Aortic Root Replacement 42 Years after Aortic Valve Replacement with the Björk-Shiley Spherical Valve in a Patient with an Aortic Root Aneurysm / 日本心臓血管外科学会雑誌

Herein, we present a case of aortic root replacement 42 years after aortic valve replacement (AVR) with the Björk-Shiley Spherical (BSS) valve in a patient with an aortic root aneurysm. The patient was a 67-year-old man who had undergone AVR with BSS and aortic root enlargement for the treatment of infective endocarditis and aortic insufficiency at 25 years of age. He underwent aortic root replacement for an enlarged aortic root (73 mm). Under general anesthesia, median re-sternotomy was performed, and the BSS valve was removed. The valve functioned well with no pannus or thrombus. We performed an aortic root replacement using a composite graft consisting of a 24-mm mechanical valve and 30-mm artificial graft. We experienced a rare case of long-term durability of the BSS valve, which functioned well for 42 years.

Surgical Management for the Patients of Mediastinal Malignancy Involving Cardiac Structures with Circulatory Impairments / 日本心臓血管外科学会雑誌

Malignant disease in the mediastinum often involves cardiac structures such as the cardiac chamber and great vessels, and causes circulatory impairments that limit therapeutic options and longevity. In the present study, we evaluated curative or palliative surgical management for 6 cases of such malignancy in the mediastinum with circulatory impairment who were operated on between January 2001 and February 2004 (4 men and 2 women aged 17 to 72 years). Procedures included tumor resection with cardiopulmonary bypass (CPB) for mitral strangulation due to left atrial myxosarcoma; pericardiectomy without CPB for constrictive pericarditis due to invasive thymoma; radical nephrectomy for renal cell carcinoma with right atrial tumor thrombus using CPB; two pericardial fenestrations with or without partial tumor resection for cardiac tamponade due to pericarditis carcinomatosis caused by malignant lymphoma or lung cancer; and right ventricular metastatic lesion resection with outflow tract reconstruction for the recurrence of renal cell carcinoma using CPB. The follow-up ranged from 4 days to 30 months. Procedure-related death occurred in the patient with invasive thymoma due to heart failure on postoperative day 4. Five operative survivors had improved quality of life and received other therapeutic options. Although the patient with malignant lymphoma died of sepsis during chemotherapy at three weeks, the remaining 4 patients were discharged from the hospital postoperatively but 3 died during follow-up due to the progression of malignant disease. The cause of death were local recurrence at 20 months after operation in the patient with myxosarcoma, liver metastasis at 13 months in the renal cell carcinoma patient, and carcinomatous cachexia at 8 months in the patient with metastatic lung cancer. The patient with recurrence of renal cell carcinoma is doing well without any symptoms of tumor progression at 30 months after metastatic lesion rsection. Despite poor prognosis of the patients of mediastinal malignancy, surgical management for circulatory impairments can be indicated with acceptable risk to lengthen survival and improve the quality of life.

Late Renal Cell Carcinoma Metastasis to the Right Ventricle without Caval Involvement / 日本心臓血管外科学会雑誌

A 72-year-old woman was admitted to our hospital because of a mass in the right ventricle. She has a history of renal cell carcinoma of the left kidney, which was completely removed by nephrectomy in 1996. Echocardiography, CT and MRI showed a large tumor in the right ventricle without any inferior vena cava involvement. A biopsy performed on that tumor confirmed that the tumor was a metastasic tumor in the right ventricle from the renal cell carcinoma. The tumor grew quickly, and almost completely obstructed the right ventricular outflow tract. On February 24, 2004; an operation was performed to remove the tumor, which protruded from the ventricular septum and occupied the right ventricular cavity from the attachment of the tricuspid valve to the right ventricular outflow tract close to the pulmonary valve. A transannular patch was placed in order to dilate the right ventricular outflow tract. Histopathology diagnosed that the tumor was a metastasis from the renal cell carcinoma. The postoperative course was uneventful. Interleukin-2 was administered postoperatively. Echocardiography performed eight months after the surgery showed that although the tumor in the right ventricle had grown, it had not produced stenosis of the right ventricular outflow tract. The patient died as a result of the recurrent tumor blocking the right ventricular outflow tract 11.5 months after the surgery.

A Case of an Elderly Patient Suffering from Acute Type A Aortic Dissection Who Received Conservative Treatment 3 Years after Aortic Valve Replacement / 日本心臓血管外科学会雑誌

An 87-year-old man who had a history of aortic valve replacement (Carbomedics n 23) due to severe aortic valve regurgitation 3 years previously was admitted to our hospital suffering from syncope. The ascending aorta was 40mm in diameter at the time. At the time of admission, the patient's ECG showed elevation of the ST segments in leads V₁-V₃ and depression in leads V₅, V₆, II, III and _aV_F. Emergency coronary angiography performed for suspected acute myocardial infarction showed a type A acute aortic dissection extending to the ostium of the left coronary artery. However, because of his age and stable condition without cardiac tamponade, we treated this patient with conservative therapy including antihypertensive medication. He experienced no major complication and was discharged 31 days after admission. It is concluded that the occurrence of acute aortic dissection after aortic valve replacement is not common, but for a patient with a dilated aortic root at the time of aortic valve replacement, strict postoperative care is necessary. An operation is the first choice of treatment for acute type A aortic dissection, but in this case the patient's overall condition had to be considered.

Lower Mid-line Skin Incision with Full Sternotomy as an Approach for Pediatric Atrial Septal Defect Repair / 日本心臓血管外科学会雑誌

Recently, the demand for better cosmetic outcomes in pediatric cardiovascular operations has been growing. Between May 1998 and April 1999, six children aged 2 to 6 years with an ostium secundum type of atrial septal defect underwent reparative operations that used an approach consisting of a lower mid-line skin incision with full sternotomy. A 4.2-5.8cm vertical skin incision (mean, 4.9±0.3cm) was made between the level of the nipple and the xyphoid process. Comparison between this series and a group of weight-matched patients who underwent conventional operations revealed no significant differences in operation time (166.0±12.0vs. 147±8.4min), cardiopulmonary bypass time (33.2±4.0vs. 32.2±2.4min), aortic cross-clamp time (13.8±2.3vs. 12.3±1.3min), or the reduction in the hemoglobin concentration in blood on the first postoperative day (1.7±0.3vs. 2.9±0.6g/dl). The surgical wound was not associated with any complications in our series, including wound infection or subcutaneous hematoma. Our technique appears to be safe and provide satisfactory cosmetic outcome.

Long-Term Follow-up of Patients with valvular and Non-valvular Extracardiac Conduits / 日本心臓血管外科学会雑誌

Here we present a long-term follow-up of 50 operative survivors, who underwent surgery between December 1975 and March 1994 for the placement of an extracardiac conduit. Twenty-six patients received conduits with various valves (VC group). The valves used were the Hancock valve in 9 patients, the St. Jude Medical valve in 5, and a valved roll made of equine pericardium in 10. Twenty-four patients received valveless Dacron conduits (NVC group). Another group of patients, also with discontinuity between the right ventricle and the pulmonary artery, who were operated on without the use of a conduit, is presented here for comparison (NCR group: 16 patients). The follow-up period for the NCR group was shorter than for the other groups. There were a total of 4 late deaths in the conduit groups, and none in the NCR group. Freedom from reoperation due to conduit stenosis was analyzed by the Kaplan-Meier method. In the VC group, freedom from reoperation at 5, 10, and 15 years, was 87.8%, 50.8%, and 31.2% respectively. In the NVC group, freedom from reoperation at 5, 10, and 15 years was 100%, 95.7%, and 60.4%. There were statistically significant differences between the values in these 2 groups. In the NCR group, only one patient (6.25%) underwent reoperation due to stenosis in the right ventricular outflow tract. Although the rate of freedom from reoperation was lower in the valveless conduit group than in the valved conduit group, the majority of patients who receive a conduit between the right ventricle and the pulmonary artery will eventually require reoperation. Avoiding the use of an extracardiac conduit, and creating continuity between the right ventricle and pulmonary artery with autologous tissue is a useful alternative and may reduce the need for reoperation.