JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Vol.50, No.4

Preface

• Handing Down the Surgical Skills―Another Point of View―　M. Nishimura

Originals

• Open Repair versus Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries:　Short- and Mid-Term Outcomes　Y. Cao et al.…225
  Open Repair versus Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries:Short-and Mid-Term Outcomes
  

  Yuchen Cao＊	Masaaki Koide＊	Yoshifumi Kunii＊
  Minori Tateishi＊	Kazumasa Watanabe＊	Satoshi Okugi＊
  Risa Shimbori＊

  
  

  （Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital＊, Hamamatsu, Japan）
  

  Objective:The mainstream strategy for blunt traumatic thoracic aortic injuries（BTAI）has been shifting from conventional open repair（OR）to thoracic endovascular aortic repair（TEVAR). Accordingly, we reviewed the short- and mid-term outcomes following surgical procedures of BTAI, comparing OR with TEVAR. Methods:We retrospectively collected data of consecutive cases of BTAI in a single institution from March 2001 to August 2019. Results:Eighteen cases were identified. Of these, 7 patients（38.9%, mean age 62.0±15.2 years）were treated with OR and 11（61.1%, mean age 61.8±21.3 years）were treated with TEVAR. There was significant reduction in the mean operative duration（OR 444±145 vs TEVAR 65±14min;p＜0.001), the mean intraoperative blood loss（OR 2,787±1,578 vs TEVAR 210±376ml;p＜0.001), the volume of blood transfusions（OR 5,042±2,219 vs TEVAR 929±751ml;p＜0.001), and the mean dose of heparin infusion（OR 20.3±4.1 vs TEVAR 7.9±8.5ml;p＜0.01). Postoperative 30-day mortality of OR and TEVAR were 28.6 and 0%（p＝0.14), respectively. There was no endoleak, 1 case of paraparesis, and 1 case of bilateral cerebellar infarction in the TEVAR group. There was no significant difference in the length of stay in the intensive care unit, the duration of hospital stay, the rate of home discharge, or the mid-term mortality and re-intervention rate（average follow-up period of 42.0±56.9 months). Conclusions:Compared with OR, TEVAR took less operative time with less bleeding, and required less blood transfusions and heparin. The short- and mid-term outcomes following TEVAR for BTAI was favorable and TEVAR appears to be applicable as a first-line treatment for BTAI.

   

  Jpn. J. Cardiovasc. Surg. 50:225-230（2021）

  Keywords：blunt traumatic aortic injury;open repair;TEVAR;short- and mid-term outcome

  
  

Case Reports

• ［Congenital Heart Disease］
• Bilateral Bidirectional Glenn Anastomosis in an Adult Patient with Aneurysmal Degeneration after an Original Blalock-Taussig Shunt　Y. Murakami et al.…231
  Bilateral Bidirectional Glenn Anastomosis in an Adult Patient with Aneurysmal Degeneration after an Original Blalock-Taussig Shunt
  

  Yu Murakami＊	Yoshihiro Oshima＊	Hironori Matsuhisa＊
  Tomonori Higuma＊	Shunsuke Matsushima＊	Shota Hasegawa＊
  Yuson Wada

  
  

  （Department of Cardiovascular Surgery, Kobe Children’s Hospital＊, Kobe, Japan）
  

  A male patient with single ventricle pulmonary stenosis, and persistent left superior vena cava underwent original Blalock-Taussig shunt（BTS）at 2 years of age and suffered from infective endocarditis at 38 years of age. A systemic work-up detected dural arteriovenous fistula and aneurysmal dilatation of the original BTS. Cardiac catheterization and cardiac magnetic resonance imaging revealed an appropriate pulmonary vasculature for bidirectional Glenn anastomosis and sufficient antegrade pulmonary blood flow through the pulmonary valve. Bilateral bidirectional Glenn anastomosis and resection of the aneurysm of the BTS-associated aneurysm were successfully performed.

   

  Jpn. J. Cardiovasc. Surg. 50:231-234（2021）

  Keywords：original Blalock-Taussig shunt;subclavian artery aneurysm;bidirectional Glenn anastomosis

  
  
• A Case of Anomalous Aortic Origin of the Right Coronary Artery Treated by Direct Coronary Reimplantation　H. Uchiyama et al.…235
  A Case of Anomalous Aortic Origin of the Right Coronary Artery Treated by Direct Coronary Reimplantation
  

  Hikaru Uchiyama＊	Kojiro Furukawa＊＊	Tomofumi Fukuda＊
  Yuichiro Hirata＊	Tatsushi Onzuka＊	Eiki Tayama＊＊＊
  Shigeki Morita＊

  
  

  （Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center＊, Fukuoka, Japan, Thorac Cardiovascular Surgery, School of Medicine, Ryukyu University＊＊, Nakagami, Japan, and Department of Surgery, School of Medicine, Kurume University＊＊＊, Kurume, Japan）
  

  Anomalous aortic origin of a coronary artery is a rare congenital anomaly that can cause myocardial ischemia and ventricular arrhythmia. This disease initially manifests as cardiac arrest in half of patients. The indications and surgical strategy remain unclear, especially in patients who are asymptomatic and have poor ischemic findings. We report a surgical strategy to treat anomalous aortic origin of the right coronary artery. A 47-year-old man with a chief complaint of chest tightness was diagnosed with anomalous aortic origin of the right coronary artery, which branches from the left sinus of Valsalva and runs an inter-arterial course. Although no objective myocardial ischemia was identified with blood tests, electrocardiography, or cardiac catheterization, we suspected that the cause of the thoracic symptoms was sharp branching of the right coronary artery, which was compressed between the ascending aorta and the pulmonary artery. To reduce the risk of sudden death in the future, we performed reimplantation of the right coronary artery. Good imaging results were obtained, and the patient is currently undergoing outpatient follow up and has not experienced recurrence of chest symptoms. We conclude that our surgical strategy to treat anomalous aortic origin of a coronary artery may be useful in the clinic.

   

  Jpn. J. Cardiovasc. Surg. 50:235-239（2021）

  Keywords：anomalous aortic origin of a coronary artery;right coronary artery from the left sinus;coronary reimplantation

  
  
• Delated Senning Procedure for Transposition of the Great Arteries with Severe Pulmonary Hypertension　Y. Yamada et al.…240
  Delated Senning Procedure for Transposition of the Great Arteries with Severe Pulmonary Hypertension
  

  Yukiko Yamada＊	Ryuhei Yamamoto＊	Humiaki Shikata＊
  Toru Okamura＊	Takamasa Takeuchi＊

  
  

  （Department of Cardiovascular Surgery, Nagano Children’s Hospital＊, Azumino, Japan）
  

  We report a case of transposition of the great arteries（TGA）with severe pulmonary hypertension from the right to left shunt in the right modified Blalock-Taussig shunt. The patient was diagnosed with TGA with a small ventricular septal defect, restrictive patent foramen ovale, and patent ductus arteriosus. Balloon atrial septostomy was performed, and an arterial switch operation（ASO）was planned. However, ASO was delayed during the neonatal period due to cerebral bleeding. Moreover, left outflow tract obstruction was noted;hence, the surgical strategy was shifted to an atrial switch operation or Rastelli type operation. The patient was palliated at the age of 5 months with a right 4-mm Gore-Tex modified Blalock-Taussig shunt. After this procedure, he was followed up at the outpatient clinic with good saturation level. However, at 9 months, he revisited the hospital due to septic shock. His SpO2 was 60% in the upper right limbs and 40% in the upper left and lower limbs. Nitric oxide inhalation and 100% oxygen were administered to improve pulmonary hypertension and subsequent differential cyanosis. Pulmonary hypertension decreased from over-systemic to 70% of the systemic arterial pressure. The Senning procedure with a fenestration in an atrial baffle was successfully performed at the age of 1 year.

   

  Jpn. J. Cardiovasc. Surg. 50:240-243（2021）

  Keywords：pulmonary hypertension;transposition of the great arteries;nitric oxide;Senning procedure

  
  
• Surgical Treatment for Occlusion of Left Coronary Artery Ostium by an Aortic Valve Cusp　Y. Komori et al.…244
  Surgical Treatment for Occlusion of Left Coronary Artery Ostium by an Aortic Valve Cusp
  

  Yuya Komori＊	Naoki Wada＊	Naohiro Kabuto＊
  Yuta Kuwahara＊	Yukihiro Takahashi＊

  
  

  （Sakakibara Heart Institute, Pediatric Cardiovascular Surgery＊, Tokyo, Japan）
  

  The patient was a 4-year-old boy, with no indication of heart disease at birth. When he was 4 years and 3 months old, he underwent surgery for cryptorchidism, and persistent changes after crying, consisting of ST-segment depression, were noted on the ECG. Therefore, it was decided that a detailed examination would be carried out. Aortography revealed that a small left coronary cusp had formed a pouch and that there was a delayed washout of the contrast material in the left coronary artery compared with the right coronary artery. Right coronary angiography showed retrograde flow to the left coronary artery. There was no significant aortic regurgitation, and no stenosis in the left coronary artery. Intraoperative findings demonstrated that the hypoplastic left coronary cusp had adhered to the aortic wall and covered the left sinus of Valsalva. Enlargement of the Valsalva was performed by placing a patch from the aortic transection site to an area directly above the coronary artery ostium. Postoperatively, the patient recovered satisfactorily and was discharged on the eleventh postoperative day. Cardiac catheterization performed 6 months after surgery showed no aortic regurgitation, no significant stenosis in the left coronary artery, and no retrograde flow from the right coronary artery. We report our experience with the rare case described above.

   

  Jpn. J. Cardiovasc. Surg. 50:244-247（2021）

  Keywords：coronary ostium occlusion;hypoplastic aortic valve;aortic valve fusion

  
  
• A Case of Partial Anomalous Pulmonary Venous Return in an Adult Patient　T. Nishi et al.…248
  A Case of Partial Anomalous Pulmonary Venous Return in an Adult Patient
  

  Toshihiko Nishi＊

  Takenori Yamazaki＊

  
  

  （Department of Cardiovascular Surgery, Kainan Hospital＊, Yatomi, Japan）
  

  Most cases of partial anomalous pulmonary venous return are associated with atrial septal defect. We however report a surgical case of partial anomalous pulmonary venous return that was diagnosed in an adult without atrial septal defect. The patient was a 44-year-old man who presented with hemoptysis. Computed tomography revealed an absent left pulmonary artery. We performed bronchial artery embolization. Partial anomalous pulmonary venous return（Qp/Qs 3.33）in which the right pulmonary vein returned to the superior vena cava and moderate aortic regurgitation were diagnosed by computed tomography and transthoracic echocardiography;this was an indication for surgery. Approximately 2 months after the emergency hospitalization due to hemoptysis, we performed a modified Warden procedure and aortic valve replacement. Postoperative computed tomography showed good reconstruction of the superior vena cava and right upper pulmonary vein. He was discharged on postoperative day 38.

   

  Jpn. J. Cardiovasc. Surg. 50:248-251（2021）

  Keywords：partial anomalous pulmonary venous return;adult congenital heart disease;Warden procedure;unilateral absence of pulmonary artery

  
  
• ［Acquired Cardiovascular Surgery］
• A Recurrent Case of Constrictive Pericarditis after Pericardiectomy Using ePTFE Pericardial Substitution　N. Sakoda et al.…252
  A Recurrent Case of Constrictive Pericarditis after Pericardiectomy Using ePTFE Pericardial Substitution
  

  Naoya Sakoda＊	Hideo Yoshida＊	Takuya Kawabata＊
  Munehiro Saiki＊＊	Yasuhumi Fujita＊	Keiji Yunoki＊＊
  Kunikazu Hisamochi＊

  
  

  （Department of Cardiovascular Surgery＊, and Department of Endovascular Treatment for Structure Heart and Aortic Disease＊＊, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan）
  

  A 67-year-old man developed the recurrence of postoperative constrictive pericarditis. He had two operation histories:the one was CABG for old myocardial infarction and the other was pericardiectomy for postoperative pericarditis at 57 and 59 years old respectively. Both operations were performed in our hospital. We used an ePTFE sheet for covering the heart in the pericardiectomy. The course post operation was good, but eight years after the pericardiectomy, he had abdominal distension and leg edema. Detailed studies revealed a recurrence of constrictive pericarditis, and reoperation was performed. The re-operative finding showed thickened sclerotic tissues on both sides of an ePTFE sheet which was applied to the cardiac surface during the previous surgery. No abnormal tissue was detected where the ePTFE sheet was not applied. The ePTFE sheet and the sclerotic tissues were removed under cardiopulmonary bypass support, and then diastolic dysfunction improved dramatically. His chest was closed without applying an ePTFE sheet. His post-operative course was uneventful and he was discharged on the 20th postoperative day. The ePTFE sheet was highly suspected as a cause of the recurrent constrictive pericarditis. An ePTFE sheet-induced constrictive pericarditis should be considered as one of the postoperative complications even in the mid and long-term period. The ePTFE sheet is useful for preventing heart or vascular injury when we perform resternotomy, but in rare cases, there is some possibility of association with a risk of pericarditis.

   

  Jpn. J. Cardiovasc. Surg. 50:252-255（2021）

  Keywords：constrictive pericarditis;ePTFE;recurrence;pericardiectomy;diastolic disfunction

  
  
• Effective Management with IMPELLA CP●Rand Hypothermia Therapy for a Case of Severe Ischemic Coronary Disease after Cardiopulmonary Arrest　A. Oryoji et al.…256
  Effective Management with IMPELLA CP●R and Hypothermia Therapy for a Case of Severe Ischemic Coronary Disease after Cardiopulmonary Arrest
  

  Atsunobu Oryoji＊	Takanori Kono＊	Kazuyoshi Takagi＊
  Kosuke Saku＊	Satoshi Kikusaki＊	Yasuyuki Zaima＊
  Takahiro Shojima＊	Tohru Takaseya＊	Koichi Arinaga＊
  Eiki Tayama＊

  
  

  （Department of Surgery, Kurume University School of Medicine＊, Kurume, Japan）
  

  A 67-year-old man was admitted to our hospital following cardiopulmonary arrest（CPA）during work. After resuscitation, coronary angiography revealed left main coronary artery stenosis and three-vessel disease. We considered that coronary artery revascularization was required, but the neurological prognosis was unknown. Thus, an IMPELLA CP●R device was inserted and systemic management, including hypothermic therapy, was initiated. Circulatory conditions were stable during hypothermia therapy. Rewarming was initiated 24h later, and we confirmed no abnormal neurological findings. Emergency off-pump coronary artery bypass was then performed. During the procedure, hemodynamic status was maintained using the IMPELLA CP●R device. After surgery, the patient was discharged without neurological complications. We report the management of a patient with severe three-vessel disease after resuscitation for CPA using an IMPELLA CP●R device and hypothermic therapy.

   

  Jpn. J. Cardiovasc. Surg. 50:256-260（2021）

  Keywords：IMPELLA;cardiopulmonary arrest severe ischemic coronary disease;OPCAB;hypothermia therapy

  
  
• A Case of Redo-Aortic Valve Replacement for a Lillehei-Kaster Valve Implanted 42 Years Ago　R. Ikeda et al.…261
  A Case of Redo-Aortic Valve Replacement for a Lillehei-Kaster Valve Implanted 42 Years Ago
  

  Ryo Ikeda＊	Atomu Hino＊	Kozo Morita＊
  Azumi Hamasaki＊	Hiroshi Niinami＊

  
  

  （Department of Cardiovascular Surgery, School of Medicine, Tokyo Women’s Medical University＊, Tokyo, Japan）
  

  We present a case of redo aortic valve replacement（AVR）in a 71-year-old man with a Lillehei-Kaster valve implanted 42 years prior. The patient initially underwent AVR and open mitral commissurotomy procedures for aortic regurgitation complicated with mitral stenosis in 1978 at the age of 29. Thereafter, he was followed at our outpatient clinic and treated without anticoagulant therapy for the initial two decades of the postoperative period. During the long-term follow-up, the mean pressure gradient remained between 40 and 60 mmHg and there were no adverse events noted before occurrence of heart failure triggered by tachycardia and pneumonia. Following improvement of heart failure, redo AVR was performed. There was no structural damage, thrombosis, or Lillehei-Kaster valve opening restrictions, though severe pannus growth on the left ventricle side was observed, which was thought to be the cause of the increased pressure gradient. This is the first known report of redo AVR after many years in a patient who underwent Lillehei-Kaster valve implantation. Furthermore, no other study has noted findings regarding pressure gradient change during the long-term follow-up period in such cases.

   

  Jpn. J. Cardiovasc. Surg. 50:261-264（2021）

  Keywords：tilted disk valve;Lillehei-Kaster valve;redo-aortic valve replacement;pannus formation;patient prosthesis mismatch（PPM）

  
  
• Nonspecific Inflammatory Aortic Regurgitation Diagnosed after Aortic Valve Replacement　Y. Ikeda et al.…265
  Nonspecific Inflammatory Aortic Regurgitation Diagnosed after Aortic Valve Replacement
  

  Yosuke Ikeda＊	Yuhei Saitoh＊	Naoki Sumi＊
  Shingo Ishiguro＊	Takeshi Soeda＊	Yoshinobu Nakamura＊

  
  

  （Department of Cardiovascular Surgery, Matsue Red Cross Hospital＊, Matsue, Japan）
  

  A case of clinical1y unsuspected nonspecific inflammatory aortic regurgitation is reported. A 69-year-old female patient underwent aortic valve replacement for aortic regurgitation. Pathological examination of resected aortic valve showed abscess formation and inflammatory granulation tissue in the non-coronary cusp. Therefore, we diagnosed nonspecific inflammatory aortic regurgitation. It is generally considered that the use of prednisolone for vasculitis syndrome is effective;however, for nonspecific inflammatory aortic regurgitation its use has not been established. Prednisolone treatment could be an option for nonspecific inflammatory aortic regurgitation.

   

  Jpn. J. Cardiovasc. Surg. 50:265-269（2021）

  Keywords：nonspecific inflammatory aortic regurgitation;aortic valve replacement

  
  
• A Case of Multiple Cardiac Papillary Fibroelastoma in the Aortic Valve　T. Kubota et al.…270
  A Case of Multiple Cardiac Papillary Fibroelastoma in the Aortic Valve
  

  Takehiro Kubota＊

  Yasushige Shingu＊＊

  Satoru Wakasa＊＊

  
  

  （Department of Cardiovascular Surgery, NHO Hakodate National Hospital＊, Hakodate, Japan, and Graduate School of Medicine, Hokkaido University＊＊, Sapporo, Japan）
  

  We report a case of multiple papillary fibroelastoma（PFE）on the aortic valve. A healthy woman in her 60s was referred to a nearby doctor with the chief complaint of palpitation and was admitted to our hospital for detailed examination. A mobile tumor was found by transthoracic echo, and she was introduced to us. We undertook excision surgery for her. Initially, it was thought to be a single tumor, and a pedunculated tumor adhering to the central aortic side of the left coronary cusp with a length of 7mm was removed. After closing the aorta, we recognized a remaining mobile tumor by transesophageal echo. We decided to perform cardiac arrest again, and we recognized one tumor with 6mm long string-like mobile mass on the right and non-coronary commissure of cardiac side, and a thorn-like mass of about 1.5mm on the non-coronary cusp of the cardiac side. We removed both tumors from the aortic valve using shaving resection and preserved the aortic valve. All of these were found to be PFE pathologically as if they were three tumors that followed the developmental stage of PFE. After surgery, PFE recurrence is extremely rare. In the case of a pedunculated tumor, it is possible to remove the tumor and preserve the valve. However, as in this case, if both sides of the valve were not carefully inspected, it can be overlooked. In addition, small tumor resection could avoid the risk of new cerebral infarction and myocardial infarction due to recurrence and could avoid reoperation.

   

  Jpn. J. Cardiovasc. Surg. 50:270-273（2021）

  Keywords：cardiac tumor;papillary fibroelastoma;recurrence

  
  
• Three Cases of Caseous Calcification of Mitral Annulus（CCMA）　Y. Gotake et al.…274
  Three Cases of Caseous Calcification of Mitral Annulus（CCMA）
  

  Yasuko Gotake＊	Hiroaki Takahashi＊	Shuto Tonoki＊
  Takaki Sugimoto＊

  
  

  （Department of Cardiovascular Surgery＊, Hyogo Prefectural Awaji Medical Center＊, Sumoto, Japan）
  

  Caseous calcification of mitral annulus（CCMA）is rare variant of mitral annular calcification（MAC). There is no clear consensus on the optimal management for CCMA. However, patients with CCMA have high risk of embolic strokes. We performed drainage and debridement in 3-cases of CCMA. All patients had a history of chronic kidney disease（CKD），and two of the three patients were undergoing hemodialysis. If a calcified mass at the mitral valve annulus is observed, especially in hemodialysis patients, CCMA should be recognized.

   

  Jpn. J. Cardiovasc. Surg. 50:274-278（2021）

  Keywords：CCMA;MAC;MR;CKD;hemodialysis

  
  
• ［Aortic Disease］
• A Case of Type A Aortic Dissection That Developed Ischemic Cardiomyopathy due to Coronary Malperfusion　E. Nagata et al.…279
  A Case of Type A Aortic Dissection That Developed Ischemic Cardiomyopathy due to Coronary Malperfusion
  

  Emi Nagata＊	Takashi Igarashi＊	Hirono Satokawa＊
  Tsuyoshi Fujimiya＊	Hiroharu Shinjo＊	Keiichi Ishida＊
  Hitoshi Yokoyama＊

  
  

  （Department of Cardiovascular Surgery, Fukushima Medical University＊, Fukushima, Japan）
  

  A 57-year-old man complained of dyspnea, and his echocardiography showed diffuse severe left ventricular dysfunction. Five days after admission and starting the treatment for congestive heart failure, a computed tomography pointed out DeBakey type 1 aortic dissection with a patent false lumen incidentally. The ostium of the left coronary artery was compressed with the false lumen, and this finding was thought to be a cause of development of left ventricular dysfunction. A modified Bentall procedure with bioprosthesis and total arch replacement were performed. The patient was discharged on the 28th postoperative day without any complications.

   

  Jpn. J. Cardiovasc. Surg. 50:279-282（2021）

  Keywords：type A aortic dissection;coronary malperfusion;ischemic cardiomyopathy;left ventricular systolic dysfunction

  
  
• Treatment Strategy for Leriche Syndrome Complicated with Ischemic Heart Disease　J. Hayashi et al.…283
  Treatment Strategy for Leriche Syndrome Complicated with Ischemic Heart Disease
  

  Jun Hayashi＊	Tetsuro Uchida＊	Yoshinori Kuroda＊
  Eiichi Ohba＊	Masahiro Mizumoto＊	Atsushi Yamashita＊
  Shingo Nakai＊	Kimihiro Kobayashi＊	Tomonori Ochiai＊

  
  

  （Second Department of Surgery, Faculty of Medicine, Yamagata University＊, Yamagata, Japan）
  

  Leriche syndrome is often complicated with ischemic heart disease（IHD). In such cases, as the internal mammary artery（IMA）supplies blood to the lower-limbs through a collateral network, coronary artery bypass grafting（CABG）using IMA is considered to worsen the lower-limb ischemia and use of intra-aortic balloon pumping prior to lower limb revascularization is not possible. Recent advances in endovascular technology enable us to perform endovascular treatment（EVT）even in Leriche syndrome. In 3 patients diagnosed with Leriche syndrome associated with IHD, tailor-made treatments were performed as one-stage or two-stage surgeries. Various techniques such as percutaneous coronary intervention（PCI), CABG, and open surgical revascularization or EVT of lower limbs were employed. EVT is a less invasive and more attractive alternative to open surgical revascularization, it led to new treatment options in patients with this particular circumstance. Considering the severity of pathophysiology, treatment strategy should be determined on a case-by-case basis.

   

  Jpn. J. Cardiovasc. Surg. 50:283-286（2021）

  Keywords：Leriche syndrome;aortoiliac occlusive disease;endovascular treatment;ischemic heart disease;coronary artery bypass grafting

  
  
• Hemolytic Anemia Caused by a Kinked Graft after Ascending Aortic Replacement for Acute Type A Aortic Dissection　H. Moriuchi et al.…287
  Hemolytic Anemia Caused by a Kinked Graft after Ascending Aortic Replacement for Acute Type A Aortic Dissection
  

  Hiroki Moriuchi＊	Naoki Washiyama＊	Yuko Ohashi＊
  Kazumasa Tsuda＊	Daisuke Takahashi＊	Katsushi Yamashita＊
  Norihiko Shiiya＊

  
  

  （First Department of Surgery, Hamamatsu University School of Medicine＊, Hamamatsu, Japan）
  

  The patient was a 50-year-old man who had undergone ascending aortic replacement and coronary artery bypass grafting at another hospital for acute type A aortic dissection 4 years before. He was diagnosed with hemolytic anemia 1 year after surgery for his progressive anemia and high serum lactate dehydrogenase level. He was referred to our hospital because frequent transfusion was required. A computed tomography showed severe kinking of the graft（110°), which we considered to be the cause of hemolysis. Peak pressure gradient was 60mmHg. To remove the cause of hemolysis and to precipitate thrombosis of the residual false lumen, we performed re-ascending aortic replacement and total arch replacement with a frozen elephant trunk. The postoperative course was uneventful and hemolysis resolved soon after the operation. Surgeons should be aware that severe kinking of a Dacron graft can be a cause of hemolysis.

   

  Jpn. J. Cardiovasc. Surg. 50:287-290（2021）

  Keywords：acute aortic dissection;kinked graft;hemolytic anemia

  
  

NP Report

• Introduction and Effects of a Japanese Nurse Practitioner in the Department of Cardiovascular Surgery, Nagasaki University Hospital　Y. Murakami et al.…291

Progress in Cardiovascular Surgery（2020）

• Update of 2020 in Peripheral Artery Disease　T. Baba and T. Ohki…294
• Progress in Valvular Heart Disease and Arrhythmias　Y. Yoshikawa…297

U-40

• U-40 Column No.4 Current Status of Surgical Technique Training Such as Off the Job Training　Y. Inoue…U1
  Current Status of Surgical Technique Training Such as Off the Job Training
  

  Yoshinori Inoue＊	Kenji Namiguchi	Yusuke Kinugasa
  Yutaro Matsuno	Hiroshi Kodama	Hiromu Horie
  Sayako Nakagawa

  
  

  （Department of Cardiovascular Surgery, National Hospital Organization Okayama Medical Center＊, Okayama, Japan）
  

  Young cardiovascular surgeons work on various trainings such as OFFJT to improve surgical techniques. In this paper, we conducted a questionnaire survey of U-40 members to find out what they are doing to acquire standard surgical techniques.

   

  Jpn. J. Cardiovasc. Surg. 50（4）:U1-U5（2021）

  Keywords：U-40;Under Forty;off the job training;Japanese board of cardiovascular surgery specialist

  
  

• K. Doi