Endoscopic Pedicle Saphenous Vein Graft Harvesting.

The excellent long-term patency of no-touch (NT) saphenous vein grafts (SVGs) makes the grafts very attractive for coronary artery bypass grafting; however, NT-SVG harvesting has a greater incidence of wound complications than conventional methods. Since 2009, we have performed endoscopic vein harvesting (EVH) in our department with very few major wound complications. Because NT-SVG harvesting is expected to provide long-term patency, if performed with EVH, the incidence of wound complications will be reduced. Thus, we began performing endoscopic pedicle SVG harvesting (Pedicle-EVH) in March 2019. Herein, we report the early results obtained using our current Pedicle-EVH procedure. No major wound complications were reported, and the early results, including patency, were satisfactory. To harvest the pedicle SVG, however, we used a different method than the NT-SVG procedure, so careful monitoring will be needed to assess long-term outcomes.

[Ventricular Pseudoaneurysm after Sutureless Repair of Postinfarction Free Wall Rupture of the Left Ventricle:Report of a Case].

We herein report a case of a left ventricular pseudoaneurysm following sutureless repair for left ventricular free wall rupture. A 78-year-old woman underwent emergency sutureless repair for left ventricular free wall rupture following acute myocardial infarction. Three months later, echocardiography revealed an aneurysm in the postero-lateral wall of the left ventricle. The ventricular aneurysm was incised during reoperation, and defect in the left ventricular wall was closed with a bovine pericardial patch. Histopathologically, the aneurysm wall did not contain any myocardium, confirming the diagnosis of pseudoaneurysm. Although sutureless repair is a simple and highly effective method for oozing-type left ventricular free wall rupture, post-procedural pseudoaneurysm can develop both in acute and chronic phases. Consequently, long-term follow-up is mandatory.

[Rupture of Tuberculous Infective Abdominal Aortic Aneurysm after Intravesical Bacillus Calmette-Guérin Instillation Therapy].

The patient was a 74-year-old male who had undergone intravesical Bacillus Calmette-Guérin(BCG) instillation therapy for bladder cancer. He visited our hospital with chief complaints of fever and abdominal pain. Abdominal aortic aneurysmal rupture and iliopsoas muscle abscess were confirmed by computed tomography( CT). We performed semi-emergency surgery, including replacement of the abdominal aorta with a synthetic graft, iliopsoas abscess debridement, and omentopexy. A rifampicin-bonded synthetic graft was used because of the possibility of tuberculous involvement after BCG instillation therapy. Examination of the tissues collected during surgery were positive for tuberculosis deoxyribonucleic acid (DNA) in a polymerase chain reaction (PCR), and showed multiple giant cell granulomas with caseous necrosis, which both strongly suggested involvement of tuberculosis. Therefore, 4 types of antituberculous drugs were administered for 40 days. This case shows that an infective aneurysm should be suspected when fever and abdominal pain develop after intravesical BCG instillation therapy.

[Thrombus in the Right Atrial Appendage Detected Incidentally during Coronary Artery Bypass Grafting;Report of a Case].

A 71-year-old male was admitted to our hospital for treatment of complete atrioventricular block. By cardiac catheterization, chronic occlusion was confirmed in the right coronary artery and circumflex branch, and coronary artery bypass grafting was planned. Although atrioventricular block disappeared by discontinuance of ß-blocker, paroxysmal atrial flutter had been confirmed before surgery. After an incision into the pericardium, changes in the color of the right atrial appendage were observed, and a thrombus was detected at the site by epicardial echography. The right atrial appendage was removed together with the thrombus, and coronary artery bypass grafting was performed as scheduled. Pathological findings suggested myocardial tissues with ischemic changes and an organized thrombus exhibiting granulomatous changes. This case suggested the need to observe the right atrial appendage carefully during cardiac surgery in patients with risk factors for atrial thrombus.

[Papillary Fibroelastoma of the Pulmonary Valve;Report of a Case].

We herein present a rare case of a papillary fibroelastoma on the pulmonary valve. A 66-year-old female underwent a graft replacement of the ascending aorta and an aortic valve replacement. Subsequent biannual checks have been performed as a follow up to surgery. An echocardiography, 3 years post surgery, revealed a growing mass, 13 mm in diameter, which was attached to the pulmonary valve. Upon surgery, the mass, which lacked a stalk, was found attached to the right semilunar cusp of the pulmonary valve. The cusp was resected with the mass in order to ensure a complete resection, and as we were unable to repair the pulmonary valve, it needed to be replaced with a mechanical valve. The pathological examination of the resected mass resulted in our diagnosis of a papillary fibroelastoma. The patient is now doing well 2 years after the surgery without any recurrence of the tumor.

[Tricuspid Valve Replacement without Removing Transvenous Pacemaker Lead].

Transvenous pacemaker lead occasionally impairs tricuspid valve coaptation because of the direct injury like a perforation, the direct interference with the valve, or the adhesion between the pacemaker leads and the valve leaflets, resulting in severe tricuspid regurgitation. In these situation, tricuspid valve replacement (TVR) is selected after the exchange from transvenous lead to epicardial lead. However this procedure has some problems such as poor threshold of the endcardial lead, the injury and the difficulty in transvenous lead removal. We performed successful TVR without removing transvenous pacemaker lead after the fixation to the annulus of posterior leaflet in tricuspid valve. This technique is useful in a patient with tricuspid regurgitation due to the influence of the pacemaker lead.

[Dual Left Anterior Descending Coronary Artery;Report of a Case].

A 77-year-old male presented with angina pectoris. On coronary angiography, the left anterior descending artery(LAD) was obstructed after branching the second septal branch. Three-dimensional (3D) images constructed with 64-slice computed tomography (CT) showed type I dual LAD. The short LAD, which had been erroneously recognized as a septal branch on coronary angiography, ran on the anterior interventricular sulcus (AIVS) where it then terminated. The long LAD, which was obstructed at its origin, ran on the left ventricular side of the AIVS, and entered the distal part of the AIVS. Coronary artery bypass grafting including a bypass to the long LAD was successfully performed. Recognition of the dual LAD, a rare coronary artery anomaly regarding its origin and course, is import ant in performing successful myocardial revascularization procedures. The 3D-CT images are extremely useful in demonstrating dual LAD, especially in cases where there is occlusion of the LAD.

Tricuspid Valve Replacement Preserving Endocardial Pacemaker Lead.

We describe a simple and reliable technique to replace the tricuspid valve preserving a permanent endocardial pacemaker lead. This technique avoids any direct contact between the pacemaker lead and the prosthetic valve, which protects the pacemaker lead from the mechanical stress of the valve prosthesis and preserves the prosthetic valve's function. doi: 10.1111/jocs.12747 (J Card Surg 2016;31:311-314).

[Surgical therapy for coronary artery stenosis with coronary artery aneurysm in the left main trunk due to Kawasaki disease; report of a case].

A 56-year-old woman was admitted for ST depression in V4 to V6 in electrocardiogram. Coronary angiography showed a coronary artery aneurysm with severe calcification on the bifurcation of the left main trunk and 99% stenosis in the left anterior descending artery. She did not have a history of Kawasaki disease in her childhood. She did not have any risk factors for ischemic heart disease, either. These findings suggested that the coronary artery lesions were related to Kawasaki disease. Percutaneous coronary intervention was impossible due to the location of the aneurysm which was on the bifurcation of the left main trunk. Single vessel coronary artery bypass grafting was performed for the stenosis in the left anterior descending artery. After the surgery, she was put on warfarin for the prevention of thrombus formation in the aneurysm. We report a rare case of coronary artery aneurysm due to Kawasaki disease.

[Primary left atrial myxofibrosarcoma; report of a case].

We herein report a very rare case of a primary left atrial myxofibrosarcoma. A 61-year-old female presented with dyspnea and a wet cough. Chest X-ray film showed cardiomegaly and pulmonary congestion. Echocardiography and computed tomography revealed a left atrial tumor obstructing blood flow to the left ventricle. She was diagnosed with acute congestive heart failure due to functional mitralstenosis secondary to a left atrial tumor, and an emergency operation was performed. The tumor, which occupied left atrium, attached to the posterior wall of the left atrium and to the mitral valve, but had not invaded the left atrial wall. The tumor was removed from the left atrial wall, preserving the mitral valve and valve leaflets. The patient's post operative course was uneventful. The pathological diagnosis was myxofibrosarcoma, which rarely develops in the heart.

[Mycotic aneurysm of the descending thoracic aorta].

A 55-year-old man was admitted with severe back pain and saccular aneurysm of the descending aorta on computed tomography. Laboratory examinations showed elevated serum C-reactive protein of 16.98 mg/dl. Graft replacement of the descending thoracic aorta was performed on an emergency basis, and a latissimus dorsi muscle flap was wrapped around the implanted graft. Because Streptococcus pneumoniae was detected in the resected tissue, proper antibiotic therapy was administrated. The patient recovered uneventfully, without any sign of infection.

The Adamkiewicz artery: demonstration by intra-arterial computed tomographic angiography.

OBJECTIVE: The purpose of this study was to evaluate the feasibility of using multidetector-row CT angiography (CTA) with intra-arterial contrast injection (IA-CTA) to depict the artery of Adamkiewicz (arteria radicularis magna, ARM). METHODS: We performed IA-CTA in 27 preoperative patients with aneurysm or dissection of the descending thoracic or thoracoabdominal aorta. ARM was examined on multiplanar and curved planar reformation images and on the paging method, and we investigated detectability and visualization of the ARM, the level of branching, and right/left frequency as well as continuity from the origin to the ARM. Furthermore, the bolus characteristic of contrast medium in IA-CTA was investigated and compared with CTA with intravenous contrast injection (IV-CTA). The bolus characteristic of the contrast medium was assessed by the determination of the CT value in the aorta in each of the 16 cases in which both IA-CTA before surgery and intravenous IV-CTA at the time of admission were performed. RESULTS: The ARMs were clearly visualized and at least one ARM to be reserved was determined in all patients (100%). The average number of ARM observed was 1.4+/-0.58 per patient (39/27). Innate origin was determined in 90% (35/39) of ARMs and it ranged between the 8th thoracic vertebra and the 3rd lumbar vertebra levels, and branching from the left accounted for 63.2% (24/38). It was possible to observe the exact continuity from the innate origin to the ARM as well as from the secondary origin to the ARM mediated by collateral vesseles in 61.5% of the total ARMs (24/39). The CT value in the aorta calculated on IA-CTA was significantly higher than that on IV-CTA (p<0.05). As a result, the high bolus characteristic of contrast medium in IA-CTA was confirmed. CONCLUSION: It was possible to detect the ARM in all patients and to obtain information about the origin by IA-CTA. This method is considered useful for preoperative assessment of a descending thoracic or a thoracoabdominal aorta for aortic aneurysm or dissection.