Y-shaped graft replacement of an isolated innominate artery aneurysm via the transmanubrial approach.

We report the rare case of an obese woman with a 32-mm isolated innominate artery aneurysm. Due to the deep location of the aneurysm within the thoracic inlet, we selected a transmanubrial osteomuscular sparing approach to obtain a clear field of vision. During the aneurysmectomy and reconstruction with a Y-shaped graft, we performed a temporary bypass using a contralateral leg of the graft to the right common carotid artery. Through these techniques, we successfully achieved complete resection and reconstruction of the aneurysm without the need for cardiopulmonary bypass.

Collapse of zone 0 landing TEVAR (Najuta) and the development of higher brain dysfunction.

Although thoracic endovascular repair (TEVAR)-specific complications often develop, stent-graft collapse is a rare, but fatal complication that requires attention. A 62-year-old male underwent TEVAR for a saccular distal arch aortic aneurysm. After the placement of the Gore TAG (W. L. Gore & Associates, Inc., Newark, DE, USA) from zones 2 to 4, a Najuta endograft (Kawasumi Laboratories, Inc., Tokyo, Japan) was deployed from zone 0. Neither intraoperative angiography nor postoperative contrast-enhanced computed tomography (CT) showed endoleaks or migration. On day 12 after surgery, the patient suddenly lost consciousness during rehabilitation, and CT revealed the collapse of the Najuta endograft. In emergency surgery, the Najuta endograft was removed and the TAG was sutured to the aorta. Although the patient survived, he developed irreversible higher brain dysfunction. The cause of the collapse was examined by the manufacturer and only a slight bird-beak configuration was noted. There were no other findings to indicate the cause of the collapse. The Najuta endograft is a semi-customized system that is created according to the three-dimensional morphology of each individual aortic arch and, thus, is expected to follow the flexion of this vessel. Nevertheless, the risk of collapse needs to be considered.

Modified Commando procedure using a double valve composite through an aorto-annulo-septotomy.

Double valve replacement of aortic and mitral valves with intervalvular fibrous body reconstruction (Commando procedure) is a challenging operation. Particularly in redo surgery for prosthetic valve endocarditis, special techniques are needed for approaching and reconstructing the valve complex. We performed a modified Commando procedure using a double valve composite through an aorto-annulo-septotomy. This approach provided a good field of vision at the combined aortic and mitral annuli without incising the left atrial roof. The double valve composite with four-layer patch wings was useful for performing double valve replacement en bloc and aorto-annulo-septotomy closure serially. Using these techniques, we successfully performed the Commando procedure for complicated prosthetic valve endocarditis.

A Case of Endovascular Aortic Repair for Abdominal Aortic Aneurysm with a Saccular Aneurysm in the Severely Angulated Proximal Landing Zone.

We report a case of endovascular aortic repair (EVAR) for the abdominal aortic aneurysm complicated by a saccular aneurysm due to a penetrating atherosclerotic ulcer in the severely angulated proximal landing zone. To secure the zone, coil embolization of the saccular aneurysm was performed before stent grafting to treat the abdominal aortic aneurysm. To precisely follow the severely angled proximal neck, we used the Excluder stent-graft system inserted by the body floss technique method instead of the stiff wire method to avoid accordion folding the proximal landing zone. These techniques may expand the indications of EVAR.

Shortened chordae tendineae of the tricuspid valve with right ventricular dysfunction caused by acute myocarditis lead to cardiogenic shock during pericardial drainage: a case report.

A 63-year-old woman was admitted to the hospital with general malaise and pericardial and thoracoabdominal effusions of unknown cause. After pericardial drainage for drug-resistant right heart failure, she developed right ventricular (RV) dysfunction and cardiogenic shock caused by severe tricuspid regurgitation (TR). Findings during emergency surgery included tricuspid valve (TV) junction failure caused by shortening of the chordae tendineae of the TV, which is an organic abnormality. Additionally, myocardial biopsy results revealed myocarditis. Although acute myocarditis developed with RV dysfunction, pericardial effusion suppressed venous return, which temporarily improved her pathological condition. However, RV dysfunction and severe TR were thought to have manifested after the venous return suppression was alleviated by pericardial drainage. Because venous return changes significantly after pericardial drainage, it is necessary to examine the need for drainage and re-evaluate the post-operative RV system.

[Comparison of Three Methods of Sternal Closure after Open Heart Surgery:Analysis of 722 Cases for 11 Years].

722 patients who returned to the intensive care unit( ICU) after completing the cardiac surgery and closing the median sternotomy from Jan 2010 to Feb 2021 at our hospital were divided into 3 groups according to the different sternal closures. Sternum was fixed with 6 wires alone in group A (n=333), with 2 absorbable plates and 6 wires in group B( n=259) or with 3 titanium plates with 20 screws and 4 wires in group C (n=130). Background characteristics were not different between the 3 groups. Total number of 3 complications (postsurgical bleeding, mediastinitis and delayed cardiac tamponade) was significantly less in group B and C than group A. Among them postsurgical bleeding needed hemostasis surgery was significantly less in group C than in group A. Surgical nor hospital mortality were not significantly different in 3 groups. Postsurgical complications were significantly less when the sternum closure was fixed with plates( absorbable, not absorbable).

Radical surgery for a mitral valve intimal sarcoma: serial patch repair of the annulus and atrium.

We report the rare case of a 48-year-old woman with a cardiac intimal sarcoma occupying the mitral valve and the left atrial roof. We resected the tumour in one block without residual lesions. The anterior mitral annulus and left atrial roof were serially repaired with the bovine pericardium, and a mechanical prosthesis was implanted in the reconstructed mitral annulus. The patient remains alive without recurrence for more than 1 and a half years postoperatively. We performed radical surgery for a mitral valve intimal sarcoma, and serial patch repair of the anterior mitral annulus and left atrial roof was a useful technique.

[Repeated Rupture of Infective Thoracic Aortic Aneurysm:Report of a Case].

A 79-year-old man was diagnosed with rupture of infective thoracic aortic aneurysm following septicemia caused by infective cholangitis. He underwent emergent endovascular aortic repair and discontinued antibiotics. Graft infection occurred and was treated 29 days after the first operation. He underwent emergent resection of the abscess with graft coverage using pedicled intercostal muscle flaps. Aortic re-rupture was found and treated 183 days after the second operation. He underwent emergency additional thoracic endovascular aortic repair and continued to take antibiotics again. We should continue a careful follow up.

[Comparative Study of Elephant Trunk and Frozen Elephant Trunk Techniques].

Twenty-six patients underwent total arch replacement for Stanford type A aortic dissection, including that with elephant trunk technique (ET group, n=10) or with frozen elephant trunk technique (FET group, n=16). We compared preoperative and intraoperative findings, postoperative results and distal aortic arch remodeling between the two groups. In FET group, anesthesia time, operation time, cardiopulmonary bypass time, cardiac arrest time and circulatory arrest time were significantly shorter than ET group. Also, intra-operative blood transfusion amount was significantly smaller than ET group. In FET group, the ratio of true lumen area and thrombosis rate of false lumen at the distal arch level were significantly higher than ET group. Other postoperative results were almost similar between the two groups.

[Aortic Para-annular Abscess Following Infective Endocarditis Requiring Three Times of Operation:Report of a Case].

A 45-year-old man was diagnosed with active aortic valve endocarditis accompanied by massive aortic regurgitation, complete atrioventricular block, para-annular abscess and a mobile large vegetation. He underwent emergency resection of the aortic valve, direct closure of the abscess with an autologous pericardium patch and mechanical valve replacement. Acquired communication between the left ventricle and the right atrium was closed simultaneously. Then, adjacent mitral para-annular abscess and another vegetation were revealed by echocardiography, and treated surgically 20 days after the first operation. He underwent mitral valve replacement and closure of the annular abscess. Twenty-one days after the second operation, aortic annular false aneurysm was detected by echocardiography, and closure of the false aneurysm and aortic valve re-replacement were performed successfully.

Isolated and Combined Valve Surgery in Elderly Patients: A Comparison of Mid-Term Results.

BACKGROUND: This study examined mid-term outcomes of valve surgery in the elderly, and focused on the difference in outcomes between isolated and combined valve surgery. METHODS: From January 2012 to June 2016, 113 consecutive patients aged 75 years and older underwent valve surgery. In all, 60 underwent isolated valve surgery (Group I), and 53 underwent combined valve surgery (Group C) involving the combination of any valve procedures or valve surgery with concurrent other procedure. Short- and mid-term outcomes were compared between the two groups. RESULTS: There was no significant difference in length of intensive care unit stay (2.8 days in Group S vs. 4.2 days in Group C, p = 0.08), hospital stay (16.2 vs. 18.7 days, p = 0.22), and mechanical ventilation (11.2 vs. 15.0 hours, p = 0.28). Neither was there any significant difference in operative mortality (1.6% vs. 5.6%, p = 0.25) nor morbidity (8.3% vs. 9.4%, p = 0.83) between the two groups. Actuarial survival rates at 1 and 3 years were 98.3% in Group S and 92.0% in Group C (log-rank p = 0.126). CONCLUSION: Once patients have tolerated combined surgery during the early postoperative period, good survival rates equaling those of isolated valve surgery can be expected.

Endovascular Repair of a False Aneurysm Developing from IgG4-Related Periaortitis during Corticosteroid Therapy.

Immunoglobulin G4 (IgG4)-related disease is a systemic autoimmune disease that can affect various organs. Corticosteroid therapy is generally an effective treatment; however, IgG4-related aortic lesions pose a risk of aortic rupture related to corticosteroid use. Here, we report a case of IgG4-related periaortitis complicated with a false aneurysm during corticosteroid therapy. Although endovascular repair was successfully performed, autoimmune pancreatitis and sclerosing cholangitis emerged after surgery. The multiple lesions associated with IgG4-related disease were resolved through continuous corticosteroid therapy. Our case suggests that both appropriate surgical intervention and continuous corticosteroid therapy are essential for the treatment of IgG4-related periaortitis.