Thoracic endovascular aortic repair of an ascending aortic pseudoaneurysm.

A 74-year-old man with a history of two thoracic aortic repairs, including a modified Bentall procedure using a mechanical valve and total arch replacement, was referred to our hospital with the development of hoarseness. Computed tomography revealed an anastomotic pseudoaneurysm between the prosthetic grafts in the ascending aorta. Two aortic cuffs for abdominal aorta were deployed through the left axillary artery using a transcatheter aortic valve replacement guidewire placed at the supra-aortic mechanical valve during ventricular rapid pacing and were successfully covered with an inlet to the pseudoaneurysm on postoperative computed tomography. The postoperative course was favorable.

[Ventricular Pseudoaneurysm after Sutureless Repair of Postinfarction Free Wall Rupture of the Left Ventricle:Report of a Case].

We herein report a case of a left ventricular pseudoaneurysm following sutureless repair for left ventricular free wall rupture. A 78-year-old woman underwent emergency sutureless repair for left ventricular free wall rupture following acute myocardial infarction. Three months later, echocardiography revealed an aneurysm in the postero-lateral wall of the left ventricle. The ventricular aneurysm was incised during reoperation, and defect in the left ventricular wall was closed with a bovine pericardial patch. Histopathologically, the aneurysm wall did not contain any myocardium, confirming the diagnosis of pseudoaneurysm. Although sutureless repair is a simple and highly effective method for oozing-type left ventricular free wall rupture, post-procedural pseudoaneurysm can develop both in acute and chronic phases. Consequently, long-term follow-up is mandatory.

[Successful Use of Left Ventricular Support Device (Impella 5.0) for Ischemic Heart Disease with Cardiogenic Shock:Report of a Case].

Postoperative hemodynamic support with an Impella 5.0 was effective in an obese man who underwent coronary artery bypass grafting (CABG) for ischemic heart disease and cardiogenic shock. A 43-year-old obese man presented to our hospital complaining severe chest pain. Coronary angiography revealed acute coronary syndrome due to severe triple-vessel disease, and the patient fell into a state of shock, which required veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The patient subsequently underwent CABG, but he was unable to be separated from VA-ECMO. Impella 5.0 was introduced through right axillary artery on the next day. VA-ECMO was converted to veno-venous (VV)-ECMO on the 3rd postoperative day to enable respiratory rehabilitation in a sitting posi-tion;his respiratory status gradually improved. VV-ECMO and the Impella 5.0 were discontinued on the 6th and 7th postoperative days, respectively. He was eventually transferred to nearby facility for further rehabilitation three months later. As of two years, his cardiac function has improved and he is doing well at home.

[Isolated Pulmonary Valve Endocarditis Accompanying Multiple Pulmonary Embolisms:Report of a Case].

Isolated pulmonary valve infective endocarditis is rare and accounts for only 1.5% to 2.0% of all cases of infective endocarditis. We present a case of isolated pulmonary valve endocarditis, which was successfully treated by pulmonary valve replacement. A 69-year-old man presented with fever and was diagnosed with active pulmonary valve infective endocarditis. He had no apparent predisposing factors. Blood cultures were positive for Streptococcus viridans, and transesophageal echocardiography showed mobile vegetation. His condition improved transiently with intravenous antibiotic therapy;however, high fever and reduced oxygen saturation recurred. Computed tomography showed multiple infiltrative shadows suggesting septic pulmonary embolisms. Urgent surgery was indicated because antibiotic treatment was ineffective. During the operation, we found that vegetation had destroyed all pulmonary leaflets. We performed pulmonary valve replacement with a stented bioprosthetic valve as well as enlargement of the right ventricular outflow tract with a bovine pericardial patch. The postoperative course was uneventful. Antibiotic therapy was continued for six weeks after surgery. For two years since surgery, the patient has experienced no recurrence of infection.

[Repeated Heart Failure after Transcatheter Aortic Valve Implantation Using Self-expandable Bioprosthetic Valve:Report of a Case].

The patient was an 81-year-old man. Transcatheter aortic valve implantation( TAVI) was performed for severe aortic stenosis using Evolut R. The patient moved to intensive care unit without an adverse event after the operation. But repeated acute heart failure occurred several times during hospital stay. Mitral regurgitation (MR) was worsened from mild at baseline to moderate or more by transthoracic echocardiography. Various factors that worsened MR after TAVI have been reported, and treatment strategy for severe aortic stenosis patients with MR should be carefully developed.

Giant aneurysmal coronary artery fistula originating from the left circumflex artery: Two case reports.

Coronary artery fistula (CAF) is one of the most common coronary artery anomalies. The most common fistulas originate from the right coronary artery and drain into the right heart structures. Due to the variety of coronary fistulas, the surgical treatment strategy is individualized for each case. We report two cases of giant aneurysmal CAF originating from the left circumflex artery. One case required coronary artery bypass grafting, while the other did not.

Acute type A aortic dissection with a tear in the posterior wall of the ascending aorta early after off-pump coronary artery bypass grafting.

The patient was a 68-year-old man who underwent triple-vessel OPCAB uneventfully with aortic proximal anastomosis at one site using the saphenous vein with a mechanical device, not a side clamp, with mild traction of the ascending aorta by aortic taping. On postoperative day 7, computed tomography revealed extremely localized AAD with a tear on the posterior wall of the ascending aorta. Emergent ascending aortic replacement was successfully performed. Surprisingly, the tear extended laterally along the traction site of the tape. To our knowledge, this is the first report of AAD early after OPCAB originating at a location other than the sites of proximal anastomosis or side clamping. Proximal anastomosis with a mechanical device to the towed aorta may indirectly or directly injure the intima of the posterior wall, causing this complication. Manipulating the aorta under abnormal pressure should be avoided.

Early results of expanding the anatomical indications for using a Gore Iliac branch endoprosthesis to treat aortoiliac and iliac aneurysms.

PURPOSE: To assess the safety and anatomical suitability of using a Gore Iliac Branch Endoprosthesis (IBE) in aortoiliac and iliac aneurysm repair. METHODS: Between 2017 and 2020, 20 patients underwent endovascular aneurysm repair (EVAR) with a Gore IBE device (bilateral IBE, n = 1) after expanding the instructions for use (IFU) criteria. We evaluated the early clinical outcomes and suitability of the IFU criteria, retrospectively. RESULTS: Six patients (30%) met all the IFU criteria. Anatomical suitability according to the IFU criteria for the collective total of 21 IBE limbs was confirmed for 10 (47.6%) proximal common iliac arteries, 21 (100%) external iliac arteries, 18 (85.7%) internal iliac arteries, and in the length from the lowest renal artery to the iliac bifurcation in 15 (71.8%) patients. Assisted primary technical success was achieved in all patients with various bail-out techniques. One patient (5%) required a bare-stent insertion 7 days after EVAR for severe stenosis in the ipsilateral limb caused by a small terminal aorta. There was no case of occlusion of an iliac branch component device. CONCLUSIONS: Gore IBEs were implanted safely and effectively with various bail-out techniques to repair aortoiliac and iliac aneurysms in our Japanese patients with a low rate of inclusion IFU criteria.

[Primary Pericardial Dedifferentiated Liposarcoma Detected by Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography;Report of a Case].

We herein present a rare case of dedifferentiated liposarcoma originating from the pericardium. A 79-year-old female was referred to our hospital with a pericardial tumor detected by fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). The tumor, 80×48 mm in size, showed increased uptake of fluorodeoxyglucose on the FDG-PET/CT without any evidence of metastasis. The tumor was resected with the pericardium, and a histopathological examination confirmed the diagnosis of dedifferentiated liposarcoma. Additional chemotherapy, radiation therapy, or a combination of both were offered but refused by the patient. Although the patient was discharged without any complications, the tumor recurred locally 2 months after the surgery, and the patient succumbed 15 months later. The FDG-PET/CT was useful not only in detecting this malignant tumor but also in diagnosing its malignant nature.

[Bronchial Occlusion with Endobronchial Watanabe Spigot for Massive Pulmonary Hemorrhage during Heart Surgery;Report of a Case].

Massive pulmonary hemorrhage, although rare, is a potentially life-threatening complications during heart surgery. We herein present 1 such case successfully treated by selective bronchial occlusion using an Endobronchial Watanabe Spigot (EWS). The 82-year-old female underwent mitral valve replacement, tricuspid annuloplasty, and maze procedure. An hour and a half after cessation of cardiopulmonary bypass, the patient suffered a massive pulmonary hemorrhage. A subsequent bronchoscopy identified the hemorrhage site at the right middle lobe bronchus (B5b), and an EWS was then selectively deployed into this bronchus to block the hemorrhage. The following day, bronchial arterial embolization was performed, enabling the removal of the spigot on the next day. The patient's respiratory condition gradually improved, allowing for extubation on the 21st postoperative day. By preventing bleeding into neighboring bronchi, which, in turn, avoids the risk of exacerbating hypoxia, bronchial occlusion with EWSs is highly effective in managing massive pulmonary hemorrhage during heart surgery.

[Endovascular Treatment Using the Fenestrated Stent Graft for Distal Aortic Arch Aneurysm with Aortic Arch Vessel Anomalies;Report of a Case].

We herein present a case of distal aortic arch aneurysm associated with the bovine arch and the isolated left vertebral artery (ILVA). Incorporating 2 fenestrations, we successfully performed an endovascular repair using the commercially available Najuta fenestrated stent graft system. During surgery, the Najuta was deployed in the aorta so as to allow for the proximal fenestration to be aligned with the orifice of the 1 branch of the aortic arch, and the distal fenestration with the orifice of the ILVA and that of left subclavian artery. Postoperatively, the patient's recovery went well without any cerebral complications, and in a subsequent computed tomography (CT), the patency of all aortic arch vessels and absence of endoleaks was confirmed. For cases of distal aortic arch aneurysm associated with arch anomalies, the endovascular treatment using the Najuta system is not only simple but also reliable in preserving blood flow to the brain and upper extremities.

Placement of a Zenith® Dissection Endovascular System in the Descending Thoracic Aorta Can Hamper Further Surgical Aortic Operations.

INTRODUCTION: The efficacy of endovascular treatment for complicated Stanford type B acute aortic dissection is being established. However, aortic events sometimes occur, and some cases require surgical intervention. REPORT: A 52 year old man underwent ascending aorta replacement for Stanford type A acute aortic dissection in August 2016. Post-operative computed tomography (CT) showed residual dissection from the aortic arch to the right common iliac artery and a large re-entry in the right common iliac artery (RCIA). Two months after the operation, CT revealed enlargement of the false lumen of the thoracic aorta and the thoracic aortic diameter. Aiming to reduce the false lumen and remodel the aorta, a three stage operation was performed, as described below. Four months after the dissection, total aortic arch replacement and a frozen elephant trunk insertion were performed as the first stage. Subsequently, as a second stage operation, thoracic endovascular repair (TEVAR) was performed using a Zenith® Dissection Endovascular System (Cook Japan Co., Ltd, Tokyo, Japan), with the aim of expanding the true aortic lumen. The implanted devices were a stent graft for the proximal part and two bare stents for the middle and distal part. As a third stage operation, abdominal aortic endovascular treatment was performed with the purpose of closing the re-entry from the RCIA. However, two years after the three stage operation, CT showed that the thoracic aorta was over 60 mm in diameter. Graft replacement of the thoraco-abdominal aorta was performed. The bare stents were expected to be easily removable from the aorta, but unexpectedly, they were strongly attached to the intima, which made it extremely difficult to perform surgical and aortic operations. DISCUSSION: Surgical operations for the aorta can become more difficult after bare stent placement in the aorta.

[Mitral Valve and Tricuspid Valve Regurgitation in a Patient with Dextrocardia and Absence of the Inferior Vena Cava].

Dextrocardia is a rare condition frequently associated with multiple and complex cardiovascular abnormalities. A 66-year-old woman, who had been diagnosed with dextrocardia at young age, was referred to our hospital with complaint of increasing dyspnea. Severe mitral regurgitation, moderate tricuspid regurgitation, and atrial fibrillation were detected. The multi detector-row computed tomography(MDCT) revealed absence of the inferior vena cava, and the hepatic vein connected directly with the right atrium. The venous cannulae were inserted into the superior vena cava directly and into the hepatic vein from the right atrium. Mitral valve repair, tricuspid valve repair, and maze procedure were successfully performed. MDCT is useful for detecting abnormality of vena cava in a cases of dextrocardia.

[Papillary Fibroelastoma of the Pulmonary Valve;Report of a Case].

We herein present a rare case of a papillary fibroelastoma on the pulmonary valve. A 66-year-old female underwent a graft replacement of the ascending aorta and an aortic valve replacement. Subsequent biannual checks have been performed as a follow up to surgery. An echocardiography, 3 years post surgery, revealed a growing mass, 13 mm in diameter, which was attached to the pulmonary valve. Upon surgery, the mass, which lacked a stalk, was found attached to the right semilunar cusp of the pulmonary valve. The cusp was resected with the mass in order to ensure a complete resection, and as we were unable to repair the pulmonary valve, it needed to be replaced with a mechanical valve. The pathological examination of the resected mass resulted in our diagnosis of a papillary fibroelastoma. The patient is now doing well 2 years after the surgery without any recurrence of the tumor.

[Total Arch Replacement for Distal Arch Aneurysm with Isolated Left Vertebral Artery;Report of a Case].

We herein present a case of distal aortic arch aneurysm with an isolated left vertebral artery(LVA). In surgery, after establishing cardiopulmonary bypass, the LVA was anastomosed to the left common carotid artery (LCCA) while under moderate hypothermia. Selective cerebral perfusion (SCP) was then initiated by inserting catheters into the brachiocephalic artery( BCA), the LCCA and the left subclavian artery (LSA). The aorta was transected between the BCA and the LCCA, and an open stent graft was deployed into the descending aorta during circulatory arrest. After reconstructing the LSA, LCCA and BCA, the ascending aorta was replaced with a graft. The patient recovered well without any cerebral complications, and computed tomography confirmed the patency of the reconstructed LVA. Regarding the surgical treatment of an aortic arch aneurysm with an isolated LVA, reconstructing the isolated LVA before SCP makes the establishment of SCP straightforward, thereby helping protect the brain from ischemia.

[Surgical Repair of Severely Calcific Constrictive Pericarditis;Report of a Case].

A 74-year-old male presented with exertional dyspnea and leg edema. Chest X-ray and computed tomography demonstrated dense calcification of the pericardium. Based on a diagnosis of constrictive pericarditis, pericardiectomy was performed without the use of extracorporeal circulation. During the operation, we employed a Harmonic Scalpel (Naginata-type) to peel off the calcified pericardium around the right and left ventricles. The calcified pericardium around the right atrium was found to be so firmly adhered to the atrial wall that peeling off the calcified tissue was difficult. Therefore, we used a Cavitron Ultrasonic Surgical Aspirator (CUSA) to break down the calcification. After the surgery, the patient's dyspnea on exertion and leg edema resolved, and he recovered without any complications. Regarding the surgical treatment of severely calcific constrictive pericarditis, Naginata-type Harmonic Scalpel and CUSA are very useful for peeling off the calcified tissue of the pericardium and/or breaking down the calcification.