楜澤 壮樹

Vascular lesions, including aneurysms, are rare but well-documented complications of von Recklinghausen's disease. Although aneurysms associated with this condition are often asymptomatic, rupture can lead to life-threatening events such as hemothorax. We report a 63-year-old male with von Recklinghausen's disease who presented with sudden onset of chest pain. Imaging revealed left-side hemothorax, and contrast-enhanced computed tomography( CT) suggested rupture of the left 10th intercostal artery. Given his hemodynamic stability, percutaneous coil embolization was performed. Angiography revealed two adjacent aneurysms at the origin of the left 10th intercostal artery, both of which were successfully embolized. Postoperative course was uneventful, and the patient was discharged on postoperative day 6. This case highlights the importance of considering vascular complications in von Recklinghausen's disease and supports the efficacy and safety of coil embolization in managing ruptured intercostal artery aneurysms.

A 63-year-old woman with severe aortic regurgitation was admitted to our hospital due to congestive heart failure. She also had antiphospholipid syndrome (APS), necessitating strict coagulation management. Given her history of cerebellar infarction, deep vein thrombosis, and recurrent miscarriages, her thrombosis risk was higher, with all three types of antiphospholipid antibodies testing positive. Before the surgery, we created a heparin-activated clotting time (ACT) titration curve using the patient's blood, and the calculated ACT corresponding to the target heparin concentration of 3 U/ml was 650 seconds. We planned to administer heparin according to this target during cardiopulmonary bypass. The patient underwent an aortic valve replacement (AVR) using a bioprosthesis and was discharged without complications.

A 48-year-old man underwent computed tomography for the examination of lower back pain, which incidentally detected a cardiac tumor in the right atrium. On echocardiography, the tumor was identified as a 30 mm round mass with a thin wall and iso- and hyper-echogenic contents that originated from the atrial septum. The tumor was successfully removed under cardiopulmonary bypass, and the patient was discharged in good health. The cyst was filled with old blood, and focal calcification was observed. Pathological examination revealed that the cystic wall was composed of thin-layered fibrous tissue lined with endothelial cells. Regarding a treatment, it is reported that early surgical removal is preferable to avoid embolic complications, however it is controversial. Furthermore, it needs to discuss about the difference between fetal/neonatal and adult cases.

No case report about takotsubo cardiomyopathy with Stanford type A acute dissection is present in the literature. Here we report a case of takotsubo cardiomyopathy that was diagnosed following Stanford type A acute aortic dissection. A 65-year-old man was admitted with dyspnea. He had experienced acute chest pain 10 days prior. Computed tomography (CT) confirmed Stanford type A aortic dissection and primary entry tear in the proximal aortic arch with a thrombosed false lumen in the ascending aorta. Echocardiography revealed takotsubo-like wall motion, with an ejection fraction (EF) of 20%. Electrocardiography (ECG) showed ST-segment elevation in V2-V3. Subsequently, coronary artery disease was excluded by coronary CT. After 1 month, ECG findings and EF appeared normal. Thirty-five days after admission, aortic arch replacement was performed with the frozen elephant trunk technique. The patient's postoperative course was uneventful. Takotsubo cardiomyopathy should be considered as a possible complication of acute aortic dissection with ST-segment elevation.

OBJECTIVES: To control intraoperative hyperglycemia in patients who underwent aortic surgery using STG-55® artificial endocrine pancreas and clarify the effectiveness of this device. METHODS: Blood glucose control using the STG-55® was performed in 18 patients (15 men and 3 women; age, 66 ± 10 years) who required hypothermic circulatory arrest (STG-55® group). Seventeen patients (10 men and 7 women; age, 71 ± 8 years) whose blood glucose was controlled using the conventional method were included in the control group. Glucose concentration was controlled with the aim of maintaining it at 150 mg/dl. RESULTS: In both groups, the blood glucose concentrations did not significantly change during the interruption of systemic perfusion; however, a sharp increase was noted immediately after reperfusion. Although the hyperglycemic status persisted after reperfusion in the control group, it was effectively suppressed in the STG-55® group (STG® vs. control group at 50 min after reperfusion: 180 ± 35 vs. 212 ± 47 mg/dl, p = 0.026) and blood glucose concentration reached the target value of 150 mg/dl at 100 min after reperfusion (STG® vs. control group: 153 ± 29 vs. 215 ± 43 mg/dl, p = 0.0008). The total administered insulin dose was 175 ± 81 U and 5 ± 3 U in the STG® and control groups, respectively (p < 0.0001). CONCLUSIONS: To treat the accelerated hyperglycemic status in aortic surgery requiring circulatory arrest, strict glycemic control using an artificial endocrine pancreas might be beneficial.

BACKGROUND: Aspergillus endocarditis (AE) is a rare and lethal cardiac infection with a high rate of mortality. AE most commonly presents in immunocompromised patients and is associated with various co-morbidities. Herein, we present a case of AE associated with lung, brain, and cervical abscesses after chemotherapy for malignant lymphoma that was successfully treated by a combination of antifungal and surgical therapy. CASE PRESENTATION: A 29-year-old man was admitted to our hospital with an unidentified fever. He was diagnosed with malignant lymphoma (extra-nodal NK/T cell lymphoma nasal type), and chemotherapy was administered. After chemotherapy, nodular lung shadows along with new brain, cervical, and myocardial abscesses appeared, despite anti-bacterial/fungal therapy. Gene analysis of the cervical abscess biopsy revealed the presence of Aspergillus fumigatus species, and the transesophageal echocardiogram showed a mobile mural vegetation in the left ventricle (22 × 8 mm). He underwent surgical resection of this mural vegetation. His postoperative course was uneventful. He remains healthy at 28 months after surgery with continued oral antifungal therapy. CONCLUSION: Although AE associated with immunosuppression is a fatal clinical presentation, combined treatment with surgical resection and antifungal therapy was effective.

Sarcopenia represented by skeletal muscle depletion is closely related to frailty and predicts prognoses in the general population. However, its predictive value for hemodialysis (HD)-dependent patients undergoing cardiac surgery has not been fully investigated. We aimed to clarify the impact of sarcopenia on the outcomes of HD-dependent patients after cardiac surgery. We retrospectively reviewed 138 HD-dependent patients who underwent cardiac surgery between January 2006 and December 2017. Sarcopenia was assessed using the psoas muscle index (PMI), which was calculated using values measured on preoperative computed tomography images and the following formula: cross-sectional area of bilateral psoas muscle/height2. Patients were divided into two groups according to the PMI: the sarcopenia group (≤ 443 mm2/m2 for men and ≤ 326 mm2/m2 for women; n = 35) and the non-sarcopenia group (> 443 mm2/m2 for men and > 326 mm2/m2 for women; n = 103). Preoperative characteristics and surgical outcomes were compared. Overall in-hospital mortality did not differ between the sarcopenia and non-sarcopenia groups. However, the patients with sarcopenia had significantly decreased long-term survival. Multivariate analysis revealed that low PMI was a significant independent predictor of long-term mortality (hazard ratio, 1.92; 95% confidential interval, 1.19-3.17; p < 0.01). Long-term survival rates in HD-dependent patients undergoing cardiac surgery are severely affected by the presence of preoperative sarcopenia defined by PMI. Preoperative risk analysis using the PMI might contribute to risk stratification of and decision-making for HD-dependent patients undergoing cardiac surgery.

Coronary perforation during excimer laser coronary angioplasty( ELCA) is a rare but life threatening complication. A 55-year-old man was admitted to our hospital for management of acute coronary syndrome. ELCA was attempted for the left anterior descending coronary artery (LAD);however, coronary perforation of LAD occurred during the procedure. The patient was transferred to the operation theater and emergency surgical repair was performed. LAD and the diagonal branch were ligated, an aorto-coronary bypass grafting for the distal LAD and the diagonal branch using the saphenous veins. His postoperative course was uneventful, and the patient was discharged on the 23rd postoperative day. In case of coronary perforation complicated by ELCA, immediate surgical repair is essential.

BACKGROUND: Rupture of the ureter with extravasation resulting from an iliac aneurysm is extremely rare. Herein, we report a case of ureteric rupture with urinary extravasation secondary to an iliac aneurysm. CASE PRESENTATION: An 80-year-old man was admitted to our hospital for sudden onset of severe abdominal pain. Contrast-enhanced computed tomography demonstrated a large left internal iliac aneurysm (6.5 cm in diameter) and a ureteric rupture with leakage of contrast media from the left ureter, indicating a spontaneous ureteral rupture. The patient was treated with placement of a ureteral double-J stent under endoscopic and X-ray fluoroscopic guidance and endovascular aortic repair. His postoperative course was uneventful and he was discharged on postoperative day 20. A computed tomography scan at 2 weeks after surgery showed no contrast extravasation from the ureter or end leak. CONCLUSION: Combination treatment with ureteral and endovascular stenting is effective in avoiding aneurysmal rupture and the serious consequences of a ureteral rupture, which include a perinephric or retroperitoneal collection, abscess formation, subsequent urosepsis, and graft infection.

The prognostic nutritional index is an effective prognostic tool used in gastrointestinal surgeries. However, its value has not been verified in cardiovascular surgeries. This study aimed to investigate its utility in hemodialysis-dependent patients undergoing cardiac surgery. We retrospectively reviewed data of 110 hemodialysis-dependent patients who underwent cardiac surgery between January 2006 and July 2016. 20 variables were evaluated for short- and long-term mortality prediction. Patients were divided into high and low prognostic nutritional index groups with values > 34 (n = 90) and ≤ 34 (n = 20), respectively. Preoperative characteristics and surgical outcomes were compared between both groups. Overall, the in-hospital mortality rate was 9% (n = 10) and the 1-, 3-, and 5-year actual survival rates were 69%, 58%, and 40%, respectively. Univariate analysis for hospital death revealed age ≥ 70 years, body mass index ≤ 18 kg/m2, total cholesterol ≤ 120 mg/dl, concomitant procedures, albumin concentration ≤ 3.0 g/dl, and prognostic nutritional index ≤ 34 as risk factors. Multivariate logistic regression analysis confirmed age ≥ 70 years and concomitant procedures as independent risk factors. Whereas ejection fraction ≤ 30% and prognostic nutritional index ≤ 34 were strong independent predictors of long-term death. Patients in the low prognostic nutritional index group had significantly longer postoperative hospitalization, higher incidence of complications, significantly higher in-hospital mortality rate, and significantly lower actual survival rate. The low prognostic nutritional index affected surgical outcomes in hemodialysis-dependent patients undergoing cardiac surgery. Perioperative nutrition management based on the prognostic nutritional index may improve surgical outcomes.

A 77-year-old man presented with exertional dyspnea. The patient had a history of ankylosing skeletal hyperostosis and sleep apnea syndrome. Echocardiographic examination revealed severe aortic valve regurgitation. The patient underwent a prophylactic tracheostomy 2 weeks before cardiac surgery to decrease his risk of perioperative respiratory failure. He successfully underwent aortic valve replacement through a lower partial sternotomy. His postoperative course was uneventful, and the tracheostoma was closed 6 months after the cardiac surgery.

A 79-year-old man developed severe bilateral ischemic symptoms in the lower limbs. Chest-abdominal-pelvic contrast computed tomography (CT) showed acute occlusion involving the abdominal aorta, and endovascular therapy (EVT) was used as emergency treatment. Two self-expandable stents placed in the thrombus area resulted in restoration of blood flow to the lower limbs, despite limited stent expansion, and movement of these limbs. Follow-up CT showed good stent expansion. The patient had a favorable recovery without additional surgery. This case suggests that EVT might be an additional option for acute abdominal aortic occlusion if surgery or thrombolytic therapies are not possible.

CASE: A 26-year-old woman who had congenital aortic valve stenosis presented with exertional dyspnea. She had undergone percutaneous balloon aortic valvuloplasty 12 years previously at the age of 14. When she was 20 years old, she delivered a neonate by elective cesarean section at the 31st week of gestation because the mean pressure between the left ventricle and the ascending aorta was 52 mmHg. OUTCOME: She successfully underwent aortic valve replacement with a bioprosthetic valve combined with replacement of the ascending aorta in order to make the next pregnancy possible. CONCLUSION: The long-term prognosis of percutaneous balloon aortic valvuloplasty might be acceptable for some patients, even though this procedure is associated with the possibility of secondary interventions.

BACKGROUND: Pannus formation may disturb the leaflet movement of the prosthetic valve. CASE PRESENTATION: A 61-year-old woman presented with exertional dyspnea. She had undergone mitral valve replacement with a bioprosthetic valve 31 years ago, which was replaced with a tilting disc valve 22 years ago. The present laboratory findings revealed hemolytic anemia. Echocardiography showed an increased mean pressure gradient through the mitral valve and moderate to severe regurgitation around the minor orifice of the tilting disc valve. She therefore underwent a third operation. Pannus formation was found on the prosthetic valve ring, but it did not obliterate the prosthetic valve orifice. After removing the valve, the posterior wall of the left ventricle was seen to be associated with thickened endocardium. A bileaflet valve was implanted. Postoperative echocardiography showed that the implanted valve functioned well. CONCLUSIONS: Nonstructural dysfunction of the mechanical heart valve might occur long after operation. These changes are particularly observed with a tilting disc valve.

A 73-year-old man was transferred for treatment of abdominal aortic aneurysm. He had no history of abdominal surgeries. Grafting between the infra-renal abdominal aorta and the bilateral common iliac arteries was performed. Proximal and distal cross clamps were applied for grafting. He developed chylous ascites on the 5th post-operative day, 2 days after initiation of oral intake. Fortunately, he responded to treatment with total parenteral hyper-alimentation for 10 days, followed by a low-fat diet. There was no recurrence of ascites.

Between 2003 and 2014, at Jichi Medical University Hospital, 11 patients with prosthetic valve endocarditis (PVE) underwent re-operation. There was 1 in-hospital death and 2 late deaths. The cause of death was cirrhosis, heart failure and sepsis, respectively. Emergency surgery, previous double valve replacement (DVR) and Staphylococcus infection were common risk factors for all 3 cases. Two cases of patients that survived who underwent mitral valve replacement (MVR) and DVR for PVE after DVR were treated with multiple antibiotic courses for bacteremia associated with hemodialysis and colon cancer. One patient who underwent DVR after mitral valve plasty which was complicated with cerebral hemorrhage, had survived and was discharged. Of the aortic PVE patients, 2 cases of aortic valve replacement (AVR) using a mechanical valve, 1 case of aortic root replacement (ARR) using a mechanical valve, and 1 ARR using the homograft, were considered cured and never relapsed. A patient with aortic PVE, who underwent AVR after cesarean section for heart failure in birth period, has received ARR twice with the mechanical valve for recurrent pseudo-aneurysm of the left ventricular outflow tract. Since hemodialysis and colon cancer is a risk factor for recurrent PVE, it is necessary to consider the long-term administration of antibiotics after surgery.

A 67-year-old man experienced acute inferior myocardial infarction. Echocardiography and computed tomography showed massive pericardial effusion. He underwent emergency operation for ischemic ventricular free wall rupture. During the operation, an oozing type rupture was found on the inferior wall and the bleeding was completely controlled by applying fibrin glue sheets. On the 5th day after the operation, ventricular tachycardia appeared with hemodynamic deterioration. Echocardiography showed a ruptured posteromedial papillary muscle with massive mitral regurgitation. Intra-aortic balloon pumping was introduced and emergency repair operation was performed. The mitral valve was replaced with a bioprosthetic valve. The postoperative course was uneventful.

A 77-year-old man presented with exertional dyspnea. He had undergone aortic and mitral valve replacement with tissue valves 6-years earlier. The patient's hemoglobin level was 9.8 g/dl and serum aspartate aminotransferase (70 mU/ml) and lactate dehydrogenase (1,112 mU/ml) were elevated. Echocardiography revealed stenosis of the prosthetic valve in the aortic position with peak flow velocity of 3.8 m/second and massive mitral regurgitation. The patient underwent repeat valve replacement. Pannus formation around both implanted valves was observed. The aortic valve orifice was narrowed by the pannus, and one cusp of the prosthesis in the mitral position was fixed and caused the regurgitation, but they were free from cusp laceration or calcification. The patient's postoperative course was uneventful, and he continues to do well 14 months after surgery.

BACKGROUND: The purpose of this study was to evaluate retrospectively the clinical performance of the Bicarbon valve (Sorin Biomedica Cardio, Saluggia, Italy) implanted at our center in Japan. METHODS: Between January 1997 and December 2011, 415 patients in our institution were implanted with the Bicarbon valve. Nine of these recipients were excluded from the study because they had already undergone valve implantation and received a Bicarbon valve in a different position. The remaining patients were analyzed for evaluation of the postoperative clinical outcomes. Of the 406 patients (mean age 60.2 ± 11.7 years), 179 underwent aortic valve replacement (AVR), 149 mitral valve replacement (MVR), and 78 both aortic and mitral valve replacement (DVR). RESULTS: There were 10 early deaths (2.5 %: 4 in the AVR group and 6 in the MVR group). Three hundred eighty-nine patients were followed up (95.8 % completeness of follow-up) with a mean follow-up of 6.6 ± 4.2 years overall (AVR 6.8 ± 4.2, MVR, 6.7 ± 4.4, and DVR 5.7 ± 3.4 years) and a cumulative follow-up of 2661 patient-years (1214, 1001, and 446 patient-years for AVR, MVR, and DVR, respectively). Ninety-nine patients died (3.7 % per patient-year: 22 valve-related and 77 valve-unrelated deaths). Survival at 10 years was 74.1 ± 4.0 % in the AVR group, 73.7 ± 4.2 % in the MVR group, and 61.0 ± 7.9 % in the DVR group. The linearized incidence of thromboembolic complications, bleeding complications, prosthetic valve endocarditis, paravalvular leaks, and sudden death in all patients was 0.5 %, 0.5 %, 0.2 %, 0.2 %, and 0.4 % per patient-year, respectively. The incidence of valve-related complications and reoperation was 1.6 % and 0.4 %, respectively. No other valve-related complications were observed. CONCLUSIONS: The Bicarbon prosthetic heart valve has shown excellent clinical results and is associated with a low incidence of valve-related complications.

A coronary artery aneurysm(CAA) that exceeds 20 mm in diameter is rare. In this case report, we describe the operative correction of a giant right CAA measuring greater than 8 cm in diameter. A 51-year-old male with a history of Kawasaki disease at 7 years of age was admitted to our hospital for evaluation of an abnormal shadow on a chest radiograph. Multi-detector row computed tomography (MDCT) demonstrated a giant, 82-mm right coronary aneurysm in the right atrioventricular groove with a layered thrombus. The patient underwent aneurysmectomy and coronary artery bypass grafting using the right internal thoracic artery under cardiopulmonary bypass. The postoperative course was uneventful, and postoperative MDCT revealed complete resection of the aneurysm and good patency of the bypass graft. The patient was discharged on the 8th postoperative day in good health.

A 73-year-old woman on hemodialysis was transferred to our hospital for surgical treatment of heart valve disease. She required both mitral and aortic valve replacement with mechanical valves, associated with tricuspid annuloplasty. After aortic de-clamping, a massive hemorrhage from the posterior atrioventricular groove was observed. Under repeated cardiac arrest, the left atrium was reopened, the implanted mitral prosthetic valve was removed and a type I left ventricular rupture (Treasure classification) was diagnosed. The lesion was directly repaired with mattress stitches and running sutures, using reinforcement materials such as a glutaraldehyde-treated bovine pericardium. To avoid mechanical stress by the prosthetic valve on the repaired site, a mechanical valve was implanted using a translocation method. The patient suffered from aspiration pneumonia and disuse atrophy for 3 months. However, she was doing well at 1 year post-operation.

CASE: A 56-year-old man presented with a sudden severe abdominal pain 13 days after the onset of type B acute aortic dissection. Chest computed tomography revealed type B aortic dissection, and the true lumen was narrowed by the expanding false lumen. Blood flow through the celiac trunk, superior mesenteric artery, and left renal artery was reduced. Blood flow through the distal abdominal aorta and bilateral femoral arteries was clearly recognized. Laboratory findings such as transaminases were rapidly worsening. OUTCOME: The patient underwent emergency fenestration of the abdominal aorta and recovered without organ failure. CONCLUSIONS: Rapidly worsening laboratory findings led us to emergency operation with successful results. Serial monitoring of laboratory findings is the key for adequate timing of operation.

We performed redo-off-pump coronary artery bypass grafting( OPCAB) via a left thoracotomy using the PAS-Port system for proximal vein graft anastomoses in a patient with posterolateral myocardial ischemia. The patient was a 76-year-old man who had undergone coronary artery bypass grafting (CABG)[ left internal thoracic artery( LITA)-left anterior descending artery( LAD), saphenous vein graft(SVG)-posterior descending artery( 4PD), and SVG-postero-lateral branch( PL)] 14 years previously. Coronary angiogram showed that the LITA-LAD graft was patent but that the SVG-PL, left main trunk( LMT) and proximal right coronary artery(RCA) were occluded, and that there were 90% stenoses of LAD #7 and SVG-4PD anastomotic site. With catheter intervention therapy, stenosis of the SVG-#4PD was dilated. We then performed revascularization from the descending aorta to the second diagonal (D2) and PL with a saphenous vein graft via left thoracotomy using off-pump technique. To avoid descending aortic clamping, we used the PAS-Port system for proximal anastomosis. The postoperative course was uneventful and the patient was discharged on postoperative day 28. A redo-CABG is thought to be with high risk. Our procedure, however is safe and useful and can be an option for redo-CABG in the posterolateral area.

A 73-year-old woman with acute aortic dissection (DeBakey type II) and cardiac tamponade was transferred to our emergency unit. She had a temporary blackout during transfer. An emergency operation was performed. We started core cooling with the superior vena cava, inferior vena cava, and transapical aortic cannulation. When the bladder temperature was 30.5 degrees C, esophageal temperature was 28.7 degrees C, and rectal temperature was 30.5 degrees C, the aortic root suddenly ruptured. We changed the arterial cannulation sites from the apex to the dissecting ascending aorta, and the ascending aorta was cross-clamped. However, the patient's pupils became dilated. Therefore, we started selective cerebral perfusion to avoid prolonged cerebral malperfusion. This procedure took approximately 30 minutes, from the aortic root rupture to selective perfusion. We performed both aortic root and ascending aortic replacement. After the operation, the patient had no neurological or other organ complications and she was discharged 11 days after surgery.