Two Cases of Minimally Invasive Right Thoracotomy Approach and Microscope-Assisted Surgery for Mitral Re-Operation; Mechanical Valve Dysfunction in the Late Operative Period / 日本心臓血管外科学会雑誌

Case 1 of stuck valve was an 84 year old man, 25 years after mitral valve replacement (MVR) using a mechanical valve. Case 2 was a 67 year old woman, 18 years after the previous operation. These patients underwent re-do replacement of the prosthesis with a minimally invasive right thoracotomy approach using a microscope. Re-do cardiac surgery is commonly regarded high risk on account of difficulty in peeling the adhension, risk of injury to the heart, lung or large vessels, longer operation time, greater amount of transfusion, higher invasion and longer admission. In both cases however, because of microscope-assist and right thoracotomy MICS technique, we safely and successfully completed the operation without any unplanned troubles. We finally had a good course with a short admission, no perioperative transfusion or no perioperative complication.

A Case of Thoracic Endovascular Aortic Repair for Subacute Aortic Dissection Stanford Type B in a Patient with Marfan Syndrome / 日本心臓血管外科学会雑誌

A 41-years-old man with Marfan syndrome developed acute aortic dissection Stanford Type B. A new entry was located at the distal aortic arch. Medical treatment was given for a month, but the proximal descending aorta expanded to 50 mm. Because he had undergone partial arch replacement at the age of 36, thoracic endovascular aortic repair (TEVAR) using the synthetic graft as proximal landing zone was performed to close the entry. Six months after TEVAR, the false lumen around the stent graft disappeared. Distal stent graft-induced new entry (d-SINE) did not occur after TEVAR. Three years after TEVAR, we performed thoracoabdominal aortic replacement because of expansion of the residual false lumen without any complication. Endovascular therapy could be useful option for extensive aortic lesion even in Marfan syndrome.

Bioprosthetic Valve Dysfunction due to Pannus after Tricuspid Valve Replacement / 日本心臓血管外科学会雑誌

Prosthetic valve dysfunction due to pannus formation is an infrequent but serious complication of tricuspid valve replacement. An 87-year-old woman underwent tricuspid valve re-replacement for severe prosthetic valve stenosis and regurgitation. On removal, thick fibrous pannus and chordal attachments were observed on the ventricular side of the cusp, which corresponded to the septal leaflet of the native valve. Microscopic examination revealed inflammatory cell infiltration accompanied with severe fibrosis and scarring had compromised and broken the prosthetic valve cusp under the pannus. The elastic fiber, which was detected in the base of the pannus, suggested it was a remnant of the native tricuspid valve leaflet. Prevention of native tissue attachment to the prosthetic valve cusp, which may cause severe pannus formation, appears to be extremely important for the long-term outcome and valve durability. The choice of prosthesis for the tricuspid position remains controversial. We should especially consider the height of stent posts and the continuity between the cusp and suture ring in the choice of the bioprosthetic valve for tricuspid position.

Debranched Thoracic Endovascular Aortic Aneurysm Repair in a Case of Blunt Aortic Injury / 日本心臓血管外科学会雑誌

A 16-year-old boy had a motorcycle accident and was given a diagnosis of blunt aortic injury (BAI) by contrast computed tomography (CT), complicated by diffuse brain injury, lung contusions and blunt liver injury. Despite conservative treatment his anemia worsened and further CT images revealed mediastinal hematoma. It was difficult to perform cardiopulmonary bypass with systemic heparinization because of his multiple injuries and therefore decided to perform endovascular stentgrafting. Aortography revealed that the proximal stent-graft landing zone to be very small, and therefore it was necessary to the cover left common carotid artery. Before stentgrafting, we performed a right subclavian artery-left common carotid artery bypass to attain a sufficient proximal landing zone, and stentgrafting was successful. We concluded that endovascular stentgrafting is an effective initial treatment for BAI complicated with multiple injuries. However, endovascular stentgrafting for BAI has some limitations because of the morphologic and anatomical characteristics of the thoracic aorta in cases of BAI. It is therefore important to perform endovascular stentgrafting for BAI on a case-by-case basis.