Ten Years' Experience of Aortic Annulus Ectasia and Ascending-Arch Aortic Aneurysm Cases in Adult Congenital Heart Disease / 日本心臓血管外科学会雑誌

<b>Background</b> : The improvement in surgical results for congenital heart disease has resulted in an increase in the number of adult congenital heart disease (ACHD) cases. Some ACHD patients are known to develop thoracic aortic aneurysm (TAA) at a young age, so we examined TAA in ACHD patients presenting at our institute over a 10-year interval. <b>Methods</b> : From 2002 to 2011, we performed 32 cases of surgery for TAA in ACHD patients. We excluded 5 cases of adult bicuspid aortic valve, 2 of TAA with untreated congenital heart disease (CHD), 1 of Marfan syndrome with CHD, and 9 of coarctation of the aorta (CoA) repair for the same site ; 15 patients were included. <b>Results</b> : The male/female ratio was 13/2, and the age of reoperation was 33.3±10.8 years. The 15 ACHD patients included 5 cases of the tetralogy of Fallot (TOF), 4 of congenital aortic stenosis (AS), 3 of ventricular septal defect (VSD), and 1 of each CoA complex, polysplenia/double outlet right ventricle (DORV), and polysplenia/corrected transposition of the great arteries (cTGA). Twelve cases of root dilatation and 2 of ascending aortic aneurysm were observed and 10 cases were concomitant with moderate to severe aortic regurgitation. Thirteen cases underwent elective surgery and the other two cases were emergency surgeries : a Bentall procedure for type 2 acute aortic dissection of polysplenia/DORV, and a Bentall and right ventricular outflow reconstruction (RVOTR) for ascending aorta/right ventricle rupture due to Konno patch detachment in congenital AS. The 13 elective cases included 11 cases of Bentall procedure, 1 of ascending aorta/hemi arch replacement, and 1 of ascending aorta replacement. Concomitant procedures were 1 case of aortic valve replacement, 1 of mitral valve replacement, 1 of subaortic stenosis release, and 2 of RVOTR. Operation time was 572.8+/-101.4 min, cardiopulmonary bypass time was 295.8+/-100.2 min, and aorta clamp time was 188.1+/-58.8 min. One hospital death was observed in 1 emergency case due to methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) sepsis, but no 30-day mortality was observed. Intensive care unit (ICU) stay was 9.4+/-10.1 days and hospital stay was 34.4+/-18.2 days. <b>Conclusion</b> : The most common ACHD found during TAA surgery in our institute was Tetralogy of Fallot. ACHD had various complications and restrictions for surgery but TAA surgery in ACHD patients was safe and feasible.

Usefulness of JapanSCORE—Comparative Study of the Usefulness of the JapanSCORE and the Logistic EuroSCORE / 日本心臓血管外科学会雑誌

Risk analysis models are becoming more important in various aspects of the clinical setting. We have used the logistic EuroSCORE as a risk analysis model, but there is divergence between the model and actual clinical reality in our country. The Japan Score is a risk model based on the Japan Adult Cardiovascular Surgery Database and it is considered to be better reflect from Japanese clinical results. We compared the logistic EuroScore (ES) and Japan Score (JS) and their predictive accuracy, using our clinical results. Between October 2006 and June 2011, 733 operations suitable for evaluation by the Japan Score were performed at our institute. Isolated coronary artery bypass grafting (CABG) was performed in 151 cases, valve surgery (Valve) in 346 cases and aortic surgery (Aorta) in 236 cases. In these cases we calculated 30-day mortality using the EuroSCORE and JapanSCORE and compared the results and prediction accuracy, by calculating the receiver operating characteristic curve (ROC curve) and the area under the ROC curve (AUC). We also calculated 30-day mortality and morbidity by the JapanSCORE and analyzed it by the same method. In the entire group, logistic 30-day mortality by ES and JS was 7.28 and 4.05% respectively. The AUC was 0.740 and 0.806, while 30-day mortality and morbidity calculated by JS was 17.72% and the AUC was 0.646. In the CABG group the 30-day mortality by ES and JS was 5.7 and 3.18% respectively, the AUC was 0.636 and 0.770, the 30-day mortality and morbidity was 13.37% and the AUC was 0.631. In the Valve group 30-day mortality by ES and JS was 6.00 and 3.79% respectively. The AUC was 0.715 and 0.794, 30-day mortality and morbidity was 17.54% and the AUC was 0.606. In the Aorta group 30-day mortality was 10.17 and 4.99% respectively. The AUC was 0.720 and 0.827. The 30-day mortality and morbidity was 20.83% and the AUC was 0.640. The 30-day mortality calculated by JS was significantly lower than that of ES (<i>p</i><0.001). The prediction accuracy of both of the ES and the JS was satisfactory but the prediction accuracy of JS was better than that of the ES. The prediction accuracy of the logistic 30-day mortality and morbidity were not as accurate as 30-day mortality. JS was a good risk analysis model not only for prediction of surgical results but also for improving surgical outcome.

Reoperation in Two Patients with SJM Toronto SPV and Medtronic Freestyle Stentless Bioprosthetic Valves / 日本心臓血管外科学会雑誌

Stentless bioprosthetic valves have been implanted for treatment of aortic valve disease, especially in elderly patients ; these valves have the advantage of durability and excellent hemodynamics compared with stented bioprosthetic valves. Although good long-term results in patients with stentless bioprosthetic valves have been reported recently, reoperation has been gradually increasing. We performed reoperation for the SJM Toronto SPV and Medtronic Freestyle valves in one patient each. The SJM Toronto SPV was used in a 30-year-old woman ; however, 8 years later, the valve showed severe calcification and adhesions, and could not be completely removed (Case 1). The other reoperation case, wherein a 69-year-old man underwent aortic valve replacement with the Medtronic Freestyle 4 years previously, showed no adhesion around the implanted valve, which could be easily removed from the autologous aortic annulus. Consequently, the first patient required reimplantation of a small mechanical valve (SJM #19). In contrast, we were able to use a stentless bioprosthetic valve (Prima Plus #23) for the second patient. Further observations on stentless bioprosthetic valves are required.

Mid-Term Clinical Results of Tissue-Engineered Vascular Autografts / 日本心臓血管外科学会雑誌

Prosthetic and bioprosthetic materials currently in use lack growth potential and therefore must be repeatedly replaced in pediatric patients as they grow. Tissue engineering is a new discipline that offers the potential for creating replacement structures from autologous cells and biodegradable polymer scaffolds. In May 2000, we initiated clinical application of tissue-engineered vascular grafts seeded with cultured cells. However, cell culturing is time-consuming, and xenoserum must be used. To overcome these disadvantages, we began to use bone marrow cells, readily available on the day of surgery, as a cell source. Since September 2001, tissue-engineered grafts seeded with autologous bone marrow cells have been implanted in 44 patients. The patients or their parents were fully informed and had given consent to the procedure. A 3 to 10ml/kg specimen of bone marrow was aspirated with the patient under general anesthesia before the skin incision. The polymer tube serving as a scaffold for the cells was composed of a copolymer of lactide and ε-caprolactone (50: 50) which degrades by hydrolysis. Polyglycolic or poly-l-lactic acid woven fabric was used for reinforcement. Twenty-six tissue-engineered conduits and 19 tissue-engineered patches were used for the repair of congenital heart defects. The patients' ages ranged from 1 to 24 years (median 7.4 years). All patients underwent a catheterization study, CT scan, or both, for evaluation after the operation. There were 4 late deaths due to heart failure with or without multiple organ failure or brain bleeding in this series; these were unrelated to the tissue-engineered graft function. One patient required percutaneous balloon angioplasty for tubular graft-stenosis and 4 patients for the stenosis of the patch-shaped tissue engineered material. Two patients required re-do operation; one for recurrent pulmonary stenosis and another for a resulting R-L shunt after the lateral tunnel method. Kaplan-Meier analysis in relation to patients' survival was 95% within 3 years. There was only 1 patient (who underwent a total cavo-pulmonary connection procedure) requiring re-intervention in the tubular graft group and the material-related event-free rate was 96% within 3 years. This tissueengineering approach may provide an important alternative to the use of prosthetic materials in the field of pediatric cardiovascular surgery. As it is living tissue, these vascular structures may have the potential for growth, repair, and remodeling. However, this approach is still in its infancy, further studies to resolve the problems presented, and longer follow-up in patients are necessary to confirm the durability of this approach.

Reoperation for Valvular Surgery and Thoracic Aortic Aneurysm Repair with Functioning IMA Grafts after Previous CABG / 日本心臓血管外科学会雑誌

The use of the internal mammary artery (IMA) is now routine in most coronary artery bypass grafting (CABG) because of its improved long-term patency and survival. A small but important percentage of these patients will require valve surgery and thoracic aortic aneurysm repair following CABG. These operations present a challenging problem for the cardiac surgeon because of difficulties regarding approach, dissection around the IMA and optimal myocardial protection. We investigated surgical results and the effectiveness of various methods of myocardial protection in 8 patients who underwent reoperations between December 1983 and June 2005. The mortality was 13%. There were 2 perioperative myocardial infarctions (25%), 6 cases of prolonged ventilation (75%), 3 cases of low output syndrome (38%), 1 case of acute renal failure (13%) and 1 case of sepsis (13%). We carried out resternotomy for 6 patients without any hospital death or perioperative myocardial infarction. Our reoperation approach had acceptable risk control with resternotomy, avoidance of dissecting the IMA and hypothermic perfusion.

Mid-Ventricular Obstructive Hypertrophic Cardiomyopathy Associated with an Apical Aneurysm: Evaluation of Possible Causes of Aneurysm Formation

Mid-ventricular obstructive hypertrophic cardiomyopathy (MVOHCM) is a rare type of cardiomyopathy, associated with apical aneurysm formation in some cases. We report a patient presenting with ventricular fibrillation, an ECG with an above normal ST segment, and elevated levels of cardiac enzymes but normal coronary arteries. Left ventriculography revealed a left ventricular obstruction without apical aneurysm. There was a significant pressure gradient between the apical and basal sites of the left ventricle. Cine magnetic resonance imaging (MRI), performed on the 10th hospital day, showed asymmetric septal hypertrophy, mid-ventricular obstruction, and an apical aneurysm with a thrombus. The first evaluation by contrast-enhanced imaging showed a subendocardial perfusion defect and delayed enhancement. It was speculated that the intraventricular pressure gradient, due to mid- ventricular obstruction, triggered myocardial infarction, which subsequently resulted in apical aneurysm formation.

Endovascular Stent Grafting of a Perforated Descending Aorta Caused by Empyema / 日本心臓血管外科学会雑誌

We performed endovascular stent grafting of a perforated descending aorta, caused by empyema after surgery for lung cancer, in a 75-year-old man. After diagnosing hemorrhage from a perforation of the proximal descending aorta, caused by left empyema, the perforation was repaired with a saphenous vein patch and a pectoralis major muscle flap. However, re-hemorrhage from the same lesion occurred 2 months postoperatively. Temporary hemostasis was achieved with gauze packing and he was transferred to our hospital for endovascular stent grafting. The infection did not resolve after fenestration, so the descending aorta was cropped out to the fenestration lesion. Therefore, endovascular stent grafting was performed on the same day. Postoperatively the bleeding stopped completely without any signs of graft infection, and he was transferred to another hospital on postoperative day 9. No re-hemorrhage or graft infection of the aortic perforative lesion occurred in the early postoperative period. However, the patient died of massive bleeding from the aorta wall of the proximal stump of the stent graft, caused by recurrence of the infection 2 months after the 2nd operation. In this situation, endovascular scent grafting provides the only chance of saving the patient's life. If endovascular stent grafting is performed as a lifesaving procedure, meticulous operative technique is imperative.

The Present Condition and Problems of Postgraduate Medical Education in Bioethics at a University Hospital: Results of a Questionnaire Survey of Medical Staff / 医学教育

We have surveyed what physicians in our department think about postgraduate education in bioethics. Although 90% of physicians recognized the importance of bioethics education, 90% of physicians had not taught bioethics to residents and had not read any bioethics books in the last 2 years. Approximately 80% of physicians believed that discussions were needed to confirm residents' awareness of bioethics and life-and-death issues but that residents and physicians do not need to read relevant books and mandatory reports to deepen their awareness of bioethics. Because many physicians in our department have little motivation to improve their view of bioethics, postgraduate education in bioethics is needed for both residents and physicians.

A Case of Papillary Fibroelastoma of the Left Ventricular Septum Complicated with a Rheumatic Valve / 日本心臓血管外科学会雑誌

A 50-year-old man was referred to our hospital with a tumor in the left ventricle. He had suffered from rheumatic fever when 14 years old. He had shown signs of chronic heart failure due to atrial fibrillation and rheumatic valves (ASr, MSr) for 10 years. There was a history of unaccountable fever and rash, so infective endocarditis was suspected and echocardiography was performed. It showed a homogeneous mass with a diameter of approximately 10mm, fixed directly to the left ventricular septum 20mm below the aortic valvular ring. At operation, the tumor was excised together with endocardium and a part of the muscular coat. The rheumatic aortic and mitral valves were replaced with a 21mm SJM AHP and a 27mm SJM MTK mitral valve, respectively. Tricuspid annuloplasty (TAP) (De Vega 29mm) was also performed. Histopathological examination of the tumor revealed benign papillary fibroelastoma. It suggested that the tumors were secondary to mechanical wear and tear, and represent a degenerative process due to rheumatic valve disease.

Surgical Treatment of Multiple Aneurysms / 日本心臓血管外科学会雑誌

Morphology, location, timing of operation, and complications of multiple aortic aneurysms were investigated in 14 patients (10 men and 4 women with a mean age of 66 years). The locations of the aneurysms were as follows: aortic arch and thoracoabdominal aorta in 1, aortic arch and infrarenal abdominal aorta in 6, descending thoracic aorta and suprarenal abdominal aorta in 1, descending thoracic aorta and infrarenal abdominal aorta in 5, and thoracoabdominal aorta and infrarenal abdominal aorta in 1. Thoracic aortic aneurysms had a mean diameter of 63±13mm. The mean diameter of the abdominal aortic aneurysms was 54±13mm. In 1 patient, thoracoabdominal and infrarenal abdominal aortic aneurysms were operated on simultaneously. Eight patients, 5 with aneurysms of the aortic arch and infrarenal abdominal aorta, 2 with aneurysms of the descending aorta and infrarenal abdominal aorta, and 1 with aneurysms of the aortic arch and thoracoabdominal aorta, underwent two-staged operation. Aortic arch aneurysm was operated first in 3 patients, and abdominal aortic aneurysm in 5. Postoperative complications included spinal cord injury in 1 patient, bowel necrosis in 1, renal impairment in 2, respiratory impairment in 2, and hepatic impairment in 1. There was no perioperative death. Three late deaths occurred. Two staged operation is better for multiple aortic aneurysms. The first operation should be performed for the larger aneurysm.