Two Cases of Minimally Invasive Right Thoracotomy Approach and Microscope-Assisted Surgery for Mitral Re-Operation; Mechanical Valve Dysfunction in the Late Operative Period / 日本心臓血管外科学会雑誌

Case 1 of stuck valve was an 84 year old man, 25 years after mitral valve replacement (MVR) using a mechanical valve. Case 2 was a 67 year old woman, 18 years after the previous operation. These patients underwent re-do replacement of the prosthesis with a minimally invasive right thoracotomy approach using a microscope. Re-do cardiac surgery is commonly regarded high risk on account of difficulty in peeling the adhension, risk of injury to the heart, lung or large vessels, longer operation time, greater amount of transfusion, higher invasion and longer admission. In both cases however, because of microscope-assist and right thoracotomy MICS technique, we safely and successfully completed the operation without any unplanned troubles. We finally had a good course with a short admission, no perioperative transfusion or no perioperative complication.

Thoracic Endovascular Aortic Repair Following Axillo-Femoral Bypass in a Patient with Stanford B Acute Aortic Dissection Accompanied by Renal Ischemia / 日本心臓血管外科学会雑誌

A 71-year-old male was admitted to our institution because of right leg pain and paleness, accompanied by sudden chest-back pain. The right femoral artery was not palpable. The reticulated cyanosis appeared on the right leg. Contrast enhanced computed tomography (CT) revealed an acute type B aortic dissection (TBAD) extending from the descending thoracic aorta to the left common iliac artery and right external iliac artery. The intimal tear was located at thoraco-abdominal aorta. There was a severe stenosis of the true lumen at bilateral common iliac arteries because of the dynamic compression caused by the extended false lumen. Blood to the right leg was not supplied from the dissected iliac artery, the peripheral circulation was maintained by collateral flow. The patient was diagnosed acute TBAD complicated with lower limb ischemia. An emergent right axillary artery-bifemoral arteries bypass was carried out for malperfusion of lower extremities. The symptoms in the lower limbs disappeared immediately. The bilateral femoral arteries were well palpated. However, 4 days later, uncontrollable severe hypertension and anuria appeared suddenly. Contrast enhanced CT revealed the stenosis of true lumen at bilateral renal arteries and an exacerbation of stenosis of true lumen at abdominal aorta. Emergent thoracic endovascular aortic repair (TEVAR) for entry closure was performed to improve the renal function and prevent mesenteric ischemia. Postoperative contrast enhanced CT revealed the complete closure of the entry tear and dilatation of the true lumen at the descending and abdominal aorta. At the bilateral renal arteries, the blood flow improved. The renal function recovered and mesenteric ischemia did not occurred. In this report, we presented a case of acute TBAD complicated with lower limbs ischemia and late onset acute ischemic renal failure. We first performed the right axillary artery-bifemoral arteries bypass grafting, after that we had to perform TEVAR to close the entry tear. One-stage emergent TEVAR should be considered for acute TBAD with the dynamic compression at the level of abdominal aorta in future.

A Case of Thoracic Endovascular Aortic Repair for Subacute Aortic Dissection Stanford Type B in a Patient with Marfan Syndrome / 日本心臓血管外科学会雑誌

A 41-years-old man with Marfan syndrome developed acute aortic dissection Stanford Type B. A new entry was located at the distal aortic arch. Medical treatment was given for a month, but the proximal descending aorta expanded to 50 mm. Because he had undergone partial arch replacement at the age of 36, thoracic endovascular aortic repair (TEVAR) using the synthetic graft as proximal landing zone was performed to close the entry. Six months after TEVAR, the false lumen around the stent graft disappeared. Distal stent graft-induced new entry (d-SINE) did not occur after TEVAR. Three years after TEVAR, we performed thoracoabdominal aortic replacement because of expansion of the residual false lumen without any complication. Endovascular therapy could be useful option for extensive aortic lesion even in Marfan syndrome.

Percutaneous Transluminal Angioplasty for Low Cardiac Output Syndrome due to Superior vena cava Stenosis with Venous Return Anomaly, after Open Heart Surgery for Pacemaker Lead-Induced Endocarditis / 日本心臓血管外科学会雑誌

We report a case of percutaneous transluminal angioplasty (PTA) treatment for low cardiac output syndrome due to superior vena cava (SVC) stenosis with venous return anomaly. A 69-year-old man was referred to our hospital for surgical treatment of tricuspid valve infective endocarditis due to infected pacemaker leads, which had been implanted for sick sinus syndrome. Preoperative computed tomography indicated polysplenia syndrome-related absence of the hepatic segment of the inferior vena cava (IVC). Preoperative coronary angiography showed a 99% stenosis in the left anterior descending artery and a total occlusion in the right coronary artery. We therefore performed pacemaker system removal, tricuspid valve plasty, coronary artery bypass surgery, and a new pacemaker implantation (epicardial leads). However, over the postoperative course we noted low cardiac output syndrome due to SVC syndrome, which appeared to be aggravated by venous return anomaly from the patient's absent IVC hepatic segment. Eight days after the surgery we conducted PTA for SVC syndrome, which notably improved the patient's hemodynamics. The patient recovered and was transferred to a rehabilitation facility 34 days after the surgery.

Lung Metastasis of Renal Cell Carcinoma Extended into the Left Atrium / 日本心臓血管外科学会雑誌

We report an extremely rare case of renal cell carcinoma (RCC) extending into the left atrium through the pulmonary vein next to lung metastasis. The patient was a 76-year-old man. Extirpation of the RCC in the right kidney was carried out. Metastasis to the lungs, mediastinal lymph nodes and the pubis were diagnosed and 4 years later, a myxoma-like tumor was formed in the left atrium by echocardiography. We extirpated of the tumor. During surgery, continuity with the metastatic lesion in the right lung, right inferior pulmonary vein and the left atrium was suggested. Histopathologic examination showed the same histopathology as seen in the RCC.

A Case of Refractory Sustained Ventricular Tachycardia with Dilated-Phase Hypertrophic Cardiomyopathy Treated by Left Ventriculotomy / 日本心臓血管外科学会雑誌

A 63-year-old man had been receiving medical treatment for hypertrophic cardiomyopathy (HCM) for 20 years. Sustained ventricular tachycardia (VT) had often occurred over the previous 2 years in spite of the administration of antiarrhythmic drugs. He therefore received an implantable cardioverter defibrillator (ICD). However, his symptoms did not improve thus dilated-phase HCM was diagnosed. Because sustained VT often occurred subsequently, the ICD had to be frequently used. An electrophysiological study (EPS) using the CARTO electroanatomical mapping system revealed the earliest activation site to be in the posterolateral wall of the left ventricle (LV). VT did not stop despite 2 endocardial catheter ablation procedures. Therefore, the VT foci was thought to be a reentry circuit on the epicardial side of the posterolateral LV wall. A part of the posterolateral LV wall that involved the reentry circuit was therefore resected. Since undergoing this surgical procedure, the patient has experienced no recurrence of VT during a follow-up period of 14 months.

Aortic Valve Re-Replacement with Aortic Root Enlargement for Aortic Valvular Stenosis after Aortic Valve Implantation with a Freestyle Stentless Porcine Valve / 日本心臓血管外科学会雑誌

We present a successfully treated case of re-operation for aortic valvular stenosis caused by implantation of a stentless prosthesis using oversizing sub-coronary insertion in a young woman. The 17-year-old Japanese woman received aortic valve replacement (AVR) with a 21mm Freestyle stentless porcine valve (Medtronic Inc.), using the oversizing modified sub-coronary insertion because of infectious endocarditis 12 years previously at another hospital. Just after the operation, she suffered severe heart failure. At 16 years old, since a cardiac murmur and dyspnea on effort appeared, and she presented severe heart failure due to significant aortic valvular stenosis with a mean aortic valve gradient 115mmHg, we performed aortic valve re-replacement (ATS AP 18mm) with an aortic root enlargement procedure. Intraoperative findings suggested that the oversizing technique was related to aortic valvular stenosis. The postoperative course has been uneventful.