Japanese Journal of Cardiovascular Surgery Vol43,No3

Preface

• The Aim for the Social Contribution and Further Development of Japanese Journal of Cardiovascular Surgery H. Yokoyama

Case Reports

• Bioprosthetic Valve Dysfunction due to Pannus after Tricuspid Valve Replacement S. Matsukuma et al.…97
  Bioprosthetic Valve Dysfunction due to Pannus after Tricuspid Valve Replacement
  
  

  Seiji Matsukuma	Kiyoyuki Eishi	Koji Hashizume
  Tsuneo Ariyoshi	Shinichiro Taniguchi and Mizuki Sumi

  
  

  （Department of Cardiovascular Surgery, Nagasaki University School of Medicine, Nagasaki, Japan）

  Prosthetic valve dysfunction due to pannus formation is an infrequent but serious complication of tricuspid valve replacement. An 87-year-old woman underwent tricuspid valve re-replacement for severe prosthetic valve stenosis and regurgitation. On removal, thick fibrous pannus and chordal attachments were observed on the ventricular side of the cusp, which corresponded to the septal leaflet of the native valve. Microscopic examination revealed inflammatory cell infiltration accompanied with severe fibrosis and scarring had compromised and broken the prosthetic valve cusp under the pannus. The elastic fiber, which was detected in the base of the pannus, suggested it was a remnant of the native tricuspid valve leaflet. Prevention of native tissue attachment to the prosthetic valve cusp, which may cause severe pannus formation, appears to be extremely important for the long-term outcome and valve durability. The choice of prosthesis for the tricuspid position remains controversial. We should especially consider the height of stent posts and the continuity between the cusp and suture ring in the choice of the bioprosthetic valve for tricuspid position.

  　

  Jpn. J. Cardiovasc. Surg. 43:97-100（2014）

  Keywords：tricuspid valve replacement;prosthetic valve failure;pannus

  
  
• Perioperative Management of Anticoagulation Therapy in a Case with Inherited Antithrombin Deficiency Receiving Aortic Valve Replacement K. Tanoue et al.…101
  Perioperative Management of Anticoagulation Therapy in a Case with Inherited Antithrombin Deficiency Receiving Aortic Valve Replacement
  
  

  Kao Tanoue	Aya Saito	Osamu Kinoshita
  Dai Kawashima	Miyuki Shibata	Tetsuro Morota
  Noboru Motomura and Minoru Ono

  
  

  （Department of Cardiothoracic Surgery, Graduate School of Medicine, The University of Tokyo）

  A 72-year-old woman was admitted to our department with a diagnosis of severe aortic stenosis was also diagnosed Inherited antithrombin deficiency was also diagnosed after she suffered from a pulmonary thromboembolic event 10 years previously and had been taking warfarin since then. On admission, her antithrombin activity was 53% of normal, and her PT-INR level was maintained around 2.5. Preoperative management of anticoagulation therapy included discontinuation of warfarin, and supplementation of antithrombin with heparin infusion. On the day of operation, antithrombin activity was maintained above 80% by administering antithrombin, and aortic valve replacement with a mechanical valve prosthesis was carried out under standard cardiopulmonary bypass support using heparin. Heparin infusion was continued with antithrombin supplementation until PT-INR recovered to round 2.5 with warfarin. Her intra-and postoperative courses did not show any thromboembolic events, and she was discharged 14 days after the surgery.

  　

  Jpn. J. Cardiovasc. Surg. 43:101-104（2014）

  Keywords：inherited antithrombin deficiency;aortic stenosis;antithrombin;cardiopulmonary bypass;anticoagulation

  
  
• A Case of Late Surgical Conversion for Type II Endoleak after EVAR H. Kanda et al.…105
  A Case of Late Surgical Conversion for Type II Endoleak after EVAR
  
  

  Hideaki Kanda	Hiroyuki Yamamoto	Yosuke Hisashi
  Yoshiya Shigehisa	Hirokazu Kawazu and Yutaka Imoto

  
  

  （Cardiovascular and Gastrointestinal Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan）

  Type II endoleak after stent graft for abdominal aortic aneurysm generally permits a wait-and-see approach, however, additional second therapy is necessary if the aneurysm increases. A 78-year-old woman had undergone endovascular treatment with a stent-graft for abdominal aortic aneurysm. Computed tomography（CT）3 months after the operation showed type II endoleak, and enlargement of the aneurysm was noted at 1 year. She underwent transarterial embolization for third and fourth lumbar arteries, but endoleak from the fourth lumbar artery remained, and the aneurysm was further enlarged. Surgical conversion was performed 2 years after the first operation. We applied a ligature to the forth lumbar artery by a laparotomy. Postoperative CT revealed disappearance of the endoleak. As endovascular treatment for abdominal aortic aneurysm is increasing and the number of cases necessitating additional therapy appears to be rising, we need to develop processes and strategies for coping with endoleaks.

  　

  Jpn. J. Cardiovasc. Surg. 43:105-107（2014）

  Keywords：abdominal aneurysm;stent-graft;type II endoleak

  
  
• Recurrent of Aortic Coarctation in Extra-anatomical Bypass Surgery S. Morishima et al.…108
  Recurrent of Aortic Coarctation in Extra-anatomical Bypass Surgery
  
  

  Shigehiro Morishima	Takashi Ono	Megumu Kanno
  Hirofumi Midorikawa	Takashi Takano and Kyouhei Ueno

  
  

  （Department of Pediatric Cardiovascular Surgery, and Cardiovascular Surgery＊, Southern Tohoku General Hospital and Southern Tohoku Research Institute for Neuroscience, Fukushima, Japan）

  Recoarctation, systemic hypertension, aortic aneurysm and intracranial aneurysm are generally observed within a certain period after the surgical procedure for aortic coarctation, which is known as a systemic diseases caused by not only morphological abnormalities but also arterial functional abnormalities of artery. Here, we report a case who showed complications of recoarctation, hypertension and subarachnoid hemorrhage after surgery for aortic coarctation. A 17-year-old boy originally presented to our hospital with upper extremity systemic hypertension. Recoarctation after surgery for aortic coarctation was diagnosed in his childhood, following which hypertension was followed while he received continuous treatment with anti-hypertensive drugs. He was hospitalized with sudden headache and loss of consciousness. Since subarachnoid hemorrhage was diagnosed by computed tomography, clipping of intracranial aneurysms was performed. After the clipping procedure, he underwent percutaneous intravascular stenting angioplasty. However, the pressure gradient remained and sufficient dilatation was not obtained because of the hypoplastic anatomical distal aortic arch（from the left internal carotid artery to the site of recoarctation）due to the development of collateral circulation with rib notch. At age 21, extra-anatomical bypass（from the ascending aorta to the descending aorta）was performed because of persistent upper extremity systemic hypertension. However, systemic hypertension continued to require antihypertensive medication.

  　

  Jpn. J. Cardiovasc. Surg. 43:108-113（2014）

  Keywords：recurrent coarctation;extra-anatomical bypass surgery;intracranial aneurysm;aortic aneurysm;hypertension

  
  
• Two Cases of Quadricuspid Aortic Valve with Aortic Regurgitation M. Osumi et al.…114
  Two Cases of Quadricuspid Aortic Valve with Aortic Regurgitation
  
  

  Masahiro Osumi	Tadashi Tashiro	Hideichi Wada
  Masaru Nishimi	Hitoshi Matsumura	Noritoshi Minematsu
  Mau Amako	Go Kuwahar	Yuta Sukehiro and Masayuki Shimizu

  
  

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

  Congenital quadricuspid aortic valve is a very rare malformation. We report two cases with severe aortic regurgitation due to isolated quadricuspid aortic valve. It consisted of three equal cusps and one smaller cusp, which was identified at the time of valve replacement surgery for severe aortic regurgitation.

  　

  Jpn. J. Cardiovasc. Surg. 43:114-117（2014）

  Keywords：quadricuspid aortic valve;aortic regurgitation;aortic valve replacement

  
  
• A Case of Aortic Root Replacement and Patch Closure for Aorto-Right Ventricular Fistula Secondary to Infective Endocarditis H. Seo et al.…118
  A Case of Aortic Root Replacement and Patch Closure for Aorto-Right Ventricular Fistula Secondary to Infective Endocarditis
  
  

  Hiroyuki Seo

  Hiromichi Fujii

  Takanobu Aoyama and Yoshikado Sasako

  
  

  （Department of Cardiovascular Surgery, Osaka Koseinenkin Hospital, Osaka, Japan）

  A 62-year-old man with a history of insulin-dependent diabetes mellitus was admitted to our hospital because of a high-grade fever and general fatigue. Laboratory data showed evidence of inflammation and Streptococcus pneumoniae was identified in the blood cultures. Transthoracic echocardiography revealed vegetations on the right coronary cusp of the aortic valve and septal leaflet of the tricuspid valve, and an aorto-right ventricular fistula secondary to abscess formation in the aortic annulus. We diagnosed active infective endocarditis with an aorto-cavity fistula and performed an emergency operation. The infected tissue was curetted as much as possible and the fistulous openings in the right ventricle and aortic root were closed using bovine pericardial patches. We subsequently performed aortic annular reconstruction and aortic full-root replacement using a Freestyle●R stentless valve. Although a permanent pacemaker was implanted to treat a complete atrioventricular block, the postoperative course was uneventful and the C-reactive protein level normalized. He was discharged on the 46th postoperative day. Postoperative echocardiography revealed no signs of valve dysfunction, recurrent endocarditis, or residual abscess cavity and shunt. Infective endocarditis with abscess formation complicated by a fistula formation between the cardiac chambers is rare, and surgical treatment for this is challenging. In such cases, both radical debridement of the infected tissue and precise closure of the fistulous tract are essential.

  　

  Jpn. J. Cardiovasc. Surg. 43:118-123（2014）

  Keywords：infective endocarditis;annular abscess;aorto-right ventricular fistula;aortic root replacement;patch closure

  
  
• A Case of Aortic Valve Replacement after Long-Term Antifungal Treatment of Candidemia T. Kono et al.…124
  A Case of Aortic Valve Replacement after Long-Term Antifungal Treatment of Candidemia
  
  

  Takanori Kono	Eiki Tayama	Hidetsugu Hori
  Tomohiro Ueda	Kenichi Imasaka	Takeaki Harada and Yukihiro Tomita

  
  

  （Department of Cardiovascular Surgery, Clinical Research Center, Kyushu Medical Center, Fukuoka, Japan）

  We report a patient with candidemia, and remote organ infection, who underwent surgical treatment of aortic valvular stenosis. The patient was a 77-year-old man. Candida glabrata was detected in a blood culture during pharmacological treatment for pyelonephritis associated with vesicoureteral transition stenosis. A ureteral stent had been placed to preserve urine outflow, and vesicoureteral surgery had been scheduled. However, the urological surgery had to be performed first because of severe aortic valvular stenosis. After long-term（5months）of antifungal treatment, Candida was no longer detected in the urine or blood cultures, but the serum β-D-glucan level did not fall below the reference value（21.6pg/ml at the last measurement). It was difficult to control the infection further, and we decided to perform aortic valve replacement. There was no evidence of endocarditis at surgery, but pathological examination revealed traces of the fungus in the tissue of the aortic valve. The post-operative course was uneventful, and urological surgery was carried out 45 days later. Infection recurred when the antifungal medication was temporarily discontinued. The infection was then controlled by resumption of the antifungal medication. The patient has been free of recurrence for the past year since the aortic valve replacement. In the present case, in which a mycosis from a remote source was not readily eradicated prior to valve replacement, we were able to obtain good results by first administering long-term antifungal medication to quell the inflammation as much as possible.

  　

  Jpn. J. Cardiovasc. Surg. 43:124-128（2014）

  Keywords：candidemia;aortic valvular stenosis;mycotic endocarditis

  
  
• A Case of Multiple Inflammatory Aneurysms Treated with Multimodality Treatment T. Sakaguchi et al.…129
  A Case of Multiple Inflammatory Aneurysms Treated with Multimodality Treatment
  
  

  Takeshi Sakaguchi	Toshiaki Watanabe	Ryo Hirayama
  Koji Hagio	Mai Matsukawa	Kenta Uekihara and Ryusuke Suzuki

  
  

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

  An 88-year-old woman presented at a local hospital with a left femoral pulsatile mass. CT revealed saccular aneurysms with irregular intima in the descending thoracic aorta, the right common femoral artery and the left superficial femoral artery. They were 60 mm, 30 mm, and 25 mm in diameter, respectively. After referral to our hospital, multiple inflammatory aneurysms were strongly suspected by detailed examinations. Endovascular treatment including thoracic endovascular aortic repair and surgical replacement were performed by two-stage operations. After steroid therapy was started postoperatively, her c-reactive protein（CRP）value decreased. Nevertheless, the thoracic aortic aneurysm enlarged and she died due to hemorrhage. Multiple inflammatory aneurysms are extremely rare. We consider that appropriate steroid therapy and close follow-up are most important.

  　

  Jpn. J. Cardiovasc. Surg. 43:129-133（2014）

  Keywords：inflammatory aneurysm;multiple aneurysms;endovascular aortic repair

  
  
• A Case of Acute Stanford Type A Aortic Dissection after Retrosternal Gastric Tube Reconstruction for Esophageal Cancer K. Uekihara et al.…134
  inflammatory aneurysm;multiple aneurysms;endovascular aortic repair
  
  

  Kenta Uekihara	Takeshi Sakaguchi	Mai Matsukawa
  Ryo Hirayama	Koji Hagio	Toshiaki Watanabe and Ryusuke Suzuki

  
  

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

  n 80-year-old man presented with a history of retrosternal gastric tube reconstruction for esophageal cancer. He experienced sudden chest pain, and temporarily lost consciousness, before being transferred to our hospital. Contrast-enhanced computed tomography revealed acute Stanford type A aortic dissection and a retrosternal gastric tube. We performed emergency operation using a median sternotomy approach. Before median sternotomy, we detected the gastric tube in the subxiphoid and suprasternal spaces. The anterior and right sides of the gastric tube were dissected bluntly from the posterior surface of the sternum and median sternotomy was performed. The gastric tube was mobilized to the left side and we were able to obtain the usual operative view for ascending aorta graft replacement. Intraoperatively, the gastric tube remained intact and uninjured. The patient was transferred to another hospital for rehabilitation on postoperative day 34.

  　

  Jpn. J. Cardiovasc. Surg. 43:134-137（2014）

  Keywords：esophageal cancer;retrosternal gastric tube reconstruction;median sternotomy;acute aortic dissec

  
  
• Two Cases of Reexpansion Pulmonary Edema after Cardiac Surgery T. Kanaya et al.…138
  Two Cases of Reexpansion Pulmonary Edema after Cardiac Surgery
  
  

  Tomomitsu Kanaya	Hiroki Hata and Nobuo Sakagoshi

  
  

  （Department of Cardiovascular Surgery, Kinan Hospital, Tanabe, Japan）

  A 54-year-old man with ischemic mitral regurgitation underwent surgical ventricular restoration, mitral valve plasty and a coronary artery bypass. A chest X-ray 7 days later revealed pleural effusion on the right side. A chest tube was inserted and about 1,000ml of fluid was drained. However, re-expansion pulmonary edema（RPE）occurred 2h later. Positive pressure ventilation and intravenous infusion with a diuretic improved the RPE. He was resuscitated on the following day to receive percutaneous cardiopulmonary support（PCPS）for unstable hypoxemia and hypotension. Oxygenation improved, PCPS was withdrawn 2 days later, and the endotracheal tube was removed. Re-expansion pulmonard. He was resuscitated on the following day to receive percutaneous cardiopulmonary support（PCPS）for unstable hypoxemia and hypotension. Oxygenation improved, PCPS was withdrawn 2 days later, and the endotracheal tube was removed. Re-expansion pulmonary edema might cause fatal short-term cardio-respiratory failure. We considered that RPE requires appropriate early diagnosis, early treatment and aggressive therapy, including PCPS.

  　

  Jpn. J. Cardiovasc. Surg. 43:138-141（2014）

  Keywords：cardiac surgery;reexpansion pulmonary edema;PCPS

  
  
• Brachiocephalic Arteriovenous Fistula after Transvenous Pacemaker Lead Extraction for Pacemaker Lead Infection H. Johno et al.…142
  Brachiocephalic Arteriovenous Fistula after Transvenous Pacemaker Lead Extraction for Pacemaker Lead Infection
  
  

  Hiroyuki Johno	Hirotaka Murata and Shouji Fujiwara

  
  

  （Cardiovascular Center, Iseikai Hospital, Osaka, Japan）

  Transvenous pacemaker lead extraction（TLE）techniques for pacemaker lead infection have developed in recent years. Several minimally invasive methods for TLE have been devised, but fatal complications are not rare in these procedures. We present the case of a 26-year-old woman with Brugada syndrome referred to our hospital with wound infection, 3 years after implantation. She had the 2 infected leads completely removed with laser sheaths and underwent antibiotic therapy. On post operative day 8, pulsatile mass with thrilling was noted at the suprasternal notch. Enhanced CT examination revealed the fistula between the brachiocephalic artery and vein（AVF). Operation was scheduled to close the fistula. Early in the morning of the scheduled operation day, extensive bleeding from the ruptured mass on the suprasternal notch occurred and emergency operation was done to suture the bleeding point and ligate both side of the fistula of the brachiocephalic vein, using an occlusion balloon inserted into the brachiocephalic artery. The postoperative course was uneventful. AVF after TLE is a rare complication. Although the cardiac implantable electronic device can provide life-saving benefits, device-associated complications should be managed carefully.

  　

  Jpn. J. Cardiovasc. Surg. 43:142-145（2014）

  Keywords：pacemaker lead infection;transvenous pacemaker lead extraction;brachiocephalic arteriovenous fistula

  
  
• A Successful Case of Cardiac Operation and Chemotherapy for Primary Cardiac Malignant Lymphoma with Superior Vena Cava Syndrome T. Tsuchida et al.…146
  A Successful Case of Cardiac Operation and Chemotherapy for Primary Cardiac Malignant Lymphoma with Superior Vena Cava Syndrome
  
  

  Takao Tsuchida	Kentaro Yano and Hitoshi Fukumoto

  
  

  （Department of Cardiovascular Surgery, Shiroyama Hospital Cardiovascular Center, Habikino, Japan）

  Primary cardiac lymphomas are rare cardiac neoplasms with poor prognoses. We report a 61-year-old man who presented with superior vena cava（SVC）syndrome. Trans-thoracic echocardiography showed a 77×91-mm mass occupying the right atrium. The tumor obstructed the SVC. The deteriorating hemodynamics of our patient prompted a surgical intervention. We resected as much of the tumor as possible under cardiopulmonary bypass. The postoperative course was uneventful, and the SVC syndrome disappeared. Pathological examination was consistent with malignant lymphoma, diffuse large B-cell type. After cardiac operation, the patient was treated with rituximab, cyclophosphamaide, adriamycin, vincristin, and prednisone（CHOP-R). The patient has been in good health for 30 months without signs of recurrence.

  　

  Jpn. J. Cardiovasc. Surg. 43:146-149（2014）

  Keywords：primary cardiac lymphoma;surgical resection;SVC syndrome

  
  
• A Case of Unique Prosthetic Valve Dysfunction with Rheumatic Valvular Disease K. Sato et al.…150
  A Case of Unique Prosthetic Valve Dysfunction with Rheumatic Valvular Disease
  
  

  Koji Sato	Kazuyoshi Sato	Masatoshi Motohashi
  Kazuaki Ishihara and Kouhei Kawazoe

  
  

  （Department of Cardiovascular Surgery, Hakodate Central Hospital, Hakodate, Japan, Department of Children’s Cardiovascular Surgery, Matsudo Municipal Hospital, Matsudo, Japan, and Cardiovascular Center, Takii Hospital, Kansai Medical University, Takii, Japan）

  An 85 year-old woman underwent mitral valve replacement with Carpentier-Edwards PERIMOUNT（CEP）at the age of 72 because of rheumatic mitral stenosis. Thirteen years after its implantation, prosthetic valve dysfunction developed increasingly severe aortic valve stenosis and she underwent double valve replacement. Prolapse was found in one leaflet of the explanted CEP valve, while neither visible calcification nor tear was detected.

  　

  Jpn. J. Cardiovasc. Surg. 43:150-153（2014）

  Keywords：Carpentier-Edwards PERIMOUNT（CEP）;CEP valve;prosthetic valve dysfunction;structural valve dysfunction（SVD）;rheumatic valvular disease;reoperation

  
  
• A Case of Giant Coronary Aneurysm of the Septal Branch N. Kanemitsu et al.…154
  A Case of Giant Coronary Aneurysm of the Septal Branch
  
  

  Naoki Kanemitsu	Kazuo Yamanaka	Takeshi Nishina
  Keiichi Hirose	Akihiro Mizuno	Daisuke Nakatsuka
  Yuki Hori	Daisuke Yasumizu and Masashi Yada

  
  

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

  We report a case of septal branch aneurysm. A 61-year-old woman was referred to our hospital because of heart murmur. Septal branch aneurysm（25×15mm）was diagnosed by echocardiography and coronary angiography, and followed up annually with multi-detector row computed tomography（MDCT). Nine years later, another aneurysm proximal to the known aneurysm, which protruded above the epicardium, has rapidly dilated from 5 to 11mm. We therefore performed closure of the orifice of the septal branch concomitant with bypass grafting;left internal mammary artery to distal LAD. After the procedure, the aneurysm in the septum had completely collapsed. Her postoperative course was uneventful.

  　

  Jpn. J. Cardiovasc. Surg. 43:154-157（2014）

  Keywords：septal branch;coronary aneurysm;surgery

  
  
• Aorto-bilateral External Iliac Artery Bypass Graft in a Patient with Leriche Syndrome and an Ileal Conduit T. Kajiyama et al.…158
  Aorto-bilateral External Iliac Artery Bypass Graft in a Patient with Leriche Syndrome and an Ileal Conduit
  
  

  Tetsuya Kajiyama	Shinya Fukui	Masataka Mitsuno
  Hiroe Tanaka	Masaaki Ryomoto and Yuji Miyamoto

  
  

  （Department of Cardiovascular Surgery, Hyogo Medical University, Nishinomiya, Japan）

  We report a patient with Leriche syndrome who had ileal conduit and a right lower quadrant stoma. A 47-year-old man with a history of bladder cancer had undergone radical total cystectomy with formation of an ileal conduit and right lower quadrant stoma 2 years previously. CT scanning revealed total occlusion of the distal aorta. He experienced right lower leg pain after 30m of walking. Through a repeat midline laparotomy incision, the abdominal aorta was dissected with a transperitoneal approach. To avoid dissection around the ileal conduit, the retroperitoneum was incised（open）at the right of the ascending colon and at the left of the sigmoid colon. A prosthetic graft（Interguard 14×7mm）was pulled bilaterally through these incisions, to the external iliac arteries. Abdominal aorto-bilateral external iliac artery bypass grafting was performed and the patient was discharged without complications on the 15th postoperative day.

  　

  Jpn. J. Cardiovasc. Surg. 43:158-161（2014）

  Keywords：Leriche syndrome;ileal conduit, reoperation

  
  

Editor’s Post Script

• M. Masuda