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A high-risk patient with aortic arch aneurysm, associated with severe calcification of the ascending aorta and iliac arteries, was treated with total debranching and antegrade thoracic endovascular aortic repair (TEVAR) via the ascending aorta. Proximal anastomosis for a triple-branched graft to the ascending aorta was performed without side clamping using the "real chimney technique." After bypassing the supra-aortic branches, a TEVAR was performed in an antegrade fashion through the ascending aorta. This case suggests that the approaches mentioned above should be considered in patients with arch aneurysms and severe calcified degeneration.

Purpose Bioelectrical impedance analysis (BIA) has been used recently to measure the body water of patients with acute heart failure. We used BIA in this study to better understand, and possibly identify a predictive marker for, perioperative water behavior in cardiac surgery patients. Methods We measured body water and studied its behavior in 44 patients undergoing surgery for cardiac valvular disease at our hospital. Measurements included the levels of extracellular water (ECW), intracellular water (ICW), and total body water, the edema index (EI), and the ratio of ECW to total body water. The first measured EI was defined as the “preoperative EI” and the maximum as the “peak EI”. Results A negative correlation was found between the preoperative EI and the preoperative estimated glomerular filtration rate (eGFR) (R = 0.644, p R = 0.625, p R = 0.366, p R = 0.464, p = 0.026). Conclusion The EI is possibly a predictive marker for perioperative water management in cardiac surgery.

Introduction and importance While the number of SAVR cases has been increasing for patients below their sixties due to the improvement of bioprosthetic valves, some early structural valve deterioration (SVD) in Trifecta valves has been reported. Case presentation We present a case of a female who presented with sudden shortness of breath. Ultrasonography diagnosed SVD. We performed redo aortic valve replacement due to SVD in Trifecta valve. With our surgical technique we could remove the bioprosthetic valve easily. Clinical discussion We could easily remove the mounted prosthetic valve along with the titanium band. These cases may emerge with acute heart failure due to sudden massive aortic regurgitation, not like the gradual progression of stenosis due to calcification. Conclusion The postoperative course in Trifecta recipients must be followed carefully., Highlights • Early structural valve deterioration with Trifecta valve • Postoperative patients using Trifecta valve should be carefully followed up. • Mounted Trifecta valve could easily be removed along with titanium band.

Objective: We evaluated the long-term outcomes of obturator bypass. Material and Methods: A total of 16 patients (13 males and 3 females; 17 limbs) who underwent obturator bypass surgery at our department between April 1995 and March 2008 were included. Results: Their ages ranged from 50 to 90 with a mean of 74 years. Inguinal infections observed in the 16 patients consisted of vascular graft infections in 13 patients, hemostatic device infections following endovascular therapy in two patients, and femoral artery infections following coronary angiography in one patient. The cumulative patency rate was 69% for 3 years and 43% for 5 years. The cumulative survival rate was 64% for 3 years and 55% for 5 years. Conclusion: Obturator bypass surgery was successfully performed with favorable results for arterial infections and vascular graft infections in the inguinal region.

Sternal instability or dehiscence results in serious sternal wound infection. We sought to assess the early outcomes with such a plating system for sternal closure in comparison to the conventional wiring technique in off-pump coronary artery bypass grafting (CABG). Patients who underwent off-pump CABG were enrolled. Thirty-one patients received plate sternal fixation. A total of 64 patients who underwent off-pump CABG by a single surgeon at our hospital from July 2013 to December 2014 were enrolled. Thirty-one patients received plate sternal fixation (Plate group), while 33 received conventional wire closure (Wire group). The early outcomes, including the pain score and analgesic usage count were compared. Dietary intake was also recorded to assess the duration of appetite loss. At discharge, the largest sternal displacement was measured on computed tomography. In the Plate group, the pain scores were significantly lower on post-operative day 5-8 and POD 9-12 from those in the Wire group. The analgesic usage count on POD 9-12 was significantly lower in the Plate group. The duration of appetite loss and hospital stay was significantly shorter in the Plate group. The displacement in both the anterior-posterior and lateral directions was significantly smaller in the Plate group. Sternal closure by rigid plate fixation contributes to a more rapid post-operative recovery through reduced pain.

Background The aim of this study is to evaluate the influence of advanced age on the postoperative course in open aortic arch repair using hypothermic circulatory arrest and selective antegrade cerebral perfusion. Methods Of 158 consecutive patients who underwent open total arch repair between 2008 and 2012, we retrospectively compared outcomes between octogenarians (group E: mean age, 83.0 ± 3.1 years [n = 40]) and their younger counterparts (group Y: mean age, 68.2 ± 10.2 years [n = 118]), and evaluated risk factors for an adverse postoperative course. Results The overall 30-day mortality was 7.0% (11/158), and by excluding 54 emergent cases, 30-day mortality was 4.8% (5/104). Ruptured cases were significantly observed in group E (17.5% [7/40] vs 3.4% [4/118]; P = .006). There were no significant differences in postoperative early results, including neurologic adverse events (12.5% [5/40] vs 6.8% [8/118]; P = .317) and 30-day death (12.5% [5/40] vs 5.1% [6/118]; P = .147) between groups E and Y. Multivariate logistic analysis revealed rupture, preoperative consciousness disorder, and extended circulatory arrest time (≥67 minutes) were risk factors for serious complications (neurologic adverse events and 30-day death) (odds ratio [OR], 10.9 [ P = .010]; OR, 5.2 [ P = .040]; and OR, 3.5 [ P = .028], respectively). A ruptured aorta was detected as an independent predictor of postoperative extended intensive care unit and hospital stay by multivariate linear regression analysis ( P = .001 and P = .007, respectively). Conclusions Advanced age was not associated with serious postoperative complications and adverse postoperative course.

Background: In recent years, minimally invasive cardiac surgery has been developed. Thus far, only at our institute has port-access aortic valve replacement (PAVR) been performed in Japan. Herein we review our experiences with PAVR, and evaluate the surgical outcomes. Methods and Results: Between May, 2007 and June, 2010, 37 cases of PAVR were performed. During the same period, 107 patients underwent conventional aortic valve replacement (CAVR) with midline sternotomy. Because we initially selected patients without high risk factors for PAVR, there were some differences in the preoperative demographic data between the CAVR and PAVR groups. Although cardiopulmonary bypass time and cross-clamp time were longer in the PAVR group (139±28 vs. 113±34min; 97±23 vs. 83±24min), there were no significant differences in total operative time between both groups. With regard to the percentage of blood transfusion requirement, postoperative ventilation time, intensive care unit stay and hospital stay the PAVR group had significantly lower outcomes (11 vs. 90; 3.4±1.9h vs. 8.2±16.3h; 1.2±0.6 days vs. 2.5±1.7 days; 11.1±4.3 days vs. 19.7±7.8 days, respectively). There were no significant differences in mortality (1/37), and morbidity between both groups. Conclusions: PAVR a feasible treatment of choice for patients with aortic valve diseases complicated by various preoperative backgrounds. (Circ J 2011; 75: 1656-1660)

A coronary artery aneurysm is uncommon and frequently asymptomatic. This report presents a surgical case of a giant coronary artery aneurysm complicated by acute myocardial infarction. A 26-year-old man with sudden chest pain was referred to our hospital. Myocardial infarction was suspected, and emergency coronary angiography was performed. A giant coronary aneurysm was found in the mid-portion of the right coronary artery. The aneurysm, which was thrombosis-occluded, was successfully resected, and the right coronary artery was anastomosed in an end-to-end fashion. Although the strategy for treating a coronary artery aneurysm without myocardial ischemia remains controversial, surgical intervention should be considered in cases with a giant coronary artery aneurysm, even if asymptomatic, provided the surgical risk is low.

A 65-year-old man presenting with visceral malperfusion complicating acute type A aortic dissection underwent emergent surgery. Bypass grafting from the right common iliac artery to the superior mesenteric artery was performed prior to central aortic repair because intestinal ischemia caused hemodynamic instability. Subsequently, the ascending aorta was replaced with a Dacron graft under a condition of circulatory arrest with selective cerebral perfusion. Endotoxin adsorption was carried out intraoperatively in parallel with cardiopulmonary bypass to prevent postoperative end-organ failure. The patient recovered uneventfully and was discharged from our hospital 31 days after surgery.

A 72-year-old man suffering from exertional dyspnea was admitted to our hospital. A computed tomography scan revealed a huge tumor occupying the interatrial septum and growing toward both the right and left atria. The tumor was successfully excised via the superior septal approach. Histological examination of the surgical specimen revealed that it was a myxoma. The patient recovered uneventfully and was discharged from our hospital 28 days after surgery. He received a permanent pacemaker implant due to sick sinus syndrome 12 months after surgery. To our knowledge, this is the first report of resection of intraseptal biatrial myxoma.

Mycotic aortic aneurysm caused by Klebsiella pneumoniae (K. pneumoniae) is extremely rare and 3 cases of K. pneumoniae-induced mycotic aortic aneurysm are present, 2 of which were located in the aortic arch and the other in the suprarenal abdominal aorta. Urgent surgery was performed for 2 cases because of impending aneurysmal rupture and progressive septic shock, whereas elective surgery was performed after radical antibiotic chemotherapy for the other case. In-situ reconstruction with rifampicin-bonded prosthetic grafts was performed, and no infective complications have occurred in any of the cases.

Cardiovascular syphilis is associated with the tertiary stage of syphilis infection; it involves the ascending aorta and can cause aortic aneurysm, aortic regurgitation, and coronary ostial stenosis. We report a surgical case of bilateral coronary ostial lesion and aortic regurgitation due to syphilitic aortitis.

Left ventricular pseudoaneurysm (LVPA) is a known serious complication of myocardial infarction or mitral valve replacement. As an alternative option, transmitral patch repair for LVPA has been reported. However, it is very difficult to complete the procedure for LVPA with a large defect. A 68-year old man with a history of inferior myocardial infarction had undergone mitral valve repair. At 4 months after surgery, the presence of a giant LVPA in the posteroinferior left ventricular wall was revealed. We performed transmitral patch repair through minithoracotomy under a three-dimensional videoscope. Since the intracardiac operation was performed under only camera vision, the perspective supplied by the three-dimensional videoscope was very useful. Endoscopic patch repair was a much less invasive procedure, and we could obtain a great intracardiac view. This technique can be an appropriate option for the treatment of LVPA after cardiac surgery.

Distal anastomosis during total arch replacement for thoracic aortic aneurysm is at times difficult, and bleeding from it is a serious problem because of its limited surgical exposure. We have modified a new procedure, the branched graft inversion (BGI) technique. We investigated the effectiveness of our technique by comparing it with the conventional stepwise technique. Between January 2008 and August 2011, 40 patients, divided into two groups of 20 each, underwent elective total arch replacement. One group underwent surgery using BGI; the stepwise technique was performed on the remaining 20 patients. Our modified BGI technique offers easy and secure distal anastomosis under good surgical procedure, resulting in shorter durations of operation, cardiopulmonary bypass, and circulatory arrest (455.1±101.3 min versus 354.7±49.3 min, p0.001; 248.2±46.6 min versus 199.7±28.2 min, p0.001; 76.6±27.7 min versus 61.6±10.4 min, p=0.029, respectively). As a result, this technique could be a useful in performing total arch replacement.

A 57-year-old man with mitral and aortic valve stenosis was admitted to our hospital. An electrocardiogram showed atrial fibrillation. After receiving informed consent, we performed a double valve replacement (DVR) with bioprostheses and maze procedure, utilizing a port-access technique. The operation and aortic cross-clamping times were 460 and 228 min, respectively. The patient's recovery was uneventful and he was discharged from our hospital with a consistent sinus rhythm 22 days after surgery. This is the first case report of port-access DVR in Japan.

老年期に至るファロー四徴症(TOF)は極めて稀であり,心内修復術を行う際のリスクの評価や姑息術の選択など,小児期とは違った問題点がある.症例は65歳の男性.血液酸素飽和度が80%台で以前より労作時呼吸困難があったが,手術は拒否されてきた.安静時の呼吸困難をきたし,精査の結果,両心室機能は良好で肺動脈の発育もよく,側副血行路の発達も認めず,諸臓器の機能も比較的良好であったため,手術としての心内修復術を選択した.結果,術後経過は順調で,術後2週間で退院した.現在NYHA I度である.高齢者であっても,条件がよいファロー四徴症では安全に心内修復術が可能であると考えられた.

We report a case of acute early bioprosthetic failure after mitral valve replacement with completely preserved annuloventricular continuity. A 77-year-old man with left ventricular dysfunction underwent double valve replacement with Carpentier-Edwards pericardial bioprostheses. Routine postoperative echocardiography revealed 1.4 cm(2) of estimated mitral valve area, and computed tomography revealed a large thrombus in the left atrium. Transesophageal echocardiography showed a restricted opening of the bioprosthetic leaflets. After a month of strict anticoagulation therapy, cusp mobility improved, with a calculated mitral valve area of 3.5 cm(2); and the left atrial thrombus had almost disappeared 2 months after initiation of therapeutic anticoagulation. Surgeons should be watchful for bioprosthetic thrombosis in patients with left ventricular dysfunction who undergo mitral valve replacement with a preserved mitral subvalvular apparatus.

Combination of off-pump coronary artery bypass grafting and epicardial pulmonary vein (PV) isolation is a less-invasive option to treat atrial fibrillation and coronary artery disease simultaneously. H However, the exposure and clamping of the left PV on a beating heart are technically challenging. We here demonstrate technical tips to perform off-pump concomitant epicardial PV isolation easily using a tape through the transverse pericardial sinus.

We describe a modified technique of left ventricular restoration after anterior myocardial infarction, referred to as endoventricular spiral plication (ESP). This technique was designed for surgical ventricular restoration with a modified spiral stitch and no patch plasty. A continuous spiral stitch can reconstruct the left ventricular shape both at the short and long axis, and appropriate restoration can be achieved by adjusting the tension of the string and the degree of spiral rotation.

Background:Right mini-thoracotomy and partial sternotomy are widely recognized as effective approaches in minimally invasive aortic valve replacement (AVR). The aim of this study was to evaluate the objective benefits of the respective approaches compared to the conventional approach.Methods and Results:A retrospective analysis was performed in 282 consecutive patients who underwent isolated and initial AVR at a single cardiovascular institute between May 2007 and December 2012. Mini-thoracotomy and partial sternotomy were performed in 62 (22%) and in 26 patients (9%), respectively. Propensity score matching produced 36 (mini-thoracotomy vs. full sternotomy) and 24 (partial sternotomy vs. full sternotomy) well-matched pairs. Compared to the conventional approach, mini-thoracotomy was associated with significantly shorter operative time (235±35 min vs. 272±73 min; P=0.009), lower prevalence of blood transfusion (42%, 15/36 vs. 67%, 24/36; P=0.025), and significantly shorter intensive care unit and postoperative hospital stay (1.4±0.8 days vs. 2.2±1.1 days, P=0.001; and 13.3±6.5 days vs. 21.5±10.3 days, P=0.001; respectively). There were no significant differences in operative and postoperative data between the partial sternotomy and full sternotomy groups.Conclusions:The objective benefits of right mini-thoracotomy included early rehabilitation and lower prevalence of blood transfusion. Significant advantages of partial sternotomy were not found. (Circ J 2014; 78: 2876–2881)

Background We introduced an initial large dose of modified St. Thomas' Hospital cardioplegic solution with the aim of providing both myocardial protection as well as a smooth intraoperative process. Methods In 90 cases of isolated aortic valve replacement, we used the modified technique of cardioplegia in 45 (group S) and conventional administration of glucose-insulin-potassium solution in 45 (group G). The patients were selected at random. In group S, we added 4 mEq of potassium to the original St. Thomas' Hospital solution and administered 30 mL·kg−1 as an initial dose. The temperature was decreased to 2℃. Results The mean of reperfusion time after declamping in group S was significantly shorter (16.7 ± 6.4 vs. 21.5 ± 10.0 min; p = 0.007). The average of postoperative maximum creatine kinase-MB was significantly lower in group S (25.6 ± 9.5 vs. 40.6 ± 37.2 IU·L−1; p = 0.014). On multivariate analysis, use of the modified cardioplegia and aortic crossclamp time were significantly associated with creatine kinase-MB level and reperfusion time after declamping. Conclusions This modified technique was an acceptable option that provided a bloodless operative field and avoided multiple cardioplegic administrations.

Although the Saphenous Vein Graft (SVG) is commonly grafted to the coronary artery with an end-to-side anastomotic technique, there is often a significant mismatch between the diameters of the SVG and the coronary artery, which may cause SVG failure. To overcome such a drawback of the standard end-to-side SVG anastomosis, we introduce a novel side-to-side anastomosis with distal end clipping of the SVG in coronary artery bypass grafting. The long-term outcome of Coronary Artery Bypass Grafting (CABG) depends predominantly on graft patency. Although an arterial graft is preferably used to improve long-term graft patency, a Saphenous Vein Graft (SVG) is also still widely used as a second bypass graft. The reported SVG patency ranging from 25% to >50% within 10 years was inferior to that of an arterial graft, despite considerable efforts to prevent SVG failure. Although the SVG is commonly grafted to the coronary artery with an end-to-side anastomotic technique, there is often a significant mismatch between the diameters of the SVG and the coronary artery, which may cause SVG failure. Moreover, the end-to-side anastomotic configuration has been reported to have an adverse effect on local hemodynamics, resulting in intimal hyperplasia in the long-term. The intimal hyperplasia, which is a major cause of late graft failure, has been shown to occur predominantly at the toe, heel, and bed of the host coronary artery around the distal anastomosis

A 73-year-old woman who had undergone ligation of patent ductus arteriosus (PDA) via a left thoracotomy 19 years earlier was admitted to our hospital under the diagnosis of thoracic aortic aneurysm. An enhanced computed tomography of the chest revealed a saccular aneurysm measuring a maximum diameter of 28 mm in the lesser curvature of the distal aortic arch; she was diagnosed with an aneurysm of ductus arteriosus after surgery for PDA. We performed total aortic arch replacement with open stent-grafting through median sternotomy. This approach enabled us to avoid the risk of dissecting adhesions around the aneurysm and clamping the aorta distal to the aneurysm.

A 53-year-old man who had undergone aortic valve replacement with a Starr-Edwards ball valve prosthesis 39 years previously was admitted to our hospital under the diagnosis of ascending aortic aneurysm. Operative findings revealed that the ball valve was functioning normally. The markedly dilated ascending aorta was replaced with a 30-mm prosthetic vascular graft, and the ball valve was replaced with a19-mm bileaflet valve prosthesis. The patient's postoperative course was uneventful, and he was discharged from our hospital 19 days after surgery. Dilatation of the ascending aorta in this case might have been caused by the poststenotic dilatation mechanism, which seems to be one of the long-term complications of Starr-Edwards ball valve implantation.

We present a 78-year-old man who developed Stanford type A aortic dissection seven years after aortic valve replacement. At the previous operation, the diameter of the ascending aorta was 40 mm. Three years later, computed tomography revealed the diameter to have expanded to 50 mm. Four years later, the patient developed aortic dissection with entry at the ascending aorta, and a graft replacement was performed.

An 82-year-old man with a mycotic aortic aneurysm of the distal arch underwent urgent surgery because of sepsis. The infected aortic arch was excised, replaced with a rifampicin-bonded prosthetic graft, and covered with omentum. Direct hemoperfusion using polymyxin B-immobilized fiber (PMX-DHP) was intraoperatively carried out in parallel with the cardiopulmonary circuit. Intraoperative PMX-DHP dramatically reduced the level of plasma endotoxin, and ameliorated hemodynamic instability and oxygenation, resulting in smooth weaning from cardiopulmonary bypass. Intraoperative endotoxin adsorption is technically simple and easy, effective in hemodynamic stabilization, and so could be a new therapeutic option for mycotic aortic aneurysm. (Circ J 2008; 72:161 ‐ 163)

Surgical therapy for acute dissection of the ascending aorta has had a high mortality. The contributing factors have been hemorrhage from the suture lines and pulmonary dysfunction following a prolongation of extra corporeal circulation (ECC) time. A method of treatment with an intraluminal prosthesis that requires no end-to-end anastomosis has been developed. We have used this method in two patients, who had acute aortic dissections type I and high risks. The first case involved a patient of advanced age and had poor pulmonary function. The second case involved a patient with poor liver function and decreased blood platelet count. The sutureless fixations shortened ECC times which were 98 and 107 minutes in the first and second cases, respectively and reduced blood loss. There were neither hospital deaths nor early graft-related complications. Our experience with these cases suggests that grafting of the aorta is less hazardous with the sutureless than with the conventional sutured anastomosis technique in the high risk patients.

Background Conventional reoperative mitral valve surgery by median sternotomy has several difficulties. We performed mitral valve replacement (MVR) under ventricular fibrillation (VF) through right mini-thoracotomy with three-dimensional videoscope for avoiding the problems. Methods Between 2006 and 2011, we performed 257 cases of MVR, in which 125 cases underwent isolated MVR. Ten cases of patients underwent reoperative MVR under VF through thoracotomy with three-dimensional videoscope (Group I), and 27 cases of patients underwent reoperative conventional MVR through median sternotomy (Group II). We retrospectively reviewed the outcomes and compared Group I with Group II. Preoperative left ventricular ejection fraction (LVEF) was significantly lower (50.5 ± 19.8% vs 64.4 ± 12.0%; p = 0.046), and significantly higher Euro SCORE was found in Group I (4.8 ± 2.0 vs 3.8 ± 2.4; p = 0.037). Results Although Group I required cooling and rewarming time, average operative times was significantly shorter in Group I (262 ± 46 min vs 300 ± 57 min; p = 0.044), and cardiopulmonary bypass times and average VF times in Group I and aortic cross-clamp times in Group II were equivalent. There was no significant difference in the average of postoperative maximum creatine kinase (CK)-MB. In-hospital mortality was 0/10 (0%) and 1/27 (3.7%), and postoperative paravalvular leakage occurred in 0/10 (0%) and 1/27 (3.7%), and stroke occurred in 1/10 (10%) and 1/27 (3.7%) for Groups I and II. Two patients underwent reoperation for bleeding in Group II. Intensive care unit stay in Group I was significantly shorter than in Group II (1.8 ± 0.6 days vs 3.0 ± 1.7 days; p = 0.025). Conclusions The higher risk of preoperative background in Group I had no effect on the operation. Mitral valve surgery under VF through right mini-thoracotomy can be an alternative procedure for reoperation after conventional various cardiothoracic surgeries.

虚血性の高度低左心機能 (心プールシンチで左室駆出率6.2%, 心エコーでLVDd=74mm, LVDs=71mm, %FS=10%) 症例に対し, 人工心肺を用いない心拍動下冠状動脈バイパス術を施行し, 良好な結果を得た1例を経験した. 症例は67歳, 男性で4年前に心筋梗塞を発症. 今回入院時の冠状動脈造影検査にて右冠状動脈の完全閉塞を含む重症3枝病変と診断. 通常の手術では人工心肺よりの離脱が困難となる可能性が高いと考え, 唯一心筋 viability が残されている右冠状動脈領域に心拍動下CABG (右胃大網動脈-右冠状動脈) を施行した. 術後心不全症状は著明に改善し, 軽快退院した. 自験例は欧米では心臓移植も考慮されるべき重症例と考えられ, 虚血性低左心機能に対する治療法として有用であると考えられた.

1982年3月より1993年1月の10年11か月の間に閉塞性動脈硬化症 (以下ASO) に対し当院で施行した腋窩-大腿動脈バイパス術は15例であった. 年齢は48歳から87歳, 平均71.2歳で全例男性であった. 術前, 全例が併存疾患を有していた. 3例が緊急手術であった. 待機手術12例のうち併存疾患のため2例の病院死がみられたが残る10例は軽快退院した. 退院例10例のうち併存疾患による遠隔期死亡4例, 不明の1例を除く生存例5例の観察期間は20～78か月, 平均47.6か月でグラフト開存率は100%であり, 全例日常生活を送っている. また, 稀な合併症としてグラフト周囲の seroma を経験した. 難治性の場合, グラフトの種類を換えることが有効であった. 腋窩-大腿動脈バイパス術は合併症を有する全身状態不良のASO患者に対し有用な術式である. 重症呼吸不全例などに対しては硬膜外麻酔と局所麻酔の併用で手術を行うことによりさらに侵襲を少なくすることが可能である.

[目的]胸部嚢状大動脈瘤に対する瘤切除パッチ形成術は,簡便な方法として施行されてきたが,術後長期での大動脈瘤発生の問題が指摘されている.今回当院における遠隔成績を検討した.[方法]1988年8月から2001年12月までに行われた,真性胸部嚢状大動脈瘤に対するパッチ形成術8例のうち,手術生存例7例の遠隔成績を追跡した.[結果]7例中6例が追跡可能であった.大動脈瘤の再拡大は3例で確認され2例に再手術を施行した.突然死を2例で認め,術後2年目に突然死した1例は,死体解剖にて吻合部の破裂を確認した.[結論]真性胸部嚢状大動脈瘤に対するパッチ形成術後には,高率に動脈瘤の再発を認めた.非常にhigh riskな症例や動脈硬化性でないものを除いて,原則的には大動脈全置換が選択されるべきと考えられた.

Giant sinus node artery aneurysms with a fistula into the left atrium are extremely rare. A 76-year old woman was admitted to our hospital for an abnormality on her chest X-ray. Coronary computed tomography (CT) angiogram revealed a giant coronary aneurysm with feeding arteries arising from the sinus node artery and the left circumflex artery. Additionally, the aneurysm had a fistula into the left atrium. The size of aneurysm was 70 × 50 mm. Coronary angiography showed contrast dye drained from the aneurysm to the left atrium through the fistula. Surgical treatment was performed. After feeding arteries were ligated, the aneurysm was opened under routine cardiopulmonary bypass. The diameter of the fistula entry was found to be 2 cm, and it was closed using a patch material. Since we were not able to identify the anatomical relationship of the fistula, mitral valve and pulmonary veins through the origin of the fistula, we used an additional right lateral left atriotomy approach. The aneurysmal wall was resected, and the cause of aneurysmal change was histopathologically diagnosed as atherosclerosis. The patient's postoperative course was uneventful, with a postoperative CT showing a complete exclusion of the aneurysm.

The prevalence of coronary artery disease in patients with aortic aneurysm is high. As an antecedent percutaneous coronary intervention with antiplatelet therapy may cause a rupture of aortic aneurysm, concomitant treatment for aortic arch aneurysm and coronary artery disease is recommended. We report a technique of a combined procedure of antegrade endovascular repair with aortic arch debranching and off-pump coronary artery bypass grafting. (J Card Surg 2012;27:518-520)

Surgeons should be aware of diaphragmatic hernia in obese patients who have undergone coronary artery bypass grafting (CABG) using a gastroepiploic artery graft (GEA), even if the antegastric route is utilized.We report a case of diaphragmatic hernia, which occurred 88 months after initial CABG. A 64-year-old obese man underwent surgical repair of a diaphragmatic hernia. At initial surgery, the diaphragm was incised vertically and re-sutured, leaving a route for GEA graft. Both the stomach and the lateral segment of the liver were dislocated in the pericardial space. The diaphragmatic defect was closed with a polytetrafluoroethylene patch.

A 54-year-old man underwent aortic repair for the infected thoracoabdominal aneurysm with a woven Dacron graft (Vascutek, Renfrewshire, Scotland) treated with gentian violet. Four months later, he complained of sudden back pain, resulting in preshock status. Computed tomographic scans showed massive hematoma around the Dacron graft, suggesting graft rupture. Initially, emergency thoracic endovascular aortic repair was performed, which was subsequently followed by open repair. The Dacron graft had a small hole, which was completely compatible with the site contacting with the rib. The graft rupture was considered due to its friction against the rib. We report on a rare event of mechanical Dacron graft rupture after the thoracoabdominal aortic replacement.

We present the technical details of en bloc resection and extended replacement of an infected aortic arch. A 74-year-old man underwent emergent surgery under a diagnosis of impending rupture of an infected aortic arch aneurysm. The patient’s chest was entered through a median sternotomy with a left thoracotomy at the fourth intercostal space. After dissection of the left phrenic and left recurrent nerves, the infected aortic arch was widely excised en bloc under circulatory arrest with selective cerebral perfusion. It was replaced with a rifampicin-bonded prosthetic graft. The prosthesis and anastomoses were covered with a harvested omental flap. Although an appropriate approach and supportive therapy are indispensable, en bloc resection of the infected tissue is an important technique when treating infected aortic aneurysms.

Endotoxin adsorption treatment (direct hemoperfusion using a polymyxin-B immobilized fiber column, or PMX-DHP) is now considered a useful option for treating severe sepsis. However, the efficacy of PMX-DHP for infective endocarditis (IE), in which the causative microorganisms are usually gram-positive cocci, remains unclear. In the present study, we investigated the impact of intraoperative PMX-DHP on clinical parameters during the treatment of IE.From November 2006 to December 2009, a total of 11 patients with active IE underwent emergent surgery using intraoperative PMX-DHP. The perioperative courses of these patients were compared with those of seven patients who underwent emergent surgery for active IE with the conventional method from January 2003 to October 2006.PMX-DHP was associated with a significant decrease in the postoperative catecholamine dose and duration. Intubation time and intensive care unit length of stay for the PMX-DHP group was significantly shorter than that for the conventional therapy group. There was also a significant difference in the number of failed organs postoperatively between the two groups.Intraoperative PMX-DHP demonstrated several positive effects, such as a drastic decrease in the doses of inotropic agents and shortening of the duration of mechanical ventilation, in patients who underwent emergent surgery for active IE. Intraoperative PMX-DHP can be a useful option for the treatment of critically ill patients with IE.

A 40-year-old woman was admitted because of progressive dyspnea on exertion. Magnetic resonance imaging revealed an atrial septal defect and an abnormal membranous structure separating the left atrium into proximal and distal chambers. Surgical correction was performed by a minimally invasive surgical approach, i.e., port-access heart surgery, under the diagnosis of cor triatriatum (subtype of Lucas Schmidt IIIA1 or IB1) complicated with atrial septal defect. The postoperative course was uneventful, and she was discharged 12 days after surgery. This case is the first report of a surgical correction for cor triatriatum using the port-access technique.

An immunologically normal 52-year-old male developed fever and abdominal dilatation after coronary artery bypass grafting; this was followed by systemic erythroderma and granulocytopenia. In spite of all kinds of available treatments, the patient died of renal failure associated with digestive tract bleeding on the 47th postoperative day. The skin biopsy showed basel vacuolar degeneration and epidermal eosinophilic necrosis. Based on these clinicopathological findings, we made a diagnosis of graft-versus-host reaction (GVHR) after blood transfusion. After this experience, we are trying operation without transfusion or with using 1500rad irradiated blood. This anti-GVHR stratedy has yielded an increase in the rate of operation without transfusion and improvement of quality of the operation itself. Consenquently GVHR do not occur in consecutive 250 open cardiosurgeries.

We encountered a case of massive tricuspid regurgitation after corrective surgery for a ventricular septal defect. Fixation of the septal leaflet to the ventricular septum at the point where it was closed with a pericardial patch and marked annular dilatation were the lesions contributing to the severe tricuspid regurgitation. The posterior leaflet of the tricuspid valve was excised from the tricuspid annulus, slid to the adhering septal leaflet, and then reattached to a safe area of the septal leaflet to prevent conduction disturbance. The sliding repair was supported by annuloplasty with a Carpentier-Edwards ring, and a concomitant right-sided Maze procedure was conducted for atrial flutter.

Papillary fibroelastoma (PFE) commonly involves the native valve tissue, especially that of the left side of the heart. PFE originates less commonly from the valve of the right side of the heart and rarely from the valve chordae. A 69-year-old man was admitted to our hospital complaining of chest discomfort in October 2005. Transthoracic echocardiography showed a highly mobile round mass measuring approximately 10mm in diameter in the right ventricle. He underwent urgent surgery. The tumor was located at the middle of the tricuspid valve chordae and was excised under cardiopulmonary bypass with cardiac arrest. He had an uneventful recovery and was discharged from the hospital 15 days after surgery. The patient has been asymptomatic and remains well without tumor recurrence 7 months after surgery.

当院で経験した孤立性腸骨動脈瘤の3症例について報告する. 症例1は, 28歳男性で左腸骨動脈破裂により仮性動脈瘤を形成し, ショック状態で救急来院した. 緊急で左腸骨動脈人工血管置換術を施行した. 症例2は60歳男性で右下肢腫脹を主訴に来院. 動静脈瘻を合併した右総腸骨動脈瘤と診断し, Yグラフト置換および瘻孔部閉鎖術を施行した. 症例3は55歳男性で肝炎の経過観察中に腹部超音波検査で両側腸骨動脈瘤を指摘された. 両側の総腸骨動脈瘤の診断でYグラフト置換術を施行した. 孤立性腸骨動脈瘤は臨床症状に乏しく, 破裂, 動静脈瘻などの合併症ではじめて発見される場合も多い. 画像診断の進歩とともに今後は無症状での発見例も増加すると思われる.

Objective: Much more concern is recently paid to the cosmetics when simple congenital heart defect is repaired. Here we present the reversed U-shaped skin incision with lower partial sternotomy for juvenile or adult female patients. Methods: Four patients with atrial septal defect (ASD) and one patient with ventricular septa] defect underwent the operation with this method. Patients’ ages ranged from 5 to 46 years old. Results: Postoperative recovery in all cases was uneventful. Only the middle portion of the operative scar was visible when the breast was well developed. The scar was completely covered by the brassiere. A numbness of the upper medial portion of the left breast was recognized in one initial patient, who underwent ASD closure and concomitant right-side Maze procedure, necessitating a wider dissection than that used for other patients. Conclusion: A reversed U-shaped skin incision with a lower sternotomy could provide relatively comfortable operative fields for cardiac surgeons, and be cosmetically appealing to female patients who require a repair of simple congenital heart defect.

FIGURE 1. A and B, Endoventricular spiral plication technique schema. A, Ple in a clockwise direction. The remaining opening of the ventricle could be clos gathering the wall of the left ventricle (LV) and reducing the distance between longand short-axis magnetic resonance images (C and D, respectively) with t shape, and thickness of the left ventricular wall is revealed. RV, Right ventricle From the Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Nov 28, 2011; revisions received Dec 16, 2011; accepted for publication Jan 4, 2012; available ahead of print Feb 1, 2012. Address for reprints: Arudo Hiraoka, MD, Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-1-10 Marunouchi, Okayama, 7000823, Japan (E-mail: bassbord1028@yahoo.co.jp). J Thorac Cardiovasc Surg 2012;144:269-70 0022-5223/$36.00 Copyright 2012 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2012.01.013