JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Vol.51, No.4

Preface

• Let’s Make Cardiovascular Surgery Better for the Next Generation H. Kamiya

Original

• Validity of the SOFA Score in Predicting Mortality in the Field of Cardiovascular Surgery K. Takai et al.…197
  Validity of the SOFA Score in Predicting Mortality in the Field of Cardiovascular Surgery
  

  Kanako Takai＊

  Takaya Nakagawa＊＊

  Takashi Yamauchi＊＊

  
  

  （Department of Critical Care Medicine＊, and Department of Cardiovascular Surgery＊＊, Higashiosaka City Medical Center, Osaka, Japan)
  

  Objective: The Sequential Organ Failure Assessment （SOFA） score is a useful tool in defining the clinical conditions and describing the acute morbidity of patient populations with critical illness. This study was performed to assess the usefulness of the SOFA score in predicting the prognosis among cardiac or thoracic aortic postoperative patients. Methods: In total, 123 patients who entered the intensive care unit after a cardiac or thoracic aortic operation from August 2019 to December 2020 were retrospectively investigated. The SOFA score cut-off value from the admission day to postoperative day 3 calculated in the first 60 patients （derivation group） was validated in the latter 63 patients （validation group）. Additionally, the Japan SCORE cut-off value calculated in the derivation group was validated in the validation group. Results: The perioperative mortality rate, in-hospital mortality rate and hospital transfer rate were 4.9, 7.3, and 13.2%, respectively. A SOFA score cut-off value of ≥7 for prediction of in-hospital mortality resulted in a sensitivity of 100% and specificity of 81% on postoperative day 2, followed by high sensitivity of 100% and specificity of 95% on postoperative day 3. A SOFA score cut-off value of ≥6 for prediction of hospital transfer resulted in a sensitivity of 57% and a specificity of 67% on postoperative day 2. Conclusion: The SOFA score on postoperative day 2 provides good discriminatory power for in-hospital mortality among cardiac or thoracic aortic postoperative patients. The SOFA scoring system could be useful for predicting short-term prognosis of patients who undergo cardiac or thoracic aortic surgery.

   

  Jpn. J. Cardiovasc. Surg. 51: 197-203 （2022）

  Keywords：sequential organ failure assessment; postoperative prognosis; cardiac operative patients

  
  

Case Reports

• ［Congenital Heart Disease］
• Valve Replacement for Progressive Mitral Valve Stenosis Associated with Geleophysic Dysplasia Y. Komori et al.…204
  Valve Replacement for Progressive Mitral Valve Stenosis Associated with Geleophysic Dysplasia
  

  Yuya Komori＊	Naoki Wada＊	Yuta Kuwahara＊
  Tsubasa Furuya＊	Yukihiro Takahashi＊

  
  

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

  The patient was an 8-years- and 4-months old girl. At the age of one, she visited a previous doctor with hepatomegaly and liver dysfunction. As a result of the examination, she was diagnosed with geleophysic dysplasia. Other than the heart, she was followed in genetics, ophthalmology, orthopedics, endocrinology, and otolaryngology. At 3 years and 5 months, she was first examined by the cardiology department and was found to have mild mitral regurgitation and aortic valve stenosis, and was followed up once a year. The patient was referred to our hospital at 7 years and 11 months, and the cardiac catheterization performed at 8 years and 2 months showed mild mitral valve regurgitation, but the mean pressure gradient was 16 mmHg and the mitral valve area was 0.60 cm2 （MVAi 0.97 cm2/m2）, and mitral valve stenosis was observed. The left atrial pressure was as high as 25 mmHg and the average pulmonary artery pressure was as high as 36 mmHg, and pulmonary hypertension was also observed. Intraoperative findings demonstrated that the mitral valve had a marked thickening of the leaflet, the papillary muscles and chordae were also thickened, and the effective valve opening area was narrowed. The leaflet and subvalvular tissue were resected as much as possible and mechanical valve replacement was performed. Postoperatively, the patient recovered satisfactorily and was discharged on the 16th postoperative day. Pathological findings showed no major disturbance in the layered structure of the papillary muscle or the leaflet itself, but it was highly thickened due to mucous degeneration of the leaflet. We report our experience with the rare case described above.

   

  Jpn. J. Cardiovasc. Surg. 51: 204-207 （2022）

  Keywords：geleophysic dysplasia; mitral valve stenosis; pediatric mitral valvular disease

  
  
• ［Acquired Cardiovascular Surgery］
• A Long-Term Survival Case after Successful Five-Fold Surgical Intervention for Recurrent Undifferentiated Pleomorphic Sarcoma in the Left Atrium T. Murakami et al.…208
  A Long-Term Survival Case after Successful Five-Fold Surgical Intervention for Recurrent Undifferentiated Pleomorphic Sarcoma in the Left Atrium
  

  Tadahiro Murakami＊	Hirokazu Minamimura＊＊	Toshio Baba＊＊
  Atsutaka Aratame＊＊

  
  

  (Department of Cardiovascular Surgery, Osaka Saiseikai-Noe Hospital＊, Osaka, Japan, and Department of Cardiovascular Surgery, Bell Land General Hospital＊＊, Sakai, Japan)
  

  Primary cardiac undifferentiated pleomorphic sarcoma is rare and is associated with very poor survival. We report a case of a 45-year-old female who presented with dyspnea on effort, in whom an echocardiographic exam showed a large mass in the left atrium and the tumor resection was performed. The pathological diagnosis of the resected tumor was undifferentiated pleomorphic sarcoma which subsequently recurred. The patient needed four re-surgeries, and chemotherapy with Pazopanib was performed. A long-term survival of 5 years after the initial surgery was achieved.

   

  Jpn. J. Cardiovasc. Surg. 51: 208-212 （2022）

  Keywords：cardiac undifferentiated pleomorphic sarcoma; re-surgery; long-term survival; Pazopanib

  
  
• A Case of Tubercular Infrarenal Abdominal Aortic Aneurysm T. Tsuji et al.…213
  A Case of Tubercular Infrarenal Abdominal Aortic Aneurysm
  

  Takashi Tsuji＊	Tadashi Takasaki＊	Michihito Nonaka＊
  Syogo Nakayama＊

  
  

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

  The patient was an 81-year-old male. During treatment of a refractory subcutaneous abscess, he was diagnosed with an infection of an infrarenal aortic aneurysm caused by unknown bacteria. Antibiotic administration was initiated, but the infection persisted and there was no improvement of the aortic infection focus or aneurysm morphology. In order to control the infection and avoid rupture of the aortic aneurysm, excision of the infectious abdominal aortic aneurysm, omental plombage, and debridement of the surrounding infected tissue were performed. According to histopathological examination of the extracted sample, findings were consistent with an infection of the aortic aneurysm. Although administration of antibiotics continued, the infection continued to worsen during the postoperative course and an enlarged subcutaneous abscess and miliary tuberculosis were indicated by computed tomography. Therefore, an acid-fast bacteria culture test of the subcutaneous abscess, sputum, and urine and Tuberculous (Tb)-real time polymerase chain reaction (PCR) tests were carried out. According to Tb-PCR test of the subcutaneous abscess, mycobacterium tuberculosis was detected. In the re-evaluation of the extracted sample, granulomatous inflammation with spindle-shaped cell fenestration around the necrotic tissue and the appearance of epithelial cells and multinucleated giant cells were observed. Findings were consistent with a tubercular infection of the aortic aneurysm. Anti-tuberculosis treatment was initiated, and significant improvement of the inflammation and subcutaneous pus in the right chest were observed. On Day 39 after surgery, the patient was discharged from the hospital and walked home with no help. We experienced a successful case of tubercular infection of an infrarenal aortic aneurysm requiring surgery. Infection was controlled and rupture of the aortic aneurysm was avoided with surgical treatment and antituberculosis therapy. (Surgical treatment by excision of infectious abdominal aortic aneurysm, omental plombage, and debridement of the surrounding infected tissue, and antituberculosis therapy were carried out.)

   

  Jpn. J. Cardiovasc. Surg. 51: 213-216 （2022）

  Keywords：tuberculous; infection of abdominal aneurysm; miliary tuberculosis; omental plombage

  
  
• A Case of Mechanical Hemolytic Anemia due to Aortic Regurgitation Jet Collision with the Mitral Valve Stent-Post K. Yoshida et al.…217
  A Case of Mechanical Hemolytic Anemia due to Aortic Regurgitation Jet Collision with the Mitral Valve Stent-Post
  

  Keisuke Yoshida＊	Yujiro Miura＊	Naoki Edo＊
  Atsuyuki Mitsuishi＊

  
  

  (Department of Cardiovascular Surgery and Cardiology, Kochi University, School of Medicine, Nankoku, Japan)
  

  The 76-year-old woman underwent double bioprosthetic valve replacement for aortic and mitral valve regurgitation without any postoperative complication. About 33 months later, the patient complained of sudden dyspnea and was diagnosed with mechanical hemolytic anemia, severe aortic regurgitant jet collision with stent post (SP) at mitral position and acute heart failure. The cause of mechanical hemolysis was suspected to be a collision of the regurgitant jet due to structural valve deterioration (SVD) with the SP because of the absence of any paravalvular leak (PVL). The externally-mounted bioprosthetic aortic valve was replaced and the inadequate projection of the SP in left ventricular outflow tract was recognized simultaneously. The patient fully recovered from heart failure and hemolytic anemia after surgery. Early SVD of externally-mounted bioprosthetic valves has often been reported, and the eccentric regurgitant jet due to SVD may collide with any sub-valvular structures. We report a rare case of hemolytic anemia due to SVD.

   

  Jpn. J. Cardiovasc. Surg. 51: 217-220 （2022）

  Keywords：mechanical hemolytic anemia; structural valve deterioration; aortic valve replacement; mitral valve stent-post

  
  
• Dual-Valve Repair in Dextrocardia and Situs Inversus Totalis M. Inagaki et al.…221
  Dual-Valve Repair in Dextrocardia and Situs Inversus Totalis
  

  Masahiro Inagaki＊	Yutaka Koyama＊	Koshi Sawada＊
  Shinji Tomita＊	Yasuhide Okawa＊

  
  

  (Department of Cardiovascular Surgery, Gifu Heart Center, Gifu, Japan)
  

  A 59-year-old man, diagnosed with severe mitral regurgitation, moderate tricuspid regurgitation, and chronic atrial fibrillation with situs inversus totalis, was referred to our hospital. A median sternotomy approach was performed. The surgeon operated from the left side of the operating table, and had an excellent exposure to the mitral and tricuspid valves during the operation. The mitral valve was repaired with the posterior cusp plication technique and ring annuloplasty. The tricuspid valve was repaired with ring annuloplasty. We use a conventional semi rigid ring turned over, because the tricuspid valve has an asymmetric configuration. FullMAZE, and left atrial appendage closure were performed, too. The postoperative course was uneventful.

   

  Jpn. J. Cardiovasc. Surg. 51: 221-224 （2022）

  Keywords：cardiac valve annuloplasty; situs inversus; mitral valve insufficiency; tricuspid valve insufficiency

  
  
• Two Cases of Minimally Invasive Right Thoracotomy Approach and Microscope-Assisted Surgery for Mitral Re-Operation; Mechanical Valve Dysfunction in the Late Operative Period T. Murakami et al.…225
  Two Cases of Minimally Invasive Right Thoracotomy Approach and Microscope-Assisted Surgery for Mitral Re-Operation; Mechanical Valve Dysfunction in the Late Operative Period
  

  Takeshi Murakami＊	Shun Nakaji＊＊	Tomohiro Odate＊＊＊
  Shinichiro Taniguchi＊	Kiyoyuki Eishi＊＊

  
  

  (Department of Cardiovascular Surgery, Sasebo Central Hospital＊, Sasebo, Japan, Department of Cardiovascular Surgery, Nagasaki University Hospital＊＊, Sasebo, Japan, and Department of Cardiovascular Surgery, Oita Prefectural Hospital＊＊＊, Oita, Japan）
  

  Case 1 of stuck valve was an 84 year old man, 25 years after mitral valve replacement （MVR） using a mechanical valve. Case 2 was a 67 year old woman, 18 years after the previous operation. These patients underwent re-do replacement of the prosthesis with a minimally invasive right thoracotomy approach using a microscope. Re-do cardiac surgery is commonly regarded high risk on account of difficulty in peeling the adhension, risk of injury to the heart, lung or large vessels, longer operation time, greater amount of transfusion, higher invasion and longer admission. In both cases however, because of microscope-assist and right thoracotomy MICS technique, we safely and successfully completed the operation without any unplanned troubles. We finally had a good course with a short admission, no perioperative transfusion or no perioperative complication.

   

  Jpn. J. Cardiovasc. Surg. 51: 225-230 （2022）

  Keywords：mechanical valve dysfunction; re-do mitral valve surgery; minimally invasive cardiac surgery

  
  
• A Case of Non-Bacterial Thrombotic Endocarditis with Atypical Massive Vegitation T. Kimura et al.…231
  A Case of Non-Bacterial Thrombotic Endocarditis with Atypical Massive Vegitation
  

  Takanobu Kimura＊	Takuki Wada＊	Shuji Setozaki＊
  Hideyuki Katayama＊	Shuntaro Shimomura＊	Hiroshi Tsuneyoshi＊

  
  

  (Department of Cardiovascular Surgery, Shizuoka Prefecture General Hospital＊, Shizuoka, Japan)
  

  The patient was a 68-year-old woman. She was diagnosed with uterine cancer after experiencing irregular genital bleeding. Contrast-enhanced computed tomography showed a 30 mm left ventricular mass and splenic infarction, and head MRI showed multiple cerebral infarctions. The patient was suffering from systemic embolism caused by the cardiac mass, and we decided to perform cardiac mass removal prior to uterine cancer treatment. A yellowish-white thrombus-like mass attached to the mitral valve, subvalvular tissue, and left ventricular endocardium was removed by a trans-septal approach under cardiopulmonary bypass. Pathological examination revealed that the mass was a fibrin-based thrombus with almost no inflammatory findings, we diagnosised non-bacterial thrombotic endocarditis（NBTE）. Postoperatively, the patient developed Takotsubo cardiomyopathy, and treatment for uterine cancer, was delayed. Hypercoagulability was not controlled well, and she developed recurrence of left ventricle vegitation, acute arterial occlusion of the lower extremities and inferior vena cava thrombosis, making active intervention for uterine cancer difficult. The patient was treated palliatively and died on POD 36. NBTE tends to be characterized by multiple small growths, but giant vegetation may also occur as in this case. Unless the primary disease causing the hypercoagulability is treated, recurrence of NBTE is possible, and prompt treatment of the primary disease is required.

   

  Jpn. J. Cardiovasc. Surg. 51: 231-234 （2022）

  Keywords：non-bacterial endocarditis; Trousseau syndrome; cardiac tumor; infective endocarditis; uterine cancer

  
  
• Two Cases of Combined Performance of Endovascular Aortic Aneurysm Repair (EVAR) and Off-Pump Coronary Artery Bypass Grafting (OPCAB) S. Motono et al.…235
  Two Cases of Combined Performance of Endovascular Aortic Aneurysm Repair (EVAR) and Off-Pump Coronary Artery Bypass Grafting (OPCAB)
  

  So Motono＊	Masami Sotokawa＊	Yushi Katagiri＊
  Shingo Otaka＊	Koji Seki＊	Tetsuyuki Ueda＊

  
  

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

  Concomitant occurrence of coronary arterial disease (CAD) with abdominal aortic aneurysm (AAA) is not rare. Combined performance of open surgery (OS) of AAA repair and coronary arterial bypass grafting (CABG) has been reported to be effective as the way to avoid the risk of rupture of the aneurysm and acute coronary syndrome (ACS), while it’s highly invasive. We successfully performed a combination performance of endovascular aneurysm repair (EVAR) and off-pump CABG (OPCAB) with the support of an intra-aortic balloon pump (IABP) in 2 cases with AAA and unstable angina pectoris (UAP). It was suggested that this strategy is a reasonable clinical option for the patient with UAP complicated with large AAA.

   

  Jpn. J. Cardiovasc. Surg. 51: 235-239 （2022）

  Keywords：abdominal aortic aneurysm (AAA); coronary arterial disease (CAD); acute coronary syndrome (ACS); endovascular aneurysm repair (EVAR); off-pump coronary artery bypass grafting (OPCAB); combined performance

  
  
• ［Aortic Disease］
• Translocation of the Isolated Left Vertebral Artery during Thoracic Endovascular Stent-Graft Repair T. Arai et al.…240
  Translocation of the Isolated Left Vertebral Artery during Thoracic Endovascular Stent-Graft Repair
  

  Takeshi Arai＊	Daichi Takagi＊	Takuya Wada＊
  Itaru Igarashi＊	Yuya Yamazaki＊	Wataru Igarashi＊
  Takayuki Kadohama＊	Hiroshi Yamamoto＊

  
  

  （Department of Cardiovascular Surgery, Akita University Graduate School of Medicine＊, Akita Japan）
  

  Spinal cord injury （SCI） is a main concern in patients who undergo thoracic endovascular therapy （TEVAR）, because the blood flow of the vertebro-basilar artery may be reduced due to the left subclavian artery （LSA） occlusion. If the left vertebral artery originates directly from the aorta, which is called the isolated left vertebral artery （ILVA）, a technical consideration for strategies regarding blood perfusion of the ILVA during TEVARs is required. We hereby aim to report three patients （No.1, No.2, and No.3） who underwent an ILVA translocation and TEVAR with Zone 2 landing for aortic dissection. The diameter of the ILVA was 4.2, 2.3, and 2.2 mm, respectively, and the right vertebral artery （RVA） was dominant in all cases. In Patient No.1 and No.2 （ILVA diameter: 4.2 and 2.3 mm, respectively）, the ILVA was anastomosed directly to the left common carotid artery. In Patient No.2, the translocated ILVA was occluded resulting in SCI, but the SCI improved when blood pressure was augmented. In Patient No.3 （ILVA diameter: 2.2 mm）, the saphenous vein graft was interposed between the ILVA and the bypass artery because the ILVA diameter was small, but postoperatively, the ILVA remained patent, and no paraplegia was observed. The occlusion of ILVA could cause SCI, even if the RVA is larger than the LVA. Reconstruction of the ILVA is a critical procedure to prevent postoperative SCIs in patients undergoing TEVARs.

   

  Jpn. J. Cardiovasc. Surg. 51: 240-244 （2022）

  Keywords：isolated left vertebral artery; thoracic endovascular aneurysm repair; spinal cord injury

  
  
• Tracheoplasty for Tracheal Collapse after the Tracheoinnominate Fistula Repair H. Sasaki et al.…245
  Tracheoplasty for Tracheal Collapse after the Tracheoinnominate Fistula Repair
  

  Hanae Sasaki＊	Ryosuke Kowatari＊	Kazuyuki Daitoku＊
  Tomonori Kawamura＊	Shiho Yamazaki＊	Masahito Minakawa＊

  
  

  （Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan）
  

  A 13-year-old boy underwent tracheostomy due to post-cardiac arrest encephalopathy in our hospital. During the second postoperative month, massive bleeding from the tracheostomy tube lumen was observed; tracheoinnominate artery fistula was diagnosed. Two weeks postoperatively, the trachea collapsed; tracheoplasty with VA-ECMO was performed. The patient was placed in respiratory distress and the tracheostomy cannula was removed. The damaged part of the trachea was trimmed to form a fusiform structure, while the horizontal mattress suture technique was used for tracheoplasty. An endotracheal tube was then placed just above the tracheal bifurcation and the tracheoplasty site was rested. On postoperative day 15, the tube was changed to a tracheostomy one; 3 months postoperatively, no tracheostomy-related complications or rebleeding were observed. Therefore, VA-ECMO assisted tracheal repair is considered a useful treatment option for patients with tracheal disruption, where suturing a prosthesis to the tracheostomy stoma site is difficult.

   

  Jpn. J. Cardiovasc. Surg. 51: 245-248 （2022）

  Keywords：tracheoinnominate artery fistula; innominate artery transection; tracheostomy; tracheoplasty

  
  
• Surgical Tumor Resection and Reconstruction of the Inferior vena cava under Cardiopulmonary Bypass for Right Renal Cell Carcinoma Extending into the Right Ventricle A. Ohkawa et al.…249
  Surgical Tumor Resection and Reconstruction of the Inferior vena cava under Cardiopulmonary Bypass for Right Renal Cell Carcinoma Extending into the Right Ventricle
  

  Akihito Ohkawa＊	Yutaka Iba＊	Riko Umeta＊
  Itaru Hosaka＊	Naomi Yasuda＊	Tsuyoshi Shibata＊
  Tomohiro Nakajima＊	Nobuyoshi Kawaharada＊

  
  

  （Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine＊, Sapporo, Japan）
  

  In cases of renal cell carcinoma causing embolism in the inferior vena cava, aggressive surgical resection is recommended and expected to improve the prognosis. The patient was a 52-year-old man who had been on hemodialysis since the age of 45 due to diabetic nephropathy. A CT scan for anemia revealed a tumor in the right kidney, and the patient was referred to the urologist at our hospital. A thorough examination revealed a diagnosis of primary right renal carcinoma with tumor embolization in the inferior vena cava （IVC） that extended to the right ventricle. During surgical resection of the tumor, a midline abdominal incision was made. The liver was detached and exposed to the IVC by the gastroenterological surgeon, followed by dissection of the right kidney for removal by the urologist. The wound was then extended to the anterior chest, and a mid-thoracic incision was made. The SVC was snared, and a right atrial incision revealed a tumor. We resected the tumor at the level of the diaphragm while blocking the IVC, and sutured the right atrium. The IVC was then incised centrally from the confluence of the right renal veins to identify the renal tumor that was resected from the lumen along with the venous wall. The missing IVC wall was reconstructed with an expanded polytetrafluoroethylene （ePTFE） patch. In this case, the patient received complete resection of a right renal cell carcinoma, with inferior vena cava embolism and tumor extending into the right ventricle, using extracorporeal circulation. He was discharged on the 29th day after surgery without any major postoperative complications. The use of cardiopulmonary bypass is considered to be an effective means of ensuring surgical safety in cases of complete resection of malignant tumors that have spread from the IVC to the heart.

   

  Jpn. J. Cardiovasc. Surg. 51: 249-253 （2022）

  Keywords：inferior vena cava; carcinoma; cardiopulmonary bypass

  
  

Progress in Cardiovascular Surgery (2021)

• Update of 2021 in Peripheral Artery Disease H. Obara…254
• Progress in Valvular Heart Disease and Arrhythmias S. Katahira…256

U-40

• U-40 Column Parallel Carrier of Cardiovascular Surgeon and Medical Innovator T. Yamada…U1

Editor’s Post Script

• K. Okada