[Combined Resection of the Aorta under Cardiopulmonary Bypass for Locally Advanced Lung Cancer].

We present two cases with locally advanced lung cancer invading the descending aorta. Case 1 is a 67 years old male, who had been followed up for stroke. Enlargement of a mass lesion in the left lung was pointed out on further examination. Case 2 is a 64-year-old man, who was referred to our hospital because of cough and abnormal shadow on the chest X-ray and computed tomography (CT). We suspected that both tumors were lung carcinoma invading the descending aorta based on enhanced CT findings. In both cases, the clinical stage was cT4N0M0 stageⅢA. They underwent left pneumonectomy with combined en bloc tubular resection and reconstruction of the descending aorta via a posterolateral thoracotomy using cardiopulmonary bypass in the right lateral decubitus position. The histologic type of both tumors was squamous cell carcinoma. The pathological staging was pT4N0M0 in case 1, and pT4N2M0 in case 2. After surgery, the first patient received chemotherapy consisting of carboplatin and vinorelbine plus pembrolizumab. He survived 17 months until sudden death of unknown reason. The second did not receive adjuvant treatment because his postoperative performance status was slightly reduced. He died of local recurrence 6 months after the operation.

[Papillary Thyroid Cancer Metastasizing Anterior Mediastinal Lymph Node with Extra-nodal Invasion to the Lung:Report of a Case].

We describe a 79-year-old female with a prior history of two times of mitral valve surgery and pacemaker implantation. She was transferred to our hospital presenting bloody sputum with dyspnea. Chest enhanced computed tomography (CT) showed a large anterior mediastinal mass of 64×52 mm in size. She underwent surgery for the mediastinal tumor through third time median sternotomy approach. As the tumor was suspected of infiltrating to the lung, combined resection of right upper lobe was additionally performed. Histological examination revealed papillary thyroid carcinoma metastasizing anterior mediastinal lymph node with extra-nodal invasion to the lung. After surgery, echography detected primary lesion in the left lobe of thyroid gland, and the patient was finally diagnosed as papillary thyroid cancer metastasizing mediastinal lymph node. Two months later, she underwent total thyroidectomy.

[Off-pump Coronary Artery Bypass Grafting for Anomalous Origin of the Left Coronary Artery: Report of a Case].

Anomalous origin of the left coronary artery from the right sinus of Valsalva is a rare anomaly known to cause sudden death in young competitive athletes. We report a case of 58-year-old male who was admitted to our hospital because of acute coronary syndrome. Emergency coronary angiography documented a critical stenosis in the right coronary artery. A cardiologist implanted a stent with good angiographic result. It was not possible to place a catheter in left coronary artery ostium at normal position. The patient was diagnosed to have an anomalous origin of the left coronary artery arising from the right sinus of Valsalva, passing between the aorta and the main pulmonary artery by coronary 3 dimensional computed tomography angiography (3D-CTA). After a stent insertion, he still had angina. Further examination of the left coronary artery including intravascular ultrasound revealed a hard plaque in the left main trunk as the culprit lesion. Because previous percutaneous coronary intervention was ineffective, off-pump coronary artery bypass grafting was performed using bilateral internal thoracic arterial grafts to the left anterior descending artery and the obtuse marginal branch. Postoperative 3D-CTA demonstrated patent grafts. Two years after the operation, he is free from chest discomfort.

[Resection under Endoscopic Guidance of Papillary Fibroelastoma in the Left Ventricular Outflow Tract:Report of a Case].

A 76-year-old man was admitted to our hospital for a thorough examination of a suspected cardiac tumor on transthoracic echocardiography. Transesophageal echocardiography demonstrated a 9.4×8.1 mm mobile stalk-like mass in the left ventricular outflow tract. A preoperative electrocardiogram revealed paroxysmal atrial fibrillation. Tumor resection and pulmonary vein isolation were performed to prevent embolism and confirm the diagnosis. The tumor was resected using an endoscope because it was difficult to evaluate the tumor under direct view from the aortic valve. Pathological diagnosis was cardiac papillary fibroelastoma. Postoperative echocardiography showed no residual tumor or aortic regurgitation. One year and eight months passed since the surgery, and no recurrence of the tumor was detected. In cases like this one, where direct observation of the tumor is difficult, we suggest that the use of an endoscope may be effective because it has the advantage of sharing information with other surgeons.

[Superior Vena Cava Syndrome due to Large Cell Neuroendocrine Carcinoma Originated in the Mediastinum].

We report a case of a 53-year-old man with superior vena cava( SVC) syndrome due to large cell neuroendocrine carcinoma (LCNEC) in the mediastinum. His chief complaint was general fatigue. On physical examination, both jugular veins were distended and his face and bilateral upper limbs were swollen. Enhanced chest computed tomography (CT) scan demonstrated a heterogenous tumor of approximately 50 mm in diameter in the middle mediastinum, which infiltrated into the SVC and right atrium, and caused SVC syndrome. Since SVC syndrome developed rapidly, the tumor was resected and the occluded SVC was replaced with a ringed polytetrafluoroethylene graft under cardiopulmonary bypass. After surgery, SVC obstruction was resolved with improvement of the initial symptoms. The patient had an uneventful recovery and was discharged from our hospital. The tumor was diagnosed as LCNEC histologically. He received postoperative adjuvant systemic chemotherapy. Unfortunately, he died of extensive brain and bone metastasis 10 months after the operation. However, we believe that surgical relief from SVC syndrome improved quality of the rest of his life.

Successful treatment of a right internal mammary artery aneurysm with thoracoscopic surgery.

Internal mammary artery aneurysms are rarely detected, with only a few cases caused by physical trauma, connective tissue diseases, and vasculitis having been reported. We describe the case of a 52-year-old woman diagnosed with a right internal mammary artery aneurysm several months after experiencing a DeBakey Ⅲ acute aortic dissection. The artery had an indication of dissection that seemed to have caused the aneurysm. Thoracoscopic resection was performed, and the patient recovered with no major complications.

Ascending aortic aneurysm exposed to direct impingement of eccentric flow jets through a tilting-disc valve prosthesis.

Single-leaflet tilting-disc aortic valve prostheses are known to generate eccentric transvalvular flow jets. These prostheses are routinely inserted with the major valve opening directed toward the non-coronary sinus to achieve more favorable hemodynamic performance. From the viewpoint of blood flow dynamics, the structural and functional properties of tilting-disc aortic valves resemble those of congenital bicuspid aortic valves with right- and left-coronary leaflet fusion, which have been associated with aortopathy in the ascending aorta. Here we describe the case of a patient who had undergone aortic valve replacement in 1987 with a Björk-Shiley tilting-disc valve and required reoperation for ascending aortic aneurysm 29 years later. Eccentric flow jets through the tilting-disc valve directly impinged on the posterior wall of the ascending aorta including the aortotomy suture line, possibly contributing to the development of the saccular aneurysm in the ascending aorta.

Renal Vein Thrombosis After Open Repair of Abdominal Aortic Aneurysm Successfully Treated by Direct Oral Anticoagulants.

INTRODUCTION: Venous thromboembolism (VTE) of the lower extremities frequently occurs after surgery. It is unknown whether the complication of renal vein thrombosis (RVT) develops after an open repair (OR) for abdominal aortic aneurysm (AAA). Furthermore, anticoagulation therapy with apixaban, a direct oral anticoagulant (DOAC), has not been described as treatment for RVT in such cases. CASE: A 64-year-old man underwent OR for AAA. Postoperative computed tomography revealed RVT in the left renal vein. Apixaban (5 mg twice a day) therapy was initiated. Six months later, we discontinued anticoagulation therapy and observed no recurrence. Following OR, our patient developed RVT for which DOACs were very useful. CONCLUSION: Thus, RVT can manifest as VTE after OR and direct anticoagulants can be considered as a therapeutic option.

To repair or not to repair: a case report of atrioventricular groove hematoma during mitral valve surgery.

BACKGROUND: Atrioventricular groove hematomas during mitral valve surgery range from simple hematomas to complex atrioventricular disruptions that cause frank rupture with massive bleeding and subsequent mortality. A small or moderate-sized hematoma is reported to be present in the left atrioventricular groove in 10 to 30% of all patients immediately after mitral valve replacement. Despite the fact that atrioventricular groove hematomas are inherently unstable and unpredictable, conservative strategies are recommended due to the high mortality associated with additional surgical repair. Such conservative strategies, however, would not resolve the potential risk of rupture, and there also appears to be a certain degree of uncertainty to be overcome using the current advances in cardiac surgery. CASE PRESENTATION: We present a case of atrioventricular hematoma during double valve replacement which was treated with conservative management. A left ventricular pseudoaneurysm developed after surgery, but spontaneously resolved completely within six months. After reflecting on our case, we developed a check sheet, including the anesthesiologist's transesophageal echocardiography findings, for reasonable intraoperative decision-making regarding conservative management vs. additional surgical repair. Our check sheet helps organize the pathophysiological understanding of the injury and integrates partial findings from complementary viewpoints, and can be used to accurately assess intense situations and develop a common understanding among surgical team members. CONCLUSIONS: Our case involved an atrioventricular groove hematoma that occurred during mitral valve surgery and caused a left ventricular pseudoaneurysm. Conservative strategies yielded positive results. We hope our experience and original check sheet will be of value to surgical teams facing similar situations.

Effective kissing stent to severe stenosis of the superior mesenteric artery replacing the common hepatic artery.

BACKGROUND: Endovascular therapy (ET) for chronic mesenteric ischemia (CMI) is a effective treatment to relieve the symptoms, such as postprandial abdominal pain, food fear, and progressive weight loss. CMI is not known to be caused by rare anatomical variation of severe stenosis of the superior mesenteric artery (SMA), with replaced the common hepatic artery to the SMA. The treatment of such a rare anatomical variation using ET technique has not been discribed. ET with kissing stent technique can be applied to the CMI accompanied with a rare anatomical variation. CASE PRESENTATION: An 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15-30 min after every meal. Abdominal computed tomography (CT) showed severe calcification of the SMA origin and bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum. As the patient did not have peritonitis, a conservative approach was used. Angiography performed after symptom resolution showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery. ET with the kissing stent technique, namely stenting to the SMA and common hepatic artery, was successfully performed and relieved the patient's symptoms. CONCLUSIONS: CMI cause the symptoms of Pneumatosis intestinalis (PI) and pneumoperitoneum. Severe stenosis of the SMA origin replacing the common hepatic artery is a rare anatomic variation, which can cause CMI symptoms. ET with a kissing stent is the effective treatment option for the mesenteric artery stenosis accompanied with such rare anatomical variation.

Clinical significance of a false lumen pathway through the arch in acute type A aortic dissection and its influence on cervical branch compromise.

OBJECTIVES: Upon onset of acute type A aortic dissection, the aortic true lumen generally becomes fixed around the supra-aortic branches in the greater curvature and Botallo's ligament in the lesser curvature of the aortic arch. Therefore, the pathways of the false lumen through the arch can be categorized as anterior, bilateral and posterior. We investigated the relationship between a false lumen pathway through the arch and cervical branch compromise, stratified by primary tear location. METHODS: Sixty-four consecutive patients with acute type A aortic dissection underwent emergency surgery at our institution between March 2005 and October 2013. Of these, 40 cases (63%) were DeBakey type I, 15 cases (23%) were type II and 9 cases (14%) were type III-D (retrograde type A). We conducted a retrospective review of preoperative computed tomographic angiography using three-dimensional image post-processing tools for 43 cases, excluding 15 cases with type II and 6 cases with type I for which preoperative digital image data were not available. RESULTS: Of the 43 cases, 14, 18 and 11 revealed anterior, bilateral and posterior pathways, respectively. Twenty-one cases (49%) showed a primary intimal tear in the ascending aorta (8 anterior, 12 bilateral and 1 posterior), 12 cases (28%) showed a primary intimal tear in the aortic arch (5 anterior, 3 bilateral and 4 posterior) and 10 cases (23%) showed a primary intimal tear in the descending aorta (1 anterior, 3 bilateral and 6 posterior). Twelve of the 14 anterior pathway cases (86%) had a total of 26 supra-aortic branch compromises, 13 of the 18 bilateral pathway cases (72%) had a total of 20 supra-aortic branch compromises, while only 4 of the 11 posterior pathway cases (36%) had a total of four supra-aortic branch compromises. None of the 11 posterior pathway cases had a dissection extending into all 3 supra-aortic branches. CONCLUSIONS: Posterior pathway cases generally showed primary tear locations in the arch or descending aorta, and cervical branch compromise was rare. Aortic dissections tended to extend into the cervical branches through the anterior side of the aortic arch. A false lumen pathway through the arch was strongly associated with cervical branch compromise in acute type A aortic dissections.

A case of carotid artery dissection after surgical repair of aortic dissection successfully treated with endovascular therapy using intravascular ultrasound.

A 71-year-old woman developed the dissection from right brachiocephalic trunk (BCT) to internal carotid artery 6 days after the operation of ascending aortic dissection. Since no improvement of symptoms was observed despite conservative therapy, we performed endovascular therapy (EVT). Although a balloon-expandable stent was implanted in the BCT to seal the entry point of the dissection, the true lumen of the carotid artery was still compressed. Thus, we covered the dissected lesion completely with multiple stents, and her neurological findings improved. This case demonstrates that EVT using multiple stents is an effective strategy to manage dissection of supra-aortic branches.

A new classification system for branch artery perfusion patterns in acute aortic dissection for examining the effects of central aortic repair.

OBJECTIVES: We developed a new classification system for branch perfusion patterns in acute aortic dissection and used it to retrospectively evaluate the perfusion status of whole aortic branches and to examine the effects of central aortic repair. METHODS: Thirty-four consecutive patients with acute type A aortic dissection underwent emergent surgery at our institution between August 2008 and December 2011. A retrospective review of pre- and postoperative computed tomographic angiography was performed. Branch perfusion patterns were categorized into three classes: Class I, dissection involving but not extending into the branch; Class II, dissection extending into the branch and Class III, dissection causing ostial avulsion. RESULTS: In cervical branches (total 169 branches), 70 branches (41%) presented with Class I patterns, 58 (34%) with Class II and none with Class III. In abdominal branches (total 135 branches), 76 branches (56%) presented with Class I patterns, 12 (9%) with Class II and 18 (13%) with Class III. In common iliac arteries (total 68 arteries), 14 arteries (21%) presented with Class I patterns, 24 (35%) with Class II and none with Class III. After repair, among 21 high-risk cervical branches, 14 branches (67%) showed improvement, 3 (14%) preserved distal perfusion supplied through the patent branch false lumen and 4 (19%) showed no improvement in high-risk perfusion pattern or worsened. Among 22 high-risk abdominal branches, 18 branches (82%) showed improvement, 3 (14%) preserved distal perfusion supplied through the patent branch or aortic false lumen and 1 (5%) showed no improvement in high-risk perfusion pattern. CONCLUSIONS: To overcome malperfusion syndromes associated with acute aortic dissection, recognition of diverse branch perfusion patterns through a universal classification system is imperative.

Surgical treatment of a bronchogenic cyst in the interatrial septum.

Bronchogenic cysts in the interatrial septum are very rare. We experienced a case in which a 39-year-old man, incidentally diagnosed through echocardiography as having a cardiac tumor, was surgically treated. Pathologic investigation of the tumor, which was located in the interatrial septum and resected, revealed that the tumor was a bronchogenic benign cyst. Tumor enucleation was performed and the resultant atrial septal defect was closed by an autopericardial patch.