Surgical Management of a Residual Shunt after Extended Sandwich Repair via a Right Ventricular Incision for Posterior Ventricular Septal Perforation / 日本心臓血管外科学会雑誌

Posterior ventricular septal perforation (VSP) is a severe complication of acute myocardial infarction (AMI). In some cases, it is difficult to manage residual shunts after VSP repair. We report a patient who required reoperation early after surgery due to a residual shunt and underwent successful repair through a newly devised maneuver. A 55-year-old man developed VSP after catheter intervention for AMI. He underwent VSP closure with extended sandwich repair via a right ventricular (RV) incision. A residual shunt was observed on the 4th day after surgery. Follow-up echocardiography showed progress of the residual shunt, and he developed cardiac failure ; therefore, reoperation was performed 16 days after the initial surgery. The residual shunt was successfully repaired with only a reinforcing left ventricular (LV) side patch via an LV incision to extend between the LV side patch and septal myocardium without removing the RV side patch. The patient's clinical course after reoperation was uneventful, and no residual shunt was observed on postoperative echocardiography.

A Case of Immunoglobulin G4-Related Thoracic Aortic Aneurysm Initially Diagnosed as Aortic Intramural Hematoma / 日本心臓血管外科学会雑誌

Immunoglobulin G4 (IgG4)-related disease is a chronic disease characterized by fibrotic mass and/or thickened lesions with elevated serum IgG4 concentrations, and infiltrations of IgG4 positive plasma cells. Since it has recently been reported to occur in the cardiovascular system, therapeutic strategy needs to be established. We report a case of IgG4-related thoracic aortic aneurysm (IgG4-R TAA) which was diagnosed postoperatively though suspected as aortic intramural hematoma preoperatively. A 70-year-old man who has medical histories of retroperitoneal fibrosis twice visited our hospital with chief complaints of cough and a CT scan was performed. Though there had been no episodes related to the onset of aortic dissection such as chest pain, an ascending aortic intramural hematoma of 52 mm in diameter was suspected and we planned to perform hemi-arch replacement. Intraoperative findings suggested that it was a true aneurysm and there was no sign of dissection. Histopathologically, the adventitia was obviously thickened with infiltrations of IgG4 positive plasma cells without infiltrations and dissection findings in the tunica media. In addition, serum IgG4 exceeded the normal value, thus it was diagnosed as IgG4-R TAA on the basis of the comprehensive diagnostic criteria. Great caution should be taken in IgG4-R TAA because it may show intramural hematoma on imaging and may develop aortic dissection and rupture as well.