[Thoracic Endovascular Aortic Repair for Stanford Type B Acute Aortic Dissection with Right Leg Malperfusion:Report of a Case].

We report a case of complicated Stanford type B acute aortic dissection with malperfusion to the right leg. The patient received conservative treatment in a previous hospital. However, he complained of pain in the right leg, which had been gradually turning pale. The patient was diagnosed with complicated Stanford type B acute aortic dissection with right leg malperfusion and was transferred to our hospital for treatment. Thoracic endovascular aortic repair (TEVAR) to close the entry to the distal aortic arch was performed, and we embolized the left subclavian artery to prevent type Ⅱ endoleak and to extend the stent-graft landing zone. We implanted a bare stent into the right external iliac artery to enlarge its true lumen. The patient was discharged from our hospital 22 days postoperatively. After the operation, computed tomography( CT) scan showed an aortic false lumen remodeling.

[Our Experience and Technical Improvement in Robot-assisted Cardiac Surgery].

Since 2014, we have used the da Vinci surgical system to perform internal thoracic artery harvest in minimally invasive direct coronary artery bypass (MIDCAB), and since 2016, we have also performed robot-assisted cardiac surgery( RACS) for mitral and tricuspid valve surgery, left atrial thrombosis, and myxoma, all of which we have had performed as minimally invasive cardiac surgery( MICS) previously. Even after the introduction, different ideas (Chordalizer, COR-KNOT, special long CP cannula, de-air technique, etc.) were developed. As a result of the learning curve, more stable surgery could be performed. However, keeping in mind that RACS is only a means and not a purpose, the RACS indication should always be carefully considered. When problems, such as intracardiac manipulation or uncontrollable bleeding, occur, safe surgery must be decided to switch to normal thoracotomy as soon as possible. A further enhancement would be expected for even better results and expansion of the RACS indications.

Aortic valve replacement and coronary artery bypass grafting through a right thoracotomy for a patient with a left chest wall tumor.

A 68-year-old man was diagnosed with severe aortic stenosis and right coronary artery occlusion on preoperative examination for total extirpation of a giant left breast liposarcoma. Prior to the intervention for the liposarcoma, he underwent successful aortic valve replacement and coronary artery bypass grafting via a right anterolateral thoracotomy to avoid the tumor close to the sternum. On postoperative day 28, the patient underwent a successful wide excision of the left chest wall tumor.

A simple technique of artificial chordae implantation in robotic cardiac surgery using a novel tube device supporting expanded polytetrafluoroethylene chordae ligation.

Artificial chordae implantation is an important technique for treating leaflet lesions in mitral valve repair. Considering that the expanded polytetrafluoroethylene (ePTFE) suture is slippery on the surface, adequate ligation without laxity should be critically considered, especially in robotic surgery. To resolve this issue, we applied a novel device that controls the length of an ePTFE suture (Chordarizer) for artificial chordae implantation in robotic mitral valve repair. After assessing the mitral valve via the right side of the left atrium, we stitched a CV-4 ePTFE suture to the target papillary muscle. Using a calliper, we measured the length of the artificial chordae and passed the CV-4 through the appropriate Chordarizer. Then, we stitched the CV-4 to the tip of the leaflet from the left ventricle side and tied it using da Vinci arms. Finally, the Chordarizer was peeled away. Chordarizer ensured safe and reliable artificial chordae implantation procedures with robotic mitral surgery, by maintaining the desired CV4 length.

[Simultaneous Surgery of Gastrectomy and Rerouting of the Pre-existing Right Gastroepiploic Artery Bypass Graft for Gastric Cancer].

The patient was a 76-year-old man with advanced gastric cancer who had a history of coronary artery bypass grafting using the right gastroepiploic artery. Although coronary angiography confirmed the patency of all the coronary artery bypass grafts, his right gastroepiploic artery was required to be cut for curative gastrectomy. To prevent serious myocardial ischemia, rerouting of the right gastroepiploic artery graft was performed using a saphenous vein graft via right mini-thoracotomy. The proximal end of the saphenous vein graft was anastomosed to the ascending aorta. Then, gastrectomy via epigastric median re-laparotomy was performed. His postoperative course was uneventful.

[Usefulness of Balloon Aortic Valvuloplasty for Determining the Operative Procedure in a Patient with Severe Aortic Stenosis Complicated with Secondary Mitral Regurgitation;Report of a Case].

A 59-year-old man on chronic hemodialysis presented with severe aortic stenosis(AS) and moderate mitral regurgitation (MR). Although aortic valve replacement was scheduled, his status deteriorated into New York Heart Association(NYHA) class III heart failure due to the exacerbation of AS and concomitant MR. Double valve replacement was considered to be too high risk for the patient, and balloon aortic valvuloplasty(BAV) was initially performed. As a result, the mean pressure gradient of the aortic valve decreased from 65 to 28 mmHg and the mean pulmonary pressure also from 52 to 33 mmHg. Furthermore, MR improved from severe to moderate following BAV. We considered the alleviation of aortic stenosis was sufficient treatment for the patient. He underwent aortic valve replacement on the following day of BAV. Postoperative echocardiogram after 1 month showed mild MR, and the estimated pulmonary systolic pressure was 35 mmHg. During the 1-year follow up, MR was not aggravated. BAV might be a useful diagnostic method to determine the operative strategy for severe AS complicated with secondary MR.

Antero-lateral partial sternotomy for extensive thoracic aortic aneurysm.

OBJECTIVES: Surgical strategies for patients with aortic arch aneurysm extending to the descending aorta remain controversial. The antero-lateral partial sternotomy (ALPS) approach has been developed as a less invasive alternative single-stage strategy for extensive thoracic arch aneurysm (ETAA). METHODS: From September 2007 to April 2011, 18 patients underwent elective total arch replacement for ETAA by the ALPS approach (ALPS group). In this approach, a skin incision was made from the bottom of the xiphoid to the anterior axillary line at the third intercostal space with a convex curved line. The thorax was entered through the third intercostal space and a partial lower sternotomy was done. Surgical outcomes were compared with those of 22 patients with ETAA who underwent elective total arch replacement by median sternotomy alone (MS) with regard to the level of distal anastomosis, postoperative complications and mortality. RESULTS: In the ALPS group, no hospital mortality occurred and one patient experienced pneumonia. No significant difference between the ALPS and MS groups was seen in operative time (384.1 ± 41.6 min vs 402.3 ± 85.3 min P = 0.423) and cardiopulmonary bypass time (220.8 ± 47.1 min vs 236.9 ± 45.4 min P = 0.286). In contrast, distal anastomosis was at a significantly lower vertebral level in the ALPS than in the MS group (5.5 ± 0.4 vs 4.3 ± 0.9, respectively: P < 0.0001). CONCLUSIONS: The ALPS approach provides good surgical exposure for distal aortic arch aneurysms extending to the descending aorta and ensures the accurate reconstruction of the distal anastomosis without major complications.

Simple and safe graft insertion in the elephant trunk technique.

The elephant trunk technique is a well-established procedure, but aortic wall injury or aneurysmal rupture may occur if the graft is forcibly pushed to insert it into the distal aorta. We have developed simple and safe insertion technique using a syringe.

Mitral valve repair in a patient with acromegaly.

We report on a successful mitral valve (MV) repair and modified Cox maze procedure in a 35-year-old male patient with acromegaly, associated with severe mitral regurgitation and atrial fibrillation. He underwent a transsphenoidal adenomectomy, 7 months after the cardiac operation, and IGF-I level was normalized postoperatively. Valvular disease in patients with acromegaly is associated with hormonal activity, and control of growth hormone and insulin-like growth factor I excesses is important in the long-term durability of mitral valve repair.

Significance of mitral valve repair for active-phase infective endocarditis.

Mitral valve repair is preferred to replacement in infective endocarditis, but in the active phase, it often requires extensive debridement of infected tissue and complex reconstruction. We investigated 22 consecutive native mitral valve operations during active-phase infective endocarditis. The time from initiation of medical treatment to operation was 16.8 ± 16.4 days. Mitral valve repair was performed in 15 (68.2%) patients, using prosthetic annuloplasty in 14, an autologous pericardial patch in 11, and artificial chordal replacement in 9. Hospital mortality was 9.1% (2 patients), due to subarachnoid hemorrhage and pneumonia. One patient died 26 months after valve replacement due to congestive heart failure. The postoperative left ventricular end-diastolic dimension was significantly smaller (45.7 ± 5.6 vs. 53.3 ± 10.2 mm) and ejection fraction was significantly higher (57.0% ± 14.7% vs. 40.1% ± 8.2%) in patients who underwent valve repair compared to those who had valve replacement. Mitral regurgitation requiring reoperation occurred in 3 patients during follow-up. Mitral valve repair is feasible in active-phase infective endocarditis, and results in improved regression of left ventricular dimensions compared to valve replacement. However, complex mitral valve repair with extensive leaflet resection may not have long-term durability.

Granulomatous endocarditis in a patient with Wegener's granulomatosis.

Echocardiographic examination of patients with granulomatous endocarditis in patients with Wegener's granulomatosis (WG) reveals vegetation-like lesions that may be misdiagnosed as infective endocarditis resulting in inappropriate therapy. Three-dimensional transesophageal echocardiography aids differential diagnosis. Here, we report the case of a WG patient with associated mitral and aortic granulomatous endocarditis. Although the patient was treated with prednisolone and cyclophosphamide, serial echocardiography did not reveal any significant changes in disease course.

Aortic valve replacement in a patient with alpha-thalassemia.

Cardiac valve disease resulting from elastic tissue defects has been demonstrated in patients with beta-thalassemia; however, valve disorders of patients with alpha-thalassemia have been rarely discussed. We present the case of a patient with alpha-thalassemia and severe aortic regurgitation with left ventricular dysfunction. The patient underwent successful aortic valve replacement with mechanical prosthesis. Histopathology of the excised valve showed elastic tissue disruption and chronic thrombus on the ventricular side. Hypercoagulative states have been observed in patients with alpha-thalassemia as beta-thalassemia; therefore special attention should be taken in perioperative anticoagulation therapy.

Easy technique for mounting the Heartstring system into the sheath.

The Heartstring system was developed to avoid the use of side-biting aortic clamps, but the sealing system sometimes tears. To solve this problem, a string is wound around the coiled seal and pulled gently.

Cardiac tamponade due to intrapericardial rupture of an amebic liver abscess.

Pericardial abscess is rare in healthy individuals, especially the amebic type. We report a case of pericardial abscess and cardiac tamponade due to intrapericardial rupture of an amebic liver abscess. A 31-year old Japanese male complained of fever to a local hospital. A liver mass was discovered in his left hepatic lobe by an abdominal echogram. He was referred to the internal department of our hospital and was treated with quinolone antibiotics. Two weeks after medication, he suddenly complained of epigastralgia and severe orthopnea and was admitted. Abdominal computed tomographic scan showed an enlarged liver mass, and massive pericardial effusion suggested cardiac tamponade. He underwent an emergency subxiphoid partial pericardiectomy under local anesthesia. 1,000 ml of light brownish fluid was removed and his condition improved. Although no ameba was cultivated from the pus, the amebic serological test was positive. Metronidazole was administered and the patient was discharged 31 days after surgery.

Giant left ventricular pseudoaneurysm after mitral valve replacement and myocardial infarction.

Left ventricular pseudoaneurysm is a rare but serious complication of mitral valve replacement or myocardial infarction. Prompt surgical correction is mandatory in cases of a large left ventricular pseudoaneurysm. A 70-year-old man had a giant left ventricular pseudoaneurysm after myocardial infarction and mitral valve replacement. The orifice of the pseudoaneurysm was closed with an e-polytetrafluoroethylene patch and the pseudoaneurysmal wall was almost resected.

Minilaparotomy for early gastric cancer.

BACKGROUND/AIMS: From the experience of laparoscopic-assisted distal gastrectomy, it was considered that a gastrectomy with lymph node dissection could be performed through a minilaparotomy, placed as for gastroduodenostomy in laparoscopic-assisted distal gastrectomy. METHODOLOGY: Ten patients with early gastric cancer underwent gastrectomy with lymph node dissection via minilaparotomy. Minilaparotomy was performed via a seven-centimeter midline incision placed at the mid-upper abdomen. Two six-centimeter-wide Kent retractors were used to suspend the abdominal wall on each side, and a multipurpose surgical arm to retract the liver. The abdominal wound could be moved horizontally by pulling these retractors to the right or left. This movable wound allowed direct visualization of almost all the operative field for gastrectomy. RESULTS: No operation was converted to a standard open gastrectomy. The patients who had a tumor in the lower third of the stomach underwent complete D2 lymph node dissection. In the patients who underwent pylorus-preserving gastrectomy, near complete D2 lymph node dissection was performed. Mean operation time was 175 minutes. No significant complication was encountered. CONCLUSIONS: It was concluded that minilaparotomy could be used as an alteration to the standard open gastrectomy.

Metastatic hepatoma originating from the pons hepatis presenting extrahepatic growth--classification of different patterns covering REX's recessus.

A metastatic liver carcinoma which developed from the pons hepatis and presented as an extrahepatic mass on ultrasonography and computed tomography is reported. There have been no other reports of hepatoma documenting the extrahepatic growth developed from the pons hepatis. Herein we study the frequency of the pons hepatis and classify the form of REX's recessus. Of 125 cases that underwent upper abdominal operation, 46 cases (38%) had nothing under REX's recessus (Type I), 48 cases (37%) had a fibrous tissue under REX's recessus (Type II), and 31 cases (25%) had a pons hepatis (Type III). In Type III, some cases suggested that the pons hepatis was ready to disconnect from side to side. We conclude that Type II is a modified form of Type III, and Type I is a modified form of Type II.