The Efficacy of Conventional Aortic Valve Replacement for Severe Aortic Valve Stenosis Divided by Risk Classification Using the Japanese Scoring System / 日本心臓血管外科学会雑誌

<b>Objective</b> : Transarterial or transapical aortic valve replacement (TAVR) procedures have been performed for high-risk patients with severe aortic valve stenosis (AS) in western countries. A high-risk patient is defined as having an STS score greater than 10%. In Japan, aortic valve replacement (AVR) with cardiopulmonary bypass (CPB) is standard care for AS, even if the patient is at high risk of developing complications. We calculated an expected operative risk of patients using a JAPAN score established by Japanese Adult Cardiovascular Surgery Database (JACVSD). <b>Patients and Methods</b> : Patients were divided into three groups : score less than 5%, low risk (LR) ; score 5-10%, moderate risk (MR) ; score more than 10%, high risk (HR). We also evaluated the efficacy of conventional AVR in each group. Between January 2002 and May 2011, we performed conventional AVR in our hospital and 116 patients who underwent AVR for symptomatic AS were enrolled in this study. <b>Results</b> : There were 79 patients in the LR group, 30 patients in the MR group and 7 patients in the HR group. The mean score was 2.6±1.1% in the LR group, 6.8±1.4% in the MR group and 23.3±16.8% in the HR group respectively. The mean follow-up period was 7.6±0.3 years. Preoperative co-morbidity was not statistically significant among three groups, however more octogenarians were found in the HR group. The aortic valve area and left ventricular ejection fraction (LVEF) were significantly smaller in the HR group. There were 4 cancer patients. The HR group had significantly longer operation and CPB times than the LR group. The operative mortality in all cases was 1.6%. Overall survival at 5 years was 78%. Actual survival at 5 years was 77% in the LR group, 82% in the MR group and 71% in the HR group. The major adverse cardiac and cerebrovascular event (MACCE)-free ratio at 5 years was 85%. Absence of death caused by MACCE at 5 years was 93%. All cancer patients died after AVR due to advancement in cancer. <b>Conclusion</b> : The results of conventional AVR with CPB were satisfactory in each group. Cancer patients may be good candidates for TAVR in the future.

Aortic Valve Replacement for Severely Calcified Aorta with SCP and Deep Hypotheramic Circulatory Arrest / 日本心臓血管外科学会雑誌

A 60-year-old man on chronic hemodialysis was found to have severe aortic stenosis causing refractory atrial fibrillation elected to undergo aortic valve replacement. However, chest CT scan revealed a severely calcified ascending aorta which prevented safe aortic cross-clamping. At operation, arterial cannulation of the systemic circulation was performed to a graft anastomosed to the right axillary artery and venous cannulation to the right atrium. Cardiopulmonary bypass was started and the body was cooled. When a rectal temperature of 25°C was achieved, cardioplegic solution was administered retrogradely to achieve cardiac arrest and circulatory arrest was performed. Immediately, brachiocephalic artery was clamped and a single selective cerebral perfusion (SCP) was started with right axillary perfusion. In addition, a selective cerebral perfusion was added via the left common carotid artery to maintain adequate flow. After anastomosing the tube graft to the distal ascending aorta, cardiopulmonary bypass was restarted, a clamp was placed on the tube graft, and the patient was rewarmed. The aortic valve was excised and a 21-mm SJM-Regent valve was placed in the intra-annular position. The systemic circulatory arrest time was 18 min. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without complications. The ascending aorta replacement described here for the treatment of aortic valve disease in a patient with a severely calcified aorta is safer than deep hypothermic circulatory arrest alone, allowing a shorter circulatory arrest period. In addition, selective cerebral perfusion by right axillary artery anastomosed graft is advantageous in that we can start selective cerebral perfusion promptly by clamping the brachiocephalic artery.

False Aneurysm in the Right Groin due to Disruption of a Knitted Dacron Prosthesis / 日本心臓血管外科学会雑誌

A 75-year-old man was admitted to our hospital with a pulsatile mass in the bilateral groin. He had received placement of a Y-shaped Cooley double velour knitted Dacron graft 20 years previously for arteriosclerosis obliterans. Computed tomography demonstrated an aneurysm near the distal anastomosis of the graft. Based on a clinical diagnosis of a non-anastomotic aneurysm, an operation was performed. When the right aneurysm was incised, it was found that the anastomosis of the graft to the common femoral artery was intact and that the graft itself had a defect, 1.5 cm in size near the distal anastomosis of the graft. The final diagnosis of the right groin aneurysm was a non-anastomotic false aneurysm due to prosthetic graft failure. The left groin aneurysm was a true aneurysm due to arteriosclerosis. After resection of the bilateral aneurysm, graft interposition with an expanded polytetrafluoroethylene (ePTFE) graft was successfully performed. Generally, arterial grafts below the groin are subject to high levels of mechanical stress, and graft failure is not uncommon. Vascular surgeons should keep in mind that graft failure is not rare in patients with long-standing prosthetic graft.

A Case of Partial Aortic Root Remodeling for Aneurysm of the Right Coronary Sinus of Valsalva / 日本心臓血管外科学会雑誌

We report a case of aneurysm located at the right sinus of Valsalva with mild aortic regurgitation (AR). The patient was a 55-year-old man with hypertension. When he consulted a local doctor complaining of back pain, aneurysm of right sinus of Valsalva was unexpectedly diagnosed by detailed examinations. He was transferred to our hospital for surgery. An echocardiogram showed mild aortic regurgitation and enlargement of the right sinus of Valsalva. Computed tomography demonstrated an unruptured and extracardiac aneurysm of the right sinus of Valsalva (diameter, 45 mm) and a right coronary artery (RCA) that originated from just above the ostium of the aneurysm. He underwent a partial aortic root remodeling procedure with trimmed Hemashield graft and the RCA was anastomosed to the Hemashield graft by the Carrel patch technique. The postoperative course was uneventful, and he was discharged on the 12th postoperative day. Postoperative angiography revealed that aneurysm of the right sinus of Valsalva was not enhanced and the RCA was patent. This procedure preserve the patient's own aortic valve and normal sinus of Valsalva and enabled him to have more physiologic hemodynamics than patch closure, although progression of the AR requires careful follow-up.

Off-Pump Coronary Artery Bypass Grafting through the Diaphragm Using the Splenic Artery for Inflow in a Redo Case with Chronic Renal Failure / 日本心臓血管外科学会雑誌

Off-pump coronary artery bypass grafting (CABG) through the diaphragm is effective in redo cases who need right coronary revascularization with a patent graft. This is a rare report of this operation using the splenic artery for inflow. A 64-year-old man on chronic hemodialysis had undergone coronary artery bypass grafting (4 vessels) 9 years previously had chest pain and was transferred to our hospital with a diagnosis of acute myocardial infarction. Coronary arteriography revealed multiple stenoses of the right coronary artery with patent bypass grafts. The patient underwent emergency off-pump CABG through the diaphragm using a saphenous vein graft bridging from the splenic artery to the posterior descending branch and A-V node branch using the sequential method. The graft was patent in postoperative angiography and he was discharged on the 13th day after the operation, free of angina.

A Case Report of Double Aortic Arch, Vascular Ring Associated with Tracheal Stenosis / 日本心臓血管外科学会雑誌

We report a case of vascular ring with tracheal stenosis, which might be related to a prolonged endotracheal intubation. A symptomatic 2-month-old boy was admitted to our institution after prolonged intubation without a definite diagnosis. His symptoms were stridor and dyspnea, but not dysphagia. Echocardiography detected a vascular ring and this was confirmed by computed tomography and magnetic resonance imaging (MRI) (Edwards IA type). The left anterior aortic arch was divided distal to the left subclavian artery through left thoracotomy and the ligamentum arteriosus was not identified. On postoperative day (POD) 2, endotracheal extubation was unsuccessfully attempted. Further examination such as MRI and bronchoscopy revealed intimal hyperplasia of the trachea with mild compression of the trachea from the outside. We performed aortopexy and division of the small long ductus which might not be a mechanism of the tracheal compression through right thoracotomy in the second operation with successful extubation on POD 3. The patient has been discharged from the hospital and followed up at the outpatient clinic without any symptom. Tracheomalacia was a common associated anomaly in vascular ring. However, other mechanisms such as inflammatory reaction associated with prolonged intubation should be considered and be avoided in the pediatric population.