[Primary Cardiac Undifferentiated Pleomorphic Sarcoma in the Left Atrium:Report of a Case].

A rare case of primary cardiac undifferentiated pleomorphic sarcoma (UPS) is reported. A 77-yearold female was admitted to the authors' hospital with complaints of palpitation and dyspnea on effort. Echocardiography revealed a mobile tumor arising from the atrial septum of the left atrium. The tumor obstructed the mitral valve and the patient experienced acute heart failure. Emergent open-heart surgery was performed to resect the tumor. Although she was discharged from hospital on postoperative day 14 in a satisfactory condition, local recurrence in the left atrium was observed 16 months after surgery. Repeated tumor resection was performed, and histological examination confirmed UPS. The patient did not agree to undergo chemotherapy or radiation therapy and died of local recurrence 27 months after the first surgery.

[Surgical Pulmonary Embolectomy for Acute Massive Pulmonary Embolism Using a Surgical Endoscope;Report of a Case].

Despite advances in medical and surgical therapeutic techniques, acute massive pulmonary embolism has a high mortality rate. Complete clot extraction without arterial wall injury is essential to save critically ill patients. Herein, we present a case of a 72-year-old woman who was treated by surgical pulmonary embolectomy using a surgical fiberscope. The patient was admitted to our hospital with a complaint of dyspnea. Computed tomography demonstrated a massive pulmonary embolism, and echocardiography revealed a floating thrombus in the right atrium and severe right heart failure. As she suffered from circulatory collapse, percutaneous cardiopulmonary support was immediately introduced and emergency surgical embolectomy was performed. Surgery was performed under circulatory arrest, and complete clot extraction was achieved using a surgical endoscope. The patient recovered well and was discharged from the hospital on day 48, with good health.

[Coronary Artery Perforation during Excimer Laser Coronary Angioplasty;Report of a Case].

Coronary perforation during excimer laser coronary angioplasty( ELCA) is a rare but life threatening complication. A 55-year-old man was admitted to our hospital for management of acute coronary syndrome. ELCA was attempted for the left anterior descending coronary artery (LAD);however, coronary perforation of LAD occurred during the procedure. The patient was transferred to the operation theater and emergency surgical repair was performed. LAD and the diagonal branch were ligated, an aorto-coronary bypass grafting for the distal LAD and the diagonal branch using the saphenous veins. His postoperative course was uneventful, and the patient was discharged on the 23rd postoperative day. In case of coronary perforation complicated by ELCA, immediate surgical repair is essential.

[Prophylactic Effectiveness of Vacuum-assisted Closure for High-risk Patients Undergoing Cardiovascular Surgery through Median Sternotomy].

Vacuum-assisted closure(VAC) therapy is mainly used for tissue defects. VAC therapy can remove exudate that could impair the healing process. We applied VAC therapy in patients considered at high risk of surgical site infection who underwent cardiovascular surgery via standard median sternotomy. Risk factors included advanced heart failure, obesity, diabetes mellitus, steroid administration, immunosuppressant administration, and chronic renal failure, etc. VAC therapy was used in 134 patients. Only 3 of these patients (2.2%) developed surgical site infection caused by Staphylococcus epidermidis;2 patients fully recovered after prolonged VAC therapy for 2 weeks, and the other required an additional sternal fixation after the sternal wires were removed for wound infection control. No patient developed infective mediastinitis. Prophylactic VAC therapy can reduce postoperative wound infection in high risk patients undergoing open heart surgery via full sternotomy.

[A Giant Right Coronary Artery Aneurysm Exceeding 8-cm in Size].

A coronary artery aneurysm(CAA) that exceeds 20 mm in diameter is rare. In this case report, we describe the operative correction of a giant right CAA measuring greater than 8 cm in diameter. A 51-year-old male with a history of Kawasaki disease at 7 years of age was admitted to our hospital for evaluation of an abnormal shadow on a chest radiograph. Multi-detector row computed tomography (MDCT) demonstrated a giant, 82-mm right coronary aneurysm in the right atrioventricular groove with a layered thrombus. The patient underwent aneurysmectomy and coronary artery bypass grafting using the right internal thoracic artery under cardiopulmonary bypass. The postoperative course was uneventful, and postoperative MDCT revealed complete resection of the aneurysm and good patency of the bypass graft. The patient was discharged on the 8th postoperative day in good health.

[Papillary Muscle Rupture after Repair of Ischemic Left Ventricular Free Wall Rupture; Report of a Case].

A 67-year-old man experienced acute inferior myocardial infarction. Echocardiography and computed tomography showed massive pericardial effusion. He underwent emergency operation for ischemic ventricular free wall rupture. During the operation, an oozing type rupture was found on the inferior wall and the bleeding was completely controlled by applying fibrin glue sheets. On the 5th day after the operation, ventricular tachycardia appeared with hemodynamic deterioration. Echocardiography showed a ruptured posteromedial papillary muscle with massive mitral regurgitation. Intra-aortic balloon pumping was introduced and emergency repair operation was performed. The mitral valve was replaced with a bioprosthetic valve. The postoperative course was uneventful.

[Pannus Formation Six-years after Aortic and Mitral Valve Replacement with Tissue Valves;Report of a Case].

A 77-year-old man presented with exertional dyspnea. He had undergone aortic and mitral valve replacement with tissue valves 6-years earlier. The patient's hemoglobin level was 9.8 g/dl and serum aspartate aminotransferase (70 mU/ml) and lactate dehydrogenase (1,112 mU/ml) were elevated. Echocardiography revealed stenosis of the prosthetic valve in the aortic position with peak flow velocity of 3.8 m/second and massive mitral regurgitation. The patient underwent repeat valve replacement. Pannus formation around both implanted valves was observed. The aortic valve orifice was narrowed by the pannus, and one cusp of the prosthesis in the mitral position was fixed and caused the regurgitation, but they were free from cusp laceration or calcification. The patient's postoperative course was uneventful, and he continues to do well 14 months after surgery.

[Surgical Treatment of Prosthetic Valve Endocarditis].

Between 2003 and 2014, at Jichi Medical University Hospital, 11 patients with prosthetic valve endocarditis (PVE) underwent re-operation. There was 1 in-hospital death and 2 late deaths. The cause of death was cirrhosis, heart failure and sepsis, respectively. Emergency surgery, previous double valve replacement (DVR) and Staphylococcus infection were common risk factors for all 3 cases. Two cases of patients that survived who underwent mitral valve replacement (MVR) and DVR for PVE after DVR were treated with multiple antibiotic courses for bacteremia associated with hemodialysis and colon cancer. One patient who underwent DVR after mitral valve plasty which was complicated with cerebral hemorrhage, had survived and was discharged. Of the aortic PVE patients, 2 cases of aortic valve replacement (AVR) using a mechanical valve, 1 case of aortic root replacement (ARR) using a mechanical valve, and 1 ARR using the homograft, were considered cured and never relapsed. A patient with aortic PVE, who underwent AVR after cesarean section for heart failure in birth period, has received ARR twice with the mechanical valve for recurrent pseudo-aneurysm of the left ventricular outflow tract. Since hemodialysis and colon cancer is a risk factor for recurrent PVE, it is necessary to consider the long-term administration of antibiotics after surgery.

Artificial endocrine pancreas with a closed-loop system effectively suppresses the accelerated hyperglycemic status after reperfusion during aortic surgery.

OBJECTIVES: To control intraoperative hyperglycemia in patients who underwent aortic surgery using STG-55® artificial endocrine pancreas and clarify the effectiveness of this device. METHODS: Blood glucose control using the STG-55® was performed in 18 patients (15 men and 3 women; age, 66 ± 10 years) who required hypothermic circulatory arrest (STG-55® group). Seventeen patients (10 men and 7 women; age, 71 ± 8 years) whose blood glucose was controlled using the conventional method were included in the control group. Glucose concentration was controlled with the aim of maintaining it at 150 mg/dl. RESULTS: In both groups, the blood glucose concentrations did not significantly change during the interruption of systemic perfusion; however, a sharp increase was noted immediately after reperfusion. Although the hyperglycemic status persisted after reperfusion in the control group, it was effectively suppressed in the STG-55® group (STG® vs. control group at 50 min after reperfusion: 180 ± 35 vs. 212 ± 47 mg/dl, p = 0.026) and blood glucose concentration reached the target value of 150 mg/dl at 100 min after reperfusion (STG® vs. control group: 153 ± 29 vs. 215 ± 43 mg/dl, p = 0.0008). The total administered insulin dose was 175 ± 81 U and 5 ± 3 U in the STG® and control groups, respectively (p < 0.0001). CONCLUSIONS: To treat the accelerated hyperglycemic status in aortic surgery requiring circulatory arrest, strict glycemic control using an artificial endocrine pancreas might be beneficial.

Left ventricular blood cyst in an adult case.

We present a 57-year-old man with a 1.5-cm-diameter blood cyst in the left ventricle, which was incidentally detected by conventional diagnostic echocardiography before colon surgery. The cyst originated from the papillary muscle, and the pathological findings were compatible with a cardiac blood cyst.

Late complications after Cabrol technique in a case with Marfan syndrome.

A patient with Marfan syndrome underwent aortic root replacement with the Cabrol technique at 37 years of age. She underwent a surgical repair for an aneurysm in the right coronary at 58 years of age, followed by a surgical repair for a pseudoaneurysm of the left coronary artery at 64 years of age.

Bioprosthetic aortic valve replacement 12 years after percutaneous aortic valvuloplasty in a young female adult with hope of pregnancy.

CASE: A 26-year-old woman who had congenital aortic valve stenosis presented with exertional dyspnea. She had undergone percutaneous balloon aortic valvuloplasty 12 years previously at the age of 14. When she was 20 years old, she delivered a neonate by elective cesarean section at the 31st week of gestation because the mean pressure between the left ventricle and the ascending aorta was 52 mmHg. OUTCOME: She successfully underwent aortic valve replacement with a bioprosthetic valve combined with replacement of the ascending aorta in order to make the next pregnancy possible. CONCLUSION: The long-term prognosis of percutaneous balloon aortic valvuloplasty might be acceptable for some patients, even though this procedure is associated with the possibility of secondary interventions.

Delayed visceral ischemia induced by type B aortic dissection.

Case: A 56-year-old man presented with a sudden severe abdominal pain 13 days after the onset of type B acute aortic dissection. Chest computed tomography revealed type B aortic dissection, and the true lumen was narrowed by the expanding false lumen. Blood flow through the celiac trunk, superior mesenteric artery, and left renal artery was reduced. Blood flow through the distal abdominal aorta and bilateral femoral arteries was clearly recognized. Laboratory findings such as transaminases were rapidly worsening. Outcome: The patient underwent emergency fenestration of the abdominal aorta and recovered without organ failure. Conclusions: Rapidly worsening laboratory findings led us to emergency operation with successful results. Serial monitoring of laboratory findings is the key for adequate timing of operation.

Fifteen-year experience with the Bicarbon heart valve prosthesis in a single center.

BACKGROUND: The purpose of this study was to evaluate retrospectively the clinical performance of the Bicarbon valve (Sorin Biomedica Cardio, Saluggia, Italy) implanted at our center in Japan. METHODS: Between January 1997 and December 2011, 415 patients in our institution were implanted with the Bicarbon valve. Nine of these recipients were excluded from the study because they had already undergone valve implantation and received a Bicarbon valve in a different position. The remaining patients were analyzed for evaluation of the postoperative clinical outcomes. Of the 406 patients (mean age 60.2 ± 11.7 years), 179 underwent aortic valve replacement (AVR), 149 mitral valve replacement (MVR), and 78 both aortic and mitral valve replacement (DVR). RESULTS: There were 10 early deaths (2.5 %: 4 in the AVR group and 6 in the MVR group). Three hundred eighty-nine patients were followed up (95.8 % completeness of follow-up) with a mean follow-up of 6.6 ± 4.2 years overall (AVR 6.8 ± 4.2, MVR, 6.7 ± 4.4, and DVR 5.7 ± 3.4 years) and a cumulative follow-up of 2661 patient-years (1214, 1001, and 446 patient-years for AVR, MVR, and DVR, respectively). Ninety-nine patients died (3.7 % per patient-year: 22 valve-related and 77 valve-unrelated deaths). Survival at 10 years was 74.1 ± 4.0 % in the AVR group, 73.7 ± 4.2 % in the MVR group, and 61.0 ± 7.9 % in the DVR group. The linearized incidence of thromboembolic complications, bleeding complications, prosthetic valve endocarditis, paravalvular leaks, and sudden death in all patients was 0.5 %, 0.5 %, 0.2 %, 0.2 %, and 0.4 % per patient-year, respectively. The incidence of valve-related complications and reoperation was 1.6 % and 0.4 %, respectively. No other valve-related complications were observed. CONCLUSIONS: The Bicarbon prosthetic heart valve has shown excellent clinical results and is associated with a low incidence of valve-related complications.

A worn Björk-Shiley prosthetic valve without valve dysfunction observed during ascending aortic replacement.

KEY CLINICAL MESSAGE: The implanted first-generation Björk-Shiley valve in our patient was functioning well before aortic surgery, but we replaced the valve because we confirmed disc erosion 39 years after implantation during the surgery. We judged that the implanted valve was no longer capable of maintaining the patient's life.