Two-Debranch TEVAR with a Functional Brain Isolation Technique and Abdominal Debranching for a Thoracoabdominal Aortic Aneurysm with a Shaggy Aorta / 日本心臓血管外科学会雑誌

A 72-year-old man presented with a thoracoabdominal aortic aneurysm which had been diagnosed six years earlier. Surgical intervention was planned due to aortic diameter enlargement up to 57 mm and back pain. Although he had a shaggy aorta, a preoperative work-up revealed pulmonary dysfunction, which made open repair via thoracotomy challenging. Therefore, a decision was made to proceed with two-stage thoracic endovascular aortic repair (TEVAR) with debranching and functional brain isolation. In the first operation, iliofemoral bypass with debranching of four abdominal vessels was performed via median laparotomy to secure the access route and distal landing zone. In the second operation, two debranching TEVAR was performed. The functional brain isolation technique was employed using cardiopulmonary bypass and balloon occlusion of the left subclavian artery to prevent an embolic stroke from the shaggy aorta during the stent graft deployment. In addition, embolic protection of abdominal branches and lower extremities was established using a balloon occlusion and a sheath in the iliac arteries. The postoperative course was uneventful with no embolic complications. Although the shaggy aorta is not evaluated in Japan SCORE or Euro SCORE, it is a risk factor for perioperative stroke. Those patients would benefit from a tailored approach to prevent embolic complications.

Left Ventricular Pseudoaneurysm Repair 44 Years after Closed Commissurotomy for Mitral Valves / 日本心臓血管外科学会雑誌

A 71-year-old woman with a history of closed commissurotomy for mitral valve stenosis 44 year ago, was diagnosed with left ventricular aneurysm by transthoracic echocardiography. She had no symptom of left ventricular aneurysm. Since there was a high risk of left ventricular rupture, we decided to undertake surgical treatment. During the surgery, we found artificial material near the left ventricular aneurysm. We resected the aneurysm wall and closed the ventricular wall using felt strip reinforcement. The wall of the aneurysm had no myocardium upon pathological examination. We diagnosed that it was a left ventricular pseudoaneurysm, and it seemed to be formed by blood oozing from the apical repair point of the hole for the dilator to perform mitral valvulotomy. The postoperative course was uneventful and she was discharged on postoperative day 20. Left ventricular pseudoaneurysm often results after myocardial infarction, and reports after cardiac surgery are rare, except in cases after mitral valve replacement. We hereby report our experience with this rare case

Mitral Valve Replacement via Right Thoracotomy for Ischemic Mitral Regurgitation in a Patient with Prior Coronary Artery Bypass Grafting / 日本心臓血管外科学会雑誌

We report a case of redo mitral valve replacement via right thoracotomy for ischemic mitral regurgitation after coronary artery bypass grafting. An 81-year-old woman with a history of multiple coronary artery bypass grafting was admitted to our institute for treatment of severe ischemic mitral valve regurgitation. She had a history of repeated hospitalization for heart failure and complained of worsening dyspnea. Coronary angiography showed patent coronary grafts. Echocardiography revealed severe mitral regurgitation with leaflet tethering and posteroinferior wall asynergy. The patient underwent mitral valve replacement (Mosaic Bioprosthesis 27 mm) via right thoracotomy approach with ventricular fibrillation under moderate hypothermia. The ventricular fibrillation time was 57 min, and the cardiopulmonary bypass time was 126 min. The patient's postoperative recovery was uneventful. She was discharged on postoperative day 19. Right thoracotomy approach provided excellent exposure of the mitral valve and minimized the risk of repeat sternotomy, including injury of previous bypass grafts, injury of right ventricle and significant hemorrhage.