[Metastatic Cardiac Tumor in the Left Atrium from Esophageal Cancer].

Metastatic cardiac lesions are clinically silent and are usually found a necropsy. The most common primary tumor resulting in cardiac metastases is carcinoma of the lung, with there being only a few reports of metastases from esophageal cancer. We report two cases of metastatic cardiac tumors in the left atrium from esophageal cancer and perform a review of the literature. Case 1:A 62-year-old woman underwent esophagectomy and adjuvant chemotherapy. No other metastases were observed. Case 2:A 49-year-old man also underwent esophagectomy and adjuvant chemotherapy for lymph node and liver metastases. In both patients, the left atrial tumors were detected on recent follow-up computed tomography. Left atrial tumors often cause cerebral emboli with neurological sequelae. Therefore, surgical resection and cryo-ablation for the prevention of local recurrence were performed on the metastatic tumors. Local recurrence was not observed after the surgery in both patients. Although chemotherapy is usu-ally the most beneficial treatment for metastatic cardiac lesions, left atrial tumor should be treated with surgical resection because of the high risk of cerebral emboli. We suggest that surgical resection with cryo-ablation may prevent local recurrence.

High-Flow Nasal Cannula Therapy With Early Extubation for Subjects Undergoing Off-Pump Coronary Artery Bypass Graft Surgery.

BACKGROUND: The effects of high-flow nasal cannula (HFNC) therapy on postoperative atelectasis and duration of oxygen therapy after off-pump coronary artery bypass graft are unknown. The purpose of this study was to compare the effects of HFNC therapy for subjects who underwent off-pump coronary artery bypass graft with the effects of standard oxygen therapy in terms of oxygen requirement and atelectasis. METHODS: This prospective single-blinded randomized, controlled trial included 148 subjects who underwent off-pump coronary artery bypass graft between 2010 and 2015 with HFNC (n = 72) or without HFNC (standard O2, n = 76). The primary end point was the percentage difference in loss of lung volume between subjects with or without HFNC therapy. Secondary end points included the total amount of oxygen administered and duration of oxygen therapy with and without HFNC therapy. RESULTS: There were significant between-group differences in the percentage loss of lung volume (P < .001), total amount of oxygen administered (P < .001), duration of oxygen therapy (P < .001), and the need for postoperative diuretic therapy (P = .037). The amount (ρ = 0.569, P < .001) and duration (ρ = 0.678, P < .001) of oxygen administered were correlated with atelectasis volume. CONCLUSIONS: Using HFNC therapy after off-pump coronary artery bypass graft shortened the duration of oxygen therapy and reduced the percentage loss of lung volume and total amount of oxygen administered when compared with standard oxygen therapy.

[Redo Valve Replacement of Wada-Cutter Prosthetic Valve at Tricuspid Valve Position 47 Years After Implantation;Report of a Case].

We experienced an explantation of Wada-Cutter prosthetic tilting disk valve of 47 years after implantation. The patient was 53 years old female who underwent the 1st operation for Ebstein's anomaly, which included tricuspid valve replacement (TVR), closure of atrial septal defect (ASD) and posterior annulorrhaphy when she was 6 years old. She was doing well after the 1st operation without symptom,but dyspnea and systemic edema worsened recently though increased admission of diuretics. Echocardiography revealed severe tricuspid valve stenosis, severe tricuspid valve insufficiency, and increased right atrium volume. The tilting disk of the valve was almost fixed. The patient underwent repeat TVR. The explanted Wada-Cutter valve was covered by pannus the whole casing and disk. The structure of the valve was preserved but the occlusion disk was almost fixed by pannus formation, not distorted or dislodged.

Long-term outcome in a case of translocated mitral valve replacement for massive mitral annular calcification.

Few reports have described long-term outcomes after translocated mitral valve replacement. We describe tips, potential pitfalls, and long-term outcome associated with the construction of a new mitral annulus and reinforcement of prosthesis attachment using a mitral prosthetic valve with an equine pericardial collar in a woman with extensive mitral valve calcification.

Outcomes of prosthetic valve replacement in women of child-bearing age.

PURPOSE: The outcomes of pregnancy are more favorable for women with bioprostheses than for those with mechanical prostheses. However, bioprostheses are associated with a high reoperation rate in young women and it remains unclear whether these young women can give birth without any complications. We analyzed the outcomes of prosthetic valve replacement and investigated the effectiveness and problems associated with bioprostheses in women of child-bearing age in Japan. METHODS: The subjects of this study were six consecutive young adult women aged under 40 years, who underwent prosthetic valve replacement between January 2007 and April 2016. RESULTS: Bioprostheses were selected for four of these six women in consideration of their child-bearing age. Mechanical valves were selected for the other two women who underwent the Konno procedure and double valve replacement (AVR, MVR) in view of their high risk for reoperation. The cardiac operations, although without mortality or morbidity, were complex and some involved multi-time procedures. Three of the women with bioprostheses had uneventful term pregnancies. CONCLUSIONS: These young women with bioprostheses were able to give birth safely; however, as multiple operations are often required, and bioprostheses may not be ideal for young women. Prosthetic valve selection for young women of child-bearing age requires adequate pregnancy counseling and long-term planning.

Aortic valve replacement in a patient with MPO-ANCA-positive Goodpasture disease.

Goodpasture disease (GD) is a rare autoimmune disorder characterized by the development of pathologic autoantibodies against both glomerular and alveolar basal membranes. Approximately one third of the patients with GD are also positive for anti-neutrophil cytoplasmic antibody (ANCA). In this case report, a 74-year-old woman was diagnosed as having myeloperoxidase (MPO)-ANCA-positive GD with severe aortic valve stenosis (AS). She underwent immunosuppressive therapy and plasmapheresis that led to GD remission. Whether a cardiac surgery affects a MPO-ANCA-positive GD in remission is unknown. We reported the outcomes after aortic valve replacement for severe AS in a patient with MPO-ANCA-positive GD.

Use of a Stent Graft for Patent Ductus Arteriosus in an Octogenarian Eliminates Ductus Flow.

Closure of a patent ductus arteriosus (PDA) in the elderly is a high-risk procedure because of tissue fragility and many possible complications. The patient in our case was an 81-year-old woman with a window-type PDA caused by cardiac failure. Based on the anatomy of the PDA and aorta and to minimize invasion, we used a stent graft to close the PDA. This approach was successful; hemodynamics improved and ductus flow was eliminated during the follow-up period without intervention from the pulmonary artery side.

[Ascending-descending Aortic Bypass and Aortic Valve Replacement for Aortic Coarctation with Bicuspid Aortic Valve and an Aberrant Right Subclavian Artery;Report of a Case].

A 53-year-old woman was developed congestive heart failure. She was diagnosed as having aortic coarctation, incompetent bicuspid aortic valve and an aberrant right subclavian artery by using echocardiography and enhanced computed tomography. Ankle brachial pressure index(ABI)in the right was 0.71 and 0.69 in the left. Blood pressure of the right arm was 60 mmHg lower than that of the left arm. To avoid perioperative adverse cardiac events due to a 2-staged operation, we performed ascending-descending aortic bypass and aortic valve replacement simultaneously through a median sternotomy. The heart was retracted cranially, and a vascular prosthesis was anastomosed to the descending aorta just above the diaphragm in an end-to-side manner. Then the graft was placed curvilinearly around the right atrium and was anastomosed to the ascending aorta. After the operation, the right and left ABI increased to 0.90 and 0.98 respectively. There was no pressure difference between the arms. The postoperative course was uneventful.

Identification of Coronary Artery Orifice to Prevent Coronary Complications in Bioprosthetic and Transcatheter Aortic Valve Replacement.

BACKGROUND: The aim of this study was to identify anatomical variations in coronary artery orifices among high-risk patients with a small aortic root undergoing bioprosthetic aortic valve replacement (BAVR) and transcatheter aortic valve replacement (TAVR) in order to prevent coronary orifice obstruction perioperatively. METHODS AND RESULTS: Coronary orifice and root structure were identified in 400 patients using aortic multidetector-row computed tomography (MDCT). We measured the aortic root diameter; intercommissural distances; and distance from coronary orifice to valve annulus, commissure, and sinotubular junction. We examined positional relationships between the coronary orifice and stent post, or sewing cuff of the bioprosthetic valve and leaflet of the transcatheter aortic valve. Most left coronary artery orifices were distributed near the center of the non-left and left-right commissures; right ones were relatively distributed on the non-right commissural side. Thirty-four patients (8.5%) with BAVR (coronary orifice near the commissure: 31, 7.8%; low takeoff: 5, 1.3%; and both: 2) and 39 (9.8%) with TAVR were at risk for coronary orifice obstruction. During BAVR, one-stitch rotation of the stent and one-stitch rotation with intra-annular implantation were used in near-commissure and low takeoff cases, respectively. During TAVR, percutaneous coronary intervention may be required in the height of the coronary orifice was ≤10 mm from the base of the ventricle aortic junction. CONCLUSIONS: Potential coronary complications during BAVR and TAVR in high-risk patients for coronary obstruction were identified using preoperative aortic MDCT. Choice of appropriate surgical technique or valve is essential.

Purulent pericardial effusion and mycotic pseudoaneurysm following insertion of a bare metal stent.

A 65-year-old male was diagnosed with purulent pericarditis, caused by Staphylococcus aureus five weeks after bare metal stenting for a 90% stenosis of the right coronary artery ostium. Subsequently, he developed a pseudoaneurysm in the right coronary sinus of Valsalva (CSV) requiring surgical intervention during the treatment of the pericarditis. Bacteremia after percutaneous coronary intervention (PCI) occurs in < 1% of patients and usually has insignificant clinical sequelae. We present an infected coronary bare metal stent of the proximal right coronary artery after PCI that resulted in a purulent pericardial effusion and mycotic pseudoaneurysm of the right coronary sinus of Valsalva (CSV). The patient successfully underwent surgical treatment.

Midterm results of left coronary artery reimplantation through the transverse sinus of the pericardium in adult Bland-White-Garland syndrome.

The anomalous origin of the left coronary artery from the pulmonary artery - known as Bland-White-Garland syndrome - is a rare congenital malformation that affects 1 in 300,000 live births. Most patients die in infancy without any surgical treatment. Some patients who survive past childhood often have varying symptoms such as myocardial ischemia, impaired left ventricular function, mitral regurgitation, and progressive heart failure, depending on the development collateral circulation. In the present report, we describe a procedure wherein the left coronary artery ostium was translocated through the transverse sinus of the pericardium in a 43-year-old mother with Bland-White-Garland syndrome and concomitant mitral regurgitation and report on the associated midterm results.

Mitral valve plasty in an adult patient without a right superior vena cava.

Persistent left superior vena cava without a right superior vena cava is an extremely rare condition. We report the case of a 65-year-old woman with this condition who underwent mitral valve plasty. During cardiac catheterization, the asymptomatic patient with mitral valve prolapse syndrome was found to have a persistent left superior vena cava without a right superior vena cava. During mitral valve plasty, cardiopulmonary bypass was established using bicaval drainage through the persistent left superior vena cava and the right atrium. A cannula was inserted into the persistent left superior vena cava to provide a large surgical field in the left atrium. We selected a technique that involved direct insertion of an L-shaped cannula into the persistent left superior vena cava and obtained a clear view of the surgical field. Proper assessment of the right superior vena cava is necessary when a persistent left superior vena cava is suspected.

Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm.

PURPOSE: To achieve early recovery and early discharge from the hospital by applying an enhanced recovery after surgery (ERAS) protocol, which is mainly used with colonic surgery, for the perioperative management of open AAA surgery. METHOD: One hundred twenty-seven open AAA surgery cases successfully carried out between 2003 and 2011 were included in this study. The ERAS protocol was used for the cases from April 2008 onward, and we performed a comparison of the conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs. RESULTS: The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n = 52) compared to the conventionally managed group (n = 75); with values of 59 ± 15 and 93 ± 25 h (p = 0.021), 9 ± 3 and 16 ± 5 days (p = 0.001), respectively. The medical costs for the ERAS group were 92 % of the costs of the conventionally managed group. CONCLUSION: Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.

Adult patent ductus arteriosus closure with a pedicled pulmonary arterial patch.

The vascular wall of patent ductus arteriosus in adults is usually fragile due to atherosclerosis with calcification. In adults, surgical treatment, such as direct or patch closure, is sometimes required for a wide, short, or calcified patent ductus arteriosus. We present a novel technique for patent ductus arteriosus closure with a pedicled patch created from the wall of a dilated pulmonary artery. We believe that this technique, in which only an autologous tissue is used, is safe and has excellent durability.

Cardiac lipoma originating from the left ventricular apex diagnosed using the magnetic resonance imaging fat suppression technique: report of a case.

A 70-year-old male patient had a tumor in the left ventricular apex that was detected by transthoracic echocardiography. He had no clinical manifestations. A diagnosis of benign lipoma was made using the noninvasive fat suppression technique of cardiac magnetic resonance imaging (MRI). Video-assisted surgery was performed to resect the tumor, and the histopathological examination confirmed the diagnosis of lipoma. A small part of the tumor was not resected. The postoperative course was uneventful. No signs of recurrence were detected on transthoracic echocardiography or MRI during a 22-month post surgical follow-up period.

Premeditated reoperation after mitral valve replacement with a Starr-Edwards ball valve for young women who desire to bear a child: report of two cases.

There are many difficulties for young women with a Starr-Edwards ball valve who want to attempt pregnancy. There is no consensus regarding whether they should maintain anticoagulation therapy throughout pregnancy with the risk of a thromboembolism or to undergo a reoperation with bioprosthetic heart valves, followed by a third operation when the valve deteriorates. This report presents two cases of young women who underwent mitral valve replacement (MVR) with Starr-Edwards ball valves (model 6120: 1M) during their childhood. Although they did not have any cardiac symptoms, transthoracic echocardiography and cardiac catheterization data demonstrated that both the patients had asymptomatic mild relative mitral stenosis. They both wished to bear a child. After the patients and their family provided thorough informed consent, redo MVRs were preformed safely with biological prostheses. The presence of significant pannus formation along the strut and sewing ring of the excised valves could also have a positive impact on the decision to undergo reoperation.

An alternative option for elderly patients with a small aortic annulus: the 16 mm ATS valve.

BACKGROUND AND AIM OF THE STUDY: The optimal procedure and prosthesis remains debatable for aortic valve replacement (AVR) in high-risk elderly patients in whom the aortic annulus is too small to allow a standard AVR procedure with even the smallest sized bioprosthetic valve available. Herein are reported the early and mid-term results of standard AVR using a 16 mm ATS Advanced Performance (AP) mechanical heart valve. METHODS: The medical records of 10 patients (mean age 75 +/- 5 years; range: 64-79 years) in whom 16 mm ATS AP valves had been implanted in the supra-annular position were reviewed retrospectively. Preoperatively, the mean body surface area was 1.46 +/- 0.1 m2 (range: 1.21-1.69 m2); mean logistic EuroSCORE 16.1 +/- 14.6% (range: 4.32-53.2%); mean peak pressure gradient (peak PG) across the aortic valve 98 +/- 28 mmHg; mean diameter of the aortic annulus 19.3 +/- 1.2 mm; mean fractional shortening 37 +/- 10%; and mean left ventricular myocardial mass index (LVMI) 173 +/- 34 g/m2. RESULTS: There were no hospital deaths, and one late death. The postoperative course was uneventful in all cases, except for one patient who developed respiratory failure. The NYHA functional class was improved from 3.0 +/- 0.7 before surgery to 1.4 +/- 0.5 postoperatively. A significant decrease in the peak PG was observed postoperatively compared to preoperative data (p < 0.01); mean values at two weeks, and at one and two years after surgery were 35 +/- 12, 35 +/- 10, and 33 +/- 10 mmHg, respectively. A significant decrease in the mean LVMI was also noted postoperatively (p < 0.01); mean values at two weeks, and at one and two years after surgery were 134 +/- 35, 110 +/- 17, and 114 +/- 22 g/m2, respectively. The mean effective orifice area index was 0.79 +/- 0.2 cm2/m2. During the mean follow up period of 56 +/- 23 months, all patients received oral anticoagulation with warfarin, and there were no cases of bleeding or thomboembolic complications. CONCLUSION: Satisfactory early and mid-term outcomes were noted following AVR with the 16 mm ATS AP valve in high-risk elderly patients with a small aortic annulus.

Clinical experience with Smart Care after off-pump coronary artery bypass for early extubation.

The purpose of this study was to compare the intubation time using Smart Care, a knowledge-based system for automated weaning, with that of conventional physician-controlled weaning after off-pump coronary artery bypass (OPCAB) and to determine the efficacy of Smart Care. During 2004, 53 sequential patients were scheduled for isolated coronary artery bypass grafting without cardiopulmonary bypass. Patients were divided into two groups: the Smart Care group (n = 10) and the control group (n = 35). Eight patients requiring hemodialysis and patients undergoing the awake OPCAB method were excluded. The intubation times were 172.6 +/- 51.6 min in the Smart Care group compared with 342.0 +/- 239.0 min in the control group (P = 0.032). No specific complications occurred with this computer-driven expert weaning system. In conclusion, the Smart Care system reduced the duration of mechanical ventilation and the respiratory care workload. This system was effective in the care of patients without complications requiring mechanical ventilation after OPCAB.

Prognosis after off-pump coronary artery bypass in patients receiving hemodialysis.

PURPOSE: This study was performed to evaluate the perioperative and long-term results of off-pump coronary artery bypass grafting (OPCAB) in hemodialysis (HD)-dependent patients. METHODS: We retrospectively analyzed the results of isolated OPCAB performed at Tokyo Women's University Medical Center East from February 27, 2000, to May 12, 2006. Perioperative data for patients receiving HD (group HD, n=39) were compared with data from patients not receiving HD (group noHD, n=60). The long-term results of group HD also were examined. RESULTS: Group HD consisted of 34 males and 5 females with a mean age of 63.2+/-10.2 years. The percentage of patients in group HD with complete all-arterial revascularization was significantly lower than in group noHD. However, the mortality rate, number of distal anastomoses, operative time, intensive care unit (ICU) stay, hospital stay, bleeding during surgery, blood transfusions, intubation time, intra-aortic balloon pumping use, and emergency ratio were similar in the two groups. During a mean follow-up of 27.0+/-13.7 months, the actuarial 1-and 5-year survival rates of group HD were 80% and 70%, respectively. CONCLUSION: In patients receiving HD, OPCAB is safe and improves survival.