Japanese Journal of Cardiovascular Surgery Vol43,No2

Preface

• M. Ochiai

Originals

• Aortic Valve Replacement with Annular Enlargement for Congenital Aortic Valve Stenosis Y. Katayama et al.…37
  Aortic Valve Replacement with Annular Enlargement for Congenital Aortic Valve Stenosis
  
  

  Yuzo Katayama	Motohiko Goda	Shinichi Suzuki
  Yukihisa Isomatsu	Norihisa Karube	Keiji Uchida
  Kiyotaka Imoto and Munetaka Masuda

  
  

  （Division of Cardiovascular Surgery, Department of Surgery, Yokohama City University School of Medicine, and Department of Cardiovascular Surgery, Medical Center, Yokohama City University, Yokohama, Japan）

  Objective:To investigate the efficacy of aortic valve replacement with annular enlargement for congenital aortic valve stenosis. Methods:Eleven patients underwent aortic valve replacement with annular enlargement for congenital aortic valve stenosis in our institute between January 2002 and July 2012. The clinical status of these patients, including preoperative and postoperative echocardiography, was evaluated in this study. Results:The median age of the patients was 15.5 years（range:9-38 years). The patients had a mean body surface area of 1.48±0.3m2（range:1.00-1.92m2). Mechanical prostheses were used in all patients and the techniques of aortic annular enlargement were the Nick procedure in 4 patients, Manouguian procedure in 3（modified Manouguian in 2), Yamaguchi procedure in 2, and Konno procedure in 2. The average follow-up period was 32.1 months（range:1-117 months). There was neither operative death nor late death. The peak/mean pressure gradient of aortic valve improved from 77.9±31.7/46.6±18.0mmHg preoperatively to 27.9±7.7/14.8±4.7mmHg postoperatively and to 28.3±11.1/14.1±7.0mmHg at intermediate-term follow-up. The estimated left ventricular mass also improved from 206.8±93.4g preoperatively to 179.7±61.1g postoperatively and to 100.4±76.3g at intermediate-term follow-up, respectively. Conclusions:Our series shows the efficacy and safety of aortic valve replacement with annular enlargement for congenital aortic valve stenosis.　 Jpn. J. Cardiovasc. Surg. 43:37-42（2014）

  Keywords：congenital heart disease;aortic valve surgery;aortic annular enlargement

  
  
• The Efficacy of Conventional Aortic Valve Replacement for Severe Aortic Valve Stenosis Divided by Risk Classification Using the Japanese Scoring System K. Daitoku et al.…43
  The Efficacy of Conventional Aortic Valve Replacement for Severe Aortic Valve Stenosis Divided by Risk Classification Using the Japanese Scoring System
  
  

  Kazuyuki Daitoku	Kaoru Hattori	Wakako Fukuda
  Norihiro Kondo	Satoshi Taniguchi	Masahito Minakawa
  Kozo Fukui	Yasuyuki Suzuki	Ikuo Fukuda and Hiroyuki Itaya

  
  

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

  Objective:Transarterial or transapical aortic valve replacement（TAVR）procedures have been performed for high-risk patients with severe aortic valve stenosis（AS）in western countries. A high-risk patient is defined as having an STS score greater than 10%. In Japan, aortic valve replacement（AVR）with cardiopulmonary bypass（CPB）is standard care for AS, even if the patient is at high risk of developing complications. We calculated an expected operative risk of patients using a JAPAN score established by Japanese Adult Cardiovascular Surgery Database（JACVSD). Patients and Methods:Patients were divided into three groups:score less than 5%, low risk（LR）;score 5-10%, moderate risk（MR）;score more than 10%, high risk（HR). We also evaluated the efficacy of conventional AVR in each group. Between January 2002 and May 2011, we performed conventional AVR in our hospital and 116 patients who underwent AVR for symptomatic AS were enrolled in this study. Results:There were 79 patients in the LR group, 30 patients in the MR group and 7 patients in the HR group. The mean score was 2.6±1.1% in the LR group, 6.8±1.4% in the MR group and 23.3±16.8% in the HR group respectively. The mean follow-up period was 7.6±0.3 years. Preoperative co-morbidity was not statistically significant among three groups, however more octogenarians were found in the HR group. The aortic valve area and left ventricular ejection fraction（LVEF）were significantly smaller in the HR group. There were 4 cancer patients. The HR group had significantly longer operation and CPB times than the LR group. The operative mortality in all cases was 1.6%. Overall survival at 5 years was 78%. Actual survival at 5 years was 77% in the LR group, 82% in the MR group and 71% in the HR group. The major adverse cardiac and cerebrovascular event（MACCE)-free ratio at 5 years was 85%. Absence of death caused by MACCE at 5 years was 93%. All cancer patients died after AVR due to advancement in cancer. Conclusion:The results of conventional AVR with CPB were satisfactory in each group. Cancer patients may be good candidates for TAVR in the future.　

  　

  Jpn. J. Cardiovasc. Surg. 43:43-48（2014）

  Keywords：aortic valve replacement;JAPAN score;transarterial aortic valve replacement

  
  

Case Reports

• Aortic Valve Replacement in a Patient with Essential Thrombocythemia A. Furuta et al.…49
  Aortic Valve Replacement in a Patient with Essential Thrombocythemia
  
  

  Akihisa Furuta	Akito Imai	Tomoya Inoue
  Toshihiko Suzuki	Keiji Yunoki	Kunikazu Hisamochi and Hideo Yoshida

  
  

  （Department of Cardiovascular Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan）

  Essential thrombocythemia（ET）is an uncommon type of myeloproliferative disorder, characterized by both thrombotic and hemorrhagic diatheses. No clear guidelines exist for the pre- or post-operative management of patients with ET undergoing cardiac surgery. Here, we present a rare case of a patient with essential thrombocythemia and severe aortic stenosis, who needed an aortic valve replacement on cardiopulmonary bypass and who suffered no complications.

  　

  Jpn. J. Cardiovasc. Surg. 43:49-52（2014）

  Keywords：essential thrombocythemia;aortic valve replacement;cardiac surgery;thrombosis;bleeding

  
  
• A Case of Unexpected Tracheal Stenosis in Marfan Syndrome after Surgical Repair for Acute Type A Aortic Dissection S. Moriyama et al.…53
  A Case of Unexpected Tracheal Stenosis in Marfan Syndrome after Surgical Repair for Acute Type A Aortic Dissection
  
  

  Shuji Moriyama

  Jun-ichi Kei and Masahiko Hara

  
  

  （Department of Cardiovascular Surgery, Kumamoto Rosai Hospital, Yatsushiro, Japan）

  A 29-year-old woman with severe chest and back pain was referred to our hospital. She exhibited the following physical symptoms of Marfan syndrome:arachnodactyly, wrist sign, thumb sign, pectus excavatum, pes planus, scoliosis, and myopia. Computed tomography revealed a Stanford type A aortic dissection with dilatation of the aortic root, therefore, emergency surgery was performed. Total arch replacement, including an elephant trunk procedure, was performed, followed by valve-sparing aortic root replacement using the reimplantation technique. Following an initially uneventful postoperative course, she was reintubated on the third postoperative day due to laryngeal edema and aspiration. On the sixth postoperative day, it was difficult to ventilate her due to severe tracheal stenosis. Although we managed to return her to spontaneous breathing under proper sedation, it was difficult to maintain stable ventilation. She developed a recurrent respiratory distress following physical irritation such as intratracheal aspiration or a postural change. We believe that during the perioperative management of patients with Marfan syndrome with thoracic deformities, such as pectus excavatum and scoliosis, the possibility of postoperative tracheal stenosis due to tracheal fragility, tracheal edema, and compression of the surrounding tissues must be considered.

  　

  Jpn. J. Cardiovasc. Surg. 43:53-57（2014）

  Keywords：Marfan syndrome;tracheal stenosis;acute type A aortic dissection;pectus excavatum;scoliosis

  
  
• Initial Experience with Beating Heart Mitral Valve Repair via Mini-thoracotomy at a Single Institution T. Nakamura et al.…58
  Initial Experience with Beating Heart Mitral Valve Repair via Mini-thoracotomy at a Single Institution
  
  

  Teruya Nakamura	Hironori Izutani	Naosumi Sekiya
  Hirotada Masuda and Yoshiki Sawa

  
  

  （Department of Cardiovascular Surgery, NHO Kure Medical Center and Chugoku Cancer Center, Kure, Japan, Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine, Toon, Japan, and Department of Cardiovascular Surgery, Osaka University of Graduate School of Medicine, Suita, Japan）

  Mitral valve reoperation through a median sternotomy is technically challenging and carries higher postoperative morbidity and mortality than the primary operation, especially for a patient with patent coronary bypass grafts. We here present 3 cases of mitral valve reoperation using the beating heart technique under normothermic cardiopulmonary bypass via a mini-thoracotomy. The reasons that precluded sternal reentry were as follows:previous coronary bypass and patent internal mammary artery grafts in 2 cases, and a history of mediastinal wound infection at the initial operation in 1 case. All cases were carried out via right mini-thoracotomy and cardiopulmonary bypass using arterial cannulation via the ascending aorta or the femoral artery, and venous cannulation via the femoral vein and the superior vena cava. Mitral valve repair was performed for 1 case, and valve replacement for 2 cases. Transfusion was not necessary, except for 1 case that had anemia due to hemolysis preoperatively. All patients were discharged without major complications. This technique is a safe and feasible option for a mitral valve reoperation that excludes re-sternotomy, extensive pericardial dissection and aortic clamping, thereby minimizing risks of bleeding, graft injury and myocardial damage.

  　

  Jpn. J. Cardiovasc. Surg. 43:58-61（2014）

  Keywords：mitral valve insufficiency;mitral valve repair;Reoperation;minimally invasive surgical procedures

  
  
• A Case of Anastomotic Stenosis after Arterial Switch Operation N. Fujimoto et al.…62
  A Case of Anastomotic Stenosis after Arterial Switch Operation
  
  

  Noriko Fujimoto	Yusuke Ando	Kazuhiro Hinokiyama
  Takashi Kajiwara	Masahiro Oe and Koji Fukae

  
  

  （Department of Cardiovascular Surgery, Kyushu University Graduate School of Medicine, Fukuoka, Japan, Department of Pediatric Cardiac Surgery and Cardiovascular Surgery, Kumamoto City Hospital, Kumamoto, Japan）

  Coronary artery obstruction, pulmonary stenosis, aortic valve regurgitation, and enlargement of the neo-aortic root are major complications of arterial switch operation（ASO）for transposition of the great arteries（TGA). Supravalvular aortic stenosis following ASO is rarely reported, and technical factors should be considered as causes in such cases. We report a case of supravalvular aortic stenosis following ASO, in which we speculated that the cause of the stenosis was tissue overgrowth caused by the surgical suture. The patient was a 4-month-old girl with TGA（II）who had undergone ASO on the 12th day after birth. Neo-aortic anastomosis was performed with 7-0 polydioxanone absorbable suture（PDS●R, Ethicon, Somerville, NJ, USA). Transthoracic echocardiography performed 1 month after the surgery showed severe stenosis at the aortic anastomosis which worsened progressively. Therefore, the patient was reoperated 4 months after the previous surgery. The concentrically stenosed aortic wall at the anastomotic site was resected and aortic reanastomosis was performed using an interrupted suture pattern with 7-0 polypropylene（Prolene●R, Ethicon). The histological findings showed proliferation of collagenous fibers around the PDS●R suture. Because of the worsening stenosis over time and the histological findings, we speculated that the tissue overgrowth in reaction to the PDS●R suture was the main cause of the stenosis. Absorbable sutures are useful because they do not leave a foreign substance in the body;however, the possibility of tissue overgrowth leading to anastomotic stenosis cannot be denied. When using absorbable suture, careful observation is mandatory unti the material is completely absorbed.

  　

  Jpn. J. Cardiovasc. Surg. 43:62-66（2014）

  Keywords：anastomotic stenosis;absorbable suture;transposition of the great arteries;arterial switch operation

  
  
• Aortic Valve Replacement Concomitant with Coronary Artery Bypass Grafting after Substernal Gastric Interposition for Esophageal Cancer Y. Morishima et al.…67
  Aortic Valve Replacement Concomitant with Coronary Artery Bypass Grafting after Substernal Gastric Interposition for Esophageal Cancer
  
  

  Yuji Morishima	Tadao Kugai	Katsuhito Mabuni
  Noriyuki Abe and Takahiro Yamazato

  
  

  （Department of Cardiovascular Surgery, Okinawa Prefectural Nanbu Medical Center and Children’s Medical Center, Haebaru, Japan）

  We present a rare case of cardiac surgery for coronary artery single vessel disease and aortic valve stenosis after substernal gastric interposition for gastric cancer An 80-year-old man, who had undergone esophagectomy and substernal gastric interposition 7 years previously, was referred to our institute for surgical treatment of coronary artery disease and aortic valve stenosis. Through a median sternotomy with cardiopulmonary bypass, we performed aortic valve replacement and coronary artery bypass grafting to the right coronary artery without injury to the gastric tube. Postoperatively, the patient was on respirator care and catecholeamine support for several days. Although urinary tract infection occurred, he recovered with antibiotic therapy. Finally, he was discharged on postoperative day 40. For cardiac surgery after substernal gastric interposition for esophageal cancer, even though the substernal gastric tube may preclude the usual median approach, median sternotomy is an appropriate alternative with close preoperative examination and careful dissection of substernal gastric tube.

  　

  Jpn. J. Cardiovasc. Surg. 43:67-71（2014）

  Keywords：esophageal cancer;retrosternal gastric tube;median sternotomy;aortic valve replacement

  
  
• Right Atrial Approach for Surgical Repair of a Posterior Postinfarction Ventricular Septal Defect H. Kawaura et al.…72
  esophageal cancer;retrosternal gastric tube;median sternotomy;aortic valve replacement
  
  

  Hiroyuki Kawaura	Atsushi Aoki	Tadashi Omoto
  Kazuto Maruta and Hirofumi Iizuka

  
  

  （Division of Cardiovascular Surgery, Department of Surgery, Showa University, School of Medicine, Tokyo, Japan）

  We performed transatrial repair of postinfarction posterior ventricular septal defect（VSP）in a 69-year-old man who was transferred to our hospital with a diagnosis of posterior acute myocardial infarction and VSP. Coronary angiogram revealed total occlusion of the right coronary artery at #3 and 75% stenosis of the left circumflex artery at #13. UCG revealed the ventricular septal defect on the posterior ventricular septum without LV wall motion abnormality. Surgical repair was planned around 3-4 weeks later because his hemodynamic state was stable without inotropes nor IABP support upon arrival. Under general anesthesia, standard median sternotomy was performed and cardiopulmonary bypass was established with the ascending aorta and bicaval cannulation. Cardiac arrest was achieved with antegrade cold crystalloid cardioplegic solution and an oblique right atrial incision was made. The VSP was visualized via the tricuspid valve. The location of VSP was confirmed with saline injection from the LA vent line. VSP was closed with two patches, consist of a Teflon felt and a bovine pericardial patch, from the left and right ventricle side with six 4-0 polypropylene mattress sutures. Also coronary artery bypass for LCx was performed with a saphenous vein graft. The postoperative course was uneventful. There was no residual ventricular septal shunt and LV function was normal by UCG. Right atrial approach for surgical repair seemed to be useful for posterior VSP.

  　

  Jpn. J. Cardiovasc. Surg. 43:72-75（2014）

  Keywords：postinfarction ventricular septal defect;posterior;right atrial approach

  
  
• Traumatic Tricuspid Regurgitation Complicated with Severe Liver Dysfunction T. Kajiwara et al.…76
  Traumatic Tricuspid Regurgitation Complicated with Severe Liver Dysfunction
  
  

  Takashi Kajiwara	Masahiro Oe	Satoshi Fujita
  Hideki Tatewaki and Koji Fukae

  
  

  （Department of Cardiovascular Surgery, Kumamoto City Hospital, Kumamoto, Japan）

  A 67-year-old man was admitted with heart failure. He had a past history of closed chest trauma due to a traffic accident at the age of 24. He had been complaining of a gradual increase of fatigue since a few years after the accident and received medical treatment. At approximately 40 years of age, he underwent cardiac catheterization and was given a diagnosis of Ebstein malformation. However surgery was not recommended. An echocardiogram showed a laceration at the tricuspid valve, enlargement of the tricuspid valve annulus and severe tricuspid regurgitation. The displacement of tricuspid valve was not present. His case was complicated with severe liver dysfunction of Child-Pugh class B and Model for End-Stage Liver Disease score 15. We performed tricuspid valve replacement with a Mosaic 31mm tissue valve. The patient required pleurodesis for refractory severe pleural effusion at 2-months and was discharged 6 months after the operation.

  　

  Jpn. J. Cardiovasc. Surg. 43:76-79（2014）

  Keywords：traumatic tricuspid regurgitation;liver dysfunction;tricuspid valve replacement;MELD score

  
  
• Tricuspid Valve Replacement in an Adult Patient with Congenitally Corrected Transposition of the Great Arteries and Situs Inversus T. Wakabayashi et al.…80
  Tricuspid Valve Replacement in an Adult Patient with Congenitally Corrected Transposition of the Great Arteries and Situs Inversus
  
  

  Takashi Wakabayashi	Kazuo Yamamoto	Tsutomu Sugimoto
  Yuki Okamoto	Kaori Kato	Shinya Mimura and Shinpei Yoshii

  
  

  （Department of Cardiovascular Surgery, Tachikawa Medical Center, Nagaoka, Japan）

  A 62-year-old woman was admitted to our hospital because of dextrocardia on her chest X-ray film. She had been in good health though the X-ray abnormality had been pointed out from her childhood. Echocardiogram, magnetic resonance imaging, and cardiac catheterization revealed situs inversus, congenitally corrected transposition of the great arteries, and severe tricuspid valve（systemic atrioventricular valve）regurgitation with mild systemic ventricular dysfunction. The surgeon stood on the patient’s left side during the operation. On cardiopulmonary bypass, the tricuspid valve, facing almost dorsally, was exposed through a superior transseptal approach. Tricuspid valve replacement with a mechanical valve was performed with leaflet preservation. Systemic ventricular function is preserved at one year after operation.

  　

  Jpn. J. Cardiovasc. Surg. 43:80-83（2014）

  Keywords：congenitally corrected transposition of the great arteries;situs inversus;tricuspid valve replacement

  
  
• Left Anterior Descending Coronary Endarterectomy for a Patient with Dextrocardia and Situs Inversus S. Hayashi et al.…84
  Left Anterior Descending Coronary Endarterectomy for a Patient with Dextrocardia and Situs Inversus
  
  

  Sachiko Hayashi	Toshihiro Fukui	Tomoya Uchimuro
  Minoru Tabata and Shuichiro Takanashi

  
  

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

  An 80-year-old woman with dextrocardia and situs inversus was admitted with chest pain. She successfully underwent off-pump coronary artery bypass grafting. The free left internal mammary artery（IMA）was anastomosed to the posterior lateral branch and the in-situ right IMA to the left anterior descending artery（LAD). The reconstruction of the LAD was performed with endarterectomy due to a diffusely diseased LAD with severe calcification. Except for the mirror-image anatomy, the surgical technique was similar to that used for patients with situs solitus.　

  　

  Jpn. J. Cardiovasc. Surg. 43:84-87（2014）

  Keywords：situs inversus totalis;dextrocardia;off-pump coronary bypass grafting;endarterectomy

  
  
• A Surgical Case of Infective Endocarditis with Intraoperative Intracranial Hemorrhages after Antibiotic Therapy for 6 Weeks H. Kato et al.…88
  A Surgical Case of Infective Endocarditis with Intraoperative Intracranial Hemorrhages after Antibiotic Therapy for 6 Weeks
  
  

  Hiroki Kato

  Ryuta Seguchi

  Teruaki Ushijima and Go Watanabe

  
  

  （Department of Cardiovascular Surgery, International University Hospital Welfare, Mita Hospital, Tokyo, Japan）

  A case of intracranial hemorrhage during valve surgery for infective endocarditis is reported. The patient was a 40-year-old man whose chief complaint was fever of unknown origin. Echocardiography demonstrated severe mitral regurgitation with vegetations. A blood culture demonstrated Streptococcus salivarius. He was treated with penicillin G and gentamicin for 6 weeks. Magnetic resonance imaging（MRI）was performed 10 days before surgery, but acute infarction, hemorrhage, or mycotic aneurysm were not observed. Mitral valve replacement was performed with a mechanical valve. Postoperatively, the patient had hemiplegia. Hemorrhage was visible in the right thalamus and left cerebellum on computed tomography. Ventricular drainage and removal of the cerebellar hematoma were performed the next day. These results suggest that to avoid cerebral complications during cardiac surgery for infective endocarditis, strict activated clotting time control and MRI just before surgery appear to be necessary.

  　

  Jpn. J. Cardiovasc. Surg. 43:88-91（2014）

  Keywords：infective endocarditis;intracranial hemorrhage

  
  
• Aortic Valve Reconstruction（AVrC）Using Autologous Pericardium for a Patient with Severe Aortic Stenosis and Chronic Renal Failure Prior to Kidney Transplant Surgery K. Watadani et al.…92
  Aortic Valve Reconstruction（AVrC）Using Autologous Pericardium for a Patient with Severe Aortic Stenosis and Chronic Renal Failure Prior to Kidney Transplant Surgery
  
  

  Keisuke Watadani	Naomichi Uchida	Keijiro Katayama
  Shinya Takahashi	Taiichi Takasaki	Tatsuya Kurosaki
  Katsuhiko Imai and Taijiro Sueda

  
  

  （Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan）

  We performed aortic valve reconstruction（AVrC）using autologous pericardium for a patient with severe aortic stenosis and chronic renal failure, prior to kidney transplantation. The patient received kidney transplantation in the early phase after cardiac surgery. The case was a 61-year-old man with severe aortic valve stenosis who received dialysis due to chronic renal failure. We performed AVrC using autologous pericardium for the following reasons. Anticoagulant therapy is not desirable because of the need to perform kidney transplantation in the early phase after cardiac surgery. Implantation of prosthesis was not desirable because the patient requires oral immunosuppression therapy after kidney transplantation. There was no significant postoperative pressure gradient of the aortic valve orifice or aortic valve regurgitation（AR). The patient received kidney transplantation 113 days after surgery. AVrC using autologous pericardium was feasible for aortic stenosis patients in a patient waiting to receive kidney transplantation because anticoagulation therapy is not necessary after AVrC.

  　

  Jpn. J. Cardiovasc. Surg. 43:92-95（2014）

  Keywords：aortic valve stenosis;aortic valve replacement;aortic valve reconstruction;dialysis; kidney transplantation

  
  

Editor’s Post Script

• T. Nitta