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Cardiovascular surgery in Jehovah's Witness is challenging for surgeons on the ground that they refuse blood transfusion. We report 11 cases of cardiovascular surgery. All of the patients underwent elective surgery with cardiopulmonary bypass. Two cases underwent minimally invasive procedures. The mean preoperative hemoglobin level was 13.0 g/dl, and hematopoietic medicines were preoperatively administrated in 4 patients. Although 10 patients recovered satisfactory without blood transfusion, 1 surgical case was lost due to uncontrollable postoperative bleeding. The clinical outcomes of the Jehovah's Witness patients are considered to be satisfactory. However, careful indication is recommended in high risk cases.

The development of a fistula between the aorta and the right atrium is a relatively rare but well-documented complication after cardiac surgery and proximal aortic dissection, and has a high mortality rate if it is not diagnosed adequately and surgically treated without delay. We report a rare case of extracardiac aorta-right atrial fistula. An 86-year-old woman underwent aortic valve replacement via median sternotomy. Two weeks after surgery, the upper median skin incision reopened, which exposed the sternum and revealed purulent discharge inside the wound. Wound and blood cultures were positive for methicillin-resistant Staphylococcus aureus. The wound was treated, and healed in approximately 2 weeks. Six weeks after surgery, the patient suddenly presented with dyspnea because of heart failure.Extracardiac aorto-right atrial fistula was confirmed by computed tomography. During surgery, we found an extracardiac fistula formed in the hematoma between the sites where the aortic vent suture was tied and the caval cannula was removed. The infection seemed to have contributed to the development of the fistula and may have persisted in the ascending aorta or artificial valve, which may have led to cerebral hemorrhage resulting in death 4 months later.

A 69-year old male was referred to our hospital for the treatment of coronary artery disease. Preoperative computed tomography (CT) revealed an abdominal aortic aneurysm (AAA) and a giant tumour of the left kidney. He underwent off-pump coronary artery bypass grafting (OPCAB) prior to aneurysmectomy and nephrectomy. Temporary epicardial pacing wires (TEPWs) were placed on the right atrium and right ventricle. The bipolar ventricular wire was removed and the unipolar atrial wire was cut flush with the skin surface on postoperative day 5. CT 7 days after the OPCAB procedure revealed a retained TEPW sutured to the right atrial wall. One month later, the patient underwent a repair of the AAA and left nephrectomy. We found that a TEPW had migrated inside the AAA intraoperatively. The retained TEPW was thus no longer observed on postoperative CT. Migration of the atrial pacing wire through the aortic lumen was suspected, although the detailed mechanism is unknown. This is the first reported case of a migrated temporary pacing wire into the aorta under noninfectious conditions., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A right ventricular cardiac tumour was incidentally detected in a 61-year-old man during a preoperative examination for coronary artery bypass grafting (CABG). Findings on computed tomography and magnetic resonance imaging suggested the differential diagnoses of myxoma, haemangioma and haemangiosarcoma, and it was difficult to identify whether the tumour was benign or malignant. (18)F-fluorodeoxyglucose-positron emission tomography strongly suggested a benign tumour. We enucleated the tumour, because an intraoperative frozen section also strongly suggested a benign origin. After resection, CABG under cardiopulmonary bypass was performed. Histopathological and immunohistochemical analysis indicated a cavernous haemangioma without evidence of malignant tissue. The patient has survived 20 months after surgery with no evidence of tumour recurrence., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Effusive constrictive pericarditis is a rare clinical entity characterized by concurrent pericardial effusion and visceral pericardial constriction. The most effective therapy for this state is pericardiectomy with complete removal of the parietal and visceral membranes, although the perioperative mortality and morbidity can be high. We presented a case of a 45-year-old man in whom a visceral pericardiectomy with waffle procedure was successfully performed using an ultrasonic scalpel without use of cardiopulmonary bypass. His postoperative course was uneventful and cardiac hemodynamics restored to normal. There were no signs or symptoms of recurrence in 2 years of follow-up.

A 44-year-old man with locally advanced central lung cancer was treated by right lower lobe lung autotransplantation after pneumonectomy using an extracellular phosphate-buffered solution for cold lung preservation. The advantage of the ex vivo operation made it possible to perform safe and definitive cancer resection without massive bleeding. Cold lung preservation brought some advantages, such as reducing the risk of ischemia-reperfusion injury compared with warm ischemia and allowing enough time to achieve microscopically negative margins. The patient returned to normal life with minimum loss of pulmonary reserve and no recurrence of lung cancer for 6 months., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 68-year-old woman was admitted to our hospital because of back pain and syncope. Transthoracic echocardiography revealed pericardial effusion, a collapsed right ventricle, a giant aneurysm connected to the coronary sinus, a dilated left main trunk coronary artery, and a dilated left circumflex artery (LCx). Furthermore, there was a coronary artery fistula arising from the LCx that drained into the coronary sinus. We diagnosed cardiac tamponade due to rupture of the coronary artery fistula or giant aneurysm, and successful emergency surgery was performed. Rupture of coronary artery aneurysm or coronary artery fistula is very rare. Transthoracic two-dimensional echocardiography was very useful in our case for the diagnosis of cardiac tamponade, giant coronary aneurysm, and coronary artery fistula.

We report a 53-year-old man who presented with dyspnea and low-grade fever. Cardiac ultrasound showed pulmonary hypertension and an ill-defined echogenic mass within the pulmonary trunk. Computed tomography scan revealed an inhomogeneous mass which filled the main pulmonary trunk with near-total occlusion, and extended into both pulmonary arteries. Anticoagulant therapy was administered based on a presumptive diagnosis of pulmonary thromboembolism. Positron-emission tomography scan was useful for differentiating the mass, which was determined as a pulmonary artery sarcoma by surgical resection. Although complete resection was impossible, the patient survived for 20 months with adjuvant chemotherapy and medical treatment.

A 57-year-old man with coronary bypass surgery experienced spontaneous rupture of a vein graft 16 months following his operation. Multislice computed tomography revealed a perforation of the saphenous vein graft to the obtuse marginal branch. 3D imaging was useful for diagnosis and in planning treatment. Hesitation to perform surgical treatment occurred due to inflammation in the patient, therefore we successfully implanted a polytetrafluoroethylene-covered stent to occlude the site of perforation. The use of a covered stent for a patient showing clear leakage of dye during angiography should be considered as an alternative to surgical intervention for a ruptured vein.

Purpose: The infusion of a cardioplegic solution is the standard method of myocardial protection during open heart surgery. However, this method interrupts the surgical procedure and it is difficult to ensure a bloodless surgical field. To address these problems, the effect of continuous retrograde gaseous oxygen persufflation (ROP) on myocardial protection was assessed in comparison to St. Thomas' solution (STS)., Methods: Eighteen adult mongrel dogs were divided into three groups of six. Group G received continuous ROP, Group C received STS every 30 min, and Group N received hypothermia alone during the 120 min hypothermic ischemia. The myocardial metabolism was assessed by measuring the coronary sinus lactate concentration, lactate extraction ratio (LER), coronary sinus lipid peroxidation (LPO) concentration, left ventricular myocardial adenosine triphosphate (ATP) concentration, and water content. Cardiac function was assessed by the percent recovery relative to the baseline., Results: In Group G, the lactate, LPO, and water content were significantly lower (P = 0.0062, P = 0.03, and P = 0.0065, respectively), and ATP was significantly higher (P = 0.028) than in Group C. The LER was only positive in Group G. In addition, the cardiac functions in Groups G and C were not significantly different., Conclusions: Retrograde gaseous oxygen persufflation was not inferior to STS in regard to myocardial protection. This technique could therefore represent a potentially promising cardioplegic method.

A 25-year-old woman with ulcerative colitis developed heart failure due to severe aortic regurgitation. Although chest X-ray 18 months previously showed a normal cardiac shadow, thoracic aortic aneurysm progressed due to Takayasu arteritis. Aortic valve and ascending aorta replacement were performed successfully, but re-valve replacement for severe aortic regurgitation due to prosthetic valve detachment and aortic root replacement for valsalva sinus rupture were required. Human leukocyte antigen analysis showed B35 and B52, the typical haplotype in cases with coexistence of both diseases and associated sustained inflammation. Close observation and early aortic root replacement were needed in this case.

We report here on a surgical case of acquired left ventricular right atrial communication (LV-RA communication) and aortic regurgitation (AR) caused by infective endocarditis (IE). We successfully treated the patient with composite patches made from polytetrafluoroethylene (PTFE) and autologous pericardium. In general, LV-RA communication is a rare congenital cardiac anomaly (Gerbode-type shunt). However, acquired LV-RA communications secondary to IE are occasionally reported.When repairing an acquired condition due to IE, particular care should be taken to avoid recurrence, persistent infection and iatrogenic atrioventricular block.

Unlabelled: Taurine (TA) administered exogenously before the induction of myocardial ischemia decreases lactic acid production and increases pyruvic acid production during ischemia. It also preserves the activity of GOT, GPT, LDH and CPK during ischemia and enhances recovery of CKMB synthesis as early as 5 minutes after onset of reperfusion. The aim of the study was to determine the optimal conditions for administering TA in order to reduce myocardial ischemia-reperfusion injury. Left ventricular (LV) function, creatine kinase (CK) and lipid peroxide products (LPOP = oxidant stress), as well as the area at risk (AAR), and infarct size (IS) after reperfusion were studied in 3 groups of isolated rat hearts perfused with Krebs Henseleit Buffer (KHB)-stabilized isolated rat hearts that were subjected to 20 minutes(') of global ischemia at 37 degrees C followed by 60' of reperfusion with KHB: Hearts were perfused with TA containing KHB for 10' just prior to ischemia or during the first 10' of reperfusion., Conclusion: Taurine before ischemia or during reperfusion was equally effective in preventing infarction; however, when administered at reperfusion, taurine reduced lipid peroxidation and myocardial injury more, thereby providing improved early recovery of function.

Objective: The Myocardial protective effects of taurine (TA) are well known. We investigated the optimal phase of giving taurine to reduce myocardial ischaemia-reperfusion injury in isolated rat hearts., Methods: Isolated rat hearts were subjected to 20 min of global ischaemia followed by 60 min of reperfusion under three different conditions: global ischaemia alone (control group; n=8); pre-ischaemic administration of taurine (pre-TA group; n=8), perfusion with 10 mmol/L taurine for 10 min just before ischaemia; post-ischaemic administration of taurine (post-TA group; n=8), perfusion with 10 mmol/L taurine for the first 10 min of reperfusion. Ventricular functional and biochemical variables, the area at risk (AAR), and infarct size (IS) after reperfusion were compared between groups., Results: Recovery of ventricular function in the post-TA group was significantly greater than that in the control and pre-TA groups in terms of left ventricular pressure and rate-pressure product. Lipid peroxide product as a marker of oxidant stress in the post-TA group was significantly less than that in the control and pre-TA groups. AAR relative to left ventricular area in the post-TA group was significantly less than that in the control and pre-TA groups. IS relative to AAR in the post-TA group was significantly less than that in the control group., Conclusion: Taurine administered before or after ischaemia prevents infarction; being a potent free radical scavenging antioxidant, it reduced myocardial injury and provided significantly better functional recovery when given immediately after reperfusion.

Objective: There are few data available on the effect of ultrasonic skeletonization with the harmonic scalpel on internal thoracic artery (ITA) and gastroepiploic artery (GEA) vessel function., Methods: Rings of segments of the skeletonized ITA, pedicled ITA, skeletonized GEA, and pedicled GEA were studied. Arterial segments were treated with high KCl and norepinephrine (NE) to obtain smooth muscle contractions. Endothelium-dependent and independent vasorelaxant potencies in 10(-6)mol/l NE-pre-constricted arteries were assessed by acetylcholine (ACh), and isosorbide dinitrate (ISDN) and diltiazem, respectively., Results: There were no differences in contractile potencies induced by high KCl and NE between the rings cut from skeletonized and pedicled grafts. The rings from skeletonized and pedicled vessels also showed equal sensitivity to ISDN and diltiazem. However, the rings from pedicled grafts showed greater relaxation responses to ACh than rings from skeletonized grafts., Conclusion: Ultrasonic complete skeletonization with the harmonic scalpel may retain smooth muscle function of skeletonized grafts, whereas endothelial function of ultrasonic skeletonized grafts may be significantly compromised.

Background: We hypothesized that surgical annuloplasty for ischemic mitral regurgitation (MR) that displaces the posterior annulus anteriorly can potentially augment posterior leaflet (PML) tethering, leading to persistent MR. Relationships between leaflet configurations and persistent ischemic MR after the annuloplasty were investigated., Methods and Results: In 31 patients with surgical annuloplasty for ischemic MR and 20 controls, posterior and apical displacement of the leaflet coaptation, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, coaptation length (CL), and the MR grade were quantified before and early after surgery in echocardiographic left ventricular long-axis views. Six of the 31 patients showed persistent MR despite annuloplasty. Compared with patients without persistent MR, those with MR showed no improvement in the left ventricular ejection fraction and systolic volume, similar reduction in the annular area, significant increase in posterior displacement of the coaptation (P<0.01), no improvement in AML tethering, greater worsening in PML tethering (P<0.01), and no increase in the CL. All tethering variables were significantly correlated with both preoperative and postoperative MR in univariate analysis, and reduced CL was the primary independent determinant of both preoperative and postoperative MR. Although increased AML tethering was the primary determinant of the preoperative CL (r2=0.46, P<0.0001), increased PML tethering was the primary determinant afterward (r2=0.60, P<0.0001)., Conclusions: Although tethering of both leaflets is the major determinant of ischemic MR before surgical annuloplasty, both leaflets tethering but with predominant and augmented PML tethering is related to persistent ischemic MR after the annnuloplasty.

Purpose: Late presence of mitral regurgitation (MR) after the Dor procedure (left ventricular (LV) reconstruction associated with coronary artery bypass grafting) for postinfarction patients carries a poor prognosis. The aim of this study was to review our experience with the Dor procedure and to analyze the correlation of surgical results with late MR., Methods: The study group comprised 19 patients with previous anterior transmural myocardial infarction (MI). Ten patients were classified as New York Heart Association (NYHA) functional class III or IV at surgery. MR was moderate in 2 patients and mild in 15 patients., Results: Myocardial revascularization was performed in all patients, with a mean of 3.7+/-1.2 grafts. Mitral valve was repaired in 6 patients. Four patients with mild MR underwent posterior annuloplasty, and 2 with moderate MR underwent rigid annular remodeling. Early postoperative NYHA functional class improved from 2.7+/-0.9 to 1.3+/-0.5; however, MR deteriorated to moderate in 5 patients with worsening NYHA functional class 3 months after surgery. Although the valve was not repaired during surgery in 4 patients with preoperative mild MR, 1 patient with moderate MR underwent annuloplasty with a rigid ring. All patients with late MR underwent more than 30-mL/m2 reduction of end-diastolic volume index at surgery. Cumulative 4-year survival including hospital deaths was 89.5%., Conclusion: To prevent the risk of late MR, a more than 30-mL/m2 reduction of end-diastolic volume index should be avoided and mitral valve repair should be performed even if preoperative functional MR is only mild.

Left ventricular (LV) volume, mitral E deceleration time, and mitral regurgitation (MR) fraction were measured by echocardiography in 14 patients with surgical LV aneurysmectomy. Late MR developed 3 to 6 months after surgery in 5 of the 14 patients (36%). Compared with patients without late MR, those with late MR had a significantly greater preoperative LV end-diastolic volume index (LVEDVI) (134 +/- 21 vs 93 +/- 19 ml/m(2), p <0.01), surgical reduction in LVEDVI (-51 +/- 14 vs -20 +/- 16 ml/m(2), p <0.01), early postoperative LV diastolic dysfunction with shortened mitral E deceleration time (106 +/- 23 vs 141 +/- 24 ms, p <0.01), and a late postoperative reincrease in LVEDVI (+28 +/- 4 vs +3 +/- 8 ml/m(2), p <0.01), suggesting that surgical LV aneurysmectomy in patients with advanced preoperative LV remodeling may result in postoperative LV diastolic dysfunction, promoting later LV redilation with ischemic MR.

Congenital factor V deficiency is an uncommon bleeding disorder that necessitates hemostatic correction before surgery. We herein describe a patient with severe factor V deficiency who underwent successful off-pump coronary artery bypass grafting with a transfusion of fresh-frozen plasma.

We report the case of a 58-year-old man with Behçet's disease who developed chest pain. Coronary angiography showed severe triple-vessel disease, and the patient was transferred to our department for urgent coronary artery bypass grafting. Because of the risk of anastomotic leakage or pseudoaneurysm formation, we performed off-pump coronary artery bypass grafting with the aortic no-touch technique. Postoperative coronary angiography showed that all the grafts were patent and no anastomotic pseudoaneurysms were observed. Pathological examination of the right internal thoracic artery specimen revealed mild intimal thickening and disruption of elastic fibers in the medial layer, both of which are characteristics of Behçet's disease. These findings indicated that the patient must be monitored carefully for postoperative pseudoaneurysm formation.

Objective: The use of non-heart-beating donors (NHBD) might increase the number of grafts available for transplantation. Experiments on heart transplantation from NHBDs demonstrated the necessity for oxygenation during preservation to allow sufficient myocardial recovery. It has been shown that, after 16 min normothermic ischemia followed by 3.3-h hypothermic preservation, excellent myocardial and cardiovascular recovery is attained, if coronary oxygen persufflation (COP) is included in the preservation protocol. Here tests are presented on the recovery of coronary endothelium derived relaxation (EDR) of NHBD hearts after preservation including COP., Methods: After 16 min normothermic ischemia, pig hearts were stored for 3.3 h at 0-1 degrees C in modified HTK plus COP (mBHTK+COP, n=6) or in two control groups without COP: (1) with mBHTK (n=6); and (2) with HTK (n=4). Following orthotopic transplantation and 3 h of reperfusion with full blood, coronary EDR was tested in vitro using Substance P (SP) under indomethacin for prostaglandin blockage. Additional tests were performed adding L-NIL to block the NO-production by iNOS or L-NNA to block total NO production., Results: The EDR in percent of precontraction was 78 +/- 7% after mBHTK+COP and 77 +/- 20% (mBHTK) or 72 +/- 7% (HTK) in the controls without significant differences between the groups. Physiologic values of normal coronaries were 75 +/- 9%. L-NIL for blockage of NO-production by iNOS resulted in unchanged relaxations. After blockage of total NO production by L-NNA, the SP-induced dilation was significantly reduced to 58 +/- 8% (mBHTK+COP) and to 48 +/- 8% (mBHTK) or 55 +/- 13% (HTK) in the controls., Conclusions: Even after 16 min of warm ischemia followed by 3.3 h of preservation with gaseous oxygen persufflation, orthotopic transplantation, and reperfusion the endothelium derived coronary dilatation was unchanged from physiologic values and similar to the controls without COP. Blockage of NO production by L-NNA resulted in equal values of EDR with or without COP, while blockage of NO production by iNOS did not influence the EDR reaction. Thus COP preservation, which has been shown to allow excellent recovery of preserved NHBD hearts, caused no damage to the coronary EDR mechanisms.

We report the clinicopathologic characteristics of the congenital quadricuspid aortic valve necessitating surgery. Among 616 patients for whom we performed an aortic valve operation over the past 20 years, nine patients (1.46%) (five men and four women, mean age 60 years) with quadricuspid aortic valve were encountered. All had aortic regurgitation (AR) except one with aortic stenosis and mild regurgitation (ASr). All were free of cardiac anomaly including that of the coronary arterial system. Macroscopically, severe calcification of the valve was seen in the one case of ASr. Fenestration of the cusp was seen in five cases of AR. Infective endocarditis was not seen. Histological study disclosed fibrous thickening and myxoid degeneration in the AR cases. In accordance with the Hurwitz and Roberts classification, four valves were type b (three equal-sized cusps and one smaller cusp), two valves were type a (four equal-sized cusps), two valves were type d (one large, two intermediate, and one small cusp), and one valve was type g (four unequal-sized cusps). Valve repair failed in one patient and was converted to valve replacement during the operation. All patients underwent successful aortic valve replacement (AVR).

Background: The coronary oxygen persufflation (COP) technique has been previously shown to allow prolonged heart preservation of 14 hr with optimal recovery in a pig model of orthotopic transplantation. This technique may be applicable to hearts grafted from non-heart-beating donors (NHBD)., Methods: Experiments were performed on pigs to test the effectiveness of oxygenated preservation, using COP for preservation of NHBD hearts. After 16 min of in situ normothermic ischemia, the hearts were flushed with histidine-tryptophan-ketoglutarate (HTK) solution or modified HTK solution (mBHTK) including 30 mmol/L 2,3-butanedione monoxime, 40 mg/L hyaluronidase,15 micromol/L adenosine, and 50 micromol/L calcium. Hearts were stored in the flush solutions for 3.3 hr or additionally persufflated with gaseous oxygen through the coronary arteries (COP) and transplanted orthotopically., Results: Simple storage in HTK did not allow recovery of these hearts, whereas mBHTK storage resulted in improved function with 1.1 L/min cardiac output. The cardiac output reached 2.8 L/min (68% of normal values) with a left ventricular developed pressure of 101 mm Hg only after mBHTK+COP. Then the hearts were able to guarantee the circulation of the recipient for the test period after weaning from the heart-lung machine., Conclusions: Even in an NHBD with more than 15 min of in situ ischemia, the use of COP in combination with mBHTK solution for 3.3-hr storage of the heart allows excellent recovery of transplanted hearts and normal weaning from the heart-lung machine. This indicates that COP combined with mBHTK may be an optimal preservation technique for use with NHBD hearts.

Erythropoietic protoporphyria (EPP) is a disorder of heme synthesis that causes excessive accumulation of protoporphyrin. The predominant clinical feature is photosensitivity triggered by light at wavelengths near 400 nm. We describe a 52-year-old man with EPP who underwent aortic valve replacement due to severe regurgitation. To prevent burn injuries, astral lamps in the operating room were covered with yellow film filters. Preoperative autologous blood donation was not undertaken. Blood priming of the extracorporeal circuit was performed to maintain adequate hemoglobin concentrations, which resulted in reduction of heme synthesis. The patient was discharged in good health without any signs or symptoms of EPP.

We herein report a case of aortic root replacement using cryopreserved allograft. A 52-year-old man received aortic valve replacement using a mechanical prosthesis for aortic stenosis. He was complicated by postoperative methicillin-resistant staphylococcus aureus mediastinitis involving the ascending aorta. Surgical therapy including debridement, omental transposition, patch closure using pericardium had not achieved satisfied result. Aortic root replacement using cryopreserved allograft was mandatory for refractory aortic infection. He had an uneventful postoperative course. The cryopreserved allograft was effective for a patient with refractory aortic root infection due to postoperative mediastinitis.

Infected aneurysms of the thoracic aorta are rare in children, and many are not diagnosed until autopsy. We report the case of a 3-year-old girl in whom an infected aneurysm of the ascending aorta was successfully repaired by Dacron patch angioplasty under cardiopulmonary bypass.

Here, we report on a 30-year-old female with primary chylopericardium who successfully underwent thoracic duct clipping and partial pericardiectomy using video-assisted thoracoscopic surgery (VATS). Recently, a few cases of this disease have been treated utilizing VATS. This is a fully detailed description of the treatment of primary chylopericardium including a description of intraoperative findings and photographs obtained during the course of VATS.