Acute Aortic Regurgitation due to Aortic Dissection Limited to the Sinus of Valsalva, Which Was Found at the Time of Surgery: a Case Report / 日本心臓血管外科学会雑誌

Aortic dissection is one cause of acute aortic regurgitation, and transthoracic echocardiography and computed tomography are useful for diagnosis. We report a case of intraoperatively discovered acute aortic regurgitation caused by aortic dissection limited to the sinus of Valsalva. The patient was a 71-year-old man who regularly visited his local doctor for hypertension and diabetes mellitus. He visited the doctor with a week-long history of cough and dyspnea, and was referred to our hospital due to acute congestive heart failure. We diagnosed severe acute aortic regurgitation as the cause of the heart failure, but the aortic root dissection was not detected by transthoracic echocardiography or plain computed tomography. Since his heart failure progressively worsened even with intensive medical therapy, urgent surgery was decided on the 6th day after hospitalization. Intraoperatively, we noted that the aortic dissection was limited to the sinus of Valsalva, and had induced aortic regurgitation due to dissected and separated aortic commissure. We changed the surgical procedure from aortic valve replacement to the Bentall procedure (Piehler method). Postoperatively, the patient was intubated for 7 days and stayed in the ICU for 14 days due to treatment for pneumothorax and organizing pneumonia. He was successfully transferred to a rehabilitation hospital on the 35th postoperative day. Acute aortic regurgitation caused by aortic dissection limited to the sinus of Valsalva is rare, so we report the case based on literature reviews and as a heart team.

A Surgical Experience of Unroofing for Anomalous Aortic Origin of Right Coronary Artery with Ischemia in Adult / 日本心臓血管外科学会雑誌

We describe a 50-year-old man who was diagnosed with anomalous aortic origin of the right coronary artery (AAORCA) by coronary angiography and coronary computed tomography performed for chest pain on exertion. Exercise-loaded myocardial scintigraphy revealed inferior wall ischemia, and hence surgery was performed. Intraoperatively, the right coronary artery was seen to run in the aortic wall, and hence, right coronary ostioplasty (unroofing) was performed. Postoperatively, coronary computed tomography revealed that the right coronary artery originated from a normal position, and exercise-loaded myocardial scintigraphy indicated no ischemia.

Severe Aortic Stenosis and Partial Anomalous Pulmonary Venous Connection in a Turner Syndrome Patient / 日本心臓血管外科学会雑誌

A 42-year-old woman with Turner syndrome was admitted to our hospital due to severe aortic stenosis. Transthoracic echocardiography demonstrated severe aortic stenosis with a bicuspid aortic valve. Enhanced computed tomography revealed that the left upper pulmonary vein connected to the innominate vein, and the ascending aorta was enlarged (maximum diameter of 41 mm). Surgical intervention was performed though median sternotomy with cardiopulmonary bypass. After achieving cardiac arrest by antegrade cardioplegia, we performed an anastomosis to connect the left upper pulmonary vein to the left atrial appendage. Then, aortic valve replacement was performed with an oblique aortotomy in the anterior segment of the ascending aorta. The aortic valve was a unicaspid aortic valve. Following completion of aortic valve replacement with a mechanical valve, reduction aortoplasty was performed on the ascending aorta. The postoperative course was uneventful.

A Case of Cardiac Tamponade due to a Ruptured Coronary Artery Aneurysm / 日本心臓血管外科学会雑誌

An unconscious 79-year-old woman was admitted. Echocardiography showed cardiac tamponade with pericardial effusion. Enhanced computed tomography revealed pericardial effusion and a coronary artery aneurysm (maximum diameter of 16 mm) on the left side of the main pulmonary artery. Emergency coronary angiography confirmed the aneurysm, which originated from a branch of the left anterior descending artery. Emergency surgery was performed through median sternotomy with cardiopulmonary bypass. After cardiac arrest by antegrade cardioplegia, the aneurysm was opened and two orifices of the arteries were observed. The orifices were ligated, and the remaining aneurysmal wall was closed with a continuous suture. A pathological examination of the aneurysmal wall demonstrated an atherosclerotic true aneurysm.

A Case of Common Hepatic Artery Aneurysm Treated by Abdominal Aorta—Proper Hepatic Artery Bypass and Coil Embolization— / 日本心臓血管外科学会雑誌

A 52-year-old man underwent a medical examination, including abdominal computed tomography (CT). Abdominal CT revealed a common hepatic artery aneurysm (25 mm in diameter) ; a portion of the aneurysm depressed the pancreas. The gastroduodenal artery branched off the common hepatic artery aneurysm. We planned coil embolization for the common hepatic artery aneurysm. However, we could not avoid occluding the proper hepatic artery ; therefore, we performed abdominal aortic-proper hepatic artery bypass with coil embolization. The patient's postoperative course was uneventful.

Magnetic Resonance Imaging Findings Differentiating Cutaneous Basal Cell Carcinoma from Squamous Cell Carcinoma in the Head and Neck Region

OBJECTIVE: This study aimed to evaluate the efficacy of magnetic resonance (MR) imaging in differentiating between cutaneous basal cell carcinoma (cBCC) and cutaneous squamous cell carcinoma (cSCC) in the head and neck region.MATERIALS AND METHODS: Among patients with cutaneous head and neck cancers, 14 with primary cBCCs and 15 with primary cSCCs with a histologic tumor height of ≥ 4 mm underwent MR examinations; the findings were then examined for correlations.RESULTS: cBCCs (71%) occurred more frequently on the nose than cSCCs (13%) (p < 0.01). The maximum diameter (23.5 ± 7.2 mm vs. 12.7 ± 4.5 mm; p < 0.01) and diameter-to-height ratio (2.8 ± 0.9 vs. 1.7 ± 0.4; p < 0.01) were significantly greater in cSCCs than in cBCCs. Superficial ulcer formation (67% vs. 21%; p < 0.05), protrusion into the subcutaneous tissue (60% vs. 21%; p < 0.05), ill-demarcated deep tumor margins (60% vs. 7%; p < 0.01), and peritumoral fat stranding (93% vs. 7%; p < 0.01) were more frequently observed in cSCCs than in cBCCs. Intratumoral T2-hyperintense foci (57% vs. 13%; p < 0.05) were more frequently observed in cBCCs than in cSCCs.CONCLUSION: cBCCs predominantly occurred on the nose with intratumoral T2-hyperintense foci, whereas cSCCs predominantly exhibited a flattened configuration, superficial ulcer formation, protrusion into the subcutaneous tissue, ill-demarcated deep tumor margin, and peritumoral fat stranding.

Negative Pressure Wound Therapy and Pectoralis Major Myocutaneous Flap in the Treatment of Postoperative Sternal Osteomyelitis after CABG / 日本心臓血管外科学会雑誌

We report two cases with postoperative sternal osteomyelitis after coronary artery bypass graft (CABG), in whom successful two-stage reconstruction was performed via negative pressure wound therapy (NPWT) and pectoralis major myocutaneous flaps. Two patients underwent CABG using bilateral internal thoracic arteries, after which they had surgical site infection (SSI). The intractable wound did not heal with irrigation and NPWT. Then, sternal osteomyelitis was observed via magnetic resonance imaging (MRI), so we planned two-stage reconstruction. The first stage of treatment consisted of complete debridement (including removal of sternal wires and necrosectomy of soft tissue and sequestrum) and application of NPWT until the remission of inflammation. The second stage consisted of wound closure with pectoralis major myocutaneous advancement flaps. After wound closure, the two patients were given 2 months of oral antibiotics, and the postoperative results were good. Two-stage reconstruction with NPWT and pectoralis major myocutaneous flaps results in excellent clinical outcome. In the first stage, the key to the successful management of postoperative sternal osteomyelitis is infection control. This includes surgical debridement and wound-bed preparation with NPWT. The pectoralis major myocutaneous flap technique is brief and does not require a second cutaneous incision or an intact internal thoracic artery. In conclusion, the pectoralis major myocutaneous flap is a useful option in two-stage reconstruction after CABG.

Total Arch Replacement with Open Stent Grafting for Aberrant Right Subclavian Artery in Two Cases / 日本心臓血管外科学会雑誌

We report two cases of total arch replacement with open stent graft for the aberrant right subclavian artery (ARSA). Case 1 was a thoracic artery aneurysm with an ARSA. We thought it would be difficult to perform in-situ reconstruction of ARSA via median sternotomy, so we performed total arch replacement with the open stent-grafting technique. Therefore the right axillary artery was reconstructed by extra-anatomical bypass and coil embolization of the ARSA proximal to the vertebral artery to achieve complete thrombosis of the ARSA. The postoperative course was uneventful. Case 2 was a Stanford type A acute aortic dissection involving an ARSA with the entry located near the ARSA. Total arch replacement was performed using the open stent-grafting technique to close the entry site and origin of the ARSA. Then the right axillary artery was reconstructed by extra-anatomical bypass and coil embolization of the ARSA. The postoperative course was uneventful. The open stent-grafting technique might be an effective alternative management of thoracic aortic disease with ARSA.

Endovascular Treatment with Stent Graft for Left Subclavian Artery Aneurysm / 日本心臓血管外科学会雑誌

A 71-year-old man underwent a medical checkup at another hospital with principal complaint of chest discomfort, and was diagnosed by computed tomography (CT) to have a left subclavian artery aneurysm. The CT revealed a 33-mm saccular aneurysm that was located at the proximal portion of the left subclavian artery. Because of the high risk of surgery, we planned to insert a stent graft into the left subclavian artery. We could not avoid occluding the ostium of the left vertebral artery with commercially-available stent grafts, and so decided to insert a surgeon-modified stent graft, in which the fabric of the distal portion of the stent graft was stripped away. The surgeon-modified stent graft was inserted from the conduit of the left axillary artery. Postoperative course was uneventful and the postoperative examination confirmed complete exclusion of the aneurysm and patency of the left vertebral artery.

An Adult Surgical Case of Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery / 日本心臓血管外科学会雑誌

Anomalous origin of the coronary artery from the pulmonary artery (ACAPA) is a rare congenital heart disease. A woman in her 60s was diagnosed as ARCAPA during examination for angina. A magnetic resonance image showed myocardial ischemia in a small area of the right coronary artery (RCA) and left anterior descending artery. Reimplantation of the RCA to the ascending aorta and patch plasty of the pulmonary artery were performed. Repositioning of the RCA orientation was necessary for relief of the kinking. The postoperative course was uneventful. She is now free from angina 15 months after surgery.

Ligation of Lumbar Arteries and Stent Graft-Conserving Aneurysmorrhaphy for Type II Endoleak / 日本心臓血管外科学会雑誌

Background : Persistent endoleak is a major cause of aneurysmal enlargement or rupture after endovascular aneurysm repair (EVAR). Although several reports have described ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy as useful strategies, treatment for type II endoleak after EVAR is controversial. Objectives : We investigated the early results in 5 patients who underwent ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy for type II endoleak. Methods : A>10 mm increase in aneurysm diameter after primary EVAR or a maximum diameter>65 mm serve as indications for intervention for type II endoleak. Under general anesthesia, following transperitoneal exposure of the abdominal aorta, the infrarenal aorta was banded using a tape at the proximal landing zone. After the aorta was opened without clamping, the lumbar arteries were ligated, and a stent graft-conserving aneurysmorrhaphy was performed. Results : The mean interval from the primary EVAR was 47±17 months. The mean operation time was 215±76 min. Blood transfusion was necessary in 4 patients (estimated blood loss 1,260±710 ml). No in-hospital deaths were observed, and the mean postoperative hospital stay was 26±20 days. One patient developed aspiration pneumonia and 1 developed surgical site infection post-surgery. The diameter of the aneurysm changed from 68±8 to 47±5 mm during hospitalization and decreased further to 36±7 mm at the last follow-up. Conclusions : The early results of ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy were favorable. Although this strategy could be useful for aneurysmal dilatation secondary to persistent type II endoleak after EVAR, the indications for this approach should be determined following careful evaluation of the patient's status considering the invasiveness of the procedure.

A Surgical Case for a Huge Pulmonary Artery Aneurysm 40 Years after Waterston Operation / 日本心臓血管外科学会雑誌

Surgical cases for pulmonary artery aneurysm after palliative operation for congenital heart disease are rare. A man in his 40s underwent Waterston operation (side-side anastomosis of the ascending aorta and right pulmonary artery) for pulmonary atresia and ventricular septal defect at the age of one. Medical follow-up was continued at a local clinic without definitive repair. He had complained of exertional dyspnea and cough for one month. CT scan on admission showed a large right pulmonary artery aneurysm and atelectasis of the right lung. An urgent operation was planned for the huge pulmonary artery aneurysm. Under cardiac arrest, the proximal end-to-side anastomosis to the aorta was conducted using a Y-shaped vascular prosthesis at the previous Waterston anastomosis. The peripheral pulmonary arteries were reconstructed by inclusion technique. Percutaneous cardiopulmonary support was necessary for one day after operation due to unstable hemodynamics. He was extubated on postoperative day (POD) 4 and transferred to our general ward on POD 5. He was discharged home on POD 38. He is now free from heart failure symptoms and recurrence of aneurysm one year after surgery. Careful follow-up is necessary for the dilatation of the pulmonary artery and aortic root. A definitive operation—Rastelli and closure of the ventricular septal defect—may be considered in the future if the pulmonary artery resistance is suitable for the repair.

A Spontaneous Rupture of the Ascending Aorta / 日本心臓血管外科学会雑誌

<p>The patient was 62-year-old woman was brought to the emergency room with chest pain and dyspnea. Computed tomography revealed a hematoma around the ascending aorta, a notch in the aortic wall, pericardial effusion and a hematoma around the pulmonary artery. We diagnosed early thrombotic type of acute aortic dissection. An ascending aorta replacement was performed via median sternotomy under hypothermic circulatory arrest. Upon operation, there was a 1.0 cm intimal tear just above the left main trunk and there was no specific evidence of aortic dissection. So we diagnosed spontaneous aortic rapture. Her postoperative course was uneventful and she was discharged 18 days after surgery.</p>

A Surgical Case of Infective Endocarditis with Intraoperative Intracranial Hemorrhages after Antibiotic Therapy for 6 Weeks / 日本心臓血管外科学会雑誌

A case of intracranial hemorrhage during valve surgery for infective endocarditis is reported. The patient was a 40-year-old man whose chief complaint was fever of unknown origin. Echocardiography demonstrated severe mitral regurgitation with vegetations. A blood culture demonstrated <i>Streptococcus salivarius</i>. He was treated with penicillin G and gentamicin for 6 weeks. Magnetic resonance imaging (MRI) was performed 10 days before surgery, but acute infarction, hemorrhage, or mycotic aneurysm were not observed. Mitral valve replacement was performed with a mechanical valve. Postoperatively, the patient had hemiplegia. Hemorrhage was visible in the right thalamus and left cerebellum on computed tomography. Ventricular drainage and removal of the cerebellar hematoma were performed the next day. These results suggest that to avoid cerebral complications during cardiac surgery for infective endocarditis, strict activated clotting time control and MRI just before surgery appear to be necessary.

A Case of Re-operation for Paravalvular Leakage after Mitral Valve Replacement Complicated by Heparin-Induced Thrombocytopenia / 日本心臓血管外科学会雑誌

Anticoagulation management in cardiac surgery can be difficult in patients with heparin-induced thrombocytopenia (HIT). We report a patient who underwent reoperation of cardiopulmonary bypass (CPB) using argatroban in combination with nafamostat mesilate. A bolus of 0.25 mg/kg argatroban was administered, followed by continuous infusion of 5-10 μg/kg/min argatroban and 100 mg/h nafamostat mesilate. No complications such as thrombosis were observed during either CPB or the perioperative period. Although we used argatroban and nafamostat mesilate, which has a shorter half-life than argatroban, the anticoagulant effect was prolonged, and the patient had an uneventful postoperative course despite requiring substantial blood transfusion.

Embolization of an Atraumatic Rupture Occurring in the Internal Thoracic Artery / 日本心臓血管外科学会雑誌

We report the findings in a 75-year-old woman who was given diagnosis of rupture of the internal thoracic artery (ITA) and was successfully treated by coil embolization. The patient suddenly felt chest pain, and a chest CT revealed a mediastinal hematoma. She was suspected to have an acute aortic dissection, and therefore transferred to our hospital. Upon careful examination, a CT showed a hematoma in the superior mediastunum and the extravasation of the left internal thoracic artery. Emergency coil embolization was thus performed to stop the bleeding. After the embolization, no further hemorrhaging was observed. The patient was uneventfully discharged in a healthy state 2 weeks later. Rupture of the internal thoracic artery is rare. However, it is important to include this potential disease in the differential diagnosis when encountering a patient presenting with an atraumatic mediastinal hematoma.

Mitral and Tricuspid Valve Repair in a Patient with an Absent Right and Persistent Left Superior Vena Cava / 日本心臓血管外科学会雑誌

Absence of the right superior vena cava with persistent left superior vena cava without any other cardiac anomalies in visceroatrial situs solitus is rare. A 41-year-old man presented with a feeling of anterior chest pressure on effort. Severe mitral regurgitation due to anterior prolapse of the A2-A3 segments and moderate tricuspid regurgitation were diagnosed. Three-dimensional CT scan revealed an absent right and persistent left superior vena cava. Electrocardiographic findings showed a typical coronary sinus rhythm. At operation, a pulmonary artery catheter was placed via the right femoral vein under fluoroscopy. After starting cardiopulmonary bypass with a single venous cannula in the inferior vena cava, an L-shaped venous cannula was directly placed into the left superior vena cava. Mitral valve repair was performed, with 4 pairs of Gore-Tex CV-5 artificial chordae and mitral ring annuloplasty through a standard transverse left atriotomy. Tricuspid ring annuloplasty was also performed. His postoperative course was uneventful. Postoperative echocardiography showed only trivial mitral and tricuspid regurgitation. In patients with such venous anomalies, the area around the coronary sinus should be protected during intracardiac procedures to preserve the coronary sinus rhythm. We therefore recommend direct venous cannulation of the left superior vena cava instead of retrograde cannulation via the coronary sinus, and standard transverse left atriotomy for mitral exposure.

A Case of Infective Endocarditis on an Annuloplasty Ring following Mitral Valve Repair / 日本心臓血管外科学会雑誌

Infective endocarditis on an annuloplasty ring following mitral valve repair is rare. A 59-year-old man underwent emergency sextuple coronary artery bypass grafting and mitral annuloplasty with a 26mm ring for acute myocardial infarction and mitral regurgitation. Seven weeks later, he was readmitted complaining of abdominal pain and diarrhea. He experienced high-grade fever with chills associated with leukocytosis and elevation of C reactive protein after gastroduodenal endoscopy. Although antibiotics were administered intravenously for several weeks, the fever persisted. Transesophageal echocardiography revealed vegetations on the mitral annuloplasty ring. Infective endocarditis was diagnosed as the culprit of the unknown fever and urgent surgery was indicated. Following redo median sternotomy, the heart was meticulously dissected out. On cardiopulmonary bypass with the heart arrested, left atriotomy was carried on the interatrial groove. Because of the small left atrium, Dubost incision was added for better mitral valve exposure. The infected annuloplasty ring was excised with the vegetations. The mitral valve was easily repaired because the valve leaflets had minimal changes except a small perforation at the base of the posterior middle scallop. After thorough debridement of the mitral valve, a glutaraldehyde-treated autologous pericardial strip was sutured along the annulus as a posterior pericardial band. Culture of the vegetation proved negative. His postoperative course was uneventful. He has been doing well for more than two and a half years with trivial mitral regurgitation and no recurrence of infection. According to the American Heart Association guidelines, endocarditis prophylaxis is not usually needed for gastrointestinal endoscopy, but is optional for high risk patients including those with prosthetic cardiac valves. Such a diagnostic procedure should be avoided soon after the application of an annuloplasty ring and if necessary, antiinfective prophylaxis may be indicated.

Aortic Valve Replacement for Porcelain Aorta with Balloon Occlusion and Deep Hypothermic Circulatory Arrest / 日本心臓血管外科学会雑誌

A 78-year-old woman on chronic hemodialysis was found to have severe aortic stenosis causing refractory hypotension during hemodialysis and elected to undergo aortic valve replacement. However, chest CT scan revealed a totally calcified “porcelain” ascending aorta which prevented safe aortic cross-clamping. MRA also showed stenosis of the origin of the left subclavian artery. At operation, an area free from calcification was identified in the lesser curvature of the ascending aorta where an aortic cannula was placed. Cardiopulmonary bypass was commenced. A single selective cerebral perfusion was added via the left axillary artery to maintain adequate flow to the dominant left vertebral artery. The patient was cooled to a rectal temperature of 24°C when a proximal transverse aortotomy was made and an occlusion balloon was inserted into the ascending aorta during circulatory arrest for 2 min. The cardiopulmonary bypass was restarted with half systemic flow. The aortic valve was excised and a 19-mm Carpentier-Edwards bovine pericardial valve was placed in the supravalvular position with simple interrupted sutures. The body was further cooled down to 19°C. On another circulatory arrest, the balloon was removed. Endarterectomy was performed along the edges of the aortotomy which was reinforced with equine pericardial strips. The aortotomy was then closed with a running suture. The circulation was restarted and the patient was rewarmed. Circulatory arrest time was 42 min. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without neurologic complications. The operative technique described here for the treatment of aortic valve disease in a patient with a porcelain aorta is safer than deep hypothermic circulatory arrest alone, allowing shorter circulatory arrest period. In addition, endarterectomy of the aortotomy edges reinforced with xenopericardial strips is useful to secure the closure line against bleeding.

A Case of Horner's Syndrome after Coronary Artery Bypass Graft Surgery / 日本心臓血管外科学会雑誌

Horner's syndrome is a rare complication after open heart surgery via median sternotomy. To date only two cases have been reported in Japan. A 77-year-old woman presented to our hospital, complaining of worsening effort angina. She was found to have old inferior myocardial infarction, severe triple vessel diseases and ischemic mitral regurgitation. At operation, the patient was placed in the supine position with the left arm abducted to approximately 80 degrees to harvest the left radial artery. At the same time, the left internal thoracic artery was dissected free from the chest wall using a Delacroix-Chevalier retractor following median sternotomy. She underwent mitral ring annuloplasty and three coronary artery bypass graftings on cardiopulmonary bypass. Her immediate postoperative course was uneventful. On postoperative day (POD) 2, however, left Horner's syndrome became apparent with the classical triad: ptosis, miosis and enophthalmos. She subsequently complained of pain and numbness of the left arm. A chest X-ray film on POD 4 revealed posterior fracture of the left first rib, suggesting that the fracture fragments or the associated hematoma could have caused direct injury of the cervical sympathetic trunk and the brachial plexus. On POD 21, the discharge day, the neurological symptoms still persisted mildly but spontaneously resolved within 6 months. In order to prevent such complications, we should treat the sternum and the ribs with great caution when using a sternal retractor and harvesting the internal thoracic arteries.