Surgical Management of Giant Unruptured Left Sinus of Valsalva Aneurysm With Severe Aortic Regurgitation.

Left sinus of Valsalva aneurysms are extremely rare. Concomitant aortic valve regurgitation is a comorbidity in this pathology. This case report summarizes successful surgical treatment with aortic root replacement with a modified Bentall procedure in a 49-year-old female patient who had an unruptured huge left sinus of Valsalva aneurysm with severe aortic valve regurgitation. The intraoperative assessment showed severe adhesion between the left main trunk of the coronary artery and the left sinus of Valsalva aneurysm, and meticulous adhesion detachment was required.

Successful Medical Treatment for Aortoesophageal Fistula after Thoracic Endovascular Aortic Repair.

Aortoesophageal fistula is a fatal disease that requires surgical treatment. Due to the patient's wishes, we chose medical treatment for aortoesophageal fistula after thoracic endovascular aortic repair for a pseudoaneurysm in the distal anastomotic site after total aortic arch replacement. Satisfactory early and long-term outcomes were obtained with complete fasting and appropriate antibiotics.

Platelet aggregation with various morphologies of neutrophils in arterial thrombus in a patient with Coronavirus disease: a case report.

Arterial thromboembolism is a life-threatening condition in COVID-19 patients; however, the mechanism of hypercoagulopathy remains unknown. A 62-year-old man with a history of obesity was diagnosed with COVID-19 pneumonia. After hospitalisation, unfractionated heparin was administered because of increased D-dimer levels; nevertheless, an arterial embolism in the left lower limb developed on the following day. Enhanced computed tomography revealed an occluded left iliac artery and intra-aortic thrombus at the juxtarenal level. Urgent thrombectomy was performed. On post-operative day 6, coumadin was initiated to treat the remaining thrombus. The patient was discharged without any complications. The removed thrombus pathologically presented platelet aggregation and degenerated neutrophils that were in various time axes; some neutrophils had clear margins of nuclear membrane, whereas others had pyknotic and fragment nuclei. We believe that the platelet formation and the neutrophils in several time axes could be key factors in promoting thrombus formation in COVID-19 patients.

Posterior mitral leaflet augmentation with autologous pericardial patch for the surgical treatment of severe atrial functional mitral regurgitation.

Atrial functional mitral regurgitation (MR) in patients with chronic atrial fibrillation has not been thoroughly discussed. Although there is insufficient evidence to surgically treat atrial functional MR, it is considered to be reasonable for those patients with severe atrial functional MR who have symptoms of heart failure despite adequate medical therapy. Herein, we report a useful technique for mitral valve repair using posterior mitral leaflet (PML) augmentation with autologous pericardium to obtain good mitral valve coaptation and eliminate atrial functional MR, including tethered PML, in a nonelderly patient.

Acute Limb Ischemia Caused by Embolus of Primary Lung Cancer Complicating Trousseau's Syndrome.

Limb ischemia caused by tumor embolus is rare. In this study, we report the case of a 77-year-old woman who suffered from acute ischemic limb. Computed tomography showed a tumor in the right bronchus invading the left atrium. The tumor fragments scattered resulting in the occlusion of the right iliac artery. The excluded embolus was revealed as a squamous cell carcinoma. Regarding the popliteal venous thrombus, Trousseau's syndrome was complicated. The patient was discharged without any complications. We believe that advanced lung cancer is a differential diagnosis of acute ischemic limbs and that successful limb rescue contributed to a patient's quality of life.

Endovascular Repair for Abdominal Aneurysm with Concomitant Aortoiliac Vein Fistula Diagnosed by Four-Dimensional Computed Tomography.

A 78-year-old man complaining of left leg swelling was diagnosed with an abdominal aortic aneurysm with an irregular margin. A four-dimensional computed tomography (CT) showed an aortoiliac vein fistula. An AFX stent graft was urgently implanted, and a Viabahn VBX was inserted into the left iliac vein. The aneurysmal sac was embolized. After the procedure, enhanced CT confirmed a patent stent graft without any endoleak or fistula. The patient was discharged ambulatory. An aortoiliac vein fistula is a differential diagnosis for leg edema, and a four-dimensional CT is beneficial in diagnosing the condition.

Reconstruction for rupture of profunda femoris artery aneurysm in a patient with sarcopenia.

Profunda femoris artery aneurysm (PFAA) is rare and has a high incidence of rupture. Herein, we report the case of an 80-year-old man who developed sarcopenia after gastric surgery. The patient presented to our hospital with a reddish thigh and was diagnosed with PFAA rupture. We performed aneurysmectomy and graft interposition in emergency. Postoperative enhanced computed tomography revealed an interposed graft, and the patient was discharged on postoperative Day 7. We considered that the PFAA patients with sarcopenia has a high risk of rupture because the muscles surrounding the profunda femoris artery became weak, and should be followed-up closely.

Echocardiography-guided aortic cannulation by the Seldinger technique for type A dissection with cerebral malperfusion.

OBJECTIVE: The purpose of this study was to assess the efficacy of echocardiography-guided ascending aortic central cannulation using the Seldinger technique during surgery for type A acute aortic dissection complicated by stroke due to cerebral malperfusion. METHODS: Between April 2007 and December 2017, 208 patients with type A acute aortic dissection underwent echocardiography-guided ascending aortic central cannulation using the Seldinger technique. We analyzed 16 of these patients (7.7%; median age, 63 years; 8 men) with stroke due to cerebral malperfusion, including 10 in a comatose state (Glasgow Coma Scale ≤8) and 6 with hemiplegia (manual muscle test ≤1) on hospital arrival. The Modified Rankin Scale was used to evaluate activities of daily living. RESULTS: The median time from onset of symptoms to establishment of cardiopulmonary bypass was 327 (176-561) minutes. The median time from the start of surgery to establishment of cardiopulmonary bypass was 34 (30-44) minutes. The mortality rate was 6.3% (1/16). In patients with preoperative coma, the Glasgow Coma Scale improved significantly after surgery from 4.5 to 15 at 30 days (P < .001). In patients with preoperative hemiplegia, 4 showed improved motor function on the manual muscle test score at 90 days. In all patients, Modified Rankin Scale scores improved significantly from 5.0 preoperatively to 1.0 after follow-up (P < .001). CONCLUSIONS: Echocardiography-guided ascending aortic central cannulation using the Seldinger technique has potential as a rapid and reliable perfusion route during surgery for type A acute aortic dissection complicated by stroke due to cerebral malperfusion.

External carotid-to-subclavian artery bypass in stent grafting of thoracic aorta.

BACKGROUND: A bypass between the left common carotid artery and the left subclavian artery has been made in some patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery. However, complications associated with temporary occlusion of the left common carotid artery are reportedly not uncommon. METHODS: Between January 2009 and September 2011, left external carotid-to-left subclavian artery bypass was made using a polytetrafluoroethylene graft in 15 patients undergoing a thoracic endovascular aortic repair that covered the orifice of the left subclavian artery. Adverse effects associated with the procedure were assessed, and patency of the bypass graft was determined by contrast-enhanced computed tomography before discharge and at least once during follow-up. RESULTS: All patients were discharged without any brain complications. All 15 bypass grafts were patent prior to discharge and during the follow-up period. One patient suffered temporary left recurrent laryngeal nerve palsy postoperatively. No other sequelae were associated with left external carotid-to-left subclavian artery bypass. CONCLUSION: Left external carotid-to-left subclavian artery bypass is a promising procedure in patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery.

Case of ischemic optic neuropathy developed eleven days after an aortic arch replacement.

We present a case of ischemic optic neuropathy (ION) developed 11 days after an aortic arch replacement in a 59 year-old male who had a history of untreated hypertension. Thoracic CT revealed severe stenosis of the right common carotid artery with poor blood flow. Aortic clamping time was 96 minutes, and selective cerebral perfusion time was 48 minutes. The lowest hemoglobin concentration of venous blood during cardiopulmonary bypass was 8.1 g/dl and the lowest arterial pressure was 60 mmHg. Due to pulmonary congestion, artificial ventilation was required until 11 post-surgical days. After removal of ventilator, the patient's consciousness was clear with no motor paralyses evident. However, the patient complained of blurred vision on that day. Bilateral papillae of the optic fund were pale. Atrophy of the papillae was also noted. Visual evoked potential was bilaterally flat suggesting bilateral optic nerve disturbance. The diagnosis of ION was made by ophthalmologist and neurologists. We speculated that low hemoglobin level during cardiopulmonary bypass was not the sole etiology of ION. Untreated hypertension, low blood flow through internal carotid artery and prolonged mechanical ventilation were also deteriorating factors of ION in this patient. We should be alert to prevent ION in such a complicated case.

Histopathological study of specimens obtained by left ventricular biopsy during ventriculoplasty for idiopathic dilated cardiomyopathy.

OBJECTIVE: Pathological changes in the myocardium in idiopathic dilated cardiomyopathy (DCM) are usually studied using endomyocardial biopsy specimens, but the relationship between pathological changes in the myocardium and clinical findings is unclear. The goal of the study was to examine correlations between clinical findings and histopathological findings in specimens of the left ventricular myocardium collected during left ventriculoplasty in DCM patients. METHODS: The subjects were 20 DCM patients (17 males and 3 females; mean age: 59 ± 14 years old) who underwent left ventriculoplasty, including 16 cases of overlapping ventriculoplasty (OLVP) and 4 of papillary muscle approximation (PMA) with left ventricular incision. Preoperative age, sex, The New York Heart Association (NYHA) classification, the brain natriuretic peptide (BNP) level, cardiothoracic ratio (CTR), echocardiographic data, history of diabetes mellitus, drug history of spironolactone, ACE inhibitor, ARB, and ß-blocker were used as clinical findings. Histopathological scores were determined for each patient and semi-quantitative data for hypertrophy, attenuation, vacuolation and fibrosis were obtained. RESULTS: A significant correlation was found between age and interstitial fibrosis. A significant inverse correlation was found between left ventricular diastolic diameter (LVDd) in echocardiographic data and interstitial fibrosis. There were no other significant relation between histopathological scores and clinical findings. CONCLUSION: From this study, we found that interstitial fibrous increased with aging and more dilated LVDd had less interstitial fibrosis. It is concluded that the kinetics of myocardial fibrosis with remodeling might be variable and histopathological findings does not reflect the clinical and hemodynamic changes in DCM patients. Further morphological data are needed to verify this result.

Compartment syndrome of bilateral lower extremities following laparoscopic surgery of rectal cancer in lithotomy position: report of a case.

A 67-year-old man underwent laparoscopic surgery for rectal cancer in the lithotomy position. After surgery he complained of bilateral lower limb pain, swollen legs, and sensory disturbance. The serum creatine kinase value was 46 662 U/l. Venography demonstrated compression from outside without any obstruction. The T2 image of magnetic resonance imaging (MRI) showed a massive swollen muscle and a partial high-intensity area in the bilateral lower limbs. The posterior compartment pressures of lower legs were high (gastrocnemius muscle: 30 mmHg [right] and 44 mmHg [left]). Compartment syndrome (superficial posterior compartment) was thus diagnosed. He underwent a fasciotomy using the single dorsal approach and the administration of a large amount of fluid. He recovered well without any motor or sensory deficits. Compartment syndrome is rare, occurring only once in every 3500 cases, but it is a severe complication of surgery in the lithotomy position. Several risk factors have been pointed out: including prolonged operation, hardness of the operating table, obesity, dehydration, and hypothermia. To prevent compartment syndrome, appropriate positioning during surgery is therefore essential. To make a timely diagnosis and identify the precise location of muscle edema, the T2 image of MRI is useful.

A case report of papillary fibroelastoma attached to chorda tendineae of mitral valve.

The case was a Japanese man of 62 years old. A bulbar mass attached to mitral valve anterior leaflet was discovered in an echocardiography within detailed examination of ischemic heart disease accidentally. We diagnosed him as ischemic heart disease and doubt of heart tumor. We thought about the danger of future embolism, surgical treatment was decided. We dissected the tumor together with one chorda tendineae of mitral valve, and a performed aorta - coronary bypass surgery. We diagnosed the tumor as papillary fibroelastoma by pathological diagnosis. Papillary fibroelastoma is extremely rare with 7-9% of benign tumor of heart primary. Most of the papillary fibroelastoma is incidentally discovered by echocardiography or autopsy. Or it is discovered for systemic embolism. The tumor is benign, but there is a problem to cause embolism. Therefore, when we discovered papillary fibroelastoma, surgical resection of the tumor is the first-line therapy. A problem on surgical therapy is the range of resection area. Papillary fibroelastoma is benign tumor, but the pathological characteristic is still unidentified. Further epidemiological and pathological studies are necessary to determine the extent of surgical excision in associated with characteristics of papillary fibroelastoma.

Aortic root reconstruction in two patients with chronic aortic dissection by aortic valve-sparing procedures using a new aortic root conduit with the sinuses of valsalva (De Paulis Valsalva graft).

The durability of the aortic valve after aortic root reconstruction by an aortic valve-sparing procedure is of particular concern because of the absence of the sinuses of Valsalva in the David type-I reimplantation method. Various improvements have been made to the David-I method. In particular, a new aortic root conduit with the sinuses of Valsalva was developed recently and is expected to improve the long-term follow-up results of the aortic valve-sparing procedures. We used a Valsalva graft in two patients with aortic root dilation accompanied by aortic regurgitation and obtained good short-term results.

Aortic root reconstruction by aortic valve-sparing operation (David type I reimplantation) in Marfan syndrome accompanied by annuloaortic ectasia and acute type-A aortic dissection.

To reconstruct the aortic root for aneurysm of the ascending aorta accompanied by aortic regurgitation, annuloaortic ectasia (AAE) and acute type-A dissection with root destruction, the Bentall operation using a prosthetic valve still is the standard procedure today. Valve-sparing procedures have actively been used for aortic root lesions, and have also been attempted in aortic root reconstruction for Marfan syndrome which may have abnormalities in the valve leaflets. We conducted a valve-sparing procedure in a female patient with Marfan syndrome who had AAE accompanied by type-A acute aortic dissection. The patient was a 37-year-old woman complaining of severe pain from the chest to the back. The limbs were long, and funnel breast was observed. Diastolic murmurs were heard. On chest computed tomography, a dissection cavity was present from the ascending aorta to the left common iliac artery, and the root dilated to 55 mm. Grade II aortic regurgitation was observed on ultrasound cardiography. Regarding her family history, her father had died suddenly at 54 years of age. She was diagnosed with type-A acute dissection concurrent with Marfan syndrome and AAE. The structure of the aortic valve was normal, and root reconstruction by a valve-sparing operation and total replacement of the aortic arch was conducted. On postoperative ultrasound cardiography, the aortic regurgitation was within the allowable range, and the shortterm postoperative results were good.

Recent surgical outcomes of acute type-A aortic dissection.

The aim of this study is to assess the early outcome of the surgical treatment of acute type-A aortic dissection using recent improvements in antegrade selective cerebral perfusion. This study included 38 patients who had undergone surgery for acute type-A aortic dissection from October 2003 through March 2006. The surgery results were evaluated in 2 groups: group A was composed of those who had undergone the surgery before the procedures of antegrade selective cerebral perfusion was changed in December 2004, and group B consisted of those who had the surgery after the change. Operations were performed with hypothermic cardiopulmonary bypass, antegrade selective cerebral perfusion during the arch repair, and open distal anastomosis. Times to awakening after the surgery were 27.6±26.2 hours in group A and 19.8±22.3 hours in group B (p= 0.5). Intubation times were 8.55±7.09 days in group A and 5.11±2.56 days in group B (p=0.06). Permanent neurologic dysfunction was observed in 3 patients in group A and 1 in group B (p=0.6). Transient neurologic dysfunction was observed in 4 patients each in groups A and B (p=1). Mortality rates were 21.1% in group A and 10.5% in group B (p=0.65). There were no significant differences in mortality or morbidity between the two groups, but the intubation time tended to be shorter in group B.

Surgical treatment of chronic atrial fibrillation: Report of 8 cases.

Since February 2003, we have conducted surgical treatment on 8 patients complicated with chronic atrial fibrillation during cardiac surgery. A radial procedure was conducted on 7 patients, and pulmonary vein isolation was conducted on 1 patient. Underlying diseases included mitral regurgitation (MR) in 5 patients, mitral stenosis (MS) in 1 patient, aortic stenosis (AS) + MS in 1 patient and chronic type A dissociation in 1 patient. Simultaneous procedures included mitral valve plasty (MVP) in 3 patients, mitral valve replacement (MVR) in 3 patients, aortic valve replacement (AVR) + MVR in 1 patient, and aortic root reconstruction by reimplantation procedure + total arch replacement in 1 patient. The operation time was 320 to 840 minutes and 458.1± 171.1 minutes on average. The cardiopulmonary bypass time was 204 to 404 minutes and 266.7 ± 62.7 minutes on average. The aortic cross-clamp time was 142 to 271 minutes and 171± 41.5 minutes on average. One patient died in hospital. Six patients returned to sinus rhythm, and 1 patient required pacemaker implantation. The follow-up period was 2 to 37 months and 13.6 ± 15 months on average. When cryoablation was changed to radiofrequency ablation to assist preparation of the block line, a tendency toward shortening of the aortic clamping time was observed.

Surgical outcome of stentless aortic valve replacement for calcified aortic stenosis.

We have conducted aortic valve replacement (AVR) using a stentless bioprosthesis (Medtronic Freestyle valve) on 10 patients with calcified aortic stenosis since March 2004. There were 64-84 years of age and 75 ± 5.5 years old on average, and included 4 males. Implantation was conducted by a modified subcoronary method in all the patients. The preoperative New York Heart Association class was class II in 80% of the patients. The preoperative left ventricular mass and the left ventricular mass index (LVMI) were 193.1-524.1 g and 144.1-299.5 g/m2 and, on average 328.4 ± 104.7 g and 217.3 ± 55.7 g/m2, respectively. The annulus dimension was 18-24 mm and, on average, 20.3 ± 1.7 mm. The size of implanted valve was 19-25 mm and, on average, 21 ± 2.2 mm. The maximum pressure gradient of the aortic valve remained at 14.2-46.5 mmHg, 25.2 ± 10.2 mmHg on average, 1 or 2 months after surgery, but the LVMI significantly improved to 153.2 ± 33.9 g/m2 (p = 0.018). The hospitalization period were 24.7 ± 16.9 days for all the patients and 19.3 ± 5.1 days for patients undergoing the AVR alone. These results show that LVMI is significantly reduced by using a stentless bioprosthesis in the early phase after surgery, and early discharge from hospital can be expected by concurrently using minimally invasive cardiac surgery.

Primary cardiac angiosarcoma: presenting with cardiac tamponade followed by cerebral hemorrhage with brain metastases.

A 49-year-old man presented with palpitation and shortness of breath. He was seen to have a massive pleural and pericardial effusion on radiography and echocardiography. Computed tomography (CT) scanning showed that cardiac tumors arose from the right atrium with epicardial and endocardial extension. Pathology examination of samples at pericardiotomy revealed them to be angiosarcoma. Two days after the surgery, he developed left hemiparesis. CT scans showed a large cerebral hemorrhage on the right temporal lobe with midline shift by brain metastases. He died 37 days after the surgery. At autopsy, he had metastases in the brain, multiple bones, and soft tissues but no lung or left-side heart involvement. Primary cardiac angiosarcoma is rare, and mostly arises from the right side of the heart. Common metastatic sites are the lungs and liver. There are only a few reports of brain metastases. In conclusion, this is a rare report of cardiac angiosarcoma presenting with pericardial tamponade. There were rapid brain and multiple bone metastases but no lung or left-side heart lesions.

A patient who underwent surgical treatment of an adult-type aneurysm in the nonpatent arterial duct.

Adult-type aneurysms in the arterial duct are rare, and their spontaneous prognosis is poor. We performed surgical treatment of an aneurysm in the arterial duct in a 62-year-old male. The patient had had hoarseness since November 2003, and was referred to our hospital in March 2004. Thoracic CT and aortography demonstrated a sacciform aneurysm in the aorta in the distal arch region on the lesser curvature side. The patient was diagnosed as having an adult-type aneurysm in the nonpatent arterial duct, and underwent surgical treatment in April 2004. Thoracotomy in the fourth left intercostal space was performed up to the thoracic aorta, and a sacciform aneurysm, measuring 35 mm x 32 mm, was detected in the arterial duct. The recurrent laryngeal nerve adhering to the front surface of the aneurysm was overextended. Under partial extracorporeal circulation, the aneurysm was excised, and replaced by an artificial blood vessel. The postoperative course was satisfactory, and the patient was discharged from the hospital 14 days after surgery. The surgical outcome was good, and the hoarseness was improved. Taking possible complications into consideration, surgical treatment can be recommended in the early stage.