Giant coronary artery aneurysm in the atrial septum.

A man in his 60s with paroxysmal atrial fibrillation was scheduled for a catheter ablation but was admitted to our department after contrast-enhanced CT showed a large homogeneous right atrial mass (52×52 mm) as well as a dilated right coronary artery (RCA). Coronary artery angiography showed a large fistula from the RCA to the mass in the right atrium. A giant coronary artery aneurysm was suspected and a surgical resection was performed. The mass was attached to the atrial septal wall and was palpated in the right atrium with a feeding artery from the RCA. The final diagnosis was an extremely rare case of giant coronary artery aneurysm originating from the RCA. The surgery was successful, and the patient was discharged 30 days later.

[Surgical Treatment with Pulsed Lavage Irrigation for Infective Endocarditis].

INTRODUCTION: Pulsed lavage irrigation (PLI) is a procedure used to wash contaminated soft tissues and prevent infection in orthopedic surgery. We applicated PLI for surgical treatment of infective endocarditis( IE). SUBJECTS AND METHODS: From January 2017 to June 2021, 6 cases underwent surgical treatment IE using PLI. We investigated an efficacy of PLI. RESULTS: Infected valves were mitral valve in 4 cases, aortic valve in 1 case, and aortic prosthetic valve in 1 case. The performed procedures were mitral valve plasty in 4 cases, aortic valve replacement in 1 case, and 1 removal of vegetation on the aortic prosthetic valve. No recurrence of IE or no deterioration of the native valve or the prosthetic valve was observed in follow-up periods. CONCLUSION: PLI was useful for surgical treatment of IE because of no recurrence of IE or no deterioration of native mitral valves or the aortic prosthetic valve.

Redo aortic valve replacement due to early structural valve deterioration in a trifecta valve: A case report.

INTRODUCTION AND IMPORTANCE: While the number of SAVR cases has been increasing for patients below their sixties due to the improvement of bioprosthetic valves, some early structural valve deterioration (SVD) in Trifecta valves has been reported. CASE PRESENTATION: We present a case of a female who presented with sudden shortness of breath. Ultrasonography diagnosed SVD. We performed redo aortic valve replacement due to SVD in Trifecta valve. With our surgical technique we could remove the bioprosthetic valve easily. CLINICAL DISCUSSION: We could easily remove the mounted prosthetic valve along with the titanium band. These cases may emerge with acute heart failure due to sudden massive aortic regurgitation, not like the gradual progression of stenosis due to calcification. CONCLUSION: The postoperative course in Trifecta recipients must be followed carefully.

Total Debranching Plus Antegrade Thoracic Endovascular Aortic Repair without Side Clamping in a Patient with Arch Aneurysm and Ascending Aorta Calcification.

A high-risk patient with aortic arch aneurysm, associated with severe calcification of the ascending aorta and iliac arteries, was treated with total debranching and antegrade thoracic endovascular aortic repair (TEVAR) via the ascending aorta. Proximal anastomosis for a triple-branched graft to the ascending aorta was performed without side clamping using the "real chimney technique." After bypassing the supra-aortic branches, a TEVAR was performed in an antegrade fashion through the ascending aorta. This case suggests that the approaches mentioned above should be considered in patients with arch aneurysms and severe calcified degeneration.

[Endoventricular Stepwise Plication for Left Ventricular Aneurysm].

A 69-year-old man was treated with oral anticoagulation for the left ventricular (LV) aneurysm. Echocardiography revealed dyskinetic apex with a mobile thrombus. The estimated LV end-diastolic and end-systolic volume index (LVEDVI, LVESVI) was 76 and 44 ml/m2, respectively. After the LV was opened at the apex parallel to the left anterior descending artery, removal of LV thrombus was performed. LV volume was 70 ml, and diameter of LV aneurysm was 3 cm. After setting a neo-apex, the boundary between the normal and aneurysmal scar tissue were doubly encircled by a pledgeted 2-0 polypropylene suture, and preserved the same diameter as the "aneurysmal neck" (3 cm) in order to secure the minimal residual LV volume. Similarly, second and third circular stitches were placed toward the neo-apex to make the ventricle into an elliptical shape. A postoperative echocardiography showed a well-reconstructed physiologic shape, LV volume( LVEDVI 62 ml/m2, LVESVI 27 ml/m2), and improved LV function.

Clinical significance of esophagogastroduodenoscopy in patients with esophageal motility disorders.

OBJECTIVES: The first aim of this study was to elucidate the detection rate of esophagogastroduodenoscopy (EGD) in patients complaining of dysphagia with esophageal motility disorders; the second was to clarify the useful parameters of EGD associated with esophageal motility disorders. METHODS: Participants included 380 patients who underwent EGD before high-resolution manometry (HRM) for dysphagia. EGD findings were investigated according to the following five parameters: resistance when passing through the esophagogastric junction (EGJ), residue in the esophageal lumen, esophageal dilation, and spastic and nonocclusive contractions. HRM diagnoses were based on the Chicago classification (v3.0). RESULTS: The percentage of abnormal EGD findings was 64.4% among patients with esophageal motility disorders, and the results differed for each esophageal motility disorder. The rate of abnormal EGD for both EGJ outflow obstruction and major disorders of peristalsis was significantly higher than that for manometrically normal subjects. On multivariate analysis, resistance when passing through EGJ, residue in the esophageal lumen, spastic and nonocclusive contraction were significantly associated with esophageal motility disorders. The sensitivity, specificity, positive predictive value, and negative predictive value of these parameters for detection of esophageal motility disorders were 75.1%, 86.6%, 84.8% and 77.8%, respectively. CONCLUSION: Esophagogastric junction outflow obstruction and major disorders of peristalsis can be screened with EGD. Among several endoscopic parameters, resistance when passing through EGJ, residue in the esophageal lumen, spastic and nonocclusive contraction are considered significantly useful indicators.

Bioelectrical impedance analysis for perioperative water management in adult cardiovascular valve disease surgery.

PURPOSE: Bioelectrical impedance analysis (BIA) has been used recently to measure the body water of patients with acute heart failure. We used BIA in this study to better understand, and possibly identify a predictive marker for, perioperative water behavior in cardiac surgery patients. METHODS: We measured body water and studied its behavior in 44 patients undergoing surgery for cardiac valvular disease at our hospital. Measurements included the levels of extracellular water (ECW), intracellular water (ICW), and total body water, the edema index (EI), and the ratio of ECW to total body water. The first measured EI was defined as the "preoperative EI" and the maximum as the "peak EI". RESULTS: A negative correlation was found between the preoperative EI and the preoperative estimated glomerular filtration rate (eGFR) (R = 0.644, p < 0.001). Positive correlations were found between the peak EI and the ICU stay (R = 0.625, p < 0.001), the peak EI and the ventilation time (R = 0.366, p < 0.01), and the preoperative EI and the ICU stay (R = 0.464, p = 0.026). CONCLUSION: The EI is possibly a predictive marker for perioperative water management in cardiac surgery.

Minimally Invasive Mitral Valve Repair Through Right Minithoracotomy　- 11-Year Single Institute Experience.

BACKGROUND: Although minimally invasive mitral valve repair (MIMVR) is increasingly being performed, only a few clinical studies from Japanese institutions have been reported.Methods and Results:From 2006 to 2017, 387 consecutive patients (135 females, mean age 56±13 years) underwent an initial isolated MIMVR through a right minithoracotomy. The mitral etiology was degenerative in 348, functional in 22, and endocarditis in 13 cases. Repair techniques included leaflet resection/plication in 280, chordal reconstruction in 109, and annuloplasty alone in 24 patients, and concomitant procedures included tricuspid valve repair and atrial fibrillation ablation in 70 (18.1%) and 78 (20.2%), respectively. Hospital mortality rate was 0.26%; 2 patients (0.5%) required intraoperative conversion to a median sternotomy. Perioperative morbidity included stroke (1.3%), reoperation for bleeding (0.8%), prolonged ventilation (0.5%), and permanent pacemaker implantation (2.1%). The transfusion rate was 14.7% and median ventilation time was 4 hours. Overall 5-year survival was 96.9%. For patients with degenerative mitral regurgitation (MR), the 5-year freedom from reoperation or severe recurrent MR, and freedom from ≥moderate MR were 94.7% and 82.2%, respectively. Repair for anterior mitral leaflet prolapse and the initial 30 cases were associated with higher occurrence of recurrent MR. CONCLUSIONS: MIMVR can be performed safely with low levels of mortality and morbidity, and provides sufficient repair durability. A learning curve exists in terms of repair durability, especially for anterior mitral leaflet repair.

A case of ruptured infective coronary artery aneurysm.

Infective coronary artery aneurysm is extremely rare and ruptured aneurysm is life-threatening. We report a case of ruptured coronary artery aneurysm, which was successfully treated by the patch closure technique and coronary artery bypass grafting. Pathological examination revealed purulent inflammation in the aneurysmal wall. Prompt diagnosis and appropriate treatment were essential.

Long-Term Results of Obturator Bypass.

OBJECTIVE: We evaluated the long-term outcomes of obturator bypass. MATERIAL AND METHODS: A total of 16 patients (13 males and 3 females; 17 limbs) who underwent obturator bypass surgery at our department between April 1995 and March 2008 were included. RESULTS: Their ages ranged from 50 to 90 with a mean of 74 years. Inguinal infections observed in the 16 patients consisted of vascular graft infections in 13 patients, hemostatic device infections following endovascular therapy in two patients, and femoral artery infections following coronary angiography in one patient. The cumulative patency rate was 69% for 3 years and 43% for 5 years. The cumulative survival rate was 64% for 3 years and 55% for 5 years. CONCLUSION: Obturator bypass surgery was successfully performed with favorable results for arterial infections and vascular graft infections in the inguinal region.

Sternal closure by rigid plate fixation in off-pump coronary artery bypass grafting: a comparative study.

Sternal instability or dehiscence results in serious sternal wound infection. We sought to assess the early outcomes with such a plating system for sternal closure in comparison to the conventional wiring technique in off-pump coronary artery bypass grafting (CABG). Patients who underwent off-pump CABG were enrolled. Thirty-one patients received plate sternal fixation. A total of 64 patients who underwent off-pump CABG by a single surgeon at our hospital from July 2013 to December 2014 were enrolled. Thirty-one patients received plate sternal fixation (Plate group), while 33 received conventional wire closure (Wire group). The early outcomes, including the pain score and analgesic usage count were compared. Dietary intake was also recorded to assess the duration of appetite loss. At discharge, the largest sternal displacement was measured on computed tomography. In the Plate group, the pain scores were significantly lower on post-operative day 5-8 and POD 9-12 from those in the Wire group. The analgesic usage count on POD 9-12 was significantly lower in the Plate group. The duration of appetite loss and hospital stay was significantly shorter in the Plate group. The displacement in both the anterior-posterior and lateral directions was significantly smaller in the Plate group. Sternal closure by rigid plate fixation contributes to a more rapid post-operative recovery through reduced pain.

Simple Interrupted Suturing for Redo Mitral Valve Replacement.

BACKGROUND: An evaluation was made of the early clinical outcomes and efficacies of simple interrupted suturing (SIS) for redo mitral valve replacement (MVR). METHODS: Among 336 mitral valve surgery patients at the authors' institution between April 2000 and May 2014, a total of 21 redo MVR using SIS (12 women, nine men; mean age 67±11 years; range 32-80 years) participated in the study. Surgical indications for redo MVR were paravalvular leakage (PVL) in 10 patients, prosthetic valve endocarditis in five, mechanical valve thrombosis in three, and structural valve deterioration (SVD) of the bioprosthesis in three. The number of previous surgeries was one in 10 patients, two in seven, and three in four. With regards to surgical technique, sharp dissection was initially performed on one side of the previous prosthetic sewing cuff, and the overall sewing cuff was thereafter completely removed following leaflet detachment. SIS (mean number of sutures 32.5 ± 3.0; range: 28-40 sutures) was performed to implant the new prosthesis, without exposing the rough surface of the previous mitral valve annulus, thereby allowing for eventual implantation of the same-sized or larger-sized prosthesis. RESULTS: The surgical procedure was successfully performed in all patients without any serious complications. Bioprostheses were selected for 11 patients, and mechanical valves for 10. Sixteen patients (76.2%) received a new prosthesis that was the same size as or larger than the previous prosthesis. Operative mortality within 30 days was 4.8%, which was similar to that of primary MVR in the same period (n = 83; 2.4%; p = 0.57). Recurrent PVL was detected in only one patient, who underwent a fourth surgery for SVD of the bioprosthesis. CONCLUSIONS: SIS for redo MVR may allow for the implantation of larger prostheses, and this novel maneuver may achieve acceptable early clinical outcomes.

[Minimally Invasive Cardiac Surgery( MICS) through a Mini-right Thoracotomy].

Recently, the concept of minimally invasive surgery has been expanding in cardiothoracic surgery. Minimally invasive cadiac surgery( MICS) is characterized by the avoidance of full sternotomy and minimizing of surgical incision. The advantages of this approach include less postoperative discomfort and earlier mobilization and discharge. Since port-access cardiac surgery for atrial septal defect was performed in March 2005, we have improved the devices and procedure and actively applied port-access surgery to mitral valve disorders and various cardiac diseases. MICS patients were, on average, extubated sooner and discharged from the intensive care unit (ICU) and hospital earlier than coventional procedures patients. Additionally, MICS patients had less risk of receiving a blood transfusion. We believe recently advanced MICS is a very feasible surgical option, and that, in the near future, the MICS technique can be used for patients with a variety of preoperative backgrounds and more complex cardiovascular disorders.

Propensity score-matched analysis of minimally invasive aortic valve replacement.

BACKGROUND: Right mini-thoracotomy and partial sternotomy are widely recognized as effective approaches in minimally invasive aortic valve replacement (AVR). The aim of this study was to evaluate the objective benefits of the respective approaches compared to the conventional approach. METHODS AND RESULTS: A retrospective analysis was performed in 282 consecutive patients who underwent isolated and initial AVR at a single cardiovascular institute between May 2007 and December 2012. Mini-thoracotomy and partial sternotomy were performed in 62 (22%) and in 26 patients (9%), respectively. Propensity score matching produced 36 (mini-thoracotomy vs. full sternotomy) and 24 (partial sternotomy vs. full sternotomy) well-matched pairs. Compared to the conventional approach, mini-thoracotomy was associated with significantly shorter operative time (235±35 min vs. 272±73 min; P=0.009), lower prevalence of blood transfusion (42%, 15/36 vs. 67%, 24/36; P=0.025), and significantly shorter intensive care unit and postoperative hospital stay (1.4±0.8 days vs. 2.2±1.1 days, P=0.001; and 13.3±6.5 days vs. 21.5±10.3 days, P=0.001; respectively). There were no significant differences in operative and postoperative data between the partial sternotomy and full sternotomy groups. CONCLUSIONS: The objective benefits of right mini-thoracotomy included early rehabilitation and lower prevalence of blood transfusion. Significant advantages of partial sternotomy were not found.

Propensity Score-Matched Analysis of Minimally Invasive Aortic Valve Replacement.

Background:Right mini-thoracotomy and partial sternotomy are widely recognized as effective approaches in minimally invasive aortic valve replacement (AVR). The aim of this study was to evaluate the objective benefits of the respective approaches compared to the conventional approach.Methods and Results:A retrospective analysis was performed in 282 consecutive patients who underwent isolated and initial AVR at a single cardiovascular institute between May 2007 and December 2012. Mini-thoracotomy and partial sternotomy were performed in 62 (22%) and in 26 patients (9%), respectively. Propensity score matching produced 36 (mini-thoracotomy vs. full sternotomy) and 24 (partial sternotomy vs. full sternotomy) well-matched pairs. Compared to the conventional approach, mini-thoracotomy was associated with significantly shorter operative time (235±35 min vs. 272±73 min; P=0.009), lower prevalence of blood transfusion (42%, 15/36 vs. 67%, 24/36; P=0.025), and significantly shorter intensive care unit and postoperative hospital stay (1.4±0.8 days vs. 2.2±1.1 days, P=0.001; and 13.3±6.5 days vs. 21.5±10.3 days, P=0.001; respectively). There were no significant differences in operative and postoperative data between the partial sternotomy and full sternotomy groups.Conclusions:The objective benefits of right mini-thoracotomy included early rehabilitation and lower prevalence of blood transfusion. Significant advantages of partial sternotomy were not found.

Initial large-dose administration of modified St. Thomas' solution.

BACKGROUND: We introduced an initial large dose of modified St. Thomas' Hospital cardioplegic solution with the aim of providing both myocardial protection as well as a smooth intraoperative process. METHODS: In 90 cases of isolated aortic valve replacement, we used the modified technique of cardioplegia in 45 (group S) and conventional administration of glucose-insulin-potassium solution in 45 (group G). The patients were selected at random. In group S, we added 4 mEq of potassium to the original St. Thomas' Hospital solution and administered 30 mL·kg(-1) as an initial dose. The temperature was decreased to 2. RESULTS: The mean of reperfusion time after declamping in group S was significantly shorter (16.7 ± 6.4 vs. 21.5 ± 10.0 min; p = 0.007). The average of postoperative maximum creatine kinase-MB was significantly lower in group S (25.6 ± 9.5 vs. 40.6 ± 37.2 IU·L(-1); p = 0.014). On multivariate analysis, use of the modified cardioplegia and aortic crossclamp time were significantly associated with creatine kinase-MB level and reperfusion time after declamping. CONCLUSIONS: This modified technique was an acceptable option that provided a bloodless operative field and avoided multiple cardioplegic administrations.

Open total aortic arch reconstruction for patients with advanced age in the era of endovascular repair.

BACKGROUND: The aim of this study is to evaluate the influence of advanced age on the postoperative course in open aortic arch repair using hypothermic circulatory arrest and selective antegrade cerebral perfusion. METHODS: Of 158 consecutive patients who underwent open total arch repair between 2008 and 2012, we retrospectively compared outcomes between octogenarians (group E: mean age, 83.0 ± 3.1 years [n = 40]) and their younger counterparts (group Y: mean age, 68.2 ± 10.2 years [n = 118]), and evaluated risk factors for an adverse postoperative course. RESULTS: The overall 30-day mortality was 7.0% (11/158), and by excluding 54 emergent cases, 30-day mortality was 4.8% (5/104). Ruptured cases were significantly observed in group E (17.5% [7/40] vs 3.4% [4/118]; P = .006). There were no significant differences in postoperative early results, including neurologic adverse events (12.5% [5/40] vs 6.8% [8/118]; P = .317) and 30-day death (12.5% [5/40] vs 5.1% [6/118]; P = .147) between groups E and Y. Multivariate logistic analysis revealed rupture, preoperative consciousness disorder, and extended circulatory arrest time (≥67 minutes) were risk factors for serious complications (neurologic adverse events and 30-day death) (odds ratio [OR], 10.9 [P = .010]; OR, 5.2 [P = .040]; and OR, 3.5 [P = .028], respectively). A ruptured aorta was detected as an independent predictor of postoperative extended intensive care unit and hospital stay by multivariate linear regression analysis (P = .001 and P = .007, respectively). CONCLUSIONS: Advanced age was not associated with serious postoperative complications and adverse postoperative course.

A Rare Case of Dacron Graft Rupture due to Friction against a Rib.

A 54-year-old man underwent aortic repair for the infected thoracoabdominal aneurysm with a woven Dacron graft (Vascutek, Renfrewshire, Scotland) treated with gentian violet. Four months later, he complained of sudden back pain, resulting in preshock status. Computed tomographic scans showed massive hematoma around the Dacron graft, suggesting graft rupture. Initially, emergency thoracic endovascular aortic repair was performed, which was subsequently followed by open repair. The Dacron graft had a small hole, which was completely compatible with the site contacting with the rib. The graft rupture was considered due to its friction against the rib. We report on a rare event of mechanical Dacron graft rupture after the thoracoabdominal aortic replacement.

Successful treatment using percutaneous drainage for aortic arch prosthetic graft infection.

Prosthetic graft infection in the ascending aorta or aortic arch is a life-threatening complication. Redo graft replacement is also associated with high mortality and morbidity rates. Conservative treatments without graft removal recently developed as alternatives to conventional surgical approach have been reported with successful outcomes. We report a case of successful treatment of prosthetic graft infection in the aortic arch, for which percutaneous catheter drainage was initially performed prior to open surgery, followed by graft coverage with an omental flap. .

Anterolateral approach for minimally invasive aortic valve replacement.

OBJECTIVE: Right anterior thoracotomy is the most common approach of minimally invasive aortic valve replacement (MIAVR) via intercostal mini-thoracotomy. However, there are some disadvantages including sacrificing the right internal thoracic artery (RITA). The aim of the present study was to investigate the efficacy of anterolateral thoracotomy (ALT), which is similar to lateral thoracotomy used for minimally invasive mitral valve surgery, for MIAVR. METHODS: From October 2012 to June 2013, 21 patients underwent MIAVR through ALT. Perioperative outcome of these patients was compared with those of 59 patients who underwent MIAVR via standard anterior thoracotomy (SAT) from May 2007 to September 2012. RESULTS: Mean age, body surface area, annular size, the ratio of aortic stenosis, and Japan score (30 days mortality), in ALT group were significantly more severe than those in SAT group. There was no significant difference in operative time; however, cardiopulmonary bypass and cross-clamping times in ALT group were significantly longer than those in SAT group. Significant differences were not found in mortality, morbidity, intubation time, blood transfusion rate, intensive care unit stay, hospital stay, and echocardiographic data such as effective orifice area index between both groups. CONCLUSIONS: Anterolateral approach has several advantages including no need to sacrifice the RITA and cosmetic benefit in female patients, offering similar results as SAT even with more severe patient characteristics.