Surgical Correction of Adult Unrepaired Tetralogy of Fallot to Facilitate Stage IIIA Uterine Cancer Treatment.

Unrepaired tetralogy of Fallot (TOF) in adults may compound cancer treatment difficulties, while strategies for adult unrepaired TOF combined with malignant neoplasms are scarce. Here, we report a case of adult unrepaired TOF with uterine cancer. A hybrid surgical strategy minimized invasiveness and the patient survived both cancer resection and adjuvant radiochemotherapy. The patient remains asymptomatic at 12 months of follow-up with no recurrence of malignancy or its markers.

Surgical extraction of a giant intracardiac lead vegetation and epicardial pacemaker reimplantation in a pacemaker-dependent hemodialysis patient.

A 57-year old male with a dual-chamber pacemaker and 40-year history of hemodialysis and autoinflammatory disease developed a large, 35 × 35 mm intracardiac vegetation on the right ventricular pacing lead. As this mass was large enough to occlude the tricuspid valve orifice, transvenous lead extraction was deemed unsuitable. Instead, an urgent surgical extraction of the whole pacemaker system, including leads and vegetation, was conducted under cardiopulmonary bypass. In light of a high risk of recurrent blood infection, a new dual-chamber pacing system was then immediately re-established using epicardial pacing leads on the right atrium and ventricle instead of transvenous electrodes. This case of a rare, giant intracardiac lead vegetation lacked most known causal factors, except for renal failure, but a possibly immunosuppressed cardiac microenvironment due to long-term steroid therapy may have been an important influencing factor.

Surgical resection of enlarged calcification formed by idiopathic localized constrictive pericarditis during total aortic arch replacement for aortic dissection.

A 75-year-old woman presented at a prior hospital with persistent cough and was treated conservatively for a thrombosed-type aortic dissection (Stanford A). One-year after discharge, follow-up computerized tomography revealed a DeBakey type II, chronic dissecting aortic aneurysm enlarged to 54 mm. She was referred to our hospital with slight edema in the face and extremities and chest radiography showed calcification around the heart. Computerized tomography performed at the prior hospital showed a large spherical mass in the anterior pericardium in addition to the aortic dissection. We therefore resected the mass immediately before a total aortic arch replacement. Surgery was successful and uneventful with patient discharge on postoperative day 21. The final differential diagnosis was idiopathic, localized, constrictive pericarditis.

Pulmonary Artery Obstruction by Idiopathic Calcification Causing Sudden Collapse in a Neonate.

We report a case of a newborn infant who experienced circulatory collapse caused by a calcified lesion occluding the main pulmonary artery (PA). The baby was full-term at birth at a normal birth weight. Cyanosis was noted immediately after birth. Echocardiography revealed a main PA occlusion caused by a calcified lesion. Bradycardia and circulatory failure occurred at postnatal day 4, and an urgent surgical resection was successfully performed. Idiopathic calcification causing both PA obstruction and circulatory collapse is rare. Our report indicates that PA calcification can cause hemodynamic instability requiring early surgical intervention.

Popliteal Artery Pseudoaneurysm Associated with Osteochondroma.

Osteochondroma is the most common benign bone tumor, which can sometimes cause vascular complications. Here we report two rare cases (a 48-year-old woman and a 28-year-old woman) presenting with pain and a pulsatile mass in the popliteal region. Computed tomography revealed pseudoaneurysm in the popliteal artery, which was closely associated with a protrusion of a femoral osteochondroma. Surgical repairs were performed, and the patients remained asymptomatic during follow-up. Therefore, considering the potential risk of vascular complications, close observation is mandatory in patients with femoral osteochondroma.

[Pseudoaneurysm Formation after Aortic Root Replacement Using Freestyle Porcine Bioprosthesis].

We report a case of pseudoaneurysm formation after implantation of Medtronic Freestyle stentless bioprosthesis with a full root technique. A 65-year-old man previously underwent aortic root replacement with a Freestyle bioprosthesis. Ten years after the initial operation, pseudoaneurysm of the aortic root with a diameter of 6 cm was observed by computed tomography. At the reoperation, there was no sign of infective endocarditis, and the pseudoaneurysm was found to originate from the ruptured left and noncoronary sinuses. The aortic root was successfully reconstructed with a composite graft bearing a stented bioprosthesis. Although Freestyle bioprosthesis has several advantages over conventional stented valves, close observation should be mandatory to prevent this potentially catastrophic complication.

[Surgical Treatment for Various Types of Thoracic Aortic Disease using Commercially Available Open Stent Graft;Early Results and Technical Pitfalls].

BACKGROUND: The open stent grafting, in other words "frozen elephant trunk (FET)" technique has been played an important role in surgical treatment of extensive thoracic aortic pathologies. J Graft Open Stent Graft (JOSG) was a new Japan-made commercially available product. We have recently introduced this attractive device as an alternative to self-made open stent graft. PATIENTS: Twenty consecutive patients underwent aortic arch replacement using the JOSG as a FET in our institution. A JOSG was implanted:atherosclerotic thoracic aortic aneurysm (n=10), acute type A aortic dissection( n=6), chronic type B dissection( n=4). RESULTS: There was no operative death, but 1 patient died of multiple organ failure 5 weeks after the operation. Spinal cord injury was observed in 1 patient. Although JOSG implantation was completed in all patients, we experienced 2 cases of technical device failure during operation. After distal anastomosis with the insertion of JOSG to the downstream aorta, antegrade perfusion of extracorporeal circulation became difficult due to JOSG obstruction. Severe kinking of JOSG might occurred because of the tortuous distal arch to descending aorta and the excellent flexing properties of the JOSG. In patients with aortic dissection presenting narrow true lumen, subsequent endovascular stent graft placement was required because of inadequate obliteration of the false lumen. CONCLUSIONS: Thoracic aortic surgery using JOSG was introduced and performed with acceptable morbidity and mortality. JOSG was expected to contribute to the surgical treatment of thoracic aortic diseases, but a few serious complications of JOSG related to its structural property should be kept in mind for the safety of the procedure.

[Introduction of Minimally Invasive Port-access Surgery for Aortic Valve Replacement;Yamagata University Hospital's Experience].

BACKGROUND: Minimally invasive cardiac surgery (MICS) through a small intercostal thoracotomy has many advantages, but it is still challenging because of limited mobility through the small skin incision and surgical field. The benefits of MICS should be reached without compromising the quality of the operation and increasing the morbidity and mortality of standard sternotomy approach. We have recently introduced MICS-aortic valve replacement (AVR) in order to establish as a standard surgical technique for the treatment of aortic insufficiency. METHODS: Eleven consecutive patients underwent MICS-AVR in Yamagata University Hospital. Anesthetic and surgical techniques were simplified and standardized as possible to overcome technical difficulties. Preoperative chest computed tomography( CT) provides useful information about suitability of the patient's anatomy for MICS approach. Furthermore, we developed a preoperative image overlay technique by projecting 3-dimensional CT image over the patient's body surface. RESULTS: There was no operative death. MICS-AVR procedure was completed in 10 patients. One patient was converted to sternotomy approach probably because of the vascular spasm through femoral artery cannulation for extracorporeal circulation. Although there were some anxious points to manage MICS procedure, preoperative planning based on the image overlay from CT image were useful for setup and instrument placement for MICS. CONCLUSIONS: MICS-AVR was introduced and safely performed with acceptable morbidity and excellent mortality at our institution. Close observation should be mandatory in order to implement individual and departmental performance monitoring with regard to the learning curves and surgical complications associated with less invasive procedure itself.

[Endoscopic Long Saphenous Vein Harvest from Femoralsite to Below the Knee through a Single Small Incision for Minimally Invasive Coronary Artery Bypass Grafting].

BACKGROUND: Endoscopic saphenous vein harvest( EVH) for coronary artery bypass grafting( CABG) has been proved to be effective in reduced wound complications without compromising graft patency and mortality. Although EVH was usually performed from femoral site, we performed endoscopic long saphenous vein harvest( ELSH) from femoral to below the knee through a single small incision. There were few reports in EVH from below the knee and ELSH. PATIENTS AND METHODS: Between September 2012 and June 2014, 13 patients who underwent ELSH in CABG. We assessed the initial evaluation in ELSH using the VirtuoSaph system. ELSH was performed by our unified procedure protocol to harvest good saphenous vein graft. RESULTS: The success rate of ELSH was 100% (13/13). The harvest time was 83.6±15.2 min, graft length was 52.1±5.6 cm, and number of side branches requiring repair was 2.6±1.6. Beating CABG was performed in all patients. The number of distal anastomoses was 3.8±0.8. Sequential bypass was 12 in total 23 saphenous vein grafts. The early patency was 95% (18/19 grafts) as evaluated by postoperative angiography or coronary enhanced computed tomography. All patients except 1( hospital death)were discharged without major or wound complications. CONCLUSIONS: The acceptable results and outcomes were demonstrated by our ELSH procedure protocol. ELSH is considered to be a feasible procedure to harvest enough graft length for 2 CABG and keep the other side of saphenous vein graft intact.

Prenatal Diagnosis of Congenital Absence of Aortic Valve: A Report of Two Cases with Different Outcomes and a Literature Review.

Congenital absence of aortic valve (AAV) is a rare cardiac anomaly associated with high mortality. We present 2 prenatally diagnosed cases of AAV. In both cases, fetal echocardiography showed no aortic valve tissue and free aortic regurgitation. At 24 weeks' gestation, case 1 showed a hypoplastic hypocontractile left ventricle and mitral atresia, but did not develop hydrops and was born at term. Bilateral pulmonary arterial banding was performed with continuous infusion of prostaglandin E1 at 5 days of age followed by Norwood and bidirectional Glenn procedures at 3 months of age. The hypoplastic non-compliant left ventricle and mitral atresia might have limited aortic regurgitation. Case 2 showed hydrops at 23 weeks' gestation. An enlarged hypocontractile left ventricle and massive mitral insufficiency were noted. The regurgitant flow was directed to the right atrium through a foramen ovale. This peculiar hemodynamic established a malignant circuit which was arbitrarily called 'inverse circulatory shunt'. Intrauterine death occurred at 28 weeks' gestation. An autopsy showed absent aortic valve leaflets but three tiny membranous remnants. Hemodynamic evaluation by fetal echocardiography should include the documentation of the presence of and assessment of the grade of aortic regurgitation, mitral regurgitation and blood flow through a foramen ovale as well as left ventricular function.

Staged Fontan operation for children with heterotaxy syndrome, bilateral ductus arteriosus, and nonconfluent pulmonary artery.

We report two cases of successful Fontan operation in children with heterotaxy syndrome associated with univentricular physiology and absent and nonconfluent central pulmonary arteries with both distal pulmonary arteries directly connected to the ipsilateral ductus arteriosus. After unilateral systemic-pulmonary shunt, the central pulmonary artery was reconstructed with a polytetrafluoroethylene prosthetic graft concomitantly with bidirectional cavopulmonary shunt. Finally, extracardiac total cavopulmonary connection was performed as an off-pump procedure. Children with bilateral ductus arteriosus and a nonconfluent pulmonary artery with univentricular physiology present a particular challenge in regard to completing Fontan operations. Careful attention should be directed at ensuring balanced growth of the bilateral distal pulmonary arteries. When planning reconstruction of the central pulmonary artery with a prosthesis, late reconstruction may be beneficial, as it enables utilization of a larger-caliber graft, obviating the need for replacement during a subsequent Fontan operation.

Two cases of tetralogy of Fallot with absent pulmonary valve repaired by modified Kreutzer's technique.

Two severely symptomatic infants of tetralogy of Fallot with absent pulmonary valve successfully repaired by a modified Kreutzer's technique are described. In addition to the standard repair of tetralogy of Fallot, our surgical technique consists of extensive pulmonary reduction arterioplasty, which allows tracheobronchial decompression. Both patients tolerated surgery and showed significant relief of airway compression and clinical symptoms, although they required prolonged mechanical ventilatory support. The modified Kreutzer's technique is relatively simple and could be sufficiently efficacious even for symptomatic infants of tetralogy of Fallot with absent pulmonary valve.

Recurrent symptomatic chylopericardium after cardiac surgery in a child.

Chylopericardium is a rare complication after cardiac surgery in children. We report a case of a recurrent chylopericardium complicating postoperative course in a 4-month-old child. Chylopericardium occurred after two separate operations 6 months apart. On both occasions, symptomatic cardiac tamponade required pericardial drainage. Differentiation of chylopericardium from simple postoperative pericardial effusion can be difficult. When chylopericardium is strongly suspected from previous history and patient background, prompt treatment, including pericardial drainage and dietary treatment, is warranted.

Aortic root replacement for prosthetic aortic valve detachment without regurgitation and with enlarged Valsalva's sinuses and complete atrioventricular block caused by Takayasu's aortitis.

We replaced the aortic root in a 43-year-old woman with Takayasu's aortitis associated with prosthetic aortic valve detachment. The patient's aortic valve had been replaced when she was 31 years old with a mechanical prosthesis to treat aortic regurgitation. Though C-reactive protein was kept almost normal with prednisolone, complete atrioventricular block suddenly appeared 12 years after the first operation. After the implantation of an artificial pacemaker, we closely followed up aortic root status. Aortography and echocardiography showed that the valve moved up and down, probably due to enlargement of the sinuses of Valsalva, without perivalvular leakage. We removed the prosthetic aortic valve, which was partially detached from the aortic valve ring at the right- and non-coronary cusps and successfully replaced the aortic root with a mechanical prosthesis inserted into a 26 mm woven graft. Although the postoperative course was uneventful, we closely continue to observe the case and to administer of antiinflammatory medication.