A Case of Three Directional Cuff Leakage from the Stent Posts of an Inspilis RESILIA Aortic Valve during Surgical Aortic Replacement / 日本心臓血管外科学会雑誌

We present the case of a 72-year-old male with Inspiris RESILIA aortic valve (Inspiris) transvalvular leakage during surgical aortic valve replacement (AVR). The patient initially underwent AVR for aortic regurgitation with a bicuspid aortic valve at the age of 64. By the age of 72, the valve had deteriorated and it was assessed that redoing the AVR was necessary. The Inspiris was inserted in the supra-annular position using the non-everting mattress suture technique with a COR-KNOT. During weaning off from cardiopulmonary bypass, transesophageal echocardiography (TEE) captured unfamiliar turbulent flows from the three stent posts. Further TEE revealed that these flows originated from the base of the stent posts, which gradually decreased and disappeared by the end of the surgery after administration of protamine. The patient has been discharged uneventfully. Paravalvular leakage has not been observed during the postoperative course and we could not find TVL in TEE 2 months postoperatively. While considering the detailed mechanism, it is possible that there is no need for re-exploration concerning three directional TVL in the Inspiris.

Evaluation of the Aortic Root Using 3D-CT Following Aortic Valve Replacement Employing the Bo Yang Root Enlargement Technique / 日本心臓血管外科学会雑誌

A 65-year-old male was diagnosed with severe aortic stenosis with an indication for surgery and referred to our department. The patient opted for aortic valve replacement using a bioprosthesis. Due to the patient's relatively small native aortic valve area, a concurrent root dilatation maneuver (Bo Yang method) was performed to prevent patient-prosthetic mismatch and to allow for the implantation of a sufficiently larger bioprosthesis, facilitating the valve-in-valve procedure. The successful implantation of an Inspiris 25-mm bioprosthesis was achieved. Post-operative 3D-computed tomography revealed no tilting or misalignment of the bioprosthesis, and a properly sized, undistorted Valsalva sinus was observed. Aortic valve replacement using the Bo Yang root enlargement technique is considered a promising alternative for relatively younger patients requiring aortic valve intervention.

A Case of Redo-Aortic Valve Replacement for a Lillehei-Kaster Valve Implanted 42 Years Ago / 日本心臓血管外科学会雑誌

We present a case of redo aortic valve replacement (AVR) in a 71-year-old man with a Lillehei-Kaster valve implanted 42 years prior. The patient initially underwent AVR and open mitral commissurotomy procedures for aortic regurgitation complicated with mitral stenosis in 1978 at the age of 29. Thereafter, he was followed at our outpatient clinic and treated without anticoagulant therapy for the initial two decades of the postoperative period. During the long-term follow-up, the mean pressure gradient remained between 40 and 60 mmHg and there were no adverse events noted before occurrence of heart failure triggered by tachycardia and pneumonia. Following improvement of heart failure, redo AVR was performed. There was no structural damage, thrombosis, or Lillehei-Kaster valve opening restrictions, though severe pannus growth on the left ventricle side was observed, which was thought to be the cause of the increased pressure gradient. This is the first known report of redo AVR after many years in a patient who underwent Lillehei-Kaster valve implantation. Furthermore, no other study has noted findings regarding pressure gradient change during the long-term follow-up period in such cases.

A Patient's Post-Cardiovascular Surgery Needs for the Differential Diagnosis of Postoperative Myocardial Ischemia Because of Macro Creatine Kinase / 日本心臓血管外科学会雑誌

A 61 year old woman who had been receiving treatment for ulcerative colitis for 14 years complained of respiratory discomfort on exertion and was diagnosed with severe mitral regurgitation due to mitral valve prolapse. Minimally invasive mitral valvuloplasty with right mini-thoracotomy was performed in our facility. Laboratory findings showed elevated levels of serum creatine kinase (CK) and CK-MB immediately after surgery. In addition to elevated levels of myocardial enzymes, ST depression was seen in an electrocardiogram on postoperative day 2 ; therefore, we suspected myocardial ischemia during the surgery. Despite the persistently elevated levels of myocardial enzymes, coronary angiography showed no significant abnormalities. Because of the possibility of false CK elevation, we performed CK electrophoresis, which revealed the presence of macro-CK type 1. CK-MB activity is often falsely elevated when determined by immune-inhibition in macro-CK patients, and that leads to the suspicion of myocardial ischemia. We considered that it may be highly difficult to identify macro-CK in a patient after cardiovascular surgery owing to elevated levels of myocardial enzymes in most such patients.

Clinical Experience with Recombinant Thrombomodulin in Patients Undergoing Cardiovascular Surgery Complicated by Disseminated Intravascular Coagulopathy / 日本心臓血管外科学会雑誌

Studies have shown that postoperative disseminated intravascular coagulopathy (DIC) occurs in some patients with cardiac disease, acute aortic dissection, and ruptured abdominal aortic aneurysm. The specific pathophysiology of DIC in these settings are related to low cardiac function, shock, infection and sepsis as well as activation of coagulation cascade in the aneurysm sac or dissected aorta. A soluble form of recombinant human thrombomodulin (rhsTM) was approved in 2008 for the treatment of DIC. This report describes the safety and efficacy of rhsTM for the treatment of DIC in patients with cardiovascular disease operated in our department. Between October 2010 and March 2012, 35 patients with postoperative DIC were treated with rhsTM. Diagnosis of DIC was based on the diagnostic criteria for DIC of the Japanese Association for Acute Medicine (JAAM). During the first 6 months of the study period, after a diagnosis of DIC was made, the patients were treated with gabexate mesilate and antithrombin III, and if patients showed no improvement with conventional treatment, they received rhsTM for 6 days. During the last 10 months of the study period, patients received rhsTM soon after a diagnosis of DIC was made. Twenty seven patients survived for 28 days after rhsTM treatment, and the mortality rate was 22.9% (8/35). Patients who survived showed improvement in acute phase DIC scores, FDP levels, D-Dimer, fibrinogen and platelet counts during rhsTM treatment, but no improvement was observed in patients who died. No serious adverse events were found up to 28 days after the start of rhsTM administration. In conclusion, this study showed no adverse events of rhsTM, and further studies are needed to confirm that rhsTM administration is an effective therapeutic modality in the management of DIC after cardiovascular surgery.

Redo CABG Using Lateral Minimally Invasive Direct Coronary Artery Bypass Technique-Selection of Grafts, Bypass Inflow and Bypass Routes- / 日本心臓血管外科学会雑誌

We performed redo coronary artery bypass grafting (CABG) using lateral MIDCAB for 3 patients with severe symptomatic ischemia in the left circumflex system alone. When the descending thoracic aorta had no atherosclerotic lesions on chest CT, it was selected as the inflow of the bypass. According to the location of the target artery, we undertook sequential or T-composite off-pump bypass using the radial artery through a left lateral thoracotomy. On the other hand, when the descending aorta was diseased, the left axillary artery was chosen as the inflow of the bypass. We selected the saphenous vein as a conduit to obtain sufficient graft length. A proximal anastomosis was made through a left infraclavicular incision, and then a distal anastomosis was done through a left lateral thoracotomy without cardiopulmonary bypass. Moreover, care was taken not to kink the grafts. The postoperative course was uneventful in all patients. Lateral MIDCAB technique was useful for redo revascularization to the circumflex system. We believe that selection of bypass conduits, routes, and bypass inflow according to the individual patient is essential for the procedure.