[A Case of Achieving CR through Chemoradiotherapy for Postoperative Oligo Lymph Node Metastasis in Gastric Cancer].

We present a case of oligo lymph node metastasis in a 70s man who had previously undergone subtotal gastrectomy for advanced gastric cancer in the prepylorus. Postoperatively, adjuvant chemotherapy was administered for a duration of 1 year. During the third postoperative year, elevated tumor markers and lymph node enlargement prompted a diagnosis of lymph node metastasis. Subsequent chemoradiotherapy resulted in a complete response(CR), which has been sustained for 2 years without any recurrence. The outcomes of this case indicate that chemoradiotherapy stands as a viable treatment option for oligo lymphatic recurrence in gastric cancer.

Papillary-Ventricular Complex Tugging for Ischemic/Functional Mitral Regurgitation.

Surgical restoration of subvalvular geometry is very important to prevent recurrence of ischemic/functional mitral regurgitation. We evaluated an approach to the radical repair of left ventricular (LV) remodeling for three different cases with responsible coronary lesions. Leaflet tethering was corrected by tugging of the papillary-ventricular complex, which consists of the base of papillary muscles and posterior LV wall. The main lesion of the postinfarction scar was concomitantly excluded. Restoration of LV remodeling diminished mitral regurgitation with minimal leaflet tethering and improved systolic LV function. This technique may be an aggressive and encouraged approach for patients with ischemic/functional mitral regurgitation.

The Growth Potential and Patency of Free Right Internal Thoracic Arteries Verified by Computed Tomography Angiography.

BACKGROUND: The use of the left internal thoracic artery (LITA) is the gold standard in coronary artery bypass graft surgery (CABG). Multiarterial grafting for CABG is being increasingly emphasized. This study aimed to resolve the utility of the right internal thoracic artery (RITA) for multiple CABG as "free" RITA and described new evidence. METHODS: One hundred sixty-three patients received solo CABG with bilateral internal thoracic arteries between 2005 and 2018. The RITA was used as in situ RITA, group A (n = 62), and the composite graft created with saphenous vein graft (SVG), group B (n = 101). The patency rate and graft size of the composite free RITA and SVG were examined by coronary computed tomography angiography. RESULTS: The average number of distal anastomoses per patient was 3.4 ± 1.0 in group A, and 4.2 ± 1.1 in group B (P < .001). The sequential grafting with free RITA was in 86 patients. The patency rate of both LITA and RITA was similar in both groups. In group B, 40 patients received late computed tomography angiography at a mean of 46 months (range, 17 to 175). The late patency rate was 95.1% in LITA and 96.9% in free RITA. The diameter of free RITA increased from 2.06 ± 0.34 mm to 2.37 ± 0.23 mm (P = .036); that of in situ LITA increased from 2.08 ± 0.51 mm to 2.44 ± 0.49 mm (P = .047); and that of composite SVG decreased from 4.1 ± 0.9 mm to 2.6 ± 0.7 mm (P < .001). CONCLUSIONS: Multiple bypass grafting can be sufficiently achieved with LITA and free RITA. The growth potential of free RITA and in situ LITA might play the important role of expected long-term patency.

Successful Handmade Monobloc Aortomitral Valve Replacement for Extensive Aortic Root Abscess.

Aortic root abscess is one of the most catastrophic complications of aortic valve endocarditis. Complete débridement is recommended regardless of the kind of infected lesion. A 37-year-old man with extensive aortic root abscess due to prosthetic aortic valve endocarditis was surgically treated. The main lesion was the aortomitral continuity extending to the commissure between the left and right coronary cusps. After débridement, the aortic annulus underneath the left coronary artery was reconstructed using a handmade aortomitral monobloc valve without aortic annuloplasty. This valve was required for the extensive root abscess of the left and noncoronary sinus to achieve complete débridement.

Endocardial Hemangioma of the Right Ventricle: Complete Excision With Right Ventricular Restoration.

Primary cardiac tumor can arise from any location in the right and left cardiac chamber. Complete excision is generally recommended because of uncertainty regarding malignancy; however it is important to minimize the resultant functional deterioration after surgery. We report a case of endocardial hemangioma (4 × 3 × 3 cm) on the free wall of the right ventricle, located between the anterior and posterior papillary muscles. We describe details of the procedure to preserve the right ventricular volume and competence of the tricuspid valve.

[Redo Valve Replacement of Wada-Cutter Prosthetic Valve at Tricuspid Valve Position 47 Years After Implantation;Report of a Case].

We experienced an explantation of Wada-Cutter prosthetic tilting disk valve of 47 years after implantation. The patient was 53 years old female who underwent the 1st operation for Ebstein's anomaly, which included tricuspid valve replacement (TVR), closure of atrial septal defect (ASD) and posterior annulorrhaphy when she was 6 years old. She was doing well after the 1st operation without symptom,but dyspnea and systemic edema worsened recently though increased admission of diuretics. Echocardiography revealed severe tricuspid valve stenosis, severe tricuspid valve insufficiency, and increased right atrium volume. The tilting disk of the valve was almost fixed. The patient underwent repeat TVR. The explanted Wada-Cutter valve was covered by pannus the whole casing and disk. The structure of the valve was preserved but the occlusion disk was almost fixed by pannus formation, not distorted or dislodged.

Immunohistochemical identification of Propionibacterium acnes in granuloma and inflammatory cells of myocardial tissues obtained from cardiac sarcoidosis patients.

BACKGROUND: Although rare, cardiac sarcoidosis (CS) is potentially fatal. Early diagnosis and intervention are essential, but histopathologic diagnosis is limited. We aimed to detect Propionibacterium acnes, a commonly implicated etiologic agent of sarcoidosis, in myocardial tissues obtained from CS patients. METHODS AND RESULTS: We examined formalin-fixed paraffin-embedded myocardial tissues obtained by surgery or autopsy and endomyocardial biopsy from patients with CS (n = 26; CS-group), myocarditis (n = 15; M-group), or other cardiomyopathies (n = 39; CM-group) using immunohistochemistry (IHC) with a P. acnes-specific monoclonal antibody. We found granulomas in 16 (62%) CS-group samples. Massive (≥14 inflammatory cells) and minimal (<14 inflammatory cells) inflammatory foci, respectively, were detected in 16 (62%) and 11 (42%) of the CS-group samples, 10 (67%) and 10 (67%) of the M-group samples, and 1 (3%) and 18 (46%) of the CM-group samples. P. acnes-positive reactivity in granulomas, massive inflammatory foci, and minimal inflammatory foci were detected in 10 (63%), 10 (63%), and 8 (73%) of the CS-group samples, respectively, and in none of the M-group and CM-group samples. CONCLUSIONS: Frequent identification of P. acnes in sarcoid granulomas of originally aseptic myocardial tissues suggests that this indigenous bacterium causes granuloma in many CS patients. IHC detection of P. acnes in massive or minimal inflammatory foci of myocardial biopsy samples without granulomas may be useful for differentiating sarcoidosis from myocarditis or other cardiomyopathies.

[A Resected Case of the Vaginal Metastasis from Rectal Cancer].

The vaginal metastasis from colorectal cancer has rarely been reported. Here, we report a resected case of the vaginal metastasis from rectal cancer. A 51-year-old woman underwent radical hysterectomy and bilateral oophorectomy for uterus cancer. Five years after the operation, vaginal tumor was observed during an internal examination. Biopsy was positive for adenocarcinoma. Enhanced computed tomography demonstrated the wall thickening of the lower rectum and the mass of 20 mm at the inferior lobe of the left lung. Colonoscopy revealed the wall thickening of the lower rectum, and biopsy indicated a diagnosis of rectal cancer. We performed abdominoperineal resection and partial resection of the vagina. Pathological examination confirmed the vaginal metastasis from the rectal cancer.

Mid-term results of mitral valve palsty in patients with mitral sclerotic lesion.

BACKGROUND: Mitral valve repair is preferred over prosthetic replacement. We surgically repaired mitral valve with degenerated sclerotic lesion and demonstrated mid-term results. METHODS: Mitral valve plasty (MVP) was performed with several procedures including ring annuloplasty, leaflet slicing and decalcification. RESULTS: There were 19 males and 19 females with a mean age of 67 ± 12 y.o (n = 38). All patients were successfully treated MVP except one case with unrepairable injuries of the thin leaflet. In patients underwent MVP (n = 37), MVP included ring annuloplasty with a rigid full ring of 32 ± 2 mm (n = 37), leaflet slicing (n = 37), decalcification (n = 15) and artificial chordae (n = 14). Mitral valve area was statistically enlarged by MVP (1.65 ± 0.57 vs 2.51 ± 0.58 cm(2), p < 0.001). Left atrial diameter was statistically reduced after the operation (55 ± 10 vs 46 ± 9 mm, p < 0.001). Severity of MR and right ventricular systolic pressure (RVSP) were statistically decreased after the operation (MR; 1.8 ± 1.0 vs 0.7 ± 0.9, p < 0.001, RVSP; 38 ± 15 vs 30 ± 9 mm Hg, p < 0.001). There were 4 cases with residual MR (Grade II, n = 3; Grade III, n = 1). The 30-days mortality was 0 %. There was one late death due to non-cardiogenic cause (the 3-year survival rate of 97 %) and no redo case due to deterioration of the mitral valve during follow-up period of 21 ± 13 months. CONCLUSIONS: Successful mid-term survival and freedom from reoperation might expect to the durability of MVP in patients with mitral sclerotic lesion.

Post-Thoracic Endovascular Aortic Repair Complicated with Mycotic Aneurysm Rupture, Repaired by Redo Thoracic Endovascular Aortic Repair.

Mycotic aneurysms although rare can be devastating. We encountered a dialysis patient with rapidly expanding distal aortic arch aneurysm who underwent axilloaxillary bypass and thoracic endovascular aortic repair (TEVAR). Three months later, he suffered mycotic aneurysm rupture for which redo TEVAR was performed. Antibiotic therapy was discontinued 16 weeks after the second operation, and renal transplantation was performed 6 months later. Dialysis was discontinued in the patient without infection recurrence.

Subvalvular Pannus Overgrowth after Mosaic Bioprosthesis Implantation in the Aortic Position.

PURPOSE: Although pannus overgrowth by itself was not the pathology of structural valve deterioration (SVD), it might be related to reoperation for SVD of the bioprostheses. METHODS: We retrospectively reviewed patients undergoing reoperation for SVD after implantation of the third-generation Mosaic aortic bioprosthesis and macroscopic appearance of the explanted valves was examined to detect the presence of pannus. RESULTS: There were 10 patients and the age for the initial aortic valve replacement was 72 ± 10 years old. The duration of durability was 9.9 ± 2.0 years. Deteriorated valve presented stenosis (valvular area of 0.96 ± 0.20 cm(2); pressure gradient of 60 ± 23 mmHg). Coexisting regurgitant flow was detected in two cases. Macroscopically, subvalvular pannus overgrowth was detected in 8 cases (80%). The proportion of overgrowth from the annulus was almost even and pannus overgrowth created subvalvular membrane, which restricted the area especially for each commissure. In contrast, opening and mobility of each leaflet was not severely limited and pannus overgrowth would restrict the area, especially for each commissure. In other two cases with regurgitation, tear of the leaflet on the stent strut was detected and mild calcification of each leaflet restricted opening. CONCLUSION: In patients with the Mosaic aortic bioprosthesis, pannus overgrowth was the major cause for reoperation.

Prediction of Long-Term Survival in Patients with End-Stage Heart Failure Secondary to Ischemic Heart Disease: Surgical Correction and Volumetric Analysis.

PURPOSE: Ischemic heart disease (IHD) may result in lethal conditions such as ischemic cardiomyopathy (ICM) and mitral regurgitation (MR). METHODS: We hypothesized preoperative LV volume would be highly associated with long-term survival in such patients. We retrospectively evaluated effects of LV end-systolic volume index (LVESVI) on survival. RESULTS: Patients were divided into two groups according to LVESVI; Group S (n = 19, <100 ml/m(2)), and L (n = 55, >100 ml/m(2)). There were 74 patients (male 61, female 13; 61 ± 10 y.o.). There was no statistical significance in preoperative parameters, including ejection fraction (EF), severity of MR, severity of tricuspid regurgitation (TR), and right ventricular systolic pressure (RVSP). After operation, LVESVI and severity of MR were statistically reduced in both groups. However, EF, severity of TR and RVSP were not statistically alleviated in both groups. In Group S, 5- and 10-year survival rates were 93% and 48%. In Group L, 5- and 10-year survival rates were 50% and 29%. There was a statistical difference in long-term survival between two groups. CONCLUSIONS: Preoperative LV volume would be one of the risk factors for long-term survival in patients with congestive heart failure secondary to IHD. Careful follow-up and optimal treatment should be recommended before LV dimension becomes too large.

Preoperative transaortic forward flow: Prediction of surgical outcomes in patients with DCM and mitral regurgitation.

BACKGROUND: In patients with dilated cardiomyopathy and mitral regurgitation, preoperative prognostic factors are very important. METHODS: We hypothesized that preoperative transaortic forward flow might be related to postoperative survival, despite mitral regurgitant volume. We retrospectively evaluated surgical outcomes and echocardiographic parameters, including forward flow through the aortic valve. RESULTS: Seventy-nine patients (54 males, 25 females; mean age 59 ± 12 years) with dilated cardiomyopathy and mitral regurgitation were divided into two groups according to postoperative outcome: 19 patients in group A suffered cardiac death, 60 in group B survived or died of another cause. In group A, death occurred after 227 ± 116 days, group B patients survived (except one who died of infection) for 505 ± 446 days; p < 0.01. Preoperatively, there was no significant difference in ejection fraction, end-diastolic and end-systolic volume index, mitral regurgitant volume, effective regurgitant orifice area, or right ventricular systolic pressure. Preoperative transaortic forward flow was significantly lower in group A vs. group B (1.57 ± 0.33 vs. 1.81 ± 0.46 L m(-2); p 0.04). In group B, transaortic forward flow was increased significantly before discharge (1.81 ± 0.51 vs. 2.43 ± 0.62 L m(-2); p < 0.01). Ejection fraction was significantly alleviated before discharge (28% ± 9% vs. 23% ± 8%; p < 0.01) and recovered to the preoperative value without repeat dilation of the left ventricle in late follow-up. CONCLUSIONS: Preoperative transaortic forward flow may be a predictor of survival in patients with dilated cardiomyopathy and mitral regurgitation, irrespective of mitral regurgitant volume.

Sublocalization of Cardiac Involvement in Sarcoidosis and Surgical Exclusion in Patients With Congestive Heart Failure.

BACKGROUND: In sarcoidosis, cardiac involvement can cause fatal conditions such as left ventricular (LV) dysfunction and rhythm disturbance. We surgically treated critical patients with congestive heart failure due to cardiac sarcoidosis. METHODS: During 14 years, 384 patients with nonischemic dilated cardiomyopathy were operated. Among them, 14 patients (3.6%) with New York Heart Association (NYHA) class IV (male/female, 3/11; 57 ± 11 years) caused by sarcoidosis underwent surgery (elective/emergent, 12/2). The akinetic lesion, as identified by speckle-tracking echocardiography, was excluded. RESULTS: Localization of akinetic lesions was achieved in 13 patients (93%). In the short axis, lesional distribution was higher in the anterior (62%) and septal segments (54%) when compared with the posterior (31%) and lateral segments (23%). Along the long axis, regional distribution was higher in the mid (85%) and apical segments (69%) when compared with the basal segment (31%). The main lesions were excluded by septal anterior ventricular exclusion (n = 5), posterior restoration procedure (n = 3), endoventricular circular patch plasty (n = 3), and linear resection (n = 2). Mitral valve surgery included mitral valve plasty (n = 7) and replacement (n = 7). In patients undergoing elective surgery, early results showed that 10 patients survived (83%) and NYHA class improved (6 patients in class II and 4 in class III). Patients who underwent emergent surgery did not survive. The observation period was 55 ± 59 months in survivors. During follow-up, 4 patients died after 42 ± 48 months. The other 5 patients have survived for 71 ± 61 months. The 3- and 5-year survival rates were 65% and 52%, respectively. CONCLUSIONS: Sarcoidosis can result in sublocalized LV involvement, which can be surgically excluded.

Posterior restoration procedures and the long-term results in indicated patients with dilated cardiomyopathy †.

OBJECTIVES: Non-transplant surgery for dilated cardiomyopathy (DCM) has been in the process of development. We performed posterior restoration for dilated akinetic or dyskinetic lesions in patients with DCM and obtained favourable outcomes. The early and long-term results of the procedures are discussed. METHODS: Between 2005 and 2013, posterior restoration procedures (PRPs) for DCM were electively performed in 58 patients (17 with ischaemic and 41 with non-ischaemic DCM). There were 45 men and 13 women with a mean age of 56 ± 12 years old. The mean preoperative ejection fraction was 24% and the preoperative New York Heart Association functional class was Class III in 24 and Class IV in 34 patients with intravenous inotrope support. Indications for PRPs were determined by using speckle-tracking echocardiography of the posterior region of the left ventricle before surgery (GE ultrasound machine, Vivid 7 or Vivid E9). After cardioplegic arrest, mitral surgery or coronary artery bypass grafting (CABG) was performed and the posterior left ventricular (LV) muscle between bilateral papillary muscles was incised or resected. The LV apex was preserved and cryoablation was applied between the cut edge and the posterior mitral annulus. All patients were followed up by transthoracic echocardiography. RESULTS: In addition to PRP, mitral surgery was performed in 56 (plasty 51, replacement 5), tricuspid annuloplasty in 21, CABG in 17, cardiac resynchronization therapy in 6 and LV lead implantation in 27 patients. Perioperative intra-aortic balloon pumping was used in 9 patients and there was no hospital mortality. After the operation, 35 patients (60%) improved their functional class to Class I or II. In the late follow-up, there were 14 cardiac deaths (congestive heart failure 10, ventricular arrhythmia 4). The 3- and 8-year survival rates were 77 or 66%, respectively. CONCLUSIONS: DCM with posterior akinesis or dyskinesis indicated by speckle-tracking echocardiography can be surgically treated with PRP. Our results demonstrated that 60% of the selected patients could avoid heart transplantation with relief of their symptoms.

Tricuspid annuloplasty with the MC3 ring and septal plication technique.

BACKGROUND: Functional tricuspid regurgitation is caused by annular dilation mainly in the posterior annulus. However, ring annuloplasty does not always prevent the recurrence of tricuspid regurgitation due to dilation of the septal annulus. We developed a septal plication technique with a 3-dimensional MC3 ring. METHODS: Between 2006 and 2011, 76 patients (male/female 30/46; mean age 68 ± 11 years) with functional tricuspid regurgitation received tricuspid ring annuloplasty. After placement of the annular sutures, the 3 commissural ring portions were fixed on the equivalent commissures to plicate the anterior and posterior annulus. The end of the septal ring portion was fixed at the optimal annular position to obtain minimal tricuspid regurgitation. All patients were followed-up for a mean of 47 ± 18 months; the longest duration was 79 months. RESULTS: Although there was no operative death, one patient died of sepsis during hospitalization (hospital mortality 1.3%). After implantation of the MC3 ring (mean size 31.0 ± 3.3 mm), additional edge-to-edge sutures were required for minor leakage in 5 (7%) patients. The degree of tricuspid regurgitation was significantly reduced at discharge (0.5 ± 0.6) and midterm (0.6 ± 0.6) compared to 2.5 ± 0.7 before the operation (p < 0.0001). CONCLUSIONS: The surgical durability of the MC3 ring was satisfactory at early and midterm follow-up, suggesting that correct plication of the septal annulus is effective for tricuspid ring annuloplasty with a 3-dimensional MC3 ring.

Temporary epicardial pacing wire migrating to and exiting from the jaw.

A 63-year-old woman underwent cardiac surgery, with atrial and ventricular temporary epicardial pacing wires being placed at the end of the procedure. Four months after the operation, the patient experienced tooth decay and underwent a tooth extraction. Thereafter, the patient developed an infected, swollen neck; computed tomography revealed that one of the temporary pacing wires had migrated into her neck. The patient was readmitted for removal of the wire, but it spontaneously exited through the skin of the lower jaw; the infection was resolved with intravenous antibiotic therapy.

[Effectiveness of tolvaptan for postoperative heart failure in a patient with combined valvular disease and pulmonary hypertension].

We report a case of a 60-year-old man with postoperative congestive heart failure( CHF) successfully treated with tolvaptan. The patient was diagnosed with pulmonary hypertension due to mitral stenosis and regurgitation combined with tricuspid regurgitation. He underwent mitral and tricuspid valvuloplasty. His postoperative course was uneventful until CHF symptoms secondary to volume overload appeared on the 4th day. Congestion with pulmonary hypertension was treated with 0.042 µg/kg/min of intravenous human atrial natriuretic peptide (hANP). His condition improved, and on the 11th postoperative day, he was weaned off hANP;oral administration of 40 mg per day of furosemide was initiated. However, 2 days after discontinuation of intravenous hANP, CHF recurred and serum sodium decreased to 128 mEq/l. Oral tolvaptan 7.5 mg per day was added to the furosemide, and CHF and hyponatremia subsequently improved. In this case, oral tolvaptan was effective for the treatment of refractory CHF with pulmonary hypertension after cardiac surgery.

Posterior restoration of left ventricle and mitral valve repair in patients with muscular dystrophy.

BACKGROUND: Congestive heart failure (CHF) is major risk factor for survival among patients with muscular dystrophy (MD). The degenerative postero-lateral wall of the left ventricle (LV), which results in systolic dysfunction and functional mitral regurgitation (MR) at the time of CHF, is not well described in MD. METHODS: We restored the LV and repaired the mitral valves of 6 patients (mean age, 43 ± 9 years) during emergency and elective procedures. Two and 4 patients were in New York Heart Association (NYHA) functional classes III and IV, respectively. One patient required emergency preoperative intraaortic balloon pump support. Before operation, speckle-tracking echocardiography was applied to detect the myocardial lesion. The postero-lateral LV wall that is critically affected in MD was excluded during posterior restoration. Functional MR was repaired using a combination of ring annuloplasty, papillary muscle approximation, and chordal cutting. The LV myocardium between the end of the LV incision line and the mitral annulus was cryoablated to prevent late ventricular arrhythmia. RESULTS: All patients survived (100%) for a mean follow-up of 59±39 (range; 5 to 101) months. The NYHA functional classes improved to I and II (n=3 each). Left ventricular end-diastolic diameter significantly decreased from 77±13 to 59±4 mm (p=0.0088), whereas ejection fraction did not significantly improve (0.24±0.1 vs 0.29±0.11, p=0.2451), although MR severity was significantly eliminated (3.5±0.5 vs 0.5±0.6, p=0.0003). No cardiac events were associated with CHF or arrhythmia during follow-up. CONCLUSIONS: Posterior restoration of the LV and mitral repair are useful for treating CHF in patients with MD, and improve survival.

[Preserving autologous heart operation for dilated cardiomyopathy].

OBJECTIVE: We report non transplant surgical procedure (preserving autologous heart operation) for the patients with dilated cardiomyopathy( DCM), clinical outcomes, and the factor of predict prognosis. PATIENT AND METHOD: Since May 2000, 258 patients received surgical procedure for 11 years. SURGICAL PROCEDURES: We performed mitral surgery (plasty or replacement) for the patients with more than mild mitral regurgitation (MR). We performed papirally muscule plication since 2005, and we performed 2nd chordal cutting since 2008, for the patients with MR due to mitral tethering. The surgical left ventricular reconstruction( SVR) was performed for the patients with dilated left ventricular. We use spackle tracking echocardiography to decide the type of SVR since 2008. RESULT: Hospital death was 18.2%, and late cardiac death was 27.5%.Almost the cause of death was congestive heart failure and ventricular arrhythmia. Five years survival was 58%, 10 years survival was 39%. Preoperative condition, emergent operation, inotropic support, intra aortic balloon pumping(IABP),affect the prognosis. But left ventricular size did not affect it. CONCLUSION: Surgical treatment for the patient with DCM should be performed with stable preoperative condition.