an adult woman, and provides a review of the existing literature.
Jpn. J. Cardiovasc. Surg. 49:330-334（2020）
Keywords：scimitar syndrome;partial anomalous pulmonary venous connection;intra-atrial baffle repair
|Shigeto Miyasaka＊||Suguru Shiraya＊＊||Tomohiro Kurashiki＊|
|Yuuki Sakaguchi＊||Junpei Tokutome＊|
（Department of Cardiovascular Surgery, Tottori Prefectural Central Hospital＊, Tottori, Japan, and Department of Cardiovascular Surgery, Hamada Medical Center＊＊, Hamada, Japan）
Congenital mitral regurgitation（MR）occurs infrequently and the number of reported adult surgical cases is small. A 77-year-old man presented with an exacerbation of congestive heart failure. He had a 19-year history of receiving medical treatment for MR and atrial fibriration. Transthoracic and transesophageal echo cardiograms revealed severe MR due to the restriction of the posterior mitral leaflet with very short chorda tendanea attached beneath the posterior leaflet preoperatively. We diagnosed this case to have congenital MR（Carpentier type III）in an adult based on the specific findings of echocardiography and mitral valve plasty was thus performed. All the dysplastic chordae of the P2 and P3 in the immovable leaflet region were cut and the reconstructed by the fifth artificial chordae. These procedures successfully allowed the posterior mitral leaflet to recover its normal shape and movability. Postoperative echocardiography showed no further mitral regurgitation and normal leaflet motion.
Jpn. J. Cardiovasc. Surg. 49:335-338（2020）
Keywords：congenital mitral regurgitation;adult;mitral valve repair
|Yuko Kubota＊||Hidekazu Hirai＊||Takanobu Aoyama＊|
|Hiroyuki Seo＊||Yasuo Suehiro＊||Shigefumi Suehiro＊|
（Department of Cardiovascular Surgery, Osaka Saiseikai Noe Hospital＊, Osaka, Japan）
Essential thrombocythemia is considered one of the chronic myeloproliferative disorders resulting in arterial thromboembolism, venous thrombosis, and bleeding tendency. We report a case of left ventricular aneurysm with successful treatment of the complications of this disease. A 66-year-old man who suddenly experienced right upper limb paralysis was carried to a nearby hospital. Computed tomography revealed multiple cerebral infarctions. An electrocardiogram confirmed findings of old myocardial infarctions in the anteroseptal wall. Echocardiography indicated a left ventricular aneurysm with mobile thrombus. The blood tests showed an abnormally high platelet count of 120×104/μl. His left ventricular thrombus showed an increasing tendency regardless of heparin administration;thus, he was transferred to our hospital. The resection of the aneurysm and left ventricular restoration was performed emergently to avoid re-embolism. There was a soft thrombus inside the aneurysm at its apex. During cardiopulmonary bypass, the activated clotting time was not prolonged easily. We gave additional heparin and antithrombin III. The patient had no problem with hemostasis or postoperative bleeding. We started low-molecular-weight heparin from the second postoperative day and he was diagnosed with essential thrombocythemia by bone marrow biopsy. We started warfarin and aspirin on the fifth day after surgery. The number of platelets increased to 183×104/μl on the 8th day;thus, oral administration of hydroxycarbamide was started. His platelet count fell to less than 100×104/μl around 3 weeks after surgery and he was discharged on the 34th day without new embolisms.
Jpn. J. Cardiovasc. Surg. 49:339-343（2020）
Keywords：essential thrombocythemia;cardiac surgery;left ventricular aneurysm;perioperative care
|Takuya Nishijima＊,＊＊||Kojiro Furukawa＊,＊＊||Yuichiro Hirata＊,＊＊|
|Tatsushi Onzuka＊,＊＊||Eiki Tayama＊,＊＊||Shigeki Morita＊,＊＊|
（Department of Cardiovascular Surgery＊, and Clinical Research Institute＊＊, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan）
Hypertrophic cardiomyopathy with apical aneurysm is known to have high risk of a sudden death due to ventricular arrhythmias or thromboembolisms. We report a surgical case of surgical case of this disease. A 67-year-old man was found to have abnormality in an electrocardiogram during his checkup, and subsequent careful examinations revealed his disease. He had no symptoms and the pressure gradient at the obstruction was about 30mmHg, but there was thrombus in the apical aneurysm. After anticoagulant therapy, the thrombus dissolved. We scheduled an operation on him because he was judged to have high risk of a sudden death. In the operation, excision of the apical aneurysm, and hypertrophic midventricular myocardium were performed, concomitant with cryoablation to the border between the aneurysm and normal myocardium. Although complete atrioventricular block occurred postoperatively and he needed permanent pacemaker implantation, he was discharged from the hospital 21 days postoperatively without any other complications. He is doing well at two years and six months, postoperatively.
Jpn. J. Cardiovasc. Surg. 49:344-348（2020）
Keywords：hypertrophic cardiomyopathy;apical aneurysm
|Shuji Nagatomi＊||Kazuhisa Matsumoto＊||Ryo Imada＊|
|Fumiya Ono＊||Naoki Tateishi＊||Yoshiya Shigehisa＊|
（Cardiovascular and Gastroenterological Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan）
We present a successful case of a patient with multiple metal allergy―cobalt, nickel, chromium, and zinc―who had a past history of systemic metal dermatitis. He was a 58-year-old man who complained of exertional chest discomfort. After admission, he had a fever and his blood culture was positive with methicillin-sensitive Staphylococcus aureus. Three days later, multiple micro cerebral infraction was detected in magnetic resonance imaging. After an improvement of inflammatory reaction, he was transferred to our facility for cardiac examination. Moderate mitral regurgitation due to valve perforation and multiple coronary vessel stenosis were detected. Mitral valve replacement and coronary artery bypass grafting were planned to perform. We chose surgical materials based on a preoperative epicutaneous（patch）test and his clinical course was uneventful without any allergic reaction. Metal contact allergy is an important issue in cardiovascular surgery. A collaboration with dermatologists is essential for the preparation of surgical materials.
Jpn. J. Cardiovasc. Surg. 49:349-353（2020）
Keywords：metal allergy;surgical implant;mitral valve replacement
|Toshiro Ito＊||Shunsuke Ohhori＊||Masato Suzuki＊|
|Kiyotaka Morimoto＊||Hideo Yokoyama＊||Youhei Ohkawa＊|
（Cardiovascular Surgery, Hokkaido Ohno Memorial Hospital, Sapporo, Japan）
A 71-year-old female, who had diabetes mellitus and chronic renal failure on dialysis, had undergone mitral valve repair and tricuspid valve annuloplasty. Five months after the operation, she suffered from infectious endocarditis and underwent mitral valve replacement. Postoperatively, a total fluid volume of 300 to 600ml/day was drained from the pericardial tube, and its appearance became milky after the start of oral intake of food. She was diagnosed with chylomediastinum. Despite fasting and total parenteral nutrition for 2 weeks and subcutaneous octreotide administration, the volume of fluid drainage was not reduced. Therefore, we planned lymphangiography treatment with Lipiodol on postoperative day 37. On operation, under local anesthesia, the left inguinal lymph node was punctured under ultrasound guidance, and Lipiodol was injected at a rate of 12ml/h for 1h. On the next day, the volume of fluid drainage was reduced, and the pericardial tube could be removed 9 days after lymphangiography.
Jpn. J. Cardiovasc. Surg. 49:354-357（2020）
|Satoshi Arimura＊||Mitsutaka Nakao＊||Naritomo Nishioka＊|
|Yohkoh Matsumura＊||Michio Yoshitake＊||Ryuichi Nagahori＊|
|Ko Bando＊||Kiyozo Morita＊||Takashi Kunihara＊|
（Department of Cardiac Surgery, Jikei University School of Medicine, Tokyo, Japan）
Here, we present a case of successful aortic valve repair of traumatic aortic regurgitation（AR). A man in his early twenties had a chest blunt trauma due to a bicycle accident 6 years earlier and suffered sternum fracture. He recovered without cardiovascular complications. Three months previously, a new diastolic murmur was detected on medical checkup. Transthoracic echocardiography（TTE）showed severe AR, and the left ventricular end-diastolic-/end-systolic dimension was 69/51mm. Transesophageal echocardiography showed severe AR with perforation of the non-coronary cusp and dilatation of the aortic annulus（29.6mm). Aortic valve repair was performed with an autologous pericardial patch and external suture annuloplasty. Postoperative TTE showed normal aortic valve function with trivial AR. He was discharged on postoperative day 11. Three months later, TTE showed trivial AR along with a reduced left ventricular dimension and improved left ventricular ejection fraction.
Jpn. J. Cardiovasc. Surg. 49:358-361（2020）
Keywords：traumatic aortic regurgitation;aortic valve repair;autologous pericardial patch;annuloplasty;aortic regurgitation
|Hitoshi Suzuki＊||Yasuhiro Sawada＊||Kentaro Inoue＊＊|
|Masaki Yada＊＊＊||Uhito Yuasa＊＊＊||Chiaki Kondo＊|
（Department of Cardiovascular Surgery, Mie Prefectural General Medical Center＊, Yokkaichi, Japan, Department of Cardiovascular Surgery, Matsusaka Chuo General Hospital＊＊, Matsusaka, Japan, and Department of Cardiovascular Surgery, Kuwana City Medical Center＊＊＊, Kuwana, Japan）
Entrapment of an intravascular ultrasonography（IVUS）catheter is an infrequent but serious complication associated with percutaneous coronary intervention（PCI). We report a case of successful surgical treatment of an IVUS catheter entrapped in a coronary stent after PCI. An-80-year-old man was admitted to a hospital with sudden anterior chest pain. He underwent PCI to left circumflex branch（Cx）and left anterior descending artery（LAD), followed by IVUS to ascertain stent expansion of the LAD stent. The IVUS catheter became entangled in the stent and could not be withdrawn from the outside. The patient was transferred to our hospital for its surgical removal. For the emergent surgery, we opened the stent region in the LAD and directly removed the IVUS catheter with the twisted stent. The opened place in the LAD was directly closed. Additional coronary bypass grafting involving two vessels was performed. The postoperative course was uneventful with no graft occlusion.
Jpn. J. Cardiovasc. Surg. 49:362-365（2020）
Keywords：Intravascular Ultrasonography（IVUS）Catheter;coronary stent;surgical removal
|Masayuki Nishiyama＊||Hiroaki Sasaki＊||Kouki Yokawa＊|
|Takayuki Shijyo＊||Yosuke Inoue＊||Yoshimasa Seike＊|
|Kyokun Uehara＊||Hitoshi Matsuda＊|
（Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan）
We present a 62-year-old woman who was diagnosed with primary pulmonary arterial sarcoma with pulmonary hypertension. CT showed a large defect inside both main pulmonary arteries in accordance with the accumulation of FDG-PET. To relieve the symptom and to prevent sudden death, removal of a massive pulmonary tumor and postoperative chemotherapy were planned. Utilizing the intermittent systemic circulatory arrest under deep hypothermia（18℃), the pulmonary artery trunk and both main pulmonary arteries were opened. The tumor stacking inside the pulmonary artery was removed and its origin at the commissure of the pulmonary artery valve was resected. The defect was repaired with a pulmonary valve replacement. Histopathological examination revealed high grade sarcoma. Her postoperative course was uneventful;however, she died of cerebral hemorrhage during chemotherapy six months after surgery.
Jpn. J. Cardiovasc. Surg. 49:366-369（2020）
Keywords：pulmonary hypertension;primary pulmonary artery sarcoma
|Shuji Tachioka＊||Katsuya Kawagoe＊＊||Yosuke Hisashi＊＊|
（Department of Cardiovascular and Gastrointestinal Surgery, Kagoshima University＊, Kagoshima, Japan, and Department of Cardiovascular Surgery, Miyazaki Prefectural Miyazaki Hospital＊＊, Miyazaki, Japan）
Herein, we report a rare case of a pseudoaneurysm at the anastomotic site of the bicarotid trunk after thoracic aortic graft replacement. A 53-year-old man with Marfan syndrome underwent a three-stage operation involving aortic root reimplantation and ascending aortic replacement;aortic valve replacement and total arch replacement;and descending aortic replacement performed for type A dissection combined with an aberrant right subclavian artery. Two years after total arch replacement, the patient presented with hoarseness and a computed tomography scan revealed an anastomotic pseudoaneurysm of the common trunk of the left and right carotid arteries. A right axillary artery-common carotid artery bypass was performed, with simultaneous insertion of a vascular stent graft from the left common carotid artery to the anastomotic site. Cervical bypass and stent implantation were both performed without shunting. He was discharged home without any neurological complications.
Jpn. J. Cardiovasc. Surg. 49:370-374（2020）
Keywords：anastomotic pseudoaneurysm;endovascular repair;bicarotid trunk
|Yoshihiro Honda＊||Yukiyo Yoshida＊||Koji Kawago＊|
|Satoru Shiraiwa＊||Kenji Sakakibara＊||Shigeaki Kaga＊|
（Department of Surgery II, Faculty of Medicine, University of Yamanashi＊, Yamanashi, Japan）
Background:Fungal mycotic aneurysm is rare;however, special care and treatment are required for the deep fungal infection itself. Case:The patient was a 69-year-old man with a history of sepsis due to Candida albicans. He suffered from back pain and moderate fever. CT revealed saccular-form aneurysm at the infrarenal abdominal aorta. After emergent in situ bifurcated graft replacement of the infected aneurysm, antifungal treatment was attempted in reference to the antifungal drug sensitivity of C. albicans from intraoperative cultures and findings of fungal endophthalmitis in an ophthalmic examination. After an uneventful acute course, follow up CT images after 12 months postoperatively revealed pseudoaneurysm formation proximal to the site of graft anastomosis. Reoperation was planned with a trans-thoracic and transabdominal approach because of concerns about thoracoabdominal aortic infection. However, the reoperation displayed only inflammatory tissue around the graft and aortic tissue. Removal of the previous graft and reconstruction of the bilateral renal artery, and the pararenal abdominal aorta to the bilateral common iliac artery was performed. Intraoperative tissue cultures revealed no evidence of microorganisms. He returned home with oral antifungal treatment and is doing well at 8 months after the reoperation. Conclusions:Management of fungal mycotic aneurysms requires both surgical treatment and antifungal treatment. Antifungal agents should be selected based on the results of a susceptibility test and after examinations for metastatic comorbidities.
Jpn. J. Cardiovasc. Surg. 49:375-379（2020）
Keywords：aortic aneurysm;mycotic aneurysm;fungal infection;Candidiasis;antifungal treatment
|Chihiro Ito＊||Hideki Ueda＊||Hiroki Kohno＊|
|Kaoru Matsuura＊||Yusaku Tamura＊||Michiko Watanabe＊|
（Department of Cardiovascular Surgery, Chiba University Hospital＊, Chiba, Japan）
A 57-year-old man, who had suffered chest, back and right leg pain about 10 years before, underwent CT and was found a chronic type B aortic dissection with an enlarged false lumen and a narrowed true lumen that was occluded at the infrarenal abdominal aorta. A conventional surgical repair seemed to be too high risk considering his comorbidities, thus we chose a staged hybrid repair. First, surgical repair of the abdominal aorta with an abdominal aortic fenestration was performed. Then, one month after the first operation, zone 2 thoracic endovascular aortic repair with left carotid-axillary artery bypass was performed. At the second operation, the stent graft was purposely deployed from zone 2 into Th12 level of a false lumen through the fenestration followed by coil embolization of a true lumen just distal to the entry tear. The postoperative course was uneventful and he had no complications at 6 months follow-up. Deploying stent graft into a false lumen could be a feasible option in case deploying into a true lumen is not suitable if the anatomical condition permits.
Jpn. J. Cardiovasc. Surg. 49:380-384（2020）
Keywords：chronic type B aortic dissection;TEVAR;deployment into false lumen;aortic fenestration
|Ryuki Yamada＊||Hideki Ueda＊||Hiroki Kono＊|
|Kaoru Matsuura＊||Michiko Watanabe＊||Tomohiko Inui＊|
|Yasunori Yakita＊||Yusuke Shibata＊||Hiroaki Yamamoto＊|
（Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine＊, Chiba, Japan）
We report a 48-year-old man who underwent hybrid aortic repair for visceral aortic patch（VAP）aneurysm. He had undergone descending thoracic aortic repair for post-dissection aneurysm at the age of 25, ascending aorta and proximal aortic arch aneurysm repair at the age of 27, and residual thoracoabdominal dissecting aortic aneurysm repair with VAP reconstruction at the age of 28. During 20 years of follow-up, the VAP gradually enlarged and eventually reached 70×61mm in diameter. Considering a possible severe adhesion after 2 previous left thoracotomies, we planned a 2-staged hybrid aortic repair. First, we performed reno-visceral debranching and as a second stage operation, endovascular aortic repair was performed successfully 39 days after the first-stage operation.
Jpn. J. Cardiovasc. Surg. 49:385-389（2020）
Keywords：visceral aortic patch aneurysm;hybrid aortic repair
|Shintaro Takago＊||Hiroki Kato＊||Naoki Saito＊|
|Hideyasu Ueda＊||Kenji Iino＊||Keiichi Kimura＊|
（Thoracic, Cardiovascular and General Surgery, Kanazawa University＊, Kanazawa, Japan）
A 52-year-old man underwent a medical examination, including abdominal computed tomography（CT). Abdominal CT revealed a common hepatic artery aneurysm（25mm in diameter）;a portion of the aneurysm depressed the pancreas. The gastroduodenal artery branched off the common hepatic artery aneurysm. We planned coil embolization for the common hepatic artery aneurysm. However, we could not avoid occluding the proper hepatic artery;therefore, we performed abdominal aortic-proper hepatic artery bypass with coil embolization. The patient’s postoperative course was uneventful.
Jpn. J. Cardiovasc. Surg. 49:390-394（2020）
Keywords：common hepatic artery aneurysm;coil embolization
|Hiroko Nemoto＊||Takahiro Ito||Ryo Izubuchi|
|Tomoki Sakata||Hirokazu Niitsu||Ryuji Hojo|
|Takao Miki||Yasutaka Yokoyama|
（Department of Cardiovascular Surgery, Yokohama City University Hospital＊, Yokohama, Japan）
The system of the Japanese Board of Cardiovascular Surgery is changing. Since the last time, we have deliberated on the medical specialty board for U-40 column articles about the problems faced by young cardiovascular surgeons. This time, we conducted the second survey to U-40 members about the realities of becoming a board-certified cardiovascular surgeon. The results showed the circumstances and details on how to acquire the board certification. Moreover, we discussed about the current problems and future perspectives for the young cardiovascular surgeons.
Jpn. J. Cardiovasc. Surg. 49（6）:U1-U5（2020）
Keywords：board-certified cardiovascular surgeon;U-40;questionnaire survey