Minimally invasive coronary artery bypass grafting with ultrasonically skeletonized internal thoracic artery.

Objective: This study aimed to examine the feasibility and safety of minimally invasive cardiac surgery coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery in the authors' initial experience. Methods: From February 2012 to May 2021, 247 consecutive patients who underwent minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery were reviewed retrospectively. Internal thoracic arteries were harvested in a full skeletonized fashion using an ultrasonic scalpel via left minithoracotomy. Bilateral internal thoracic arteries were used in 108 patients, and the internal thoracic arteries as in situ grafts were used in 393 anastomoses. Total arterial revascularization was performed in 126 patients, and 142 patients underwent aortic nontouch minimally invasive coronary artery bypass grafting. Results: The patients' mean (range) age was 65.9 ± 11.5 (30-90) years. The mean (range) number of anastomoses performed was 2.6 ± 1.1 (1-6). Forty-six patients (18.6%) had 4 grafts, 94 patients (38.1%) had 3 grafts, and 60 patients (24.3%) had 2 grafts. Minimally invasive coronary artery bypass grafting was completed without conversion to sternotomy in all patients. Cardiopulmonary bypass was performed in 3 patients (1.2%), reinterventions due to bleeding were performed in 7 patients (2.8%), and chest wound infections were observed in 5 patients (2.0%). There was 1 (0.4%) mortality. Conclusions: Minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery is feasible and has shown good perioperative outcomes. This approach has the potential for further optimization with revascularization strategies.

[Usage of New Device to Prevent Sternum Separation after Median Sternotomy in 140 Cases].

While minimally invasive cardiac surgery (MICS) has become increasingly popular recently even in the field of cardiovascular surgery, the conventional full median sternotomy is still the main approach to the mediastinum, especially for cases which cannot be applied for MICS or in the facilities where MICS is not performed. It has been known that sternal instability is one of the leading causes of sternal infection after median sternotomy. Therefore, we have sought for an additional product to secure strong sternal stability. Since August in 2018, we used a new type of corrugated plate( Super Fixsorb Wave) which is placed inside the sternum in addition to regular sternal wires for 140 patients who had full median sternotomy. Up to now, we have no complications regarding sternotomy including mediastinitis. We believe that additional use of Super Fixsorb Wave enables firm sternal stability and prevents mediastinitis following full median sternotomy.

[Cardiac Rehabilitation in Minimally Invasive Cardiac Surgery Coronary Artery Bypass Grafting].

OBJECTIVES: A purpose is to compare the in-hospital rehabilitation progress after minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG) with that after off pump coronary artery bypass grafting( OPCAB). METHODS: We analyzed 60 patients who underwent coronary artery bypass grafting surgery from January 2015 to December 2016. Fourteen patients underwent MICS CABG (MICS CABG group) and 46 patients underwent OPCAB (OPCAB group). The post-operative days to start standing position and independent walking, and hospitalization duration were analyzed between the 2 groups. RESULTS: There were no significant differences between the groups:standing position(1.2 vs 1.2 days) and independent walking(4.8 vs 4.9 days). Hospitalization duration was shorter in MICS CABG group(14.3 vs 17.5 days). CONCLUSION: MICS CABG may shorten hospitalization length compared with OPCAB, however, further research will be needed.

[Minimally Invasive Coronary Artery Bypass Grafting Using Bilateral In Situ Internal Thoracic Arteries].

A 73-year-old male with diabetes mellitius was referred to our hospital for coronary artery bypass grafting (CABG). Preoperative coronary angiography revealed three-vessel coronary disease. Minimally invasive coronary artery grafting (MICS CABG) via left thoracotomy was selected to decrease surgical site infection due to severe diabetes. In situ bilateral internal thoracic arteries (BITA) were harvested using a long type Harmonic scalpel. In situ right internal thorac artery( RITA)-left anterior descending artery (LAD), in situ left internal thorac artery( LITA)-high lateral branch (HL), and aorta-saphenous vein graft (SVG)-#4 posterior descending artery were performed. BITA, the ascending aorta for proximal anastomosis, and all coronary targets were directly accessed with off-pump technique. There were no major postoperative complications. Postoperative 3D-computed tomography angiography (CTA) revealed all grafts were patent. We believe that use of BITA in MICS CABG is feasible, and can provide satisfactory quality. Further research however, will be needed.

[New Intracoronary Shunt Cannula in Off-pump Coronary Artery Bypass Grafting].

In off-pump coronary artery bypass grafting(OPCAB), a bloodless operative field has great influence on the quality of anastomosis. In addition, maintenance of distal coronary flow during anastomosis stabilizes hemodynamics. We introduced a new intracoronary shunt cannula, Mini Shunt Pro (MSP). MSP adopts the step-tip, which allows easy insertion and reduces the risk of intimal injury. The distal and proximal sides of the tips of MSP are 0.25 mm different in diameter, which improves its fitness to the coronary artery and enhances a bloodless operative field. This new shunt cannula is considered to be safe and useful for high-quality anastomosis in OPCAB.

[Minimally Invasive Coronary Artery Bypass Grafting Using Proximal Anastomoses Device;Report of a Case].

A 68-years-old male with diabetes mellitius (HbA1c 6.5%) was referred for coronary artery bypass grafting(CABG). Preoperative coronary angiography (CAG) signed 3-vessels coronary disease[#2 75 %,#4 posterior descending (PD) 75%,#6 90%,#14 90%]. Minimally invasive coronary artery grafting (MICS CABG) was selected because of faster postoperative recovery than off-pump CABG via a 10 cm left 5th thoracotomy approach. In situ bilateral internal thoracic artery(BITA) and saphenous vein (SVG) was harvested by special manner using long type Harmonic. Bypass graft design was in situ right internal thoracic artery-LAD, in situ left internal thoracic artery-left circumtlex#14, and aorta-SVG-#4PD-#4atrio-ventricular. BITA, the ascending aorta for proximal anastomoses, and all coronary targets were directly accessed with off-pump technique. Heartstring III Proximal Seal System was used to anastomose SVG to the ascending aorta. There were no major postoperative complications. Postoperative CAG revealed all grafts patent and postoperative hospital stay was 14 days. This case was the 1st usage of Heartstring III Proximal Seal System in our clinic. We believe that the usage of Heartstring III Proximal Seal System in MICS CABG is realistically possible, and providing good quality;however, further research will be needed.

[Rupture of Saccular Brachiocephalic Artery Aneurysm after One Year and Seven Months from Coil Embolization;Report of a Case].

A 52-years-old man, who had undergone coil embolization of saccular aneurysm of the brachiocephalic artery, presented with right back discomfort. Diagnosis by computed tomography was difficult because of an artifact from the coils. Angiography, on the other hand, revealed a rupture of the aneurysm, and emergency surgery was performed. A Y-shaped graft was anastomosed to the ascending aorta under partial clamp. Then, one of its branches was anastomosed to the common carotid artery also under partial clamp in an end-to-side fashion. The cerebral blood flow monitored by a regional oximetry system (INVOS) remained stable. The other branch was anastomosed to the subclavian artery in end-to end fashion. No postoperative neurologic complications occurred. Angiography was useful in diagnosis of brachiocephalic artery aneurysm rupture after coil embolization. INVOS was also useful for monitoring the cerebral blood flow during surgery.

[Mitral Valve Plasty in a Patient with Situs Inversus Totalis; Usefulness of Retrograde Cardioprotective Beating Test].

We report the usefulness of retrograde cardioprotective(RC)-beating test as a method to evaluate mitral valve plasty (MVP). MVP has been established as an effective procedure for mitral regurgitation, but nevertheless, a problem remains as to how to reduce postoperative residual regurgitation. In order to solve this problem, it is crucial to image the 3 dimensional structures of the mitral valve and its systolic condition. However, it is quite difficult especially in cases of situs inversus totalis (SIT). RC-beating test gives a clear view of the mitral valve and precisely evaluates the performance of MVP, which is particulary helpful in SIT patients. It also shows where to revise in cases of residual regurgitation.

Herniation of transverse colon into mediastinum after pedicled omental grafting for mediastinitis: report of a case.

We describe a rare complication and the treating experience of it after pedicled omental grafting for mediastinitis. The patient was diagnosed as an acute mediastinitis soon after the total arch replacement was performed. A two-staged strategy to treat postoperative mediastinitis was scheduled, i.e., the setting up of a vacuum-assisted closure system until the improvement of inflammation followed by wound closure with pedicled omental grafting. The treatment for acute mediastinitis was successful and the patient followed a favorable postoperative course. During the follow-up, chest X-ray film suggested the gradual enlargement of mediastinum and CT showed the herniation of transverse colon into mediastinum. Surgical correction for the hernia was scheduled and performed successfully by the laparoscopic procedure to prevent a possible cardiac and pulmonary dysfunction.

Premature atrial contraction as a predictor of postoperative atrial fibrillation.

BACKGROUND: Postoperative atrial fibrillation occurs in 20%-60% of patients after cardiac surgery. Recently, premature atrial contraction has been considered an initiator of atrial fibrillation. This study evaluated whether the frequency of premature atrial contractions predicts the occurrence of postoperative atrial fibrillation. METHODS: The subjects of this study were 70 patients with no history of atrial fibrillation who had undergone a 24-h Holter electrocardiogram before off-pump coronary artery bypass. Their records were reviewed and postoperative electrocardiograms and telemetry strips were analyzed for postoperative atrial fibrillation. RESULTS: Postoperative atrial fibrillation was documented in 22 (31.4%) patients. The frequency of preoperative premature atrial contractions was significantly higher in the postoperative atrial fibrillation group (4128 ± 7186 vs. 69 ± 221 beats/24 h, p < 0.001). The incidence of postoperative atrial fibrillation increased with the frequency of preoperative premature atrial contractions which occurred in 60% of patients in the upper 50th percentile group of preoperative premature atrial contractions. Multivariate logistic regression analysis revealed the upper 50th percentile group of preoperative premature atrial contractions (odds ratio = 67; 95% confidence interval: 5.51-838; p = 0.001) to be an independent predictor of postoperative atrial fibrillation. CONCLUSION: A high frequency of preoperative premature atrial contractions is a strong independent predictor of postoperative atrial fibrillation in off-pump coronary artery bypass.

[Evaluation of long-term results in patients who underwent reconstruction of thoracic wall with curved metal plates].

Between 1992 and 2011, 22 patients underwent surgery of reconstruction of thoracic wall with curved metal plates for multiple rib fracture and resection of thoracic wall tumor. They were divided into 2 groups according to original disorders. Twelve cases of group A accepted surgical stabilization of traumatic multiple rib fractures with the metal plates fixed on the fractured ribs as an external brace. Ten patients of group B were suffered from thoracic wall tumors, including 1 fibrous dysplagia, 1 chondroma, 5 invasive lung cancer, 2 rib metastases and 1 primary chest wall cancer. After the resection of tumors, an average of 3.2 ribs were removed, the defects of full thickness chest wall were reconstructed using a combination of a polypropylene mesh and the metal plates. In both groups, there were no displacement of the plates and allergic reaction. Only 2 patients needed removal of the fixed plates due to pyothorax caused by pneumonia after crushing thoracic injuries. The long metal reconstruction plates with many perforations were very useful for reconstruction of chest wall because they were long enough to cover the whole length of widely resected chest defects and moderately soft enough to be appropriately bent or twist by hand at the time of operation. Moreover long-term result of the reconstructed chest wall was safe and satisfactory without severe complication.

[Vacuum-assisted closure in a patient with methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after thoracic aortic surgery].

Mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA) is a serious complication in cardio-thoracic surgery. In mediastinitis cases, acute thoracic aortic graft infection is a lethal status. We described a successful treatment of MRSA thoracic graft infection by V.A.C. ATS therapy. Ascending aortic graft replacement was performed in a 55-year-old man, and deep mediastinitis by MRSA occurred on postoperative day 6. On postoperative day 8, negative pressure wound therapy (NPWT) using a home-made system, was carried out after re-sternotomy, debridement of inflammatory tissues and irrigation. Following the 1st NPWT, V.A.C. ATS therapy was introduced. MRSA vanished from the mediastinum after V.A.C. ATS therapy, and the mediastinum was closed with the omentum. He was discharged 43 days after the 1st operation. We consider that the advantage of V.A.C. ATS therapy is "making a bed-side free status" in even mediastinitis patients, which enables active walking and reinforcement of physical strength. V.A.C. ATS therapy might be useful for the treatment of MRSA mediastinitis.

Surgical resection of primary cardiac lymphoma presenting as a huge mass: report of two cases.

Primary cardiac lymphoma (PCL) is a rare malignancy that is sometimes diagnosed at later stages because it is not associated with specific symptoms. Although chemotherapy is the standard for treating PCL, the value of surgical resection is controversial. We describe two patients who were treated by surgical resection and chemotherapy. Case 1 is a 37-year-old man with a history of acute lymphocytic leukemia and shortness of breath, and Case 2 is a 70-year-old woman with general fatigue. Both of them were presented at hospital. In Case 2, arrhythmic syncope occurred and direct current cardioversion was performed. Echocardiography showed a massive tumor in the right atrium and disturbed hemodynamics in both cases. The restricted venous return was alleviated by emergency surgery. The pathology report indicated primary cardiac lymphoma that was regressed by post-operative chemotherapy. A massive PCL should be surgically resected to prevent sudden death.

[Surgical treatment of coronary aneurysm after percutaneous coronary intervention].

A 61-year-old man with acute myocardial infarction underwent percutaneous coronary intervention with stent for the left main coronary artery (LMT) and the left anterior descending artery (LAD). Three months later, we recognized the LMT aneurysm complicated with possible thrombus formation, which developed in size during 6 months. In addition, the LAD stent showed significant in-stent stenosis. For the purpose of supplying blood flow to the distal of LAD, and avoiding myocardial infarction due to distal thrombosis possibly originated from LMT aneurysm, we decided to perform surgical operation. On preoperative examination, this patient had an obstruction of the right internal carotid artery. Although the direct repair of LMT aneurysm requires conventional approach with cardiopulmonary bypass, we applied off-pump coronary artery bypass grafting( OPCAB) considering the risk of cerebrovascular event. Consequently, OPCAB was performed in usual fashion [right internal thoracic artery (RITA) -LAD, left internal thoracic artery-left circumflex artery (LITA-LCX)] followed by the ligation of the proximal of LAD and LCX without cardiopulmonary bypass. The patient had a good operative course.

Evaluation of ITA Graft Function Using CT Angiography.

OBJECTIVE: A less invasive method to assess internal thoracic artery (ITA) graft function after coronary artery bypass grafting (CABG) is desired. This study reports the novel method to estimate ITA graft function using CT angiography. MATERIALS AND METHODS: Fifty ITA grafts were assessed. Hounsfield Unit transition of each graft on the same cross section was detected during the Test Bolus Injection, which led to the making of a time density curve (TDC), for each ITA. Variables from the TDC were compared statistically with data obtained from Pulse Doppler Echo (PDE), the best indicator of graft function, of ITA grafts. RESULTS: The ascending slope of the TDC was significantly associated with the following PDE data: Velocity time integral (VTI), VTI × Heart Rate (HR) and Mean Flow of ITA graft. A multivariate analysis showed an especially strong relationship with the ascending slope of the TDC and VTI × HR (R(2) = 0.588). CONCLUSION: The ascending slope of the TDC means the concentration transition of contrast media, which may be affected by the blood stream in the ITA graft. This study suggests the possibility of the ability to assess ITA graft function by CT angiography.

Influence of pressure load on durability of pulmonic xenobioprostheses in young adults.

The aim of this study was to investigate the effects of pressure load (pulmonary arterial pressure) on the long-term durability of second-generation xenobioprostheses in the pulmonary position in young adults. Thirteen patients survived pulmonary valve replacement for pulmonary regurgitation using the second-generation aortic porcine bioprosthesis at Sapporo Medical University School of Medicine between 1985 and 2009. The mean age at pulmonary valve replacement was 40.5 years, and the mean prosthetic valve size was 25.3 mm. Two patients developed structural valve deterioration 6 and 9 years, respectively, after pulmonary valve replacement. Both prosthetic valves with structural valve deterioration were subjected to long-term high levels of pressure load. No valve structural failure was observed in the remaining 11 patients who experience low-pressure load during a mean follow-up period of 11.9 years. The freedom from structural valve deterioration at 15 years was 75.8% for the overall population, but 100% for those with low-pressure load. Our findings suggest that the long-term durability of pulmonary-site bioprosthetic valves in young adult patients is promising but that pressure load might be a risk of the limited durability of the valve.

Endovascular stent-grafting of anastomotic pseudoaneurysms following thoracic aortic surgery.

PURPOSE: Anastomotic pseudoaneurysm is a rare but life-threatening complication after thoracic aortic surgery. Endovascular stent-grafting is a less invasive treatment for thoracic aortic aneurysm; however, its clinical usefulness for anastomotic pseudoaneurysms following thoracic aortic surgery is unclear. METHODS: A series of 12 anastomotic pseudoaneurysms in 10 patients, which occurred following thoracic aortic surgery, underwent endovascular stent-grafting in our university hospital. Eight emergent endovascular stent-grafting cases were included in this study. A hand-made stent-graft, reconstructed by suturing graft material to an endoskeleton of modified Gianturco Z stents, was used in all cases. RESULTS: The delivery success rate was 91.7%, and the hospital mortality rate was 25.0%. Two cases were converted to open surgery during the postoperative phase because of a type I endoleak. Complete absorption or shrinkage of the anastomotic pseudoaneurysm was observed in seven of nine cases. CONCLUSION: Endovascular stent-grafting for patients with anastomotic pseudoaneurysms of the thoracic aorta following thoracic aortic surgery has become a possible optimal treatment. However, long-term outcome remains unclear, and periodical follow-up is required.

Hybrid treatment for aortic arch and proximal descending thoracic aneurysm: experience with stent grafting for second-stage elephant trunk repair.

BACKGROUND: Aortic aneurysm affecting the arch and proximal descending thoracic aorta may require a two-stage repair, which includes proximal elephant trunk graft placement and completion of descending thoracic aortic repair. The combination of open surgery and endovascular grafting may improve the morbidity and mortality of the patient population at risk. METHODS: Between February 2001 and March 2007, 258 patients underwent thoracic aortic endovascular grafting at our institution, wherein 31 patients underwent a hybrid approach involving proximal arch repair and elephant trunk graft replacement, and endovascular completion procedures. All patients, who underwent combined endovascular and open procedures in the management of the aortic arch and proximal descending thoracic aortic aneurysms, were reviewed and analysed retrospectively. RESULTS: The interval between the first and second stage ranged from 0 to 14 months with a mean interval of 3.1 months. Follow-up ranged from 0 to 70 months with a mean of 31 months. Technical success was achieved in all patients. The 1, 12, 36 and 60-month mortality rates were 6.4%, 16.5%, 26.7% and 26.7%, respectively. Caudal migration of the endograft occurred in three patients, who underwent conversion to open surgery. Two cases of paraparesis but no paraplegias or strokes were recorded. CONCLUSIONS: Staged procedures using endovascular grafting in the treatment of the arch and proximal descending thoracic aneurysm may have the potential to reduce morbidity and mortality rates. Although long-term results are still pending, this early experience demonstrates the safety and early-term effectiveness of this hybrid approach, which consists both of endovascular and open surgical procedures.

Pulmonary sequestration associated with asymptomatic aspergillosis.

Intralobar pulmonary sequestration associated with asymptomatic aspergillosis is a rare case. We describe the case of a 65-year-old woman with intrapulmonary sequestration, anomalous systemic arterial supply to the left lower lobe and aspergillosis who underwent left lower lobectomy and ligation of an anomalous artery by Video-Assisted Thoracoscopic surgery (VATS). Pathological examination showed the parenchymal distortion and chronic inflammation. Aspergillus were found in the cyst. VATS lobectomy for intralobar pulmonary sequestration is a safe and valid procedure.