[A Case of Achieving CR through Chemoradiotherapy for Postoperative Oligo Lymph Node Metastasis in Gastric Cancer].

We present a case of oligo lymph node metastasis in a 70s man who had previously undergone subtotal gastrectomy for advanced gastric cancer in the prepylorus. Postoperatively, adjuvant chemotherapy was administered for a duration of 1 year. During the third postoperative year, elevated tumor markers and lymph node enlargement prompted a diagnosis of lymph node metastasis. Subsequent chemoradiotherapy resulted in a complete response(CR), which has been sustained for 2 years without any recurrence. The outcomes of this case indicate that chemoradiotherapy stands as a viable treatment option for oligo lymphatic recurrence in gastric cancer.

[Redo Valve Replacement of Wada-Cutter Prosthetic Valve at Tricuspid Valve Position 47 Years After Implantation;Report of a Case].

We experienced an explantation of Wada-Cutter prosthetic tilting disk valve of 47 years after implantation. The patient was 53 years old female who underwent the 1st operation for Ebstein's anomaly, which included tricuspid valve replacement (TVR), closure of atrial septal defect (ASD) and posterior annulorrhaphy when she was 6 years old. She was doing well after the 1st operation without symptom,but dyspnea and systemic edema worsened recently though increased admission of diuretics. Echocardiography revealed severe tricuspid valve stenosis, severe tricuspid valve insufficiency, and increased right atrium volume. The tilting disk of the valve was almost fixed. The patient underwent repeat TVR. The explanted Wada-Cutter valve was covered by pannus the whole casing and disk. The structure of the valve was preserved but the occlusion disk was almost fixed by pannus formation, not distorted or dislodged.

[A Resected Case of the Vaginal Metastasis from Rectal Cancer].

The vaginal metastasis from colorectal cancer has rarely been reported. Here, we report a resected case of the vaginal metastasis from rectal cancer. A 51-year-old woman underwent radical hysterectomy and bilateral oophorectomy for uterus cancer. Five years after the operation, vaginal tumor was observed during an internal examination. Biopsy was positive for adenocarcinoma. Enhanced computed tomography demonstrated the wall thickening of the lower rectum and the mass of 20 mm at the inferior lobe of the left lung. Colonoscopy revealed the wall thickening of the lower rectum, and biopsy indicated a diagnosis of rectal cancer. We performed abdominoperineal resection and partial resection of the vagina. Pathological examination confirmed the vaginal metastasis from the rectal cancer.

Post-Thoracic Endovascular Aortic Repair Complicated with Mycotic Aneurysm Rupture, Repaired by Redo Thoracic Endovascular Aortic Repair.

Mycotic aneurysms although rare can be devastating. We encountered a dialysis patient with rapidly expanding distal aortic arch aneurysm who underwent axilloaxillary bypass and thoracic endovascular aortic repair (TEVAR). Three months later, he suffered mycotic aneurysm rupture for which redo TEVAR was performed. Antibiotic therapy was discontinued 16 weeks after the second operation, and renal transplantation was performed 6 months later. Dialysis was discontinued in the patient without infection recurrence.

[Effectiveness of tolvaptan for postoperative heart failure in a patient with combined valvular disease and pulmonary hypertension].

We report a case of a 60-year-old man with postoperative congestive heart failure( CHF) successfully treated with tolvaptan. The patient was diagnosed with pulmonary hypertension due to mitral stenosis and regurgitation combined with tricuspid regurgitation. He underwent mitral and tricuspid valvuloplasty. His postoperative course was uneventful until CHF symptoms secondary to volume overload appeared on the 4th day. Congestion with pulmonary hypertension was treated with 0.042 µg/kg/min of intravenous human atrial natriuretic peptide (hANP). His condition improved, and on the 11th postoperative day, he was weaned off hANP;oral administration of 40 mg per day of furosemide was initiated. However, 2 days after discontinuation of intravenous hANP, CHF recurred and serum sodium decreased to 128 mEq/l. Oral tolvaptan 7.5 mg per day was added to the furosemide, and CHF and hyponatremia subsequently improved. In this case, oral tolvaptan was effective for the treatment of refractory CHF with pulmonary hypertension after cardiac surgery.

[Redo coronary artery bypass grafting after pneumonectomy].

A 77-year-old man who had undergone left pneumonectomy 16 years and quadruple coronary artery bypass grafting (CABG) 4 years previously presented with unstable angina pectoris. Coronary angiography revealed severe stenosis of the left main trunk and the proximal left anterior descending artery(LAD), and the severely narrowed left internal thoracic artery (LITA)-LAD graft. Computed tomography(CT) presented a marked shift of the heart and great vessels into the left hemithorax with a hyperinflated right lung crossing the midline. The LAD would not seem to be accessible by median sternotomy. Off-pump coronary artery bypass grafting (OPCAB) with a saphenous vein graft to LAD was performed through a rib-cross left thoracotomy. The patient's postoperative course was uneventful, and postoperative CT revealed a patent graft. OPCAB through rib-cross thoracotomy is safe and useful and can be an option for redo CABG, particularly in instances of previous pneumonectomy.

[Management of cardiopulmonary bypass during cardiac surgery for patients with heparin-induced thrombocytopenia].

We experienced 4 cases of open heart surgeries under preoperative diagnosis of heparin-induced thrombocytopenia(HIT). We performed operation with argatroban instead of heparin. The argatroban was administered intravenously with a bolus of 100 µg/kg. After activated clotting time(ACT)reached over 200 seconds, continuous infusion of argatroban was started, 1~2 µg/kg/min until the level of ACT over 250 in the case of off-pump coronary artery bypass grafting(OPCAB), with 6~10 µg/kg/min, or the level of ACT over 400 with the use of cardiopulmonary bypass (CPB). All cases required more than 60 minutes to achieve the target ACT level after starting the argatroban. In 1 case it was impossible to achieve target level of ACT by argatroban alone, and heparin was used concomitantly. In 1 case there was a complication of membrane occlusion of CPB. Open cardiac surgery with the use of argatroban required specific care for coagulation to complete operation.

[Preserving autologous heart operation for dilated cardiomyopathy].

OBJECTIVE: We report non transplant surgical procedure (preserving autologous heart operation) for the patients with dilated cardiomyopathy( DCM), clinical outcomes, and the factor of predict prognosis. PATIENT AND METHOD: Since May 2000, 258 patients received surgical procedure for 11 years. SURGICAL PROCEDURES: We performed mitral surgery (plasty or replacement) for the patients with more than mild mitral regurgitation (MR). We performed papirally muscule plication since 2005, and we performed 2nd chordal cutting since 2008, for the patients with MR due to mitral tethering. The surgical left ventricular reconstruction( SVR) was performed for the patients with dilated left ventricular. We use spackle tracking echocardiography to decide the type of SVR since 2008. RESULT: Hospital death was 18.2%, and late cardiac death was 27.5%.Almost the cause of death was congestive heart failure and ventricular arrhythmia. Five years survival was 58%, 10 years survival was 39%. Preoperative condition, emergent operation, inotropic support, intra aortic balloon pumping(IABP),affect the prognosis. But left ventricular size did not affect it. CONCLUSION: Surgical treatment for the patient with DCM should be performed with stable preoperative condition.

[Acute Type A aortic dissection with superior mesenteric arterial dissection; report of a case].

We report a case of acute type A dissection with acute abdomen due to blood flow insufficiency in the superior mesenteric artery. A 73-year-old man was presented to hospital complaining sudden onset of chest pain. Contrast-enhanced computed tomography revealed a type A aortic dissection, that extended from the ascending aorta to the left common iliac atery. Superior mesenteric artery was compressed by the thrombosed false lumen. Epigastric pain was exacerbated acutely, we decided to treat the bowel ischemia 1st, and after that, if bowel ischemia was reversible, central repair operation performed. Emergent saphenous vein bypass was performed from the right external iliac artery to the superior mesenteric artery. Then total arch replacement was performed using cardiopulmonary bypass. The patient complicated with postoperative paralytic ileus, he completely recovered without bowel resection.

[Non-occlusive mesenteric ischemia after off-pump coronary artery bypass grafting].

Non-occlusive mesenteric ischemia( NOMI) after cardiac surgery is a rare but catastrophic complication. Although NOMI is generally recognized to be associated with extracorporeal circulation, we present a fatal case of a patient who developed NOMI after off-pump coronary artery bypass grafting (OPCAB). An 85-year-old man with left main trunk and triple vessel disease underwent OPCAB. He developed severe abdominal pain with metabolic acidosis 9 hours postoperatively. Selective angiography of the superior mesenteric artery( SMA) showed narrow and spastic branches of the SMA. A continuous intra-arterial perfusion with papaverine was started, but he died of multiple organ failure on the 3rd postoperative day. We emphasize the importance of early diagnosis and adequate treatment of NOMI including prompt exploratory laparotomy.

Papillary-Ventricular Complex Tugging for Ischemic/Functional Mitral Regurgitation.

Surgical restoration of subvalvular geometry is very important to prevent recurrence of ischemic/functional mitral regurgitation. We evaluated an approach to the radical repair of left ventricular (LV) remodeling for three different cases with responsible coronary lesions. Leaflet tethering was corrected by tugging of the papillary-ventricular complex, which consists of the base of papillary muscles and posterior LV wall. The main lesion of the postinfarction scar was concomitantly excluded. Restoration of LV remodeling diminished mitral regurgitation with minimal leaflet tethering and improved systolic LV function. This technique may be an aggressive and encouraged approach for patients with ischemic/functional mitral regurgitation.

[Preserving autologous heart operation for ischemic cardiomyopathy].

OBJECTIVE: We report our surgical procedure (preserving autologous heart operation) for the patients with ischemic cardiomyopathy (ICM), and the results. PATIENT AND METHOD: Since May 2000, 212 patients received surgical procedure for ten years. SURGICAL PROCEDURES: We performed complete coronary artery bypass grafting (CABG), mitral surgery (plasty or replacement) for the patients with more than mild mitral regurgitation. We performed papirally muscle plication since 2005, and we performed 2nd chordal cutting since 2008, for the patients with mitral regurgitation (MR) due to severe mitral tethering. The surgical left ventricular reconstruction (SVR) was performed for the patients with dilated left ventricular. We use speckle tracking echocardiography to decide the type of the procedure of surgical left ventricular reconstruction since 2008. RESULT: Hospital death was 8.0%, and late death was 9.9%. Almost of the cause of death was congestive heart failure and ventricular arrhythmia. Five years survival was 78%, 10 years survival was 73%. CONCLUSION: The non transplant surgery for the patient with ICM was effective with the combination of CABG, mitral valve plasty (MVP) or mitral valve replacement (MVR), SVR. The size of left ventricle (LV) after SVR seemed to be a factor for late outcome of the surgery.

The Growth Potential and Patency of Free Right Internal Thoracic Arteries Verified by Computed Tomography Angiography.

BACKGROUND: The use of the left internal thoracic artery (LITA) is the gold standard in coronary artery bypass graft surgery (CABG). Multiarterial grafting for CABG is being increasingly emphasized. This study aimed to resolve the utility of the right internal thoracic artery (RITA) for multiple CABG as "free" RITA and described new evidence. METHODS: One hundred sixty-three patients received solo CABG with bilateral internal thoracic arteries between 2005 and 2018. The RITA was used as in situ RITA, group A (n = 62), and the composite graft created with saphenous vein graft (SVG), group B (n = 101). The patency rate and graft size of the composite free RITA and SVG were examined by coronary computed tomography angiography. RESULTS: The average number of distal anastomoses per patient was 3.4 ± 1.0 in group A, and 4.2 ± 1.1 in group B (P < .001). The sequential grafting with free RITA was in 86 patients. The patency rate of both LITA and RITA was similar in both groups. In group B, 40 patients received late computed tomography angiography at a mean of 46 months (range, 17 to 175). The late patency rate was 95.1% in LITA and 96.9% in free RITA. The diameter of free RITA increased from 2.06 ± 0.34 mm to 2.37 ± 0.23 mm (P = .036); that of in situ LITA increased from 2.08 ± 0.51 mm to 2.44 ± 0.49 mm (P = .047); and that of composite SVG decreased from 4.1 ± 0.9 mm to 2.6 ± 0.7 mm (P < .001). CONCLUSIONS: Multiple bypass grafting can be sufficiently achieved with LITA and free RITA. The growth potential of free RITA and in situ LITA might play the important role of expected long-term patency.

Successful Handmade Monobloc Aortomitral Valve Replacement for Extensive Aortic Root Abscess.

Aortic root abscess is one of the most catastrophic complications of aortic valve endocarditis. Complete débridement is recommended regardless of the kind of infected lesion. A 37-year-old man with extensive aortic root abscess due to prosthetic aortic valve endocarditis was surgically treated. The main lesion was the aortomitral continuity extending to the commissure between the left and right coronary cusps. After débridement, the aortic annulus underneath the left coronary artery was reconstructed using a handmade aortomitral monobloc valve without aortic annuloplasty. This valve was required for the extensive root abscess of the left and noncoronary sinus to achieve complete débridement.

Endocardial Hemangioma of the Right Ventricle: Complete Excision With Right Ventricular Restoration.

Primary cardiac tumor can arise from any location in the right and left cardiac chamber. Complete excision is generally recommended because of uncertainty regarding malignancy; however it is important to minimize the resultant functional deterioration after surgery. We report a case of endocardial hemangioma (4 × 3 × 3 cm) on the free wall of the right ventricle, located between the anterior and posterior papillary muscles. We describe details of the procedure to preserve the right ventricular volume and competence of the tricuspid valve.

Immunohistochemical identification of Propionibacterium acnes in granuloma and inflammatory cells of myocardial tissues obtained from cardiac sarcoidosis patients.

BACKGROUND: Although rare, cardiac sarcoidosis (CS) is potentially fatal. Early diagnosis and intervention are essential, but histopathologic diagnosis is limited. We aimed to detect Propionibacterium acnes, a commonly implicated etiologic agent of sarcoidosis, in myocardial tissues obtained from CS patients. METHODS AND RESULTS: We examined formalin-fixed paraffin-embedded myocardial tissues obtained by surgery or autopsy and endomyocardial biopsy from patients with CS (n = 26; CS-group), myocarditis (n = 15; M-group), or other cardiomyopathies (n = 39; CM-group) using immunohistochemistry (IHC) with a P. acnes-specific monoclonal antibody. We found granulomas in 16 (62%) CS-group samples. Massive (≥14 inflammatory cells) and minimal (<14 inflammatory cells) inflammatory foci, respectively, were detected in 16 (62%) and 11 (42%) of the CS-group samples, 10 (67%) and 10 (67%) of the M-group samples, and 1 (3%) and 18 (46%) of the CM-group samples. P. acnes-positive reactivity in granulomas, massive inflammatory foci, and minimal inflammatory foci were detected in 10 (63%), 10 (63%), and 8 (73%) of the CS-group samples, respectively, and in none of the M-group and CM-group samples. CONCLUSIONS: Frequent identification of P. acnes in sarcoid granulomas of originally aseptic myocardial tissues suggests that this indigenous bacterium causes granuloma in many CS patients. IHC detection of P. acnes in massive or minimal inflammatory foci of myocardial biopsy samples without granulomas may be useful for differentiating sarcoidosis from myocarditis or other cardiomyopathies.

Subvalvular Pannus Overgrowth after Mosaic Bioprosthesis Implantation in the Aortic Position.

PURPOSE: Although pannus overgrowth by itself was not the pathology of structural valve deterioration (SVD), it might be related to reoperation for SVD of the bioprostheses. METHODS: We retrospectively reviewed patients undergoing reoperation for SVD after implantation of the third-generation Mosaic aortic bioprosthesis and macroscopic appearance of the explanted valves was examined to detect the presence of pannus. RESULTS: There were 10 patients and the age for the initial aortic valve replacement was 72 ± 10 years old. The duration of durability was 9.9 ± 2.0 years. Deteriorated valve presented stenosis (valvular area of 0.96 ± 0.20 cm(2); pressure gradient of 60 ± 23 mmHg). Coexisting regurgitant flow was detected in two cases. Macroscopically, subvalvular pannus overgrowth was detected in 8 cases (80%). The proportion of overgrowth from the annulus was almost even and pannus overgrowth created subvalvular membrane, which restricted the area especially for each commissure. In contrast, opening and mobility of each leaflet was not severely limited and pannus overgrowth would restrict the area, especially for each commissure. In other two cases with regurgitation, tear of the leaflet on the stent strut was detected and mild calcification of each leaflet restricted opening. CONCLUSION: In patients with the Mosaic aortic bioprosthesis, pannus overgrowth was the major cause for reoperation.

Mid-term results of mitral valve palsty in patients with mitral sclerotic lesion.

BACKGROUND: Mitral valve repair is preferred over prosthetic replacement. We surgically repaired mitral valve with degenerated sclerotic lesion and demonstrated mid-term results. METHODS: Mitral valve plasty (MVP) was performed with several procedures including ring annuloplasty, leaflet slicing and decalcification. RESULTS: There were 19 males and 19 females with a mean age of 67 ± 12 y.o (n = 38). All patients were successfully treated MVP except one case with unrepairable injuries of the thin leaflet. In patients underwent MVP (n = 37), MVP included ring annuloplasty with a rigid full ring of 32 ± 2 mm (n = 37), leaflet slicing (n = 37), decalcification (n = 15) and artificial chordae (n = 14). Mitral valve area was statistically enlarged by MVP (1.65 ± 0.57 vs 2.51 ± 0.58 cm(2), p < 0.001). Left atrial diameter was statistically reduced after the operation (55 ± 10 vs 46 ± 9 mm, p < 0.001). Severity of MR and right ventricular systolic pressure (RVSP) were statistically decreased after the operation (MR; 1.8 ± 1.0 vs 0.7 ± 0.9, p < 0.001, RVSP; 38 ± 15 vs 30 ± 9 mm Hg, p < 0.001). There were 4 cases with residual MR (Grade II, n = 3; Grade III, n = 1). The 30-days mortality was 0 %. There was one late death due to non-cardiogenic cause (the 3-year survival rate of 97 %) and no redo case due to deterioration of the mitral valve during follow-up period of 21 ± 13 months. CONCLUSIONS: Successful mid-term survival and freedom from reoperation might expect to the durability of MVP in patients with mitral sclerotic lesion.

Total right ventricular exclusion improves left ventricular function in patients with end-stage congestive right ventricular failure.

BACKGROUND: We developed a total right ventricular (RV) exclusion procedure for the treatment of isolated congestive RV failure. The objective of the present study was to elucidate the effects of a complete removal of RV volume overload (RVVO) on the surgically created single left ventricle (LV). METHODS AND RESULTS: Three adults (2 arrhythmogenic RV dysplasia, 1 Ebstein) and 5 children (all Ebstein) in NYHA class IV underwent the procedure. The RV free wall was resected from the heart, and the tricuspid orifice was closed. Pulmonary blood supply was obtained by a cavopulmonary connection in 6 patients and a systemic-pulmonary shunt in 2. The LV function was evaluated by 2-dimensional echocardiography 1 month after the surgery. All patients are alive. The paradoxical movement of the interventricular septum and geometry of the LV expressed by its eccentricity (2.1 to 1.2, P<0.01) were normalized after the operation in all 8 patients. LV end-diastolic volumes (59% to 109% of normal value, P<0.01), indexed maximal left atrial area (6.5 to 10.5 cm2/m2, P<0.01), LV ejection fraction (27% to 62%, P<0.01), and cardiac index (2.1 to 3.3 L/min/m2, P<0.05) all significantly increased. CONCLUSIONS: Removal of the RVVO by means of the total RV exclusion procedure provides effective volume loading, restores a cylindrical shape, and improves contractile function of the LV, thus leading to increased systemic output.

Prediction of Long-Term Survival in Patients with End-Stage Heart Failure Secondary to Ischemic Heart Disease: Surgical Correction and Volumetric Analysis.

PURPOSE: Ischemic heart disease (IHD) may result in lethal conditions such as ischemic cardiomyopathy (ICM) and mitral regurgitation (MR). METHODS: We hypothesized preoperative LV volume would be highly associated with long-term survival in such patients. We retrospectively evaluated effects of LV end-systolic volume index (LVESVI) on survival. RESULTS: Patients were divided into two groups according to LVESVI; Group S (n = 19, <100 ml/m(2)), and L (n = 55, >100 ml/m(2)). There were 74 patients (male 61, female 13; 61 ± 10 y.o.). There was no statistical significance in preoperative parameters, including ejection fraction (EF), severity of MR, severity of tricuspid regurgitation (TR), and right ventricular systolic pressure (RVSP). After operation, LVESVI and severity of MR were statistically reduced in both groups. However, EF, severity of TR and RVSP were not statistically alleviated in both groups. In Group S, 5- and 10-year survival rates were 93% and 48%. In Group L, 5- and 10-year survival rates were 50% and 29%. There was a statistical difference in long-term survival between two groups. CONCLUSIONS: Preoperative LV volume would be one of the risk factors for long-term survival in patients with congestive heart failure secondary to IHD. Careful follow-up and optimal treatment should be recommended before LV dimension becomes too large.