Virtual Reality Simulation for Minimally Invasive Coronary Artery Bypass Grafting With Aortic No-Touch Total Arterial Grafting Technique.

OBJECTIVE: Virtual reality can be applied preoperatively by surgeons to gain precise insights into a patient's anatomy for planning minimally invasive coronary artery bypass grafting (CABG) with in situ arterial grafts. This study aimed to examine virtual reality simulation for minimally invasive CABG with in situ arterial grafts. METHODS: Preoperative stereolithographic files in 35 in situ arterial grafts were converted using 320-slice computed tomography and workstation. The accurate length and direction of each graft were confirmed through virtual reality glasses. The simulation of graft designs was performed by using an immersive virtual reality platform. RESULTS: The mean harvested lengths of in situ left internal thoracic artery (n = 17), right internal thoracic artery (n = 12), and gastroepiploic artery (n = 6) grafts predicted by virtual reality simulation were 21.4 ± 3.4 cm, 21.2 ± 3.6 cm, and 22.8 ± 4.8 cm. The required lengths of these grafts predicted by virtual reality simulation were 15.8 ± 2.3 cm, 16.4 ± 2.1 cm, and 14.5 ± 4.4 cm. Minimally invasive CABG using virtual reality simulation was completed in 17 patients, of whom 16 patients underwent aortic no-touch total arterial CABG. The surgical strategy was adjusted in 11.8% of the cases due to the 3-dimensional virtual reality-based anatomy evaluation. The early mortality and morbidity were 0%, and the patency of the graft was 100%. The median time to return to full physical activity was 7.1 days. CONCLUSIONS: This study demonstrated the successful development and clinical application of the first dedicated virtual reality platform for planning aortic no-touch total arterial minimally invasive CABG. Virtual reality simulation can allow the accurate preoperative understanding of anatomy and appropriate planning of the graft design with acceptable postoperative outcomes.

Minimally invasive coronary artery bypass grafting with ultrasonically skeletonized internal thoracic artery.

Objective: This study aimed to examine the feasibility and safety of minimally invasive cardiac surgery coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery in the authors' initial experience. Methods: From February 2012 to May 2021, 247 consecutive patients who underwent minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery were reviewed retrospectively. Internal thoracic arteries were harvested in a full skeletonized fashion using an ultrasonic scalpel via left minithoracotomy. Bilateral internal thoracic arteries were used in 108 patients, and the internal thoracic arteries as in situ grafts were used in 393 anastomoses. Total arterial revascularization was performed in 126 patients, and 142 patients underwent aortic nontouch minimally invasive coronary artery bypass grafting. Results: The patients' mean (range) age was 65.9 ± 11.5 (30-90) years. The mean (range) number of anastomoses performed was 2.6 ± 1.1 (1-6). Forty-six patients (18.6%) had 4 grafts, 94 patients (38.1%) had 3 grafts, and 60 patients (24.3%) had 2 grafts. Minimally invasive coronary artery bypass grafting was completed without conversion to sternotomy in all patients. Cardiopulmonary bypass was performed in 3 patients (1.2%), reinterventions due to bleeding were performed in 7 patients (2.8%), and chest wound infections were observed in 5 patients (2.0%). There was 1 (0.4%) mortality. Conclusions: Minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery is feasible and has shown good perioperative outcomes. This approach has the potential for further optimization with revascularization strategies.

Morphological changes of the tricuspid valve complex in functional tricuspid regurgitation on contrast-enhanced computed tomography.

BACKGROUND: Whether it is possible to perform morphological evaluation of functional tricuspid regurgitation (FTR) on contrast-enhanced computed tomography (CT) was examined by evaluating the relationships between the parameters measured on contrast-enhanced CT and TR severity on transthoracic echocardiography. METHODS: Fifty patients underwent contrast-enhanced CT. Tricuspid annulus area (TAA), tricuspid annulus circumference (TAC), right ventricular volume (RVV), and the distances between the tips and bases of the papillary muscles were measured on contrast-enhanced CT in diastole and systole. The 50 cases were divided into 34 in the TR ≤ mild group (no TR: 3 cases, trivial TR: 24 cases, mild TR: 7 cases), and 16 in the TR ≥ moderate group (moderate TR: 8 cases, severe TR: 8 cases) using the TR grade measured by transthoracic echocardiography, and then differences between the groups were examined. RESULTS: Significant differences were found in TAA, TAC, and RVV (p < 0.01) and the distances between the tips of the anterior and posterior papillary muscles (p < 0.05) in both diastole and systole. Since the septal papillary muscle could not be identified in 18 cases (36.0%), only the distance between the anterior and posterior papillary muscles was measurable in all cases. On receiver-operating characteristic (ROC) curve analysis, the areas under the ROC curves (AUCs) of TAA, TAC, and RVV were all > 0.7, and the maximum AUC was 0.925 for dRVV. CONCLUSIONS: TAA, TAC, RVV, and the distance between the tips of the anterior and posterior papillary muscles measured on contrast-enhanced CT were shown to be significantly increased in the TR ≥ moderate group. Detailed morphological assessment of FTR is possible by contrast-enhanced CT.

[Penetrating Right Ventricular Injury by Suicide Attempt:Report of a Case].

Penetrating heart injury is rare in Japan. A 35-year-old man stabbed himself with a fruit knife that was about 10 cm in length on the left precordium in an attempt to commit suicide and was transferred to our hospital. His vital signs were stable, and the knife remained stabbed in the left precordium. Cardiac injury and cardiac tamponade were suspected on computed tomography, and emergency surgery was performed. A large amount of red hematoma was found in the mediastinum and the pericardial space after median sternotomy. The knife had created a fissure of about 15 mm in the free wall of the right ventricle, and the injury was repairable. The knife passed through the sixth costal cartilage and the left internal thoracic artery, and hemostasis was easy. The patient's postoperative course was uneventful, but due to the suicide attempt and adjustment disorder, the patient was transferred to a psychiatric hospital on postoperative day 10.

Novel quantitative and objective structured assessment of technical skill for slip knotting.

OBJECTIVE: Currently, no quantitative and objective method has been established for evaluating competencies in basic surgical techniques. The aim of this study was to develop a structured assessment tool for slip knotting and verify how well current board certification system discriminates the level of basic surgical skill. METHODS: We examined 171 cardiovascular surgical fellows using a novel assessment method for slip knotting that was developed by the committee of the Under-Forty of the Japanese Society of Cardiovascular Surgery. We compared the scores and examinees' surgical experience for validation. We analyzed the relationship between board certification and the scores. RESULTS: The scores differentiated the general surgical board-certified surgeons from those without certification. Surgical experiences such as training years and number of operated cases and scores were correlated. Among the board-certified surgeons, the group with daily off-the-job training, or simulator-based skill training had a significantly higher mean score (67.4 ± 3.0 vs 55.4 ± 3.1, p = 0.008) and lower rate of poor scorers (7.1% vs 38.5%, p = 0.004). A multivariate analysis revealed that board certification did not predict high scores. Daily off-the-job training was the only independent predictor of high scores (odds ratio: 2.41, 95% confidence interval: 0.01-1.20, p = 0.014). CONCLUSIONS: This novel quantitative and objective assessment tool for technical skill in slip knotting was found to be valid to examine the skill for slip knotting. In this study, current board certification discriminated the level of basic surgical skill. However, it could not distinguish extremely low scorers perfectly. Some board-certified surgeons showed poor technical competency, especially those without off-the-job training.

Correction to: Novel quantitative and objective structured assessment of technical skill for slip knotting.

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[A Case of Chronic Myelogenous Leukemia That Developed Fibrous Pericarditis Owing to Nilotinib Use].

A 64-year-old man was diagnosed with chronic-phase chronic myelogenous leukemia(CML)in May 2009. He was treated with imatinib and achieved complete cytogenetic response(CCyR)in 2 months. After 4 months of treatment, he developed interstitial pneumonia and became intolerant to imatinib. He was then switched to nilotinib from October of the same year. In June 2013, he was diagnosed with drug-induced pericarditis resulting from nilotinib use, and thus, nilotinib was discontinued. Subsequently, he was followed up without specific treatment for CML. In January 2014, he was admitted to the Dept. of Cardiovascular, Renal and Metabolic Medicine at our hospital because of heart failure. After examinations of cardiac function, he was diagnosed with constrictive pericarditis. Therefore, pericardiolysis was performed by the Dept. of Cardiovascular Surgery at our hospital. Pathologic findings showed hyaline-like fibrous tissue proliferation in the pericardium, which was diagnosed as fibrous pericarditis induced by nilotinib. We report a case of chronic myelogenous leukemia that developed fibrous pericarditis owing to nilotinib use.

[New Intracoronary Shunt Cannula in Off-pump Coronary Artery Bypass Grafting].

In off-pump coronary artery bypass grafting(OPCAB), a bloodless operative field has great influence on the quality of anastomosis. In addition, maintenance of distal coronary flow during anastomosis stabilizes hemodynamics. We introduced a new intracoronary shunt cannula, Mini Shunt Pro (MSP). MSP adopts the step-tip, which allows easy insertion and reduces the risk of intimal injury. The distal and proximal sides of the tips of MSP are 0.25 mm different in diameter, which improves its fitness to the coronary artery and enhances a bloodless operative field. This new shunt cannula is considered to be safe and useful for high-quality anastomosis in OPCAB.

Histomorphologic superiority of internal thoracic arteries over right gastroepiploic arteries for coronary bypass.

OBJECTIVE: In this study, we compared the histologic and morphometric properties of both internal thoracic arteries and the right gastroepiploic artery (GEA) in patients undergoing coronary artery bypass grafting (CABG). METHODS: We microscopically examined transverse sections of segments of both internal thoracic arteries and the right GEA obtained from 83 consecutive patients who underwent CABG. RESULTS: There were no significant differences between the internal thoracic arteries. Significant differences were found between the left and right internal thoracic arteries and GEA in the intimal width (21.8, 21.5, and 71.7 µm, respectively; P < .01), intima-to-media ratio (0.286, 0.256, and 0.749, respectively; P < .01), and media width (148.5, 157.5, and 164.8 µm, respectively; P = .43). No atherosclerotic lesions, medial calcification, or intimal thickening were seen in the internal thoracic arteries; however, atherosclerotic lesions were seen in the GEA. The intima of the GEA was thicker than that of the internal thoracic arteries. Intimal thickening of the GEA, but not the internal thoracic arteries, was positively correlated with risk of arteriosclerosis. In patients with diabetes mellitus, dietary/drug therapy and insulin therapy were associated with GEA intimal thickness (P = .02 and .01, respectively). CONCLUSIONS: The internal thoracic arteries have equivalent histologic and morphometric properties that differ from those of the GEA only in intimal width. The former had no intimal thickening, and is thus preferable to the GEA for CABG.

Utility of three-dimensional transesophageal echocardiography for diagnosis of unroofed coronary sinus.

We report a case of unroofed coronary sinus (URCS) in a 42-year-old female. At an outpatient clinic, she was found to have an atrioventricular septal defect and mitral regurgitation with pulmonary hypertension, and she was transferred to our institute for surgical treatment. Both atrioventricular valves were located at the same level, and both the right atrium (RA) and right ventricle were enlarged on two-dimensional transthoracic echocardiography. Color Doppler imaging demonstrated severe mitral and tricuspid regurgitation and a left-to-right shunt from the left atrium (LA) to the RA. Although an ostium primum defect of the atrial septum was suspected, the exact position of the shunt flow was unclear. Two-dimensional transesophageal echocardiography (2D-TEE) could visualize a direct communication between the LA and coronary sinus. Three-dimensional transesophageal echocardiography (3D-TEE) clearly visualized the entire route from the coronary sinus into the LA and RA. The utility of 3D-TEE as a modality complementary to 2D-TEE in diagnosis of URCS was confirmed.

Successful diagnosis of pericardial rupture caused by blunt chest trauma using contrast ultrasonography.

A 65-year-old male developed acute myocardial infarction due to coronary artery dissection and tricuspid valve injury after blunt chest trauma. Acute myocardial infarction was treated by coronary artery intervention; however, refractory heart failure with pleural effusion remained. The first transthoracic echocardiography (TTE) on admission failed to clearly visualize the tricuspid valve and right ventricle due to poor image quality. A follow-up TTE with contrast ultrasonography revealed pericardial rupture in addition to tricuspid regurgitation. Ruptures of the tricuspid papillary muscle and pericardium were confirmed during surgery and were repaired successfully. Blunt chest trauma results in various cardiac injuries including cardiac rupture, intramural hematoma, valvular injury, coronary artery injury, and electrical disturbances, leading to critical conditions and high mortality. Of such blunt trauma-induced injuries, coronary artery dissection, tricuspid valve injury, and pericardial rupture caused by blunt chest trauma are rare, and simultaneous occurrence of the three types of injuries that were successfully repaired has not been reported. In addition, this case indicates the utility of contrast ultrasonography for diagnosis of pericardial rupture caused by blunt chest trauma.

[Mitral Valvuloplasty of Infective Endocarditis During Pregnancy].

This report describes a case in which we treated a patient who developed infective endocarditis in the mitral valve at 28 weeks' gestation. The condition was resolved by performing mitral valvuloplasty 2 days after an emergency cesarean section. Although the patient was in a relatively stable period at 32 weeks' gestation, the mother had an extremely high risk of embolism;thus, emergency surgery was required. We believe that an accurate diagnosis in a timely manner and a valvuloplasty shortly after cesarean section saved the life of the mother and child.

Stress echocardiographic assessment of mitral valve function repaired using rough-zone trimming.

BACKGROUND: We invented novel mitral valve repair technique; rough-zone trimming procedure (RZT) for anterior mitral valve prolapse. Prolapse site was resected in obtuse triangle shape and sutured edges to creates deep coaptation and improves regurgitation. Though it is simple and reproducible technique, functional mitral stenosis is a risk. Valve function and hemodynamics were investigated using dobutamine stress echocardiography (DSE) in patients after mitral valve repair using RZT. METHODS: Patients underwent RZT for the anterior mitral valve (AML, n = 10), quadrangular resection (QR) of the posterior mitral valve (PML; n = 4), RZT + QR of bileaflet valves (bileaflet; n = 4) and healthy individuals (control; n = 10) and were assessed by DSE (doses up to 20 µg/Kg/min). Echocardiographic data including mitral valve area (MVA), mitral valve mean pressure gradient (MVmeanPG), and systolic pulmonary artery pressure (sPAP) were measured at rest and at peak stress. RESULTS: Rest/stress MVA (cm(2)), MVmeanPG (mmHg) and sPAP (mmHg) were 2.8 ± 0.4 and 3.4 ± 0.3, 3.3 ± 1.1 and 7.4 ± 4.1, and 25.7 ± 4.7and 49.1 ± 4.1, respectively, in the AML group. Dobutamine stress increased all parameters but not to pathological levels. The results were similar to those of the other groups after mitral valve repair, whereas MVA was larger and MVmeanPG was lower in the control than in the AML group. CONCLUSIONS: Valve repair using RZT does not pathologically obstruct the mitral valve, either at baseline or during dobutamine stress, and does not affect valve hemodynamics and reserve.

New parameter of the right gastroepiploic arterial graft using the power spectral analysis device named MemCalc soft.

OBJECTIVES: Transit-time flow measurement (TTFM) parameters such as mean graft flow (MGF, ml/min), pulsatility index (PI) and diastolic filling (DF, %) have been extensively researched for internal mammary arterial or saphenous vein grafts. In our experience of using the right gastroepiploic arterial (GEA) graft for right coronary artery (RCA) grafting, we observed unique GEA graft flow waveforms. We analysed the GEA graft flow waveforms for their effectiveness in determining GEA graft patency by power spectral analysis. METHODS: Forty-five patients underwent off-pump coronary artery bypass using the GEA graft for RCA grafting individually. The means of intraoperative MGF, PI and DF were compared between patent and non-patent grafts, postoperatively. Furthermore, the GEA flow data were output and analysed using power spectral analysis. RESULTS: Forty grafts were 'patent' and five were 'non-patent'. There were no significant differences in the mean TTFM parameters between the patent and non-patent grafts (MGF: 22 vs 8 ml/min, respectively, P = 0.068; PI: 3.5 vs 6.5, respectively, P = 0.155; DF: 63 vs 53%, respectively, P = 0.237). Results of the power spectral analysis presented clear differences; the power spectral density (PSD) of patent grafts presented high peaks at frequency levels of 1, 2 and 3 Hz, and the non-patent graft PSD presented high peaks that were not limited to these frequencies. The PSD had a sensitivity and specificity of 80 and 87.5%, respectively. CONCLUSIONS: Power spectral analysis of the GEA graft flow is useful to distinguish between non-patent and patent grafts intraoperatively. This should be used as a fourth parameter along with MGF, PI and DF.

Impact of novel intraoperative evaluation for mitral valve regurgitation: the retrograde cardio-protective beating test.

PURPOSE: The saline injection test is commonly employed during mitral valvuloplasty. However, discrepancies in regurgitation between the naked eye findings during the saline injection test and the postoperative echocardiographic findings have been noted. Here, we describe the new retrograde cardio-protective beating test (RC-beating test) which allows direct transatrial evaluation of the valve in the fully loaded, beating heart under cross-clamping by means of the retrograde perfusion of warm oxygenated blood into the coronary sinus. METHODS: From January 2006 to June 2012, 63 patients (mean age, 59 ± 15 years) with degenerative mitral valve regurgitation underwent mitral valve repair with application of this novel evaluation. RESULTS: In 20 of the 63 patients (31.8%), minor residual leaks that were not remarkable in the saline injection test were detected during the RC-beating test and were completely corrected. Almost all patients (n = 61, 96.8%) revealed no mitral regurgitation on intraoperative transesophageal echocardiography. The results of the RC-beating test were satisfactory, and discrepancies were not recognized at all between this evaluation and the postoperative echocardiographic findings. The ultrastructure of the mitochondria showed significant myocardial preservation. CONCLUSION: The RC-beating test is a simpler and more accurate evaluation for mitral valve repair than the saline injection test. This novel evaluation enables a safe and more complete mitral valve repair.

Evaluation of gastroepiploic arterial grafts to right coronary artery using transit-time flow measurement.

OBJECTIVES: The objective of this study was to analyse the relationship between the intraoperative transit-time flow measurement (TTFM) parameter values and the postoperative angiographic results of gastroepiploic arterial (GEA) grafts to the right coronary artery (RCA). We investigated whether the intraoperative TTFM parameter values are reliable indicators of early patency in GEA grafts to the RCA. METHODS: Patients undergoing off-pump coronary artery bypass surgery with GEA grafts were included in this study. Eighty-three GEA grafts were individually anastomosed and examined by angiography 1 week after surgery. The quality of each graft was graded using FitzGibbon grading (Study 1) and graft-flow grading (Study 2). RESULTS: Study 1: Seventy-two grafts were determined as Grade A and 11 as Grades B or O. There were no significant differences in the average of mean graft flow (MGF), pulsatility index or diastolic filling percentage between Grade A and Grades B or O grafts. Study 2: Sixty-two grafts were graded as good-graft dominant, 16 as bidirectional and 5 as occlusion including string. The average of the MGF, pulsatility index and diastolic filling percentage in the grafts graded as bidirectional and occlusion including string were not significantly different from those of grafts graded as good-graft dominant. CONCLUSIONS: Previously reported cut-off values for intraoperative TTFM parameters could not be adapted for the early patency of GEA grafts to the RCA. However, the smoothness of the graft-flow curve may be a reliable predictor of postoperative graft patency.

[Intraoperative evaluation for residual mitral valve regurgitation; usefulness of the retrograde cardioprotective beating test].

Intraoperative evaluation is important for successful mitral valve plasty (MVP). We performed a saline injection test and a retrograde cardioprotective beating test (RC-beating test) for intraoperative evaluation. The concept of the RC- beating test is evaluation of residual mitral valve regurgitation( MR) under cardiac beating. A 66-year-old man with severe MR underwent MVP. The P3 chorda was ruptured and we performed quadrangular resection. The saline injection test showed trivial regurgitation. We then performed the RC-beating test and it revealed severe leakage from the posterior commissure(PC). Since the PC had a sclerotic change, another quadrangular resection was performed. Moreover,as the anterior leaflet( A3) was slightly elongated, the region was resected in an obtuse-angled triangle shape and repaired by suturing the edges. The final RC-beating test showed no residual leakage. The RC-beating test is useful for detecting residual mitral valve leakage.

Acute dilatation of the ascending aorta and aortic valve regurgitation in Loeys-Dietz syndrome.

Loeys-Dietz syndrome (LDS) is a recently recognized connective tissue disorder caused by mutations of the transforming growth factor (TGF)-ß receptors. It is an autosomal dominant syndrome characterized by the triad of arterial tortuosity and aneurysms, hypertelorism, and bifid uvula or cleft palate. We treated an 18-year-old woman with a 100-mm-diameter aortic root aneurysm and severe aortic valve regurgitation. She underwent urgent aortic root replacement and bioprosthetic valve implantation. LDS was diagnosed by postoperative genetic screening results. Histopathologic examination of the aortic wall showed diffuse degeneration and elastin fragmentation in the media.

[Aortic valve surgery in a patient with cold agglutinin disease; effectiveness of continuous retrograde cardioplegia].

A 76-year-old female was hospitalized because of congestive heart failure and anemia. A thorough examination led to a diagnosis of severe aortic stenosis and cold agglutinin disease. The critical temperature for hemagglutination was 27 °C, which caused particular problems with regard to the myocardial protection temperature during surgery. Aortic valve replacement was performed safely by increasing the normal myocardial protection temperature from 15 °C to 32 °C and using 3 times the normal volume of cardioplagic fluid. As a result of strict perioperative thermal management, the operation was completed without any complications.