JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Vol.51, No.5

Preface

• Cardiac Surgeons in TAVR Era K. Doi

Special Contribution

• How Can Patient-Centered Medicine Be Implemented in Hospital ? Interpretation of Medical Accident S. Takamoto…259
  How Can Patient-Centered Medicine Be Implemented in Hospitals ? Interpretation of Medical Accident
  

  Shinichi Takamoto＊

  
  

  (Honorary President, The Japanese Society for Cardiovascular Surgery＊, Emeritus Professor, The University of Tokyo＊, Director, San-Ikukai Hospital＊)
  

  The concept of Patient-Centered Medicine was first proposed by E. Balint in 1969 and since then it has widely disseminated world over and also in Japan. The Ministry of Health in Japan aims to implement Patient-Centered Medicine in all hospitals to improve the quality of medical care. In cases of medical death with problems all Hospital Administration Doctors should explain to the patient family the true interpretation. However, some Hospital Administration Doctors did not do this because true explanation might damage reputation of the hospital. The Ministry of Health should change persons who would request investigation of the medial accident at the Medical Safety Research Organization, from Hospital Administration Doctors to special Doctors who could recognize the good quality of medicine at the medical safety committee in special Medical Societies. If Medical Safety Research Organization could make real truth and future apply for the medical accident, hospital members could learn how to improve nice medical activity for severe patients with mission of Patient-Centered Medicine. Overall, it is hoped that the quality of medical care for patients will improve if the medical system become more Patient-Centered.

   

  Jpn. J. Cardiovasc. Surg. 51: 259-264 （2022）

  Keywords：Patient-Centered Medicine; medical accident; Hospital Administration Doctors; Medical Safety Research Organization

  
  

Original

• Surgical Repair of Cardiac Chamber Injury by Catheter Ablation for Atrial Fibrillation S. Sumino et al.…265
  Surgical Repair of Cardiac Chamber Injury by Catheter Ablation for Atrial Fibrillation
  

  Satoshi Sumino＊

  
  

  (Department of Cardiovascular Surgery, Sapporo Shiroishi Memorial Hospital＊, Sapporo, Japan)
  

  Background: Cardiac tamponade developing in the catheter ablation procedure is a very rare complication, but might result in the fatal outcome unless the prompt diagnosis and appropriate treatments are done. There are few published reports regarding the surgical intervention for this critical complication. Objective and Methods: From January 2012 to December 2021, 10 patients underwent emergency surgical repair of cardiac chamber injuries by atrial fibrillation catheter ablation. The trends of the injury and the strategy of the emergency surgery were assessed. Results: All the patients were successfully rescued by emergency surgical repair. Two of them underwent the surgery under cardiopulmonary bypass. There were 12 injury sites including 5 of left atrium and left atrial appendage. Intraoperative findings suggested that the cause of the cardiac tamponade was mainly due to mechanical chamber injury by ablation catheter manipulations in all cases. Four patients who were all octogenarians necessitated prolonged hospitalization due to disuse syndrome secondary to acute renal failure postoperatively. Conclusions: Cardiac chamber injury by catheter ablation for atrial fibrillation could be surgically repaired by the evaluation of pre-operative dynamic state and predictive diagnosis of injury sites. Pre-operative evaluation of drained pericardial blood gas analysis and hemodynamic state provide helpful information to organize surgical strategies. The left atrial roof seems to be easily injured because of anatomical reasons and the contact force of the ablation catheter. Pre-operative cardiogenic shock status was suspected as the principal cause of the post-operative complication. Owing to the pre-operative dynamic instability, aged patients in particular might suffer from serious complication such as acute renal injury followed by disuse syndrome. Mutual collaboration with cardiologists should lead to prompt and exact treatment.

   

  Jpn. J. Cardiovasc. Surg. 51: 265-269 （2022）

  Keywords：atrial fibrillation; catheter ablation; complication; surgical repair of cardiac injury

  
  

Case Reports

• ［Congenital Heart Disease］
• A Case of Cone Reconstruction and Aortic Valve Replacement for an Adult Patient Diagnosed with Ebstein’s Anomaly Incidentally during Preoperative Examination of Severe Aortic Regurgitation H. Sunadoi et al.…270
  A Case of Cone Reconstruction and Aortic Valve Replacement for an Adult Patient Diagnosed with Ebstein’s Anomaly Incidentally during Preoperative Examination of Severe Aortic Regurgitation
  

  Hiroki Sunadoi＊	Noriyoshi Ebuoka＊＊	Masato Fusegawa＊
  Hidetsugu Asai＊＊	Takashi Sugiki＊	Yutaka Makino＊

  
  

  (Department of Cardiovascular Surgery, Oji General Hospital＊, Tomakomai, Japan, and Department of Congenital Cardiovascular Surgery, Hokkaido Medical Center for Child Health and Rehabilitation＊＊, Sapporo, Japan)
  

  Recently, there have been some reports that cone reconstruction can be performed in the repair of Ebstein’s anomaly with acceptable result on a child. On an adult with Ebstein’s anomaly, optimal surgical indication and choice of the operative procedure are controversial. A man in his seventies was diagnosed with Ebstein’s anomaly incidentally during preoperative examination of severe aortic regurgitation. We performed aortic valve replacement and cone reconstruction, because his tricuspid regurgitation was moderate. There was no severe complication and he was discharged. No sign of recurrence have been observed after 4 months follow up. We present a case in which cone reconstruction and aortic valve replacement were successfully performed on an adult patient diagnosed with Ebstein’s anomaly and severe aortic regurgitation.

   

  Jpn. J. Cardiovasc. Surg. 51: 270-273 （2022）

  Keywords：Ebstein’s anomaly; Cone reconstruction; aortic valve replacement

  
  
• ［Acquired Cardiovascular Surgery］
• A Case of Surgical Treatment of Primary Cardiac Intimal Sarcoma in the Left Atrium T. Murakami et al.…274
  A Case of Surgical Treatment of Primary Cardiac Intimal Sarcoma in the Left Atrium
  

  Tadahiro Murakami＊	Hirokazu Minamimura＊＊	Toshio Baba＊＊
  Atsutaka Aratame＊＊	Hidekazu Hirai＊	Hiroyuki Seo＊
  Daisuke Kaku＊

  
  

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

  Primary cardiac malignant tumor is rare and is associated with very poor survival. We report a case of a 45-year-old female who presented with dyspnea and general edema due to severe congestive heart failure, in whom an echocardiographic exam showed a large mass in the left atrium, mitral valve regurgitation and tricuspid valve regurgitation and the tumor resection, mitral valve repair and tricuspid annuloplasty were performed under semi-emergency. The pathological diagnosis of the resected tumor was cardiac intimal sarcoma which recurred; the patient needed re-surgery after 1 year and 5 months, and chemotherapy by pazopanib was performed. She died due to widespread metastasis. A relatively long-term survival of two years and 1 month after the initial surgery was achieved.

   

  Jpn. J. Cardiovasc. Surg. 51: 274-279 （2022）

  Keywords：primary cardiac malignant tumor; cardiac intimal sarcoma; pazopanib; re-surgery

  
  
• Successful Heparin Management Using HMS PLUS for a Patient with Endocarditis and Antiphospholipid Syndrome Undergoing Valve Replacement Y. Kitagata et al.…280
  Successful Heparin Management Using HMS PLUS for a Patient with Endocarditis and Antiphospholipid Syndrome Undergoing Valve Replacement
  

  Yuta Kitagata＊	Hiroshi Tsuneyoshi＊	Hideyuki Katayama＊
  Takumi Wada＊	Kenta Yamada

  
  

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

  A 71-year-old woman was diagnosed with antiphospholipid antibody syndrome following an acute myocardial infarction and had been taking anticoagulants ever since. Three years later, she was hospitalized with high fever and substantial fatigue. She was diagnosed with infective endocarditis because the blood culture was positive, and scattered cerebral infarction was seen on magnetic resonance imaging, along with an iliopsoas muscle abscess and purulent discitis. She was treated with antibiotics, and her blood culture became negative; however, she was referred to our hospital for surgical treatment because of severe mitral regurgitation due to the progressive valve destruction. She also had aortic regurgitation and underwent mitral and aortic valve replacement. The mitral valve exhibited strong thickening of both leaflets, including the subvalvular tissue, and perforation was observed in the posterior leaflet, P2. The operation time was 4 h and 2 min, and the aortic clamp time was 92 min. The culture of the mitral valve leaflet was negative. She had antiphospholipid antibody syndrome and intraoperative activated clotting time (ACT) management was difficult; therefore, her heparin blood levels were measured and managed using HMS PLUS. The target heparin blood concentration during cardiopulmonary bypass was set at 3 mg/kg and controlled; no thrombotic tendency or increase in circuit pressure was observed during the operation, and the procedure was completed without any problem. She resumed heparin administration 6 h after the operation and continued oral anticoagulant therapy. She recovered without problems and was discharged 12 days after the operation. Management using HMS PLUS may be useful in patients with antiphospholipid syndrome undergoing cardiovascular surgery.

   

  Jpn. J. Cardiovasc. Surg. 51: 280-284 （2022）

  Keywords：antiphospholipid syndrome; infective endocarditis; HMS PLUS; heparin blood concentration; activated clotting time

  
  
• Extensive Left Atrial Resection and Double Valve Repair for a Patient with Atrial Functional Mitral Regurgitation Associated Giant Left Atrium T. Itoh et al.…285
  Extensive Left Atrial Resection and Double Valve Repair for a Patient with Atrial Functional Mitral Regurgitation Associated Giant Left Atrium
  

  Takahito Itoh＊	Kanako Kobayashi＊	Yujiro Kawai＊
  Satoshi Ohtsubo＊

  
  

  (Department of Cardiovascular Surgery, Tokyo Saiseikai Central Hospital＊, Tokyo, Japan)
  

  A 72-year-old woman who had undergone three atrial catheter ablations for chronic atrial fibrillation was referred for surgical treatment for severe atrial functional mitral regurgitation. She suffered not only dyspnea but also dysphagia due to esophagus compression by a giant left atrium 15×12×11 centimeters in size. In her surgery, mitral valve repair using a 36-millimeter artificial ring, tricuspid annuloplasty and resection of the left atrial appendage were performed. In addition, the posterior, lateral, and superior wall of left atrium, 4 centimeters in width, was extensively resected to reduce left atrial volume. Postoperative echocardiography showed a decrease in both mitral and tricuspid regurgitation to trivial levels as well as an improvement in left ventricular diastolic function. Postoperatively her dysphagia disappeared and NYHA class improved from III to I. In her chest X ray, the cardiothoracic ratio fell from 80% to 56%, and the tracheal bifurcation angle decreased from 110 to 90 degrees. In a patient with a giant left atrium due to atrial functional mitral regurgitation, a favorable clinical outcome resulted from double valve repair combined with extensive left atrial resection.

   

  Jpn. J. Cardiovasc. Surg. 51: 285-290 （2022）

  Keywords：left atrium resection; giant left atrium; atrial functional mitral regurgitation; spiral resection; left ventricular diastolic dysfunction

  
  
• Surgical Closure of an Atrial Septal Defect Attenuated Migraine R. Ueda et al.…291
  Surgical Closure of an Atrial Septal Defect Attenuated Migraine
  

  Ryoma Ueda*	Hisashi Sakaguchi＊	Atsushi Iwakura＊
  Manabu Morishima＊	Shinya Takimoto＊	Junpei Kobiki＊
  Yousuke Sugita＊

  
  

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

  The prevalence of migraine is higher in patients with atrial septal defect (ASD) (24.2%) than in the general Japanese population (9.4%). A few studies have reported that transcatheter closure of an interatrial shunt is known to attenuate migraine. We experienced hat surgical closure of the ASD improved migraine that was refractory to medication therapy. A 46-year-old man presented to a neurologist for evaluation of severe headache and was diagnosed with migraine. Brain magnetic resonance imaging (MRI) revealed evidence of previous multiple cerebral infarctions. Transesophageal echocardiography detected inferior sinus venosus-type ASD, and a bubble study showed the presence of a right-to-left shunt. Owing to the high index of clinical suspicion for paradoxical embolism via the ASD and the fact that percutaneous catheter closure was contraindicated for inferior sinus venosus-type ASD, we performed surgical closure of the ASD in this patient. The patient’s migraine symptoms disappeared immediately after surgery, and no recurrence has been observed eight months after surgery. This is the first case report that surgical closure of ASD led to attenuate migraine. Our study highlights the association between right-to-left shunts and migraine, as well as the usefulness of the surgical closure of ASD as a therapeutic strategy for patients with migraine.

   

  Jpn. J. Cardiovasc. Surg. 51: 291-295 （2022）

  Keywords：surgical closure of atrial septal defect; migraine; right-left shunt

  
  
• A Case of Calcified Amorphous Tumor in the Left Ventricular Outflow Tract M. Arimoto et al.…296
  A Case of Calcified Amorphous Tumor in the Left Ventricular Outflow Tract
  

  Munehito Arimoto＊

  Yosuke Kitanaka＊

  Masashi Tanaka＊＊

  
  

  (The Department of Cardiac Surgery, Kawaguchi Municipal Medical Center＊, Kawaguchi, Japan, and The Department of Cardiovascular Surgery, Nihon University School of Medicine＊＊, Tokyo, Japan)
  

  We report a case of a hemodialysis patient with a calcified amorphous tumor （CAT） located in Left ventricular outflow tract. A 69-year-old female with chronic kidney disease on hemodialysis for 10 years complained about palpitation and chest tightness. Echocardiography and cardiac MRI revealed a mobile mass in the left ventricular outflow tract （LVOT）. We had a follow-up 6 months after finding mass. We thought that as the mass had potential for embolism, we should remove it; we performed an operation, tumor resection without harming the aortic valve. Her clinical course was uneventful. Pathological examination showed that the mass contained calcified nodules and fibrotic tissue. These findings showed CAT.

   

  Jpn. J. Cardiovasc. Surg. 51: 296-299 （2022）

  Keywords：calcified amorphous tumor; hemodialysis; left ventricular outflow tract

  
  
• Mitral Valve Replacement while Preserving Calcified Annulus in Severe Mitral Annular Calcification H. Matabe et al.…300
  Mitral Valve Replacement while Preserving Calcified Annulus in Severe Mitral Annular Calcification
  

  Hiroya Matabe＊	Tomoyuki Minami＊	Naoto Yabu＊
  Ichiya Yamazaki＊	Shinichi Suzuki＊＊

  
  

  (Department of Cardiovascular Surgery, Fujisawa City Hospital＊, Fujisawa, Japan, and Yokohama City University Hospital, the Department of Surgery, Yokohama, Japan)
  

  A 70-years-old woman who had been on hemodialysis for 8 years was referred to our institution to undergo mitral surgery for mitral valve stenosis. Intraoperative investigations confirmed severe calcification of the posterior mitral leaflet and all-around mitral annulus. We excised the mitral leaflet using the Ultrasonic Surgical System and preserved the calcified annulus to prevent a fatal complication such as left ventricular rupture. We passed 2-0 polyester mattress sutures through the calcified annulus from the left ventricle to the left atrium, and mitral valve replacement was performed using a reversed 19 mm On-X mechanical heart valve for the aortic valve. The postoperative course was uneventful. Mitral annular calcification is a factor of fatal complications such as left ventricle rupture and coronary artery injury. We succeeded in preserving the calcified annulus and using a small diameter mechanical heart valve.

   

  Jpn. J. Cardiovasc. Surg. 51: 300-303 （2022）

  Keywords：mitral valve replacement; mitral annular calcification; left ventricle rupture; prosthesis-patient mismatch

  
  
• ［Aortic Disease］
• Acute Type A Aortic Dissection in a Pregnant Woman with Loeys-Dietz Syndrome T. Wakami et al.…304
  Acute Type A Aortic Dissection in a Pregnant Woman with Loeys-Dietz Syndrome
  

  Tatsuto Wakami＊

  Kazufumi Yoshida＊

  Tadaaki Koyama＊

  
  

  (Department of Cardiovascular Surgery, Kobe City Medical Center, General Hospital＊, Kobe, Japan)
  

  A 43-year-old pregnant woman was transferred to our hospital at 30 weeks’ gestation for evaluation of chest and back pain. The patient was diagnosed with Stanford type A acute aortic dissection and had a family history of aortic dissection, with physical findings characteristic of hereditary connective tissue disease; however, she did not undergo comprehensive evaluation. The patient underwent cesarean delivery followed by total hysterectomy to prevent uncontrollable obstetric bleeding. She subsequently underwent total arch replacement and the Bentall procedure. The patient’s postoperative course was unremarkable, and neither the mother nor the newborn showed any complications. Genetic testing revealed Loeys-dietz syndrome in the mother.

   

  Jpn. J. Cardiovasc. Surg. 51: 304-307 （2022）

  Keywords：acute aortic dissection; Stanford type A; pregnancy; hysterectomy; Loeys-dietz syndrome

  
  
• A Case of Takotsubo Cardiomyopathy with ST Elevation during Total Arch Replacement K. Hayashida et al.…308
  A Case of Takotsubo Cardiomyopathy with ST Elevation during Total Arch Replacement
  

  Kyoko Hayashida＊

  Shinsuke Masuda＊

  Kazuki Morimoto＊

  
  

  (Department of Vascular Surgery, Maizuru Kyosai Hospital＊, Maizuru, Japan)
  

  Aside from myocardial infarction, coronary spastic angina, and air embolism of the coronary arteries, Takotsubo cardiomyopathy is a rare cause of ST elevation during the perioperative period of cardiovascular surgery. Here we report a case of Takotsubo cardiomyopathy that developed with ST elevation during total arch replacement. A 71-year-old man was found to have an abnormality on chest X-ray. A thoracic aortic aneurysm with a maximum diameter of 68 mm was diagnosed on CT, and surgical intervention was indicated. Preoperative ECG showed no abnormality. Transthoracic echocardiography showed normal left ventricular wall motion. No valvular disease was observed. Coronary angiography showed a 50% stenotic lesion in the right coronary artery, but it was not considered significant. Total arch replacement was performed under moderate hypothermic circulatory arrest with anterograde selective cerebral perfusion. After retrograde terminal warm blood cardioplegia and aortic declamping while removing air from the root cannula, ST elevation in the II, III, and chest leads was noted and transesophageal echo showed impaired left ventricular wall motion. However, the right ventricular wall motion appeared normal under direct vision. While cardiopulmonary bypass was maintained with total perfusion, the ST level gradually improved. He was weaned from cardiopulmonary bypass 62 min after aortic declamping. ST elevation was observed again during sternal closure, so the patient was taken to the cardiac catheterization room immediately after the operation. Coronary angiography showed no significant change from before surgery. Left ventriculography revealed hypokinesia of the apex, leading to a diagnosis of Takotsubo cardiomyopathy. Inotropic agents and coronary dilators were discontinued. After confirming the stability of hemodynamics and the improvement of ST elevation on ECG, the patient was extubated on the first day after surgery and left the intensive care unit on the third day. On the 15th day, he was discharged from the hospital. This case shows that, if the right ventricular wall motion is normal despite ST elevation in the II and III leads intraoperatively, Takotsubo cardiomyopathy is a potential cause of the left ventricular dysfunction that might be considered in the differential diagnosis.

   

  Jpn. J. Cardiovasc. Surg. 51: 308-313 （2022）

  Keywords：Takotsubo cardiomyopathy; ST elevation; thoracic surgery

  
  
• A Case of Anastomotic Pseudoaneurysm due to Late Dysruption of Knitted Dacron Graft Treated by Hybrid Operation S. Takimoto et al.…314
  A Case of Anastomotic Pseudoaneurysm due to Late Dysruption of Knitted Dacron Graft Treated by Hybrid Operation
  

  Shinya Takimoto＊	Takanori Taniguchi＊＊	Atsushi Iwakura＊
  Kyokun Uehara＊	Manabu Morishima＊	Yasue Fujiwara＊
  Junpei Kobiki＊	Yosuke Sugita＊	Taku Shirakami＊

  
  

  (Department of Cardiovascular Surgery＊, and Department of Radiology＊＊, Tenri Hospital, Tenri, Japan)
  

  Knitted Polyester prosthetic grafts can cause long-term dilatations and formation of anastomotic or non-anastomotic aneurysms, and rupture in result. We experienced a case of anastomotic pseudoaneurysm and recurrent non-anastomotic dilatation of the ascending aorta-abdominal aorta bypass by Cooley Double Velour Knitted Dacron (CDVKD) graft for a patient with atypical coarctation of the aorta (Takayasu Aortitis, type III), which case needed treatment two times over 30 years after the initial operation. The first additional treatment was Thoracic Endovascular Aortic Repair (TEVAR) for non-anastomotic aneurysm was done as 1st operation. Thirty-two years after the initial operation, the second treatment was a hybrid operation consisting of 4 procedures: bilateral axillo-external iliac bypass, taking down of the CDVKD graft at the proximal anastomotic site, endovascular repair (EVAR) with modified Double D Technique, and coil packing at the distal anastomotic site of the CDVKD graft. The patient was discharged at 37-POD. No complication and no endoleak has occurred in the 2.5 years since the operation.

   

  Jpn. J. Cardiovasc. Surg. 51: 314-320 （2022）

  Keywords：late dysruption of knitted Dacron graft; cooley double velour knitted Dacron graft; EVAR; Double D Technique

  
  
• A Case of Blunt Traumatic Aortic Injury with a Pseudoaneurysm in the Aortic Arch between the Brachiocephalic and Left Common Carotid Arteries M. Nagahama…321
  A Case of Blunt Traumatic Aortic Injury with a Pseudoaneurysm in the Aortic Arch between the Brachiocephalic and Left Common Carotid Arteries
  

  Maiko Nagahama＊	Kenji Mogi＊	Manabu Sakurai＊
  Takashi Yamamoto＊	Yoshiharu Takahara＊

  
  

  (Division of Cardiovascular Surgery, Heart and Vascular Institute, Funabashi Municipal Medical Center＊, Funabashi, Japan)
  

  A 44-year-old man was injured by concreate boards falling on the left side of his body, and he was transferred to our hospital on suspicion of a blunt traumatic aortic injury. The contrast-enhanced CT axial scan showed the abnormal alignment of the brachiocephalic artery and a mediastinal hematoma. However, a 3D-CT image showed a pseudoaneurysm in the aortic arch between the brachiocephalic and left common carotid arteries. Immediately, partial arch replacement was performed. A 20 mm disruption was detected on the intimal surface of the arch aorta between the brachiocephalic and left common carotid arteries. This case was a very rare condition of blunt traumatic aortic injury.

   

  Jpn. J. Cardiovasc. Surg. 51: 321-323 （2022）

  Keywords：blunt traumatic aortic injury; brachiocephalic artery; psuedoaneurysm

  
  

Progress in Cardiovascular Surgery (2021)

• Update of 2021 in Coronary Surgery K. Kikuchi…324

U-40

• U-40 Column Role of Vascular Surgeons in The Japanese Society for Cardiovascular Surgery S. Higa et al.…U1

• Y. Saiki