JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Vol.51, No.3

Preface

  • Academic Activities under COVID-19 Pandemic―　K. Okada

Case Reports

  • ［Congenital Heart Disease］
  • Surgical Correction of Coronary Arteriovenous Fistula in the Newborn Period　F. Murayama and K. Nomura…129
    Surgical Correction of Coronary Arteriovenous Fistula in the Newborn Period
    Fumiaki Murayama＊ Koji Nomura＊

    (Department of Cardiovascular Surgery, Saitama Children’s Medical Center＊, Saitama, Japan)

    Coronary arteriovenous fistula （CAVF） is defined as an abnormal communication between the coronary artery and a cardiac cavity or a major blood vessel. It is the most common congenital anomaly of the coronary arteries, but it is relatively rare, accounting for only approximately 0.4％ of all congenital heart diseases. Most cases of CAVF are clinically asymptomatic in young patients, but with increasing age, symptoms begin to appear and surgical treatment is required. In rare cases of CAVF, however, symptoms may appear in the neonatal period and early surgery may be required. In this article, we report the case of a 12-day-old patient diagnosed after birth with CAVF between the aneurysmatic left anterior descending artery and the right ventricle. This patient required early surgical intervention due to concerns about worsening heart failure and developing coronary artery ischemia. Although various surgical options were considered, we opted for an arteriotomy of the left anterior descending artery and closed the fistula with two autologous pericardial patches. There has been no signs of postoperative ischemic changes or enlargement of the coronary aneurysm during the 4 years of follow up, and careful monitoring will continue.

     

    Jpn. J. Cardiovasc. Surg. 51 : 129-132 （2022）

    Keywords：coronary arteriovenous fistula ; neonate ; coronary artery anomaly


  • Two-Stage Intracardiac Repair for Total Anomalous Pulmonary Venous Return (Ib + Ib) with a Persistent Left Superior vena cava and an Enlarged Coronary Sinus　Y. Kuwahara et al.…133
    Two-Stage Intracardiac Repair for Total Anomalous Pulmonary Venous Return （Ib+Ib） with a Persistent Left Superior vena cava and an Enlarged Coronary Sinus
    Yuta Kuwahara＊ Naoki Wada＊ Takayuki Kawamura＊
    Tsubasa Furuya＊ Yuya Komori＊ Naohiro Kabuto＊
    Yukihiro Takahashi＊

    (Department of Congenital Cardiovascular Surgery, Sakakibara Heart Institute＊, Tokyo, Japan)

    This study reports the case of a 0-day-old girl who was transferred to our hospital for suspected total anomalous pulmonary venous return due to her postnatal cyanosis. After she was presented at our hospital, pulmonary vein stenosis was diagnosed and emergency surgery was planned. Preoperative computed tomography showed abnormal perfusion of the pulmonary veins into the left and right superior vena cava separately on the left and right sides. Given that the persistent left superior vena cava was refluxing into the coronary sinus, the coronary sinus was enlarged greatly, and the left atrial volume was small. In the neonatal period, the right pulmonary vein was anastomosed to the right atrium, and the left pulmonary vein was anastomosed to the unroofed coronary sinus. Thereafter, at 4 months of age, the patient underwent two-stage intracardiac repair with re-routing of the right pulmonary vein and extracardiac ligation of the left vena cava. The postoperative course was good. Intracardiac repair via a two-stage surgery was effective for total anomalous pulmonary venous return （Ib+Ib） with a persistent left superior vena cava and an enlarged coronary sinus.

     

    Jpn. J. Cardiovasc. Surg. 51 : 133-137 （2022）

    Keywords：total anomalous pulmonary venous return ; two-stage surgery ; persistent left superior vena cava


  • A Surgical Case of Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery in Early Infancy　Y. Hosoya et al.…138
    A Surgical Case of Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery in Early Infancy
    Yuta Hosoya＊ Yosuke Kugo＊ Tomohisa Kawahito＊
    Homare Yoshida＊＊ Yasushi Shimoe＊＊

    (Department of Pediatric Cardiovascular Surgery＊, and Department of Cardiovascular Surgery＊＊, National Hospital Organization Shikoku Medical Center for Children and Adults, Zentsuji, Japan)

    Anomalous origin of the right coronary artery from the pulmonary artery （ARCAPA） is a rare congenital defect, and few cases have been reported in the pediatric age group. Unlike the anomalous origin of the left coronary artery from the pulmonary artery （ALCAPA）, patients with ARCAPA are usually asymptomatic and often diagnosed incidentally. Here, we present a surgical case of a 2-month-old male who was suspected of having ARCAPA in the neonatal period. The patient was suspected of having ARCAPA due to the detection of a heart murmur and the results from an echocardiogram taken the 4th day after birth. Coronary angiography on the 37th day after birth showed the contrast flow to the pulmonary artery through the right coronary artery from the left coronary artery; thus, we diagnosed ARCAPA. Surgical intervention should be performed before the appearance of myocardial ischemia due to decreasing pulmonary artery pressure, so we performed reimplantation of the right coronary artery to the ascending aorta and patch plasty of the pulmonary artery at 2 months after birth. The patient was discharged from the hospital on the 16th day after the operation, and a 6-month postoperative coronary angiography revealed good right coronary flow and the disappearance of collaterals.

     

    Jpn. J. Cardiovasc. Surg. 51 : 138-141 （2022）

    Keywords：anomalous origin of the right coronary artery from the pulmonary ; reimplantation of coronary artery


  • ［Acquired Cardiovascular Surgery］
  • A Case of Surgical Repair for End-Stage Tricuspid Regurgitation with Severe Liver Dysfunction and Hepatic Encephalopathy　J. Eishi et al.…142
    A Case of Surgical Repair for End-Stage Tricuspid Regurgitation with Severe Liver Dysfunction and Hepatic Encephalopathy
    Junichiro Eishi＊ Takashi Miura＊ Ichiro Matsumaru＊
    Hiroko Taguchi＊ Taku Inoue＊ Akihiko Tanigawa＊
    Tessyo Kitamura＊ Syun Nakaji＊ Kikuko Obase＊
    Kiyoyuki Eishi＊

    （Cardiovascular Surgery, Nagasaki University Hospital＊, Nagasaki, Japan）

    We report the case of a patient with severe tricuspid regurgitation and severe liver dysfunction who was successfully treated by tricuspid valve repair with spiral suspension and perioperative management of high cardiac output. The patient was a 77-year-old woman who presented with chronic atrial fibrillation with bradycardia （heart rate approximately 50 bpm）. She had been diagnosed with severe tricuspid valve and mitral valve regurgitation at the age of 74. As her heart failure and hepatic failure grew worse, and hepatic encephalopathy also occurred, she was admitted to the hospital. Her Child-Pugh score for liver disease was Grade C at the preoperative assessment, suggesting that she was in the high-risk category for open heart surgery. Therefore, further medical treatment was required before selecting the surgical treatment. After the implantation of a pacemaker （VVI mode, 80 bpm）, the cardiac output increased with a cardiac index of 5.17 L/min/m2 compared with 2.97 L/min/m2 prior to pacemaker implantation. Furthermore, the symptoms of heart failure improved and total bilirubin decreased from 3.9 mg/dl to 1.7 mg/dl, and surgery was performed. Tricuspid regurgitation was treated with spiral suspension, and mitral regurgitation due to annular dilation was treated with annuloplasty. Following the surgery, the cardiac index was maintained from 4.3 L/min/m2 to 5.8 L/min/m2 with central venous pressure below 10 mmHg by the assistance of intra-aortic balloon pumping. The patient was extubated 30 h after surgery, and was discharged on postoperative day 54. At the time of discharge, total bilirubin was 1.5 mg/dl. At 1.5 post-operative years, the patient is New York Heart Association functional Class II and tricuspid valve regurgitation is mild.

     

    Jpn. J. Cardiovasc. Surg. 51 : 142-146 （2022）

    Keywords：tricuspid regurgitation ; spiral suspension ; liver dysfunction ; pacemaker implantation ; intra-aortic balloon pumping


  • Left Ventricular Pseudo-False Aneurysm Perforating into the Right Ventricle　T. Murase and S. Tamura…147
    Left Ventricular Pseudo-False Aneurysm Perforating into the Right Ventricle
    Toshifumi Murase＊ Susumu Tamura＊

    (Department of Cardiovascular Surgery, Odawara Cardiovascular Hospital＊, Odawara, Japan)

    We report the case of a 52-year-old man who presented with a 2-week history of exertional dyspnea and was admitted to our hospital with heart failure. Coronary angiography showed severe three-vessel disease ; left ventriculography revealed an aneurysm in the inferior left ventricular （LV） wall perforating into the right ventricle. We suspected the LV aneurysm was from a previous myocardial infarction （MI） that had perforated into the right ventricle, although the time of MI was unclear. The patient was treated with medications initially. We subsequently treated the patient by LV aneurysm closure using a patch and direct closure of the perforation by incising the aneurysm. Coronary artery bypass grafting was performed in the left anterior descending artery, the diagonal artery, and the right coronary artery simultaneously. After having an uneventful postoperative course, he was discharged from the hospital in a stable condition. A pathology examination confirmed a diagnosis of LV pseudo-false aneurysm.

     

    Jpn. J. Cardiovasc. Surg. 51 : 147-150 （2022）

    Keywords：pseudo-false aneurysm ; left ventricle ; right ventricle


  • A Case of Coronary Artery Bypass Grafting for a Patient with Eosinophilic Granulomatosis and Polyangiitis　M. Nagatsuka et al.…151
    A Case of Coronary Artery Bypass Grafting for a Patient with Eosinophilic Granulomatosis and Polyangiitis
    Motoki Nagatsuka＊ Yusuke Gunji＊ Hideo Kagaya＊
    Shigeru Hattori＊ Kenichiro Noguchi＊ Ikuo Katayama＊

    （Department of Cardiovascular Surgery, Shonan Kamakura General Hospital＊, Kamakura, Japan）

    We present herein the case of a 45-year-old man with a coronary artery aneurysm （diameter 19 mm） in the proximal part of the left anterior descending branch associated with eosinophilic granulomatosis with polyangiitis （EGPA）. As coronary angiography showed #6 : 100% and #12-2 : 90%，and Tc-99 m myocardial scintigraphy showed exertional ischemia in the anterior septum, revascularization was considered to be indicated. Prednisolone and mepolizumab were administered preoperatively to suppress the activity of vasculitis due to eosinophilia, and surgery was performed when the eosinophil count normalized. The patient underwent off-pump coronary artery bypass grafting （LITA-LAD, SVG-OM2）. The patient was discharged, and the postoperative course was uneventful. In coronary artery bypass grafting for EGPA, eosinophils may infiltrate the internal thoracic artery and result in vasculitis, which may affect the patency rate. Perioperative management of vasculitis may thus be important.

     

    Jpn. J. Cardiovasc. Surg. 51 : 151-156 （2022）

    Keywords：eosinophilic granulomatosis with polyangiitis （EGPA） ; coronary artery aneurysm ; coronary artery bypass grafting （CABG）


  • An Autopsy Case of Transthyretin-Related Cardiac Amyloidosis (TTR-CA), Which Fell into Low-Output Syndrome after Cardiac Surgery　Y. Tsuji et al.…157
    An Autopsy Case of Transthyretin-Related Cardiac Amyloidosis （TTR-CA）, Which Fell into Low-Output Syndrome after Cardiac Surgery
    Yasuhiro Tsuji＊ Noboru Nishiwaki＊ Kozo Kaneda＊＊
    Shigeo Nagasaka＊＊

    （Department of Cardiovascular Surgery, Saiseikai Izuo Hospital＊, Osaka, Japan, and Department of Cardiovascular Surgery, Takanohara Central Hospital＊＊, Nara, Japan）

    We present the case of 83-year-old male patient. He was under observation as an outpatient with mild to moderate aortic stenosis and regurgitation since 75 years old. He underwent surgery because of repeated hospitalization by heart failure due to progressive aortic valve stenosis and regurgitation, mitral valve stenosis and regurgitation, and tricuspid regurgitation. Elective aortic valve replacement, mitral valve replacement and tricuspid valve repair was performed. Even though his condition after surgery was stable, suddenly feature like low output syndrome appeared on day 6, and led to a mortality on day 8 after operation. Ejection fraction was kept above 50 percent before and after surgery, which indicated to Heart Failure with preserved Ejection Fraction （HFpEF）. After autopsy examination, by immunohistochemical staining identified transthyretin, we demonstrated previously undiagnosed transthyretin-related cardiac amyloidosis （TTR-CA）.

     

    Jpn. J. Cardiovasc. Surg. 51 : 157-162 （2022）

    Keywords：cardiac amyloidosis ; transthyretin ; Heart Failure with preserved Ejection Fraction


  • ［Aortic Disease］
  • A Case of Redo Ascending Aortic Replacement for Anastomotic Pseudoaneurysm through Right Thoracotomy in a Patient with Severe Coagulation Disorder　E. Nagata et al.…163
    A Case of Redo Ascending Aortic Replacement for Anastomotic Pseudoaneurysm through Right Thoracotomy in a Patient with Severe Coagulation Disorder
    Emi Nagata＊ Yoshiyuki Sato＊ Koki Takahashi＊

    （Department of Cardiovascular Surgery，Ohta Nishinouchi Hospital＊，Koriyama，Japan）

    A 51-year-old man presented to our hospital with general fatigue and lower extremity edema due to right heart failure with severe coagulation disorder. He had undergone ascending aortic and total arch replacement for type A acute aortic dissection when he was 49 years old and had diagnosed with anastomotic pseudoaneurysm in the ascending aorta by computed tomography 1 year after the operation. Preoperative computed tomography showed an enlargement of the pseudoaneurysm. Since re-median sternotomy seemed to be high risk strategy for bleeding due to severe coagulation disorder, we decided to perform ascending aortic replacement through right thoracotomy. We opened the pseudoaneurysm and found an aorto-right atrium fistula. Redo ascending aortic replacement with direct closure of the fistula was successfully performed. The postoperative course was uneventful.

     

    Jpn. J. Cardiovasc. Surg. 51 : 163-166 （2022）

    Keywords：anastomotic pseudoaneurysm ; right thoracotomy ; coagulation disorder ; aorto-right atrium fistula


  • A Case Report on Localized Acute Aortic Dissection of the Sinus of Valsalva Associated with a Bicuspid Aortic Valve Diagnosed with the Onset of Acute Coronary Syndrome　Y. Sakaguchi et al.…167
    A Case Report on Localized Acute Aortic Dissection of the Sinus of Valsalva Associated with a Bicuspid Aortic Valve Diagnosed with the Onset of Acute Coronary Syndrome
    Yuuki Sakaguchi＊ Junpei Tokutome＊ Tomohiro Kurashiki＊
    Shigeto Miyasaka＊

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

    We experienced a rare case of a patient who had a bicuspid aortic valve associated with acute aortic dissection limited to the sinus of Valsalva involving the left main coronary artery and acute coronary syndrome. The patient was a 36-year-old male who was identified as having a congenital bicuspid aortic valve. He visited our emergency room with a chief complaint of acute chest/back pain. He was diagnosed with acute coronary syndrome based on ECG findings and underwent an emergency coronary angiography. This test revealed filling defects at the entrance of the left main coronary artery, with aortic dissection limited to the sinus of Valsalva suspected. Emergency chest contrast-enhanced CT (ECG gated) led to his being diagnosed as having an acute aortic dissection limited to the sinus of Valsalva. After an intra-aortic balloon pump was inserted in order to maintain the coronary blood flow by surgery, emergency coronary artery bypass surgery and a modified Bentall procedure (the Carrel patch method) were carried out. His postoperative course was good and he was discharged home on the 19th disease day.

     

    Jpn. J. Cardiovasc. Surg. 51 : 167-171 （2022）

    Keywords：bicuspid aortic valve ; localized acute aortic dissection of Valsalva sinus ; acute coronary syndrome


  • A Case of Placement of the Reversed Gore Exclucder Contralateral Leg for Isolated Left Iliac Mycotic Artery Aneurysm　K. Shimoishi et al.…172
    A Case of Placement of the Reversed Gore Exclucder Contralateral Leg for Isolated Left Iliac Mycotic Artery Aneurysm
    Koichiro Shimoishi＊ Yoshihiro Fukumoto＊ Kenichi Arata＊
    Tomoyuki Matsuba＊ Yuki Ogata＊ Akira Hiwatashi＊
    Goichi Yotsumoto＊

    (Department of Cardiovascular Surgery, Kagoshima-City Hospital＊, Kagoshima, Japan)

    A 49-year-old female with ruptured left common iliac mycotic arterial aneurysm （Lt. CIAA） was brought to our hospital as an emergency case. In Japan, endovascular treatment is unsuitable for the treatment of mycotic aneurysms, but findings from a Swedish national database showed that there was no difference in the long-term prognosis lasting over 10 years. Therefore, we performed endovascular aortic repair （EVAR） and saved the patient’s life. The diameter of the proxymal sealing zone was larger than that of the distal zone. We used the Gore Excluder leg, which was inverted and implanted to match the caliber. Percutaneous abscess drainage was also performed on postoperative day 7 when hemostasis was confirmed for early infection control. The patient was discharged at 8 weeks postoperatively. After discharge from the hospital, oral antibiotics were continued until 6 months after the surgery. Six months postoperatively, contrast-enhanced computed tomography showed that the abscesses have disappeared. Blood samples that were taken at one month after the completion of antibiotics showed no evidence of the recurrence of infection and a curative course was achieved.

     

    Jpn. J. Cardiovasc. Surg. 51 : 172-177 （2022）

    Keywords：mycotic aneurysm ; stent graft ; prosthetic vascular graft


  • Thoracic Endovascular Aortic Repair Following Axillo-Femoral Bypass in a Patient with Stanford B Acute Aortic Dissection Accompanied by Renal Ischemia　K. Hisatomi et al.…178
    Thoracic Endovascular Aortic Repair Following Axillo-Femoral Bypass in a Patient with Stanford B Acute Aortic Dissection Accompanied by Renal Ischemia
    Kazuki Hisatomi＊ Shun Nakaji＊＊ Shiro Hazama＊

    (Department of Cardiovascular Surgery, Sasebo City General Hospital＊, Sasebo, Japan)

    A 71-year-old male was admitted to our institution because of right leg pain and paleness, accompanied by sudden chest-back pain. The right femoral artery was not palpable. The reticulated cyanosis appeared on the right leg. Contrast enhanced computed tomography (CT) revealed an acute type B aortic dissection (TBAD) extending from the descending thoracic aorta to the left common iliac artery and right external iliac artery. The intimal tear was located at thoraco-abdominal aorta. There was a severe stenosis of the true lumen at bilateral common iliac arteries because of the dynamic compression caused by the extended false lumen. Blood to the right leg was not supplied from the dissected iliac artery, the peripheral circulation was maintained by collateral flow. The patient was diagnosed acute TBAD complicated with lower limb ischemia. An emergent right axillary artery-bifemoral arteries bypass was carried out for malperfusion of lower extremities. The symptoms in the lower limbs disappeared immediately. The bilateral femoral arteries were well palpated. However, 4 days later, uncontrollable severe hypertension and anuria appeared suddenly. Contrast enhanced CT revealed the stenosis of true lumen at bilateral renal arteries and an exacerbation of stenosis of true lumen at abdominal aorta. Emergent thoracic endovascular aortic repair (TEVAR) for entry closure was performed to improve the renal function and prevent mesenteric ischemia. Postoperative contrast enhanced CT revealed the complete closure of the entry tear and dilatation of the true lumen at the descending and abdominal aorta. At the bilateral renal arteries, the blood flow improved. The renal function recovered and mesenteric ischemia did not occurred. In this report, we presented a case of acute TBAD complicated with lower limbs ischemia and late onset acute ischemic renal failure. We first performed the right axillary artery-bifemoral arteries bypass grafting, after that we had to perform TEVAR to close the entry tear. One-stage emergent TEVAR should be considered for acute TBAD with the dynamic compression at the level of abdominal aorta in future.

     

    Jpn. J. Cardiovasc. Surg. 51 : 178-182 （2022）

    Keywords：acute type B aortic dissection ; lower limb ischemia ; axillo-bifemoral bypass ; thoracic endovascular aortic repair ; malperfusion


  • ［Peripheral Artery Disease］
  • A Case of Popliteal Endarterectomy in a Patient Post CABG　K. Hashimoto et al.…183
    A Case of Popliteal Endarterectomy in a Patient Post CABG
    Kazunori Hashimoto＊ Harunobu Matsumoto＊＊ Takayuki Yamamoto＊
    Tetsuya Sato＊ Satoshi Ito＊

    (Department of Cardiovascular Surgery, Yokohama City Minato Red Cross Hospital＊, Yokohama, Japan, and Department of Vascular Surgery, Saitama Medical University Hospital＊＊, Saitama, Japan）

    A 74-year-old man having a right refractory foot ulcer was referred to our hospital with a diagnosis of arteriosclerosis obliterans. Angiography of the lower extremities showed occlusive lesions in the middle popliteal artery and lower-leg arteries. Preoperative examination revealed decreased cardiac function and severe stenosis of the left and right coronary arteries. Therefore, we first performed coronary artery bypass grafting, followed by revascularization of the lower limbs at a later date. Owing to the lack of suitable autologous vein grafts, our procedure of choice was popliteal endarterectomy via a posterior approach with short saphenous vein angioplasty. The patient’s foot ulcer healed completely following surgery. His postoperative course was uneventful, and he remained symptom-free during a 1-year follow-up.

     

    Jpn. J. Cardiovasc. Surg. 51 : 183-186 （2022）

    Keywords：arteriosclerosis obliterans ; endarterectomy ; popliteal artery occlusion


NP Report

  • Current Situation and Issues of Nurses Who Have Completed Tokuteikoui Training in Department of Cardiovascular Surgery, Fujita Health University　M. Nagaya et al.…187

Progress in Cardiovascular Surgery (2021)

  • Advance in Thoracic Aortic Surgery in 2021　N. Washiyama…191
  • Progress in Surgery for Heart Failure　T. Ushijima and A. Shiose.…194
U-40
  • U-40 Column Considerations from U-40 for the Special Session of the Annual Meeting on the New Japanese Board of Cardiovascular Surgery　Y. Kinugasa et al.…U1
    Considerations from U-40 for the Special Session of the Annual Meeting on the New Japanese Board of Cardiovascular Surgery
    Yusuke Kinugasa＊ Kaori Mori Chiharu Tanaka

    (Department of Cardiovascular Surgery, Chikamori Hospital＊, Kochi, Japan)

    With the official launch of the new Japanese board of cardiovascular surgery, there are various changes compared to the old system, such as the choice of training period. We conducted a questionnaire survey to find out how U-40 members perceive and understand the new system. Based on the results of the survey, we discussed and presented the current situation and prospects of the new system at the 52nd Annual Meeting of the Japanese Society for Cardiovascular Surgery.

     

    Jpn. J. Cardiovasc. Surg. 51(3) : U1-U0 (2022)


Editor’s Post Script
  • N. Azuma