JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Vol.51, No.6

Preface

• Enjoy Your Work and Life to the Fullest A. Shiose

Editorial Comment

• Issues in Medical Accident Investigation and Mitral Valve Surgery by MICS Y. Ueda…331

Original

• Background and Outcomes of TAVR in Low-Rrisk Score Patients K. Shigetomi et al.…334
  Background and Outcomes of TAVR in Low-Risk Score Patients
  

  Kyoko Shigetomi＊	Joji Ito＊	Shinsuke Kotani＊
  Minoru Tabata＊, ＊＊

  
  

  (Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center＊, Urayasu, Japan, and Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine＊＊, Tokyo, Japan)
  

  Objective: This study aimed to examine the background and outcomes of transcatheter aortic valve replacement (TAVR) in patients with low-risk scores. Methods: We retrospectively reviewed 69 patients with risk scores of<4% undergoing TAVR in a single institution from January 2016 through June 2021. Results: The mean age of the patients was 81±4.5 years, and 52% of them were women. The reasons for TAVR selection included very old age (≥85 years; 20%); frailty (51%); ascending aortic calcification (4.3%); history of mediastinal radiation therapy (2.8%); and respiratory diseases (10%)． Six patients required early discharge and recovery for another surgery following treatment of aortic stenosis or family members’ care, and 2 patients had an estimated life expectancy of 1-5 years. Also, three patients strongly desired TAVR despite having none of the objective factors that favor TAVR. The median lengths of stay in the ICU and after TAVR were 1 day (1-11 days) and 5 days (3-40 days)． There was neither operative mortality nor a need for aortic valve reintervention. Kaplan–Meier curves showed that the one-year survival rate was 99%, and two-year and three-year survival rates were 97% each. The causes of late death were sepsis, unknown factor, and intracranial hemorrhage. Discussion: The short-term and medium-term outcomes of TAVR with low-risk score patients were favorable although the patient background was poor due to high-risk factors for surgery that were excluded from the risk scores.

   

  Jpn. J. Cardiovasc. Surg. 51: 334-338 （2022）

  Keywords：aortic valve stenosis; transcatheter aortic valve replacement; transcatheter aortic valve implantation; low-risk

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• Role of the Nurse Practitioner (NP) in Cardiovascular Surgery ―Comparative Study of Surgical Assistants for NPs and Physicians― M. Saitoh et al.…339
  Role of the Nurse Practitioner (NP) in Cardiovascular Surgery－Comparative Study of Surgical Assistants for NPs and Physicians－
  

  Masato Saitoh＊	Takuma Yamasaki＊＊	Tomoaki Tanabe＊＊
  Shuichi Tochigi＊＊	Shoh Tatebe＊＊	Yuki Ichimori＊＊
  Imun Tei＊＊

  
  

  (Department of Cardiovascular Surgery, Nurse Practitioner＊, and Department of Cardiovascular Surgery＊＊, Ayase Heart Hospital, Tokyo, Japan)
  

  Background: Despite the recent increase in the number of institutions introducing nurse practitioners to perioperative management following cardiovascular surgery, limited reports have evaluated their performance. Objective: The current study aimed to evaluate nurse practitioners’ intervention based on perioperative outcomes following cardiovascular surgery. Methods: We performed a retrospective visualization of perioperative data following open-heart surgeries conducted at our hospital from April 1, 2019 to May 31, 2021, with the NP (99 patients) and DR (109 patients) groups consisting of patients whose first assistant was a nurse practitioner and physician, respectively. Results: No significant differences in patient characteristics were observed between the two groups. There were no significant differences in the operative time (304.4±92.7 vs. 301.4±86.8: min; p＝0.947), death within 30 days (n)(2 vs. 2; p＝0.923), and ICU stay (5.72±4.42 vs. 6.65±5.43: days; p＝0.302), between the two groups. No significant difference was observed in the occurrence of postoperative complications between the two groups. The NP group had significantly shorter hospital stay (18.6±6.7 vs. 23.0±9.8: days; p<0.001) and duration of ventilator management (19.7±22.6 vs. 28.8±50.2: h; p＝0.047) than the DR group. Discussion: The NP and DR groups exhibited comparable surgical outcomes. Perioperative management by a team including nurse practitioners, rather than by physicians alone, has been considered to reduce the duration of time spent on ventilator management and enable earlier hospital discharge, resulting in shorter hospital stays. This suggests that nurse practitioners, including surgical assistants under the direct supervision of physicians, may be able to safely perform perioperative management.

   

  Jpn. J. Cardiovasc. Surg. 51: 339-344 （2022）

  Keywords：nurse practitioners; cardiovascular surgery; physician assistant

  
  
• Migration of a Retained Epicardial Pacing Wire into the Pulmonary Artery A. Sakai et al.…345
  Migration of a Retained Epicardial Pacing Wire into the Pulmonary Artery
  

  Ai Sakai＊	Yoshitaka Yamamoto＊	Hiroki Nakabori＊
  Naoki Saito＊	Junko Katagiri＊	Hideyasu Ueda＊
  Keiichi Kimura＊	Kenji Iino＊	Akira Murata＊
  Hirofumi Takemura＊

  
  

  (Department of Cardiovascular Surgery, Kanazawa University＊, Kanazawa, Japan)
  

  Pericardial pacing wire placement may occasionally result in intravascular or intratracheal wire migration, infective endocarditis, and sepsis; reportedly, the incidence of complications is approximately 0.09 to 0.4%. We report a case of a retained epicardial pacing wire that migrated into the pulmonary artery. A 66-year-old man underwent coronary artery bypass grafting for angina pectoris, with placement of an epicardial pacing wire on the right ventricular epicardium, 6 years prior to presentation. Some resistance was encountered during wire extraction; therefore, it was cut off at the cutaneous level on postoperative day 8. Computed tomography performed 6 years postoperatively revealed migration of the pacing wire into the pulmonary artery, and it was removed using catheter intervention. Surgeons should be aware of complications associated with retained pacing wires in patients in whom epicardial wires are retained after cardiac surgery.

   

  Jpn. J. Cardiovasc. Surg. 51: 345-349 （2022）

  Keywords：retained epicardial pacing wires; migration; complication

  
  
• Aortic Stenosis with Alkaptonuria Y. Mori et al.…350
  Aortic Stenosis with Alkaptonuria
  

  Yotaro Mori＊	Noriyuki Takashima＊	Shunta Miwa＊
  Yuji Matsubayashi＊	Naoshi Minamidate＊	Masahide Enomoto＊
  Kenichi Kamiya＊	Tomoaki Suzuki＊

  
  

  （Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science＊, Otsu, Japan）
  

  A 72-year-old female received surgical aortic valve replacement for severe aortic stenosis in our hospital. During surgery, black pigmentation was observed in the aortic valve, aorta intima and mitral valve anterior leaflet collocated with calcification. We suspected Alkaptonuria(AKU) as a possible diagnosis for those surgical findings, past medical history and physical findings. A urine test for organic acids showed homogentisic，confirming the diagnosis of AKU. AKU is very rare genetic metabolic abnormality that occurs in about 1 in 25,000 to 100,000 people. AKU involves deficiency in the gene coding for HGA-1,2-dioxygenase, which metabolizes homogentisic acid to maleylacetoacetic acid in the tyrosine metabolic pathway. HGA accumulates in the body, causing black pigmentation in places including the aorta intima and mitral valve.

   

  Jpn. J. Cardiovasc. Surg. 51: 350-353 （2022）

  Keywords：Alkaptonuria; aortic valve stenosis; metabolism abnormality; ochronosis

  
  
• A Case of Commando Procedure for Paravalvular Leakage after Redo Aortic Valve Replacement and Mitral Valve Replacement R. Takayanagi et al.…354
  A Case of Commando Procedure for Paravalvular Leakage after Redo Aortic Valve Replacement and Mitral Valve Replacement
  

  Ryo Takayanagi＊	Masato Suzuki＊	Shun Watanabe＊
  Shunsuke Ohhori＊	Ryo Suzuki＊	Kiyotaka Morimoto＊
  Hideo Yokoyama＊	Toshiro Ito＊

  
  

  (Cardiovascular Surgery, Hokkaido Ohno Memorial Hospital＊, Sapporo, Japan)
  

  A 76-year-old female was admitted with complaints of dyspnea on exertion and lower leg edema. She had undergone an aortic valve replacement thirty-nine years before and a redo aortic valve replacement and mitral valve replacement twenty-eight years before. She also had hemolytic anemia with jaundice. Echocardiography showed severe paravalvular leakage in the aortic and mitral valves, and a blood flow in the aortic annulus that flows from the aortic side into the left atrium. We diagnosed heart failure and hemolytic anemia due to paravalvular leakage and decided to perform a double-valve replacement for the third time. On operation, after removing the aortic valve through aortotomy, aorto-mitral fibrous continuity was extensively calcified and perforated, and its strength was not enough to sew the prosthetic valve to it. Therefore, we decided to perform the Commando procedure. Aortotomy was extended between the noncoronary aortic sinus and the left coronary aortic sinus until it reached the dome of the left atrium. After the prosthetic mitral valve was excised, annuloplasty of the posterior mitral annulus was performed using a bovine pericardial patch, and the new prosthesis mitral valve was implanted. The anterior part of the annulus corresponding to the aorto-mitral fibrous continuity was reconstructed by sewing the base of a two-tongued triangular bovine pericardial patch to the sewing cuff of the mitral prosthesis. After closing the left atrial ceiling with the posterior patch, the aortic prosthesis was secured to the aortic annulus and the pericardial patch. The anterior patch was used to close the right side of the aortotomy. The postoperative course was uneventful, and postoperative echocardiography revealed no paravalvular leakage.

   

  Jpn. J. Cardiovasc. Surg. 51: 354-358 （2022)

  Keywords：Commando procedure; paravalvular leakage; redo valve surgery; aorto-mitral fibrous continuity

  
  
• ［Acquired Cardiovascular Surgery］
• Open Stent Grafting for Aortic Arch Aneurysm with an Aberrant Right Subclavian Artery S. Goto et al.…359
  Open Stent Grafting for Aortic Arch Aneurysm with an Aberrant Right Subclavian Artery
  

  Shinnosuke Goto＊	Hiroshi Mitsuoka＊	Masanao Nakai＊
  Takahiro Suzuki＊	Shinji Kawaguchi＊	Daisuke Uchiyama＊
  Yuta Miyano＊	Muneaki Yamada＊	Yasuhiko Terai＊
  Ryouta Nomura＊

  
  

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

  We report a case of a 56-year-old woman. She had a history of emergent ascending aorta replacement due to type A dissection. Seven years later, aortic arch enlargement (55 mm) was detected on CT scan, and indicated secondary repair. Because of the existence of the aberrant right subclavian artery (ARSA), the safer surgical management needed to be discussed. Total arch replacement with the use of open stent-grafting technique and extra-anatomical reconstruction of ARSA was chosen for the treatment. In the operation, straight woven grafts (7 mm in diameter) were firstly anastomosed to the bilateral axillary arteries. Deep hypothermic circulatory arrest with antegrade cerebral perfusion through median sternotomy was established. The aortic arch was transected between the right and left subclavian arteries. The left subclavian artery was ligated at its origin, and an aortic open stent graft was inserted distally. An aortic reconstruction was performed between the left common carotid artery and the left subclavian artery with a 4 branched J-graft. The left carotid artery was reconstructed anatomically, and the tube grafts anastomosed to the bilateral axillary arteries were reconstructed in an extra-anatomical fashion. On the 11th postoperative days, coil-embolization of the ARSA was performed to complete the treatment. The patient had an uneventful post-operative recovery. Total arch replacement using an open stent-grafting technique was a feasible treatment option for the aortic arch aneurysm with ARSA.

   

  Jpn. J. Cardiovasc Surg. 51: 359-362 （2022）

  Keywords：open stent grafting; aberrant right subclavian artery; aortic arch aneurysm

  
  
• Ruptured Abdominal Aortic Aneurysm Concomitant with Lower Extremity Ischemia,following Abdominal Blunt Trauma M. Ohara et al.…363
  Ruptured Abdominal Aortic Aneurysm Concomitant with Lower Extremity Ischemia, following Abdominal Blunt Trauma
  

  Masato Ohara*	Shunya Suzuki*	Fukashi Serizawa*
  Yuki Sekine*

  
  

  (Department of Vascular Surgery, Ishinomaki Red Cross Hospital*, Ishinomaki, Japan)
  

  The case patient was a 61-year-old man who fell while working on the back of a truck and bruised his abdomen. Immediately thereafter, the patient started experiencing lumbar pain and weakness in both lower limbs. He was then transported to our hospital by ambulance. Based on the abdominal CT findings, he was diagnosed with acute lower limb ischemia due to a ruptured abdominal aortic aneurysm. The patient underwent graft replacement surgery within 3.5 hours after the onset of the rupture. The patient had no adverse findings, such as ischemia-reperfusion injury and compartment syndrome, after resumption of blood flow （6.5 hours after the onset） and both lower limbs were well perfused. Although there was mild muscle weakness and numbness in the distal left lower limb, the patient was discharged 9 days after surgery.

   

  Jpn. J. Cardiovasc. Surg. 51: 363-367 （2022）

  Keywords：traumatic aortic injury; ruptured abdominal aortic aneurysm; acute aortic occlusion

  
  
• ［Peripheral Artery Disease］
• A Case of Accidental Right Subclavian Artery Injury during Central Venous Catheterization through the Right Internal Jugular Vein R. Umeta et al.…368
  A Case of Accidental Right Subclavian Artery Injury during Central Venous Catheterization through the Right Internal Jugular Vein
  

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

  
  

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

  An 88-year-old man was diagnosed with right renal pelvic carcinoma and underwent laparoscopic right nephroureterectomy. On postoperative day 3, he developed aspiration pneumonia and sepsis and received antibiotic therapy. A central venous catheter (CVC) with an outer diameter of 12 G was inserted via the right internal jugular vein for total parenteral nutrition. On the day after catheterization, pulsatility reverse flow was observed in its lumen, and arterial mispuncture was suspected. Enhanced computed tomography (eCT) revealed that the CVC was inserted at the right internal jugular vein and had penetrated the right subclavian artery, and the CVC tip was positioned at the ascending aorta. Our team discussed the strategy, including direct arterial suture, endovascular therapy, and a percutaneous closure device. Because the patient was too frail to endure direct arterial closure, we chose endovascular therapy. Under general anesthesia, we pulled the CVC. Immediately afterwards, we deployed a GORE® VIABAHN® VBX using the transaxillary approach. On postoperative day 1, eCT showed that the GORE® VIABAHN® VBX was positioned from the right subclavian artery bifurcation, and there were no complications of hemorrhage, endoleak, or migration. His postoperative course was uneventful, and he was transferred to another hospital on postoperative day 16.

   

  Jpn. J. Cardiovasc. Surg. 51: 368-371 （2022)

  Keywords：central venous catheter; arterial puncture; iatrogenic vascular injury; subclavian artery; peripheral intervention

  
  
• A Case of Hybrid Therapy for Deep Femoral Artery Aneurysm in a Frail Older Patient K. Manabe et al.…372
  A Case of Hybrid Therapy for Deep Femoral Artery Aneurysm in a Frail Older Patient
  

  Kaichiro Manabe＊	Hidetake Kawajiri＊	Takuma Kobayashi＊
  Satoshi Numata＊	Keiichi Kanda＊	Hitoshi Yaku＊

  
  

  (Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine＊, Kyoto, Japan)
  

  An 89-year-old man complained of pulsatile masses in his right groin. Computed tomography (CT) scans revealed an aneurysm of the right deep femoral artery. He was admitted to our hospital with a diagnosis of deep femoral artery aneurysm (DFAA). The clinical frailty scale score was 6 (moderately frail), and he also suffered chronic obstructive pulmonary disease (COPD). Considering his complicated frail and impaired pulmonary function, conventional graft replacement and aneurysmectomy were thought to be quite a high risk. Thus, we selected endovascular treatment. It was not possible to secure a sufficient proximal landing zone for measurement, we did not select a stent-graft treatment. Therefore, we performed hybrid therapy with proximal neck ligation and distal outflow coil embolization. The postoperative course was uneventful, and CT disclosed complete occlusion of the aneurysm.

   

  Jpn. J. Cardiovasc. Surg. 51: 372-375 （2022）

  Keywords：deep femoral artery aneurysm; endovascular treatment; frail; hybrid therapy

  
  

Progress in Cardiovascular Surgery (2021)

• Advances in the Congenital Heart Disease Y. Hirata…376
• Advancement in the Field of MICS in 2021 S. Hosoba…378
• Mechanisms of Lidocaine Cardioplegia: del Nido Solution H. Yamamoto…381

U-40

• U-40 Column Considering the Non-technical Skill Learned through the Experiences in Organizational Management of U-40 Committee C. Tanaka et al.…U1

• M. Ono