[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.

Robotic Transmitral Approach for Hypertrophic Cardiomyopathy With Systolic Anterior Motion.

BACKGROUND: Surgical intervention is indicated in symptomatic hypertrophic cardiomyopathy (HCM) patients with a ventricular outflow pressure gradient more than 50 mmHg. The transmitral approach, along with the transapical and transaortic approaches, is routinely used for myectomy, but all are open procedures. We describe a robotic transmitral approach that can be used to resolve septal hypertrophied muscle and eliminate mitral regurgitation (MR) using 1 cardiac incision. Methods and Results: We retrospectively analyzed 20 adult patients with obstructive HCM who exhibited concomitant severe MR and systolic anterior motion (SAM). The 2 groups comprised 12 standard full-sternotomy transaortic and 8 robotic transmitral approaches. The pre-intraventricular pressure gradient was 69±14.2 mmHg in the robotic transmitral group and 70.2±17.4 mmHg in the transaortic group (P=0.876). Both groups had a similar left ventricular ejection fraction (65±8% vs. 72±9%, P=0.901) and maximal ventricular wall thickness (22.3±4.5 and 21.7±6.0, P=0.835). Postoperative MR was reduced to less than grade II in all patients. In the robotic group, the postoperative pressure gradient was 1.5±2.6 mmHg, which was lower than that of the transaortic group at 10.6±10.8 mmHg (P=0.019). The cross-clamp time was 95.3±7.7 min in the robotic group and 104.7±20.8 min in the transaortic group (P=0.193). The operation time was 237.5±22.4 and 309.6±28.5 min (P<0.01) in the robotic transmitral and transaortic groups, respectively. CONCLUSIONS: Using a robotic transmitral approach to treat with patients with HCM, SAM, and MR is feasible and reliable. Through 1 atrial incision, it is possible to resolve hypertrophy of the septum and eliminate both severe MR and SAM.

[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.

A knot-pusher technique with hand-tying precision through a mini-thoracotomy.

This study documents the application of a knot-pusher technique via a mini-thoracotomy with the traditional one-handed knot-tying rationale using an existing long-shaft knot-pushing device. This technique achieved the typical hand-tying precision and secured tight knots in minimally invasive cardiac surgery.

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.

Extensive aortic root endocarditis caused ventricular septal rupture.

A 79-year-old man was referred to us for severe cardiac decompensation. Chest radiography showed severe pulmonary edema, and transesophageal echocardiography revealed extensive vegetations on all aortic valve leaflets with severe aortic valve regurgitation, heterogeneous cavities adjacent to the aortic annulus, and ventricular septal rupture into the right-ventricular outflow tract. After extensive debridement of the aortic root (including the infected ventricular septum), the ventricular septum and aortic root were reconstructed using autologous and bovine pericardial patches, and a bioprosthetic stented valve was placed. The postoperative course was uneventful, and he remains recurrence-free 4 years after surgery.

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.

Coronary Artery Bypass in Young Patients-On or Off-Pump?

A definitive conclusion regarding whether on-pump or off-pump coronary artery bypass is preferable in young patients is lacking. The aim of our study was to perform a long-term comparison of the two approaches in young patients. We analyzed the National Health Insurance Research Database, using data for patients between 18 and 45 years of age who had undergone isolated coronary artery bypass between 2001 and 2011. The study endpoints were: all-cause death, major adverse cardiac and cerebrovascular events, and repeat revascularization within 30 days, 1 year, 5 years, and the entire 10-year follow-up period. A total of 344 patients received off-pump surgery and 741 patients received on-pump surgery. Preoperative characteristics and comorbidities were similar in both groups, and all-cause mortality was almost equal (p = 0.716). The 5-year survival rates were 93.9% and 92.2% in the off-pump and on-pump groups, respectively, and the 10-year survival rates were 86.3% and 82.1%, respectively. The repeat revascularization rate was significantly lower in the on-pump group (p = 0.0407). Both the on-pump and off-pump methods offer equally good long-term outcomes in terms of mortality and major adverse cardiac and cerebrovascular events. However, the need for repeat revascularization is a concern in the long term after off-pump surgery.