[Vegetation Developed in the Artificial Graft of Ascending Aorta:Report of a Case].

The case was a 65-year-old woman. She underwent graft replacement of ascending aorta because she developed Stanford type A acute aortic dissection in November 2016. After six months she had a fever, so she underwent contrast-enhanced computed tomography and echocardiography at the previous hospital. An abnormal shadow was found in the artificial blood vessel, and the blood culture test was positive. The abnormal shadow was suspected to be a vegetation and was referred to our department. Vegetation was highly mobile and emergency surgery was performed considering the risk of embolism. Intraoperative findings showed that vegetation was attached to the anastomotic site of the artificial blood vessel. She was transferred to a rehabilitation hospital 57 days after the operation and is currently rehabilitating.

[Mitral Valve Plasty Late after Tetrology of Fallot Repair:Report of a Case].

The case was a 32-year-old man. Blalock-Taussig shunt was performed at five months-old for tetralogy of Fallot, and intracardiac repair was performed at four years-old. He was admitted with a diagnosis of infective endocarditis. Preoperative echocardiography showed vegetations on the mitral valve and severe mitral regurgitation. Severe right heart pressure load findings, pulmonary valve stenosis and regurgitation, and residual ventricular septal defect were also observed. The surgery included mitral valve repair, reconstruction of the right ventricular outflow tract, pulmonary valve replacement, and closure of the ventricular septal defect. The postoperative course was favorable. The cause of mitral regurgitation was an abnormal chordae tendineae attached to the interventricular septum and valve destruction by infective endocarditis.

A case of type-2 endoleak from a bronchial artery after endovascular aortic repair for Kommerell diverticulum.

We describe a case of type-2 bronchial artery endoleak after endovascular aortic repair of Kommerell diverticulum (KD) involving right-sided aortic arch and aberrant left subclavian artery (LSA). A 68-year-old woman underwent an endovascular repair of KD with an aberrant LSA in our hospital. Follow-up computed tomography (CT) at 6 months after the procedure showed an endoleak. Digital subtraction angiography revealed a type-2 endoleak from a bronchial artery, but no type-1 or type-2 endoleak from the aberrant left subclavian artery. We performed coil embolization of the KD and the left subclavian artery. The endoleak disappeared in the postoperative CT.

Left sinus of Valsalva aneurysm causing acute myocardial infarction with compression of the left main coronary trunk.

Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that commonly originates from the right or noncoronary sinuses and rarely from the left sinus. SVA is usually diagnosed in the setting of clinical sequelae of a rupture. We herein report a case of an unruptured left SVA presenting as acute myocardial infarction. A 54-year-old woman with a history of radical operation for patent ductus arteriosus in childhood was transferred to our hospital. An electrocardiogram indicated extensive myocardial ischemia with ST elevation. Urgent coronary angiography was performed but was unable to identify the left coronary artery. Subsequent aortography and computed tomography revealed a large SVA originating from the left sinus and compressing the left coronary artery. The patient died after approximately one month of intensive care, including mechanical circulatory support and coronary artery bypass grafting. Autopsy confirmed that the left main coronary trunk was stretched and compressed by the SVA and revealed unexpected atherosclerosis in the left anterior descending artery. Although a left SVA is an extremely rare anomaly, it occasionally provokes fatal myocardial infarction. Since an SVA might hinder performing percutaneous coronary intervention, cardiac surgery should be considered when myocardial ischemia is recognized. Learning objective: We herein report a case of an unruptured left sinus of Valsalva aneurysm (SVA) with acute myocardial infarction. Urgent percutaneous coronary intervention (PCI) was unsuccessful, as the left coronary artery was compressed by the SVA. The patient died after intensive care, including coronary artery bypass grafting (CABG). SVA, especially from the left sinus, is extremely rare but occasionally provokes myocardial infarction by compressing the coronary arteries. Because SVA might hinder PCI, CABG should be considered when myocardial ischemia is recognized.

Severe mitral regurgitation in chronic adult T-cell leukemia/lymphoma with granulomatous valvular inflammation.

Adult T-cell leukemia/lymphoma (ATLL) is a mature peripheral T-cell neoplasm caused by human T-cell leukemia virus type I (HTLV-1) infection. Besides the oncogenic property, HTLV-1 causes HTLV-1-associated myelopathy/tropical spastic paraparesis and certain inflammatory diseases via a complex host immune response to latent virus infection. Cardiac involvement of ATLL is rare, with the majority of cases being disclosed in postmortem autopsy in patients with advanced subtypes. We herein report the case of a 64-year-old female patient with indolent chronic ATLL with severe mitral regurgitation. Although the condition of ATLL was stable, dyspnea on exertion gradually progressed over the course of three years and echocardiography revealed marked thickening of the mitral valve. Finally, the patient experienced hemodynamic collapse with atrial fibrillation and underwent surgical valve replacement. The removed mitral valve was grossly edematous and swollen. A histological examination revealed a granulomatous reaction mimicking the active phase of rheumatic valvulitis, with the infiltration of ATLL cells that were immunohistochemically positive for CD3, CD4, FoxP3, HLA-DRα, and CCR4. The postoperative course was uneventful, with the exception that Sjögren's syndrome was noted. The history of rheumatic fever was unclear, and such unique valvular pathology was presumably related to autoimmune mechanisms associated with HTLV-1 infection. Learning objective: We report a case of chronic adult T-cell leukemia/lymphoma (ATLL) with isolated valvular infiltration with a unique histology of granulomatous reaction. Human T-cell leukemia virus type I infection may accelerate autoimmune reactions and cardiac inflammation, irrespective of indolent clinical subtype. Among ATLL cases, possible progression of valvular insufficiency and heart failure in patients with cardiac symptoms should be carefully evaluated.

15-year outcomes of the JOCRI study (JOCRIED study): a randomised comparison of off-pump and on-pump multiple arterial coronary revascularisation.

OBJECTIVE: The Japanese Off-Pump Coronary Revascularization Investigation (JOCRI) study reported a non-significant difference in early outcomes and graft patency between off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting in 2005. The JOCRIED study aimed to review the long-term outcomes of the JOCRI study participants. METHOD AND RESULTS: The JOCRIED study enrolled 123 of the JOCRI study participants completing the clinical follow-up between August 2018 and August 2020; 61 patients in the off-pump group and 62 patients in the on-pump group. The follow-up period was 13.8 ± 2.8 years. The groups were compared regarding mortality, the incidence of major adverse cardiac and cerebrovascular events and repeat revascularisation. The 15-year cumulative survival rate (off-pump vs on-pump, respectively; 77.7% vs 75.3%; p = 0.85), major adverse events-free survival rate (62.5% vs 55.6%; p = 0.27) and repeat revascularisation-free rate (84.8% vs 78.0%; p = 0.16) were not significantly different between the two groups. Revascularisation was the most common major adverse events in the JOCRIED participants. Although percutaneous coronary intervention was performed in 8 patients (13%) in the off-pump group and in 14 patients (23%) in the on-pump group (p = 0.23), no patients underwent redo coronary artery bypass grafting. CONCLUSIONS: Off-pump coronary artery bypass grafting provides comparable 15-year outcomes to on-pump coronary artery bypass grafting.

Safety and efficacy of an ultrashort-acting ß1-blocker on left ventricular dysfunction.

Landiolol hydrochloride, an ultrashort-acting ß1-selective blocker, is a highly regulated drug. This study evaluated the safety and efficacy of this drug for cases of coronary artery bypass grafting (CABG) with left ventricular dysfunction. Between September 2006 and August 2009, 32 patients with a left ventricular ejection fraction of <40% underwent CABG. Two groups of patients, a group administered landiolol hydrochloride and a control group not administered this drug, were compared. The administration of landiolol hydrochloride was initiated at 1 µg/kg per minute (γ) after cardiopulmonary bypass in on-pump cases and after completion of all the distal anastomoses in off-pump cases. We observed no significant differences between the groups with respect to preoperative patient background or incidences of complications, except for postoperative atrial fibrillation. The heart rate decreased significantly 30 minutes after landiolol hydrochloride administration, but no change was observed in arterial pressure. No change was observed in other parameters; the hemodynamics were stable. The occurrence of atrial fibrillation during the intensive care unit stay (during landiolol hydrochloride administration) was significantly lower in the administration group. The difference remained significant after multiple logistic regression analysis; landiolol hydrochloride was the sole inhibitory factor.

[Mitral valve replacement in a patient with multiple myeloma].

We herein report a case of a 71-year-old male with untreated multiple myeloma (MM) and congestive heart failure due to moderate mitaral regurgitation, who successfully underwent mitral valve replacement and tricuspid annuloplasty. MM has various complications such as bleeding tendency, anemia, renal dysfunction, hyperviscosity syndrome, and susceptibility to bacterial infection. Considering bleeding tendency and post-operative anti-coagulant therapy, a bioprosthesis was chosen in this case. The postoperative course was uneventful. When cardiac surgery is indicated in patients with MM, we must carefully consider and manage the specific perioperative problems and indications for cardiac procedures.

Hybrid zone zero debranching thoracic endovascular aortic repair of ascending aortic injury after surgery and radiotherapy for breast cancer.

Thoracic endovascular aortic repair of the ascending aorta remains challenging. We have reported the case of an 81-year-old woman with ascending aortic injury who underwent a life-saving hybrid repair. The patient had previously undergone extended radical mastectomy and postoperative radiotherapy for breast cancer, which had resulted in a right thoracic wall defect and bone exposure and osteonecrosis of the sternum. Therefore, the ascending aorta was directly compressed by the sternum at the level of the brachiocephalic artery bifurcation, causing persistent bleeding from the thoracic wall. Hybrid zone 0 debranching thoracic endovascular aortic repair with a left subclavian artery inflow was emergently performed and achieved hemostasis.

Efficacy of propafenone hydrochloride in preventing postoperative atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Atrial fibrillation (AF) is one of the most common complications after coronary artery bypass grafting (CABG), and the incidence of postoperative AF (PAF) is estimated to range from 10% to 40%. PAF is a serious complication that is related to unstable hemodynamics, development of embolisms, patient discomfort, and increased medical costs associated with the prolongation of hospital stay. Sometimes, immediate attention is also necessary. In this study, we assessed the efficacy of treatment with the antiarrhythmic drug propafenone hydrochloride, which was administered in the early postoperative period, in preventing the development of PAF, and we attempted to identify risk factors for PAF. MATERIALS AND METHODS: The subjects were 78 patients who underwent isolated off-pump CABG between July 2007 and October 2008. We conducted the study by dividing the patients into 2 groups, a group of 26 patients who received propafenone hydrochloride (P group) and a control group of 52 patients who did not receive this drug (C group). The patients in the P group were given propafenone hydrochloride (150-450 mg/day orally) for 10 days, starting on the day after surgery, and were observed for the development of AF by means of continuous 12-lead electrocardiographic monitoring. Development of AF was defined as AF that lasted

Transgraft embolization by using long needle for the treatment of type II endoleaks after endovascular abdominal aortic repair.

We used a long custom needle (LCN) to improve transgraft embolization (TGE) in 10 reported cases that underwent TGE with LCN for type II endoleak (T2E) treatment after endovascular abdominal aortic aneurysm repair. TGE was performed with a LCN enabling the usage of microcatheter and embolization coils in 10 cases with T2E after endovascular abdominal aortic aneurysm repair. Embolization was successfully achieved in the nidus in all 10 cases. The aneurysmal sac diameter significantly decreased by TGE, and none of the 7 of 10 cases exhibited recurrence of sac expansion or T2E throughout the 2-year follow-up period.

Endoscopic radial artery harvesting for coronary artery bypass grafting: the initial clinical experience and results of the first 50 patients.

BACKGROUND: The radial artery (RA) is a commonly used arterial conduit in coronary artery bypass grafting (CABG). Traditional open-vessel harvest often leads to postoperative wound complications and cosmetic problems. Endoscopic RA harvesting (ERAH) has been widely used to prevent these problems. The purpose of this study was to assess these problems and graft patency in the first 50 patients who underwent ERAH. METHODS: Between February 2006 and October 2007, 50 patients underwent ERAH with the VasoView system (Boston Scientific). These patients were compared with 50 patients who underwent the traditional open technique. RESULTS: The mean age was 62.8 years in both groups. All RAs were successfully harvested. No conversion was made from ERAH to the traditional open technique. The mean harvesting time (forearm ischemic time) was 27.4 + or - 6.5 minutes, and the mean length of the RA in the ERAH group was 18.5 cm. Neither wound complications, such as wound infection and skin necrosis, nor severe neurologic complications were recorded. The patency rate was 95.9% (95/99) in the ERAH group and 94% (94/100) in the open group. CONCLUSION: ERAH can be performed safely, and the early results are satisfactory. Endoscopic vessel harvesting is therefore recommended as the technique of choice for RA harvesting.

Aortic dissection late after aortic valve replacement.

We experienced 3 cases of an aortic dissection occurring late after an aortic valve replacement, and successfully treated by an aortic root replacement. An aortic dissection involving the ascending aorta can develop late after an aortic valve replacement, and such an occurrence is associated with a high mortality and morbidity. The development of effective surgical strategies at the initial aortic valve surgery, strict control of blood pressure after aortic valve replacement, serial evaluations of aortic size, and the prophylactic replacement of the ascending aorta for patients with aortic dilatation after aortic valve replacement, all play clinically important roles in preventing an aortic dissection after aortic valve replacement. When an aortic dissection occurs in patients with a previous aortic valve replacement, an aortic root replacement should be performed in order to avoid leaving the fragile diseased aortic wall including the sinus of Valsalva.

Four-stitch side-to-side anastomosis for sequential coronary artery bypass grafting.

Sequential bypass (SB) is an effective method of implementing complete myocardial revascularization of complex coronary stenoses. The SB allows a single graft to be used for bypass in several locations, which facilitates multi-branch revascularization. We have developed a simple SB technique, four-stitch side-to-side anastomosis, and report its clinical effectiveness in 428 patients.

Splenic abscess associated with active infective endocarditis.

Splenic abscess is a rare complication in infective endocarditis. Here, we present two cases of splenic abscess associated with active infective endocarditis. Body computed tomography before emergency valvular surgery revealed abscess in the spleen. In case 1, the abscess was localized within the spleen; splenectomy and valve replacement were performed through the same median skin incision. In case 2, the splenic abscess was diagnosed as ruptured; valve replacement was performed, followed by splenectomy through a separate skin incision. No recurrence of infection occurred after surgery in either case. In surgical treatment for active infective endocarditis, body computed tomography is essential to diagnose splenic abscess preoperatively. If there is an abscess, then splenectomy and valvular surgery should be performed simultaneously to prevent reinfection after valvular surgery. The approach to the spleen should be individualized according to the extension of the abscess.

Extensive resection and double-patch reconstruction for left atrial myxoma.

The efficacy and safety of surgical intervention for atrial myxoma are established, but the operative approach to tumor resection and atrial reconstruction are controversial. A biatrial approach is generally used for excision of atrial myxoma and has many advantages. In contrast, there are a few reports about the method of double-patch reconstruction, and the right and left atrium are individually reconstructed with the two patches. We found it to be effective in the case reported here. We suggest that this method can be applied to atrial myxoma in which extensive resection is necessary.

Preventive effect of intraoperative landiolol administration on atrial fibrillation after off-pump coronary artery bypass grafting.

INTRODUCTION: Postoperative atrial fibrillation (AF) is a common complication of cardiac surgery that is associated with an increased incidence of other complications. This study evaluated the safety and efficacy of landiolol hydrochloride--an ultrashort-acting ß1-selective blocker and highly regulated drug, positioned as a class 1 antiarrhythmic in Japan guidelines--for the prevention of AF after off-pump coronary artery bypass grafting (CABG). METHODS: Between January 2011 and November 2013, 116 patients underwent CABG at Fukuoka University Hospital. They were divided into two groups: group L consisted of patients who were administered landiolol hydrochloride at 2 µg/kg/min after completion of all distal anastomoses; group C was the control group consisting of patients who were not administered landiolol. Patient backgrounds, intraoperative variables and incidence of postoperative complications were compared. RESULTS: No significant between-group differences were observed in patient backgrounds or incidence of complications other than postoperative AF, which occurred significantly less frequently in group L. After administration of landiolol, heart rate decreased but no change was observed in arterial pressure or other parameters, and patient hemodynamics remained stable. CONCLUSION: Intraoperative and perioperative administration of low-dose landiolol has a preventive effect on the development of AF after CABG surgery.

Direct and transapical central cannulation for acute type a aortic dissection.

OBJECTIVE: The choice of cannulation site for the treatment of acute Stanford type A aortic dissection is much debated. We believe that central cannulation is quick to perform, easy to use, and safe to manage acute type A aortic dissection. MATERIALS AND METHODS: We retrospectively investigated 26 cases of acute aortic dissection performed using two different central cannulation methods between April 2011 and March 2012. Direct ascending aortic cannulation was performed using the Seldinger technique in 20 patients, and transapical ascending aortic cannulation was performed in six patients in whom puncture was difficult. RESULTS: Patients were 21-86 years old (mean age, 67 years). The surgical techniques used to treat aortic dissection were hemiarch repair in 21 patients and total arch replacement in 5 patients. The mean length of surgery was 393 min. One death (3.8%) was attributed to intestinal ischemia. CONCLUSION: During surgery for acute aortic dissection, central cannulation using either transapical or direct puncture can be performed quickly and safely, and satisfactory short-term outcomes can be obtained. Because acute aortic dissection can present with various conditions, there is no single perfect surgical or cannulation method; therefore, the choice of surgical procedure should be individualized for each patient.