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Membranous ventricular septal aneurysm (MSA) complicated with annuloaortic ectasia (AAE) is rare in adults. Herein, we reported two successful surgical cases of this setting. One case is 50-year-old man with extensive infective endocarditis with underwent aortic coarctation repair in childhood. MSA was incidentally diagnosed at preoperative examination. The other patient is 53-year-old man who had severe aortic regurgitation complicated with AAE and membranous type ventricular septal defect with MSA. Simultaneous surgery comprising patch closure of MSA and aortic root replacement was performed in both patients. As for patch closure of MSA, the technical modification should be necessitated according to the fragility of the upper margin of the MSA.

A 67-year-old woman presented with dyspnea on effort and cyanosis due to massive tricuspid regurgitation and an atrial septal defect with right to left shunt. She was diagnosed with Ebstein disease at the age of 53 when she underwent surgery for varicose veins. Echocardiography showed the severe apical displacement of the septal and posterior leaflet. The anterior leaflet also partially displaced to the apex and demonstrated tethering caused by a dilated right ventricle. Cardiac magnetic resonance imaging showed a dilated right atrium and an enlarged atrialized right ventricle, in addition to marked low cardiac output in the dilated right ventricle. The surgical findings corresponded to Carpentier classification type C. Cone reconstruction was performed. Bidirectional Glenn anastomosis was reguired because of low cardiac output in the remaining functional right ventricle after Cone reconstruction. The patient's postoperative course was uneventful, and tricuspid regurgitation and stenosis remained mild. The patients had no occurrence of right heart failure or arrhythmia for two years after surgery.

A shaggy aorta with a mobile atheromatous plaque in a thoracic lesion is considered a risk factor for cerebral infarction during aortic arch surgery. The brain isolation technique was introduced to prevent embolic stroke either by manipulating the severely atheromatous aorta, or by producing a sandblasting effect using the arterial jet in cardiopulmonary bypass. We performed total arch replacement with the aid of a brain isolation technique in four patients with aortic arch aneurysm complicated with a shaggy aorta between 2016 and 2020. Antegrade selective cerebral perfusion was established prior to systemic perfusion of the cardiopulmonary bypass. Total arch replacement using the frozen elephant technique was performed in all patients. There was no operative mortality, and all patients were discharged without major neurological complications. Therefore, the brain isolation technique could be a useful adjunctive method to prevent embolic stroke in patients who undergo total arch replacement for aortic arch aneurysm with a shaggy aorta.

The purpose of this study was to evaluate the short- and mid-term outcomes of open aortic arch surgery and debranching thoracic endovascular aortic repair( TEVAR) in octogenarians.Between 2011 and 2019, 26 patients with atherosclerotic aortic arch aneurysms underwent surgery at our institution [open aortic arch surgery( group O):10 patients, debranching TEVAR(group D):16 patients].There was no operative death in either group. The mean length of hospitalization and intensive care unit stay were 49 and 13 days in group O and 12 and 2 days in group O, respectively. Kaplan-Meier analyses of overall survival (1/6/12/24/36/48 months) showed mortality rates of 100/100/88/88/70/70% in group O and 100/100/87/61/43/26% in group D, respectively.The acceptable outcomes was demonstrated in octogenarians underwent both open aortic arch surgery and debranching TEVAR. Because of early postoperative recovery, debranching TEVER is considered to be a feasible alternative to conventional open aortic arch surgery in octogenarians.

We present a case of palliative pleuro-peritoneal shunt for refractory hydrothorax complicated with unresectable cardiac tumor. The patient was a 77-year-old woman, who was admitted to our hospital for evaluation of intractable pleural effusion. It was attributed to severe diastolic dysfunction associated with cardiac tumor. The cardiac tumor occupied a large area of the anterior surface of the right atrium, and curative surgical resection was difficult. Therefore, we planned multidisciplinary staged treatment with chemotherapy followed by tumor excision. Persistent intractable bilateral pleural effusion necessitated repeat chest drainage. To maintain the patient's quality of daily life, bilateral pleuro-peritoneal shunts were inserted. Then, the problem of pleural effusion was resolved and her symptoms were improved. However, she expired 3 months later, due to deterioration of general condition. Pleuro-peritoneal shunting is a useful palliative approach to improve quality of life in patients with refractory hydrothorax.

We report a case of patch closure of posterior type ventricular septal perforation (VSP) with posterior left ventricular aneurysm (PLVAN) through right ventricular incision. A 70-year-old man was transferred to our hospital because of persistent epigastric pain. He was diagnosed with inferior acute myocardial infarction, and percutaneous coronary intervention was performed to the right coronary artery[ atrio-ventricular(AV)]. After 2 weeks, he developed congestive heart failure and was treated with inotropic support and intra-aortic balloon pumping. Echocardiography and computed tomography (CT)showed posterior type VSP between PLVAN and the right ventricle. The operation was performed via standard median sternotomy and under cardiopulmonary bypass. After right ventricle incision parallel to the left anterior descending artery, there was VSP (20×20 mm) behind the trabecular septmarginalis (TSM). We closed VSP with a 2-layer patch (40×40 mm) consisted of Dacron and bovine pericardial patches. Postoperative echocardiography showed no residual shunt, and postoperative CT showed no enlargement of PLVAN. He was discharged home on foot without right heart failure and has been well without major complications.

Pregnant women undergoing mechanical valve replacement are at a considerable risk of thromboembolic events, bleeding, and fetotoxicity associated with the administration of vitamin K antagonists and some other anticoagulants. We present our clinical experience of pregnancy and childbirth in a young woman who underwent aortic valve replacement (AVR) with a mechanical valve. A young woman underwent AVR with a bioprosthetic valve for a diagnosis of aortic regurgitation and bicuspid aortic valve at age 23. Four years later, structural valve deterioration(SVD) of the prosthetic valve necessitated redo AVR with bioprosthesis. Three years after the redo AVR, she developed recurrent SVD of the bioprosthesis, and the 3rd AVR operation was performed using an On-X mechanical valve, which allows reduced anticoagulation. She conceived 5 months after AVR using the On-X valve. Anticoagulation therapy was administered with a low-dose vitamin K antagonist combined with heparin infusion during pregnancy. No anticoagulation-induced maternal and fetal complications occurred throughout the pregnancy. The On-X valve, which allows lower levels of anticoagulation is useful in women wishing to get pregnant.

A 76-year-old man who have a history of pancreaticoduodenectomy was admitted to our hospital for surgical treatment of pararenal abdominal aortic aneurysm. He underwent thoracoabdominal aortic aneurysm repair through the Stoney's thoracoabdominal incision under partial cardiopulmonary bypass. Postoperatively, laboratory examination showed elevated pancreatic amylase and computed tomography revealed acute pancreatitis. Pancreatitis was successfully treated by giving IV protease inhibition and the patient went well thereafter. In patients with a history of pancreaticoduodenectomy, gentle surgical maneuver around the residual pancreas and adequate perfusion of celiac artery during thoracoabdominal aortic aneurysm repair were considered mandatory.

A 45-year-old man diagnosed with severe mitral regurgitation was admitted to our hospital for surgical treatment. Preoperative computed tomographic imaging revealed a persistent left superior vena cava. At operation, cardiopulmonary bypass was established with ascending aortic and bicaval cannulation. In addition to 2 venous cannulas, we directly cannulated to the left superior vena cava for sufficient venous drainage. Mitral valve plasty consisted of triangular resection of P2 segment was performed through the right side left atriotomy. Postoperative course was uneventful and echocardiography 3 months after the operation showed trivial mitral regurgitation. Precise preoperative evaluation concerning the persistent left superior vena cava should be mandatory for appropriate management of cardiopulmonary bypass.

The SOLO SMART valve is a bovine pericardial stentless bioprosthesis which shows superior hemodynamic performance compared to the stented valves. It is designed for supraannular and subcoronary implantation. We report our surgical experience and results in patients undergoing aortic valve replacement(AVR) with this new bioprosthesis.Since June 2016, 19 patients with various types of aortic valve disease (mean age:72±7 years, 58% males) have undergone AVR with a SOLO SMART stentless bioprosthesis. Fourteen patients(74%)showed aortic stenosis( AS) and 9 patients(47%)had concomitant procedures;coronary bypass grafting (n=4), mitral valve surgery (n=3), total arch replacement (n=1), and pulmonary venous isolation( n=1). There was 1 patient with active infective valve endocarditis( IE) complicated with annular abscess and 1 patient was a redo AVR case. Surgical results of these patients were evaluated retrospectively. The hemodynamic performance was investigated with transthoracic echocardiography in pre and postoperative period.There was no operative death and 1 hospital death (postoperative subdural hematoma;Heyde syndrome). One patient showed a mild trans-prosthetic valve leak. No patient required reoperation. Although postoperative transient thrombocytopenia was noted, it had cured at the time of discharge. At the last echocardiographic evaluation, the peak and mean gradients in the patients undergoing AVR for AS were 17±7 and 9±5 mmHg, respectively. No prosthesis-patient mismatch (PPM) occurred in any patient.AVR using a SOLO SMART stentless bioprosthesis was performed with acceptable morbidity and mortality. The SOLO SMART stentless bioprosthesis showed excellent hemodynamic performance and early results. Because of favorable effective orifice area, the valve is attractive for patients at risk for PPM. Furthermore, it is expected to contribute to more complex AVR with concomitant mitral valve surgery, active IE or redo situation.

A 45 year-old-man who had undergone ventricular septal defect repair during childhood presented with hoarseness. He was diagnosed as having a distal aortic arch aneurysm by using computed tomography, and was referred to our hospital for surgical treatment. The operation was performed via a 4th intercostal thoracotomy in the right lateral position. The aortic aneurysm occupied the upper pleural cavity. The aortic arch was pressed up by the aortic aneurysm, so visual identification and clamping of the proximal aorta and the left subclavian artery were extremely difficult. Extracorporeal circulation was established via the right femoral artery and vein. Aneurysmal resection and graft replacement were performed using the open proximal method and retrograde cerebral circulation. The aneurysmal wall and proximal aorta were fragile and the proximal aorta was narrow, although the distal aorta was normal. The difference in diameters between the proximal and distal aorta suggested the presence of coarctation of the aorta.

The Bentall procedure is a reliable treatment of various types of aortic root pathology. Furthermore, the aortic valve-sparing aortic root replacement also has been accepted as an ideal procedure especially in young patients. Recently, we have developed a simple valve-sparing operation focused on standardization and reproducibility.From 2011 to 2017, 44 consecutive patients underwent aortic root replacement( Bentall 17, David 27)in our institution. Surgical results of these patients were evaluated retrospectively. Geometric parameters of reconstructed aortic root were analyzed to evaluate aortic valve function.There were 2 operative death( Bentall 2, David 0). Valve-sparing procedure was completed without conversion to valve replacement and no significant aortic insufficiency was noted soon after the operation. Patients underwent David operation were divided into 2 groups according to the annular diameter. There were 15 patients with large annulus and 12 with small annulus. The postoperative valve function was reproduced in both large and small annulus groups. From the results of geometric analysis of the aortic root, patients with large annulus and sino-tubular(ST) junction were anatomically more suitable and better treated with reimplantation technique. On the other hand, even in patients with small annulus, effective plication of ST junction and adequate suspension of commissure posts might be contribute to restore the valve competency with reimplantation technique. Two patients had aortic valve replacement 6 and 12 months after reimplantation, respectively.The acceptable outcome was demonstrated in patients underwent aortic root replacement. Aortic valve was reproduced well with our simple modification of valve-sparing operation. Although our modified technique is considered to be safe, reproducible and technically less demanding, close observation would be mandatory in this particular circumstance.

We report a rare case of aneurysmal formation of the left brachial artery complicated with infective endocarditis of the mitral valve. A 67-year-old man was referred to our institution for further examination of pulsatile mass at the left upper extremity. Computed tomography showed a left brachial arterial aneurysm with a diameter of 4 cm and gradual expansion of the aneurysm was also recognized. Furthermore, echocardiography revealed severe mitral valve regurgitation with a vegetation. There was no feature of congestive heart failure. He was diagnosed with subacute infective endocarditis and infective left brachial arterial aneurysm. Considering these clinical findings, staged surgical treatment was planned. He underwent resection of the brachial arterial aneurysm and bypass grafting with an autologous saphenous vein on an urgent basis. One month after the initial operation, elective mitral valve plasty was successfully performed. Although aneurysmal formation of the brachial artery subsequent to infective endocarditis is rare, we should keep this potentially serious complication in mind.

We report a case of pseudoaneurysm formation after implantation of Medtronic Freestyle stentless bioprosthesis with a full root technique. A 65-year-old man previously underwent aortic root replacement with a Freestyle bioprosthesis. Ten years after the initial operation, pseudoaneurysm of the aortic root with a diameter of 6 cm was observed by computed tomography. At the reoperation, there was no sign of infective endocarditis, and the pseudoaneurysm was found to originate from the ruptured left and noncoronary sinuses. The aortic root was successfully reconstructed with a composite graft bearing a stented bioprosthesis. Although Freestyle bioprosthesis has several advantages over conventional stented valves, close observation should be mandatory to prevent this potentially catastrophic complication.

The open stent grafting, in other words "frozen elephant trunk (FET)" technique has been played an important role in surgical treatment of extensive thoracic aortic pathologies. J Graft Open Stent Graft (JOSG) was a new Japan-made commercially available product. We have recently introduced this attractive device as an alternative to self-made open stent graft.Twenty consecutive patients underwent aortic arch replacement using the JOSG as a FET in our institution. A JOSG was implanted:atherosclerotic thoracic aortic aneurysm (n=10), acute type A aortic dissection( n=6), chronic type B dissection( n=4).There was no operative death, but 1 patient died of multiple organ failure 5 weeks after the operation. Spinal cord injury was observed in 1 patient. Although JOSG implantation was completed in all patients, we experienced 2 cases of technical device failure during operation. After distal anastomosis with the insertion of JOSG to the downstream aorta, antegrade perfusion of extracorporeal circulation became difficult due to JOSG obstruction. Severe kinking of JOSG might occurred because of the tortuous distal arch to descending aorta and the excellent flexing properties of the JOSG. In patients with aortic dissection presenting narrow true lumen, subsequent endovascular stent graft placement was required because of inadequate obliteration of the false lumen.Thoracic aortic surgery using JOSG was introduced and performed with acceptable morbidity and mortality. JOSG was expected to contribute to the surgical treatment of thoracic aortic diseases, but a few serious complications of JOSG related to its structural property should be kept in mind for the safety of the procedure.

Endoscopic saphenous vein harvest( EVH) for coronary artery bypass grafting( CABG) has been proved to be effective in reduced wound complications without compromising graft patency and mortality. Although EVH was usually performed from femoral site, we performed endoscopic long saphenous vein harvest( ELSH) from femoral to below the knee through a single small incision. There were few reports in EVH from below the knee and ELSH.Between September 2012 and June 2014, 13 patients who underwent ELSH in CABG. We assessed the initial evaluation in ELSH using the VirtuoSaph system. ELSH was performed by our unified procedure protocol to harvest good saphenous vein graft.The success rate of ELSH was 100% (13/13). The harvest time was 83.6±15.2 min, graft length was 52.1±5.6 cm, and number of side branches requiring repair was 2.6±1.6. Beating CABG was performed in all patients. The number of distal anastomoses was 3.8±0.8. Sequential bypass was 12 in total 23 saphenous vein grafts. The early patency was 95% (18/19 grafts) as evaluated by postoperative angiography or coronary enhanced computed tomography. All patients except 1( hospital death)were discharged without major or wound complications.The acceptable results and outcomes were demonstrated by our ELSH procedure protocol. ELSH is considered to be a feasible procedure to harvest enough graft length for 2 CABG and keep the other side of saphenous vein graft intact.

Minimally invasive cardiac surgery (MICS) through a small intercostal thoracotomy has many advantages, but it is still challenging because of limited mobility through the small skin incision and surgical field. The benefits of MICS should be reached without compromising the quality of the operation and increasing the morbidity and mortality of standard sternotomy approach. We have recently introduced MICS-aortic valve replacement (AVR) in order to establish as a standard surgical technique for the treatment of aortic insufficiency.Eleven consecutive patients underwent MICS-AVR in Yamagata University Hospital. Anesthetic and surgical techniques were simplified and standardized as possible to overcome technical difficulties. Preoperative chest computed tomography( CT) provides useful information about suitability of the patient's anatomy for MICS approach. Furthermore, we developed a preoperative image overlay technique by projecting 3-dimensional CT image over the patient's body surface.There was no operative death. MICS-AVR procedure was completed in 10 patients. One patient was converted to sternotomy approach probably because of the vascular spasm through femoral artery cannulation for extracorporeal circulation. Although there were some anxious points to manage MICS procedure, preoperative planning based on the image overlay from CT image were useful for setup and instrument placement for MICS.MICS-AVR was introduced and safely performed with acceptable morbidity and excellent mortality at our institution. Close observation should be mandatory in order to implement individual and departmental performance monitoring with regard to the learning curves and surgical complications associated with less invasive procedure itself.

A 40-year-old man had undergone total arch replacement using the elephant trunk technique. Three years after the initial operation, stenosis of the elephant trunk due to enlargement of a false lumen was detected. Replacement of the descending thoracic aorta was performed. A narrow segment of the elephant trunk was compressed by old hematoma and lapped around the connective tissue. A new graft was anastomosed to the narrow segment of the elephant trunk in an end-to-side fashion. Postoperative course was uneventful, and he was discharged 18 days after the operation.

Port-access minimally invasive cardiac surgery (MICS) is complicated by limited skin incision and surgical field. In order to optimize the set-up and port placement in this surgery, we have employed image overlay technique prior to operation consisted of three-dimentional computed tomography (3DCT)image projection on the patient surface. With the aid of this technique, we successfully performed port-access MICS in 12 patients and mitral valve replacement in 1 patient with severe mediastinal displacement after previous pneumonectomy. Image overlay projection could allow surgeons to view underlying anatomical structures virtually and obtain a good operative field. Our proposed technique would be expected to make port-access MICS easier and probably safer in this particular circumstance.

True left ventricular aneurysms are thought to arise from the expansion and thinning of the transmural infarct area, whereas false aneurysms result from containment of ventricular rupture by pericardial adhesions. We reported a case of true left ventricular aneurysm with pseudoaneurysm( mixed type aneurysm) which was treated surgically.

We describe a case of replacement with a cryopreserved homograft for graft infection. A 48-year-old man had been performed ascending aorta replacement using woven dacron graft for type A aortic dissection. Two months ago, methicillin-resistant Staphylococcus aureus infection was suspected because of high-grade fever. Computed tomography (CT) scan revealed abscess formation around the prosthetic graft and redo operation using cryopreserved homograft was scheduled to avoid re-infection into mediastinum at Tohoku University Hospital, an institute cooperating with University of Tokyo tissue bank. However, Catastrophic Great East Japan Earthquake occurred the day before the scheduled date, and the patient could not have an operation at the institution. He was transferred to our hospital by helicopter. Then homograft was successfully implanted in ascending aorta after complete excision of infectious graft.

We present a rare case of papillary fibroelastoma arising from the pulmonary valve. A 45-year-old man had been suffered from palpitation. Transthoracic echocardiography clearly demonstrated a mobile rounded mass in the right ventricular outflow tract. He underwent surgical extirpation of the tumor. A fragile, yellow tumor on the pulmonary valve was recognized at operation. The pulmonary valve was repaired with autologous pericardium. Operation was performed successfully. The diagnosis as a papillary fibroelastoma was made by histopathological examination. The post-operative course was uneventful and echocardiography showed no residual tumor of the heart.

A 71-year-old female fell down the stairs, hit the right chest and was admitted to our hospital with right chest pain. Computed tomography revealed cardiac effusion and left hemothorax due to traumatic cardiac injury. She underwent emergency operation. Median sternotomy revealed a lot of clot and no acute bleeding. However, severe bleeding started as soon as the clot was removed. The right atrium was teared by 7 cm at the site parallel to the right coronary artery. While the cardiac injury was covered with the operator's hand, cardiopulmonary bypass was established. The injury was sutured with an aid of the heart positioner to achieve complete hemostasis. Successful repair of rupture of the right atrium was reported.