[Coronary Artery Bypass Grafting in a Patient with Hemophilia A Assisted by Thromboelastography: Report of a Case].

We report a case of coronary artery bypass grafting using thromboelastography in a 42-year-old male patient with hemophilia A. He was diagnosed with hemophilia A at the age of three years old, and was also infected with hepatitis C and human immunodeficiency virus (HIV). He complained of chest pain at home and was brought to our institute and diagnosed with acute myocardial infarction. Concerned about the risk of bleeding, coronary artery bypass grafting was selected to avoid permanent administration of antiplatelet agents. Although there were concerns about bleeding caused by various coagulation factor abnormalities due to the use of cardiopulmonary bypass, we could accurately assess the coagulation factors by using thromboelastography and replenishing them in appropriate amounts. The operation was performed safely as usual and successfully finished.

Coil embolization of a celiac artery pseudoaneurysm under balloon-assisted flow control: A case report.

Coil migration can occur when coil embolization is used for treating pseudoaneurysms associated with large arteries. The double microcatheter technique is useful for preventing coil migration; the balloon catheter can reduce blood flow and active bleeding upon balloon inflation, and can also compress the bleeding point and arrest bleeding temporarily. We report a case describing the management of a pseudoaneurysm with coil embolization using double microcatheters and a balloon catheter to control blood flow and prevent coil migration. A 73-year-old male patient presented with a pseudoaneurysm of the celiac artery arising from the splenic artery stump following surgery. Coil embolization of the pseudoaneurysm using a double microcatheter embolization technique with a balloon catheter was considered. A balloon catheter was inserted into the celiac artery and active bleeding was temporarily arrested with the inflated balloon. First, a microcatheter was inserted into the balloon catheter, and another microcatheter was placed in the celiac artery. An electrical detachable coil was inserted into the proximal common hepatic artery just distal to the pseudoaneurysm. The second electrically detachable coil was inserted while the first coil remained attached. After detachment of the second coil, additional electrically detachable coils were inserted for similar embolization. The balloon was gradually deflated. Finally, the first coil was detached and we confirmed absence of the bleeding. Our case report demonstrated that a balloon catheter can control the flow vessels, and the double microcatheter embolization technique with a balloon catheter is useful for coil embolization in high-flow or large vessels.

Complete response of glottic cancer to intra-arterial infusion chemotherapy combined with radiotherapy: A report of 4 cases.

Surgical resection is recommended for advanced-stage, resectable glottic cancer. However, total laryngectomy results in the loss of vocal function and reduces patients' quality of life. At our institution, patients with cT3N0M0 stage III resectable glottic cancer who wish to preserve their larynx are treated with super-selective cisplatin infusion with concomitant radiotherapy (RADPLAT) to improve local control over systemic chemotherapy. Herein, we present 4 patients with glottic cancer who underwent biweekly intra-arterial infusion chemotherapy combined with radiation therapy 3 times. For intra-arterial infusion chemotherapy, 100 mg cis-diaminodichloroplatinum was infused into the superior thyroid artery, including the superior laryngeal artery branch. Thereafter, intensity-modulated radiation therapy was administered at doses of 70 Gy in 35 fractions for 3 patients and 66 Gy in 33 fractions for 1 patient. These patients showed complete response after chemoradiotherapy with no recurrence or metastases during the follow-up period to date (mean follow-up period: 56 months, range: 39-76 months).

Transcatheter aortic valve implantation with pre-existing mitral valve prosthesis using cardiopulmonary bypass: A case report.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is rarely performed in patients with a pre-existing mitral valve prosthesis, which was excluded from the Placement of Aortic Transcatheter Valve trial. Cardiopulmonary bypass (CPB) can provide sufficient hemodynamic stability to facilitate safe implantation; specifically, we prefer using normothermic femoro-femoral CPB. Careful attention should be paid to determine the positional relationship between the two valves in such patients. PRESENTATION OF CASE: We present a case of transfemoral TAVI using femoro-femoral CPB in a 90-year-old female patient with a pre-existing bioprosthetic mitral valve. Baseline echocardiography revealed severe aortic valve stenosis; hence, emergency balloon valvuloplasty was performed. Three months later, elective TAVI was performed; subsequently, left ventricular ejection fraction reached 63 % without mitral valve regurgitation or stenosis. DISCUSSION: Despite the safety of TAVI using CPB in older patients, cannula insertion into peripheral vessels carries a high risk. CONCLUSION: As CPB can increase tissue invasion for a short duration, the safety of this procedure needs further validation.

[Re-operative Cardiac Surgery in Patients with Patent In Situ Coronary Artery Bypass Grafts].

BACKGROUND: Re-operative cardiac surgery after prior coronary artery bypass grafting( CABG), using in situ graft is a challenge. Technical difficulties regarding this procedure include risks of graft injury and myocardial protection. The conventional strategy involves re-sternotomy, dissection, and temporary occlusion of the in situ graft to prevent cardioplegia washout. However, the problem with this procedure is that injury to the in situ graft can result in catastrophic complications. METHODS: We reviewed 25 redo cases of patients who had prior CABG with patent in situ grafts. The in situ grafts were dissected and clamped in 18 (group C) patients, whereas in 7 (group U) patients, the in situ grafts were not dissected or clamped. All patients underwent re-sternotomy, aortic cross clamping and cardiac arrest with cardioplegia. Besides, myocardial protection was obtained using moderate hypothermia and systemic potassium injection in group U. RESULTS: There were no injuries to the in situ grafts in either group. The peak creatine kinase-MB values were not significantly different between the two groups. Postoperative ejection fraction was preserved in both groups. CONCLUSIONS: The simplified approach of no-clamping technique yielded safety and effectiveness for myocardial protection in redo cases for patients with prior CABG in the presence of patent in situ grafts.

[Concomitant Transapical Transcatheter Aortic Valve Implantation and Coronary Artery Bypass Grafting via the Left Thoracotomy].

A 79-year-old man presented with progressive congestive heart failure symptom as a result of severe aortic stenosis. A rescue balloon aortic valvuloplasty was performed. After a transient improvement, computed tomographic scan revealed a porcelain aorta, and it showed a high risk for a surgical aortic valve replacement. Routine preoperative coronary angiography revealed tight stenosis of a proximal left anterior descending coronary artery. Percutaneous coronary intervention was performed unsuccessfully due to the severe calcification of the coronary artery. Therefore, a concomitant transapical transcatheter aortic valve implantation and coronary artery bypass grafting via the left thoracotomy was indicated. Under a veno-arterial extracorporeal circulatory support, we performed the transcatheter aortic valve implantation (TAVI) and coronary artery bypass grafting (CABG) successfully via a left thoracotomy. Even though the approach for TAVI is from fifth and CABG is from forth intercostal space respectively, it could be manipulated using the same skin incision. Concomitant TAVI and CABG via the left thoracotomy might be a reasonable and feasible option for the patients presented with severe aortic stenosis and coronary artery disease who are not eligible for conventional surgical solutions.

Evaluation of Computed Tomography Attenuation Value of Proximal Femoral Marrow to Diagnose and Differentiate Hematologic Malignancies, Myelofibrosis, and Aplastic Anemia.

OBJECTIVE: The aim of this study was to diagnose hematologic diseases using computed tomography (CT) number of proximal femoral marrow. METHODS: The average CT number of marrow in hematologic diseases was measured on the caudal side of the greater trochanter. RESULTS: The CT numbers were -60.3 ± 16.8 in 12 patients with aplastic anemia, -53.2 ± 19.4 in 11 patients with monoclonal gammopathy of undetermined significance, -44.2 ± 21.1 in 10 normal controls, -30.9 ± 42.3 in 9 patients with chronic lymphatic leukemia, -29.8 ± 29.9 in 17 patients with benign anemia, -13.7 ± 40.9 in 33 patients with multiple myeloma, 0.32 ± 44.6 in 17 patients with myelodysplastic syndrome (MDS), 18.7 ± 40.0 in 44 patients with acute myeloid leukemia, 50.3 ± 27.4 in 13 patients with acute lymphatic leukemia, 51.5 ± 16.8 in 8 patients with myelofibrosis, and 56.4 ± 15.6 in 9 patients with chronic myeloid leukemia. Significant differences were observed between acute myeloid leukemia and MDS, between MDS and aplastic anemia, and between multiple myeloma and monoclonal gammopathy of undetermined significance (P < 0.01). CONCLUSION: The marrow CT numbers may be indicators of hematologic diseases and can be used as a diagnostic tool.

[Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis with Preexisting Mitral Prosthesis;Report of a Case].

An 81-year-old woman presented with progressive congestive heart failure. Seventeen years before, she had undergone mitral valve replacement with a mechanical prosthesis. Echocardiography revealed severe aortic stenosis with a depressed left ventricular ejection fraction of 32%.At first, rescue balloon aortic valvuloplasty (BAV) was performed. After transient improvement of symptoms, she was readmitted 2 months later with recurrence of severe congestive heart failure. Transcatheter aortic valve implantation (TAVI) with an Edwards Sapien valve was performed. During the procedure, BAV was performed to confirm that the balloon did not interfere the movement of the mechanical valve. Moreover, supported by a veno-arterial extracorporeal membrane oxygenation, we could prevent myocardial ischemia during rapid pacing and slowly deploy the valve in a precise position. TAVI can be safely and successfully performed in patients with a preexisting mechanical mitral prosthesis.

Bronchogenic cyst of the interatrial septum.

Although bronchogenic cysts are the most common primary mediastinal cysts, intracardiac bronchogenic cysts are extremely rare. We report a case of a bronchogenic cyst of the interatrial septum in a 42-year-old woman who presented with recent onset of dyspnea on exertion. Cardiac investigations including transthoracic echocardiography and computed tomography revealed a cystic homogeneous mass in the interatrial septum. The patient underwent surgical resection, and the resultant atrial septal defect was repaired using an autologous pericardial patch. Histopathological examination of the resected specimen revealed findings consistent with a benign bronchogenic cyst. Although bronchogenic cysts are extremely rare, they should be considered in the differential diagnoses of intracardiac tumors. Complete resection of bronchogenic cysts is recommended primarily for diagnostic and potentially therapeutic purposes.

[Total Arch Replacement with Concomitant Thoracic Endovascular Aortic Repair Via the Ascending Aorta for Extended Thoracic Aneurysm;Report of a Case].

The patient was a 66 year-old male. Computed tomography (CT) angiography showed a huge aneurysm(120 mm) in the aortic arch and chronic type B aortic dissection(45 mm) in the descending aorta. Echocardiography showed patent ductus arteriosus( PDA). Because of pulmonary hypertension due to PDA, it was considered unacceptable to put him under general anesthesia twice. We performed thoracic endovascular aortic repair (TEVAR) via the ascending aorta and total arch replacement (TAR) simultaneously to prevent paraplegia. After establishment of cardiopulmonary bypass( CPB), a stent graft was inserted via the ascending aorta to cover the dissection site of descending aorta, the aorta was opened under circulatory arrest, and PDA was suture closed. Another stent graft whose two proximal rows of Z-stent was removed, was inserted to descending aorta via the ascending aorta landing on the previous stent graft. The proximal end of this stent graft was anastomosed to the distal end of the prosthetic arch graft and arch branches were reconstructed as usual. The postoperative course was uneventful.

Assistive Techniques for Proximal Anastomosis in Minimally Invasive Coronary Artery Bypass Grafting.

We introduce assistive techniques for proximal anastomosis in off-pump minimally invasive coronary artery bypass grafting (MICS CABG) to overcome difficult access to the ascending aorta in MICS CABG. An 8-cm left thoracotomy is made in the fifth intercostal space. ThoraTrak retractor (Medtronic Inc, Minneapolis, MN USA) is used to open the thoracotomy and is pulled to the cephalad and rightward direction toward to the ascending aorta. The pericardium is opened from the ascending aorta to the left ventricular apex and to the inferior vena cava. Two retraction sutures on the pericardial edge are used to laterally displace the heart. After dissecting between the ascending aorta and main pulmonary artery, the Octopus tissue stabilizer (Medtronic Inc, Minneapolis, MN USA), of which the suction tip is bent 60 degrees, is used to retract the pulmonary artery caudally. A flexible side-biting clamp (Vitalitec Inc.) is placed on the ascending aorta, and proximal anastomoses are handsewn on the ascending aorta. A total of 31 proximal anastomoses were completed with this technique between November 2013 and June 2015. All proximal anastomosis was completed without any difficulty. In MICS CABG, the technical challenges in proximal anastomosis due to difficult access to the aorta can be overcome safely by using this technique.

Minimally Invasive Coronary Artery Bypass Grating Using Bilateral In Situ Internal Thoracic Arteries.

When performing minimally invasive coronary artery bypass grafting (MICS CABG), it is difficult to access the right internal thoracic artery (ITA) under direct vision. We successfully performed off-pump MICS CABG using the bilateral in situ ITAs through a 8-cm left thoracotomy under direct vision for a 76-year-old man. His postoperative course was uneventful and all the grafts were patent. This novel, minimally invasive approach safely preserves the sternum and delivers the benefits of bilateral in situ ITA grafting, providing an alternative to conventional CABG and off-pump CABG.

[Minimally Invasive Cardiac Surgery with Lower Partial Sternotomy for Combined Valve Disease;Report of a Case].

Combined valve surgery is usually performed with standard sternotomy although the efficacy and safety of single valve surgery with partial sternotomy has been established. We report a successful case of triple valve surgery with lower partial sternotomy. A 69-year-old woman underwent aortic valve replacement, mitral and tricuspid valve repair via lower partial sternotomy for moderate aortic and mitral valve regurgitation as well as severe tricuspid valve regurgitation. The operation was successfully performed with enough surgical field, without using any specific technical devises for minimally invasive cardiac surgery or blood transfusion. The ascending aorta, the superior vena cava and the right femoral vein were cannulated for cardiopulmonary bypass. The procedure was completed as in a conventional approach, except for a small incision for the femoral vein. This approach has several advantages;less trauma, less pain, earlier recovery, and better cosmetic outcomes. Triple valve surgery can be completed using lower partial sternotomy with benefits.

Off-Pump Minimally Invasive Coronary Artery Bypass Grafting With a Heart Positioner: Direct Retraction for a Better Exposure.

OBJECTIVE: Lateral and inferior territories are difficult to expose during off-pump minimally invasive coronary artery bypass grafting (MICS CABG). The use of cardiopulmonary bypass is required at times. We initiated a direct retraction method by using a cardiac positioner for a better exposure, in order to complete off-pump, multivessel MICS CABG safely. METHODS: We recently initiated multivessel MICS CABG, performed via a 6- to 9-cm left thoracotomy. For distal anastomoses, the lateral pericardial edge was pulled to the chest wall to optimize exposure of the lateral and inferior area. Next, a single- or multisuction cardiac positioner was put on the sides of the target vessel through the small thoracotomy and pulled directly toward the incision. Finally, a distal anastomosis was made with an epicardial stabilizer via the thoracotomy, as in standard off-pump CABG. RESULTS: There was no mortality or conversion to sternotomy. A total of 10 cases were targeted for off-pump multivessel MICS CABG with this approach. Nine were completed, while 1 still required pump assist. The average number of distal anastomoses was 2.8 ± 0.8. Two were successful off-pump quadruple bypass grafting with sequential anastomoses. All patients were discharged and remain well to this day. CONCLUSIONS: Most multivessel MICS CABG was feasible without pump assist even at the initiation period. This approach is easy and helpful in providing good exposure of target vessels without requirement of additional incisions.

[Massive Pulmonary Hemorrhage During Cardiac Operation;Report of a Case].

The incidence of pulmonary hemorrhage during cardiac operation is not freqent but one of severe and lethal complications. We report a case of massive pulmonary hemorrhage, hemoptysis, suspected to be induced by a Swan-Ganz catheter. The patient had satisfactory progress postoperatively. An 80-year-old female patient underwent mitral valve replacement, tricuspid annuloplasty, and maze procedure. A Swan-Ganz catheter was inserted via the right jugular vein and fixed just at 40 cm as in usual preoperative induction. Operative procedures were uneventful, but active and massive airway hemorrhage started while weaning off cardiopulmonary bypass. A hematoma spreading under the visceral pleura of the right middle-lobe lung was found. We immediately replaced the endotracheal tube with a double-lumen one, and promptly decided to do lung lobectomy. These strategies were very helpful to rescue the patient, and led to her good recovery after the severe pulmonary hemorrhage, possibly induced by a catheter.

[Surgical technique of saphenous vein harvesting using a Cusco vaginal speculum].

We used Cusco vaginal speculum in harvesting saphenous vein graft (SVG) as an assist device for making a skin tunnel. After making 2 incisions of 3 to 4 cm, the SVG was dissected in a usual procedure. Then Cusco vaginal speculum was inserted into the skin tunnel between the 2 incisions. The SVG was dissected in a usual fashion under direct vision with the speculum. This procedure requires only small incisions, short learning curve and low cost. The new technique using Cusco vaginal speculum can be a reliable option for harvesting SVG.