Kyobu geka. The Japanese journal of thoracic surgery最新文献

Background: We evaluated early and mid-term outcomes of modified Bentall procedure with French cuff technique for aortic root disease.

Methods: Between 2017 and 2024, 45 patients underwent modified Bentall procedure with French cuff technique. We excluded patients who had cardiopulmonary resuscitation. The mean age was 64.8± 14.0 years, and 35 patients were male( 77.8%). The mean predicted operative mortality rate according to JapanSCORE 2 was 11.2%.

Results: No patients had any trouble with bleeding from the aortic root. Hospital mortality was 2.2%, as one patient died due to a fungal infection. Twelve patients( 26.7%) experienced complications during hospitalization. The 3- and 5-year overall survival rates were 97.7% and 88.0%, respectively. Freedom from reoperation was 93.7% and 93.7% at 3 and 5 years, respectively. One patient underwent re-aortic valve replacement due to a stuck valve, and one underwent re-Bentall due to a seroma. There were no pseudoaneurysm formations of the aortic root and coronary ostia during the followed-up.

Conclusions: The modified Bentall procedure with French cuff technique may be a useful technique with good outcomes.

Aortic root replacement is based on the Bentall procedure, and if appropriate cases are selected, valve-sparing surgery has good results. However, peri-operative myocardial infarction has been reported as a serious morbidity, and coronary artery reconstruction must be performed preventing this complication. Our results also indicate that prevention of kinking of the right coronary artery was associated with an improved prognosis. We believe that the enlarged sinus of Valsalva was replaced by a composite graft, the ostium of the right coronary artery was consequently located distance away from the graft. By reconstructing the right coronary artery in a left posterior and cephalic position, i.e., by traction toward the left shoulder, we can compensate for this misalignment and prevent kinking. Bentall procedure with a prosthetic composite graft has been a gold standard procedure as an aortic root replacement. When appropriate cases are selected, valve-sparing surgery can yield better results. However, peri-operative myocardial infarction has been reported as a serious morbidity. In addition, our present clinical analysis revealed that prevention of kinking of the right coronary artery is associated with an improved long-term prognosis. The technical aspects of coronary artery reconstruction are therefore of paramount importance. In particular, the more likely the right coronary artery is to be misaligned and kinked. The larger the sinus of Valsalva, the more likely the right coronary artery is to be misaligned and kinked. After excision of the enlarged sinus of Valsalva and replacement with an adequate size of prosthetic composite graft, the optimal position for the reattached right coronary button should be altered from the preoperatively deviated position due to the aneurysmal sinus of Valsalva. We believe that reconstructing the right coronary artery in a cephalad position and in a slightly counterclockwise direction by rotating the tip of the right coronary button towards the left shoulder may compensate for potential misalignment and help prevent kinking of the critical branch.

Objective: This study aimed to review the results of the bio-Bentall procedure in patients over 65 years of age at our hospital.

Materials and methods: Of the 65 aortic root replacement procedures performed at our hospital from October 2015 to January 2024, we reviewed 45 bio-Bentall procedures performed on patients 65 years of age or older. These patients consisted of 39 men and 6 women, with a mean age of 72 years. There were 5 patients with aortic dissection and 40 patients with non-dissection, and 6 patients had reoperation. There were 19 concomitant surgeries, including coronary artery bypass grafting, valve surgery, and aortic procedure. The bioprosthetic valves used were Magna EASE in 17 patients, Inspiris in 25 patients, Trifecta in 2 patients, and Avalus in 1 patient. All Valsalva grafts used were J Graft Valsalva.

Results: The mean intubation time was 19 hours, and the mean intensive care unit( ICU) stay was 6 days. The number of in-hospital deaths was 3 patients, and the mean length of hospital stay was 18 days. The remote mortality rate was 4( 1 heart failure, 2 lung cancer, and 1 pancreatic cancer). There have been no case of reoperation, structural valve deterioration (SVD), or thromboembolism to date, and the rates of freedom of reoperation, SVD, and thromboembolism were all 100%. The 1-, 3-, 5-, and 7-year survival rates were 91.1%, 86.4%, 83.6%, and 83.6%, respectively.

Conclusion: The surgical and long-term outcomes of the bio-Bentall procedure in patients over 65 years of age were stable. In patients who may outlive the bioprosthetic valve life, it is important to perform an appropriate and durable Bentall procedure, including valve-in-valve, prioritizing the future of each patient.

The remodeling of sinus of Valsalva( Yacoub operation) is being standardized by adding annular fixation and technique for cusp prolapse as a refined method of valve sparing aortic root repair. It is important to design whole configurations of Valsalva sinus( diameters of aortic annulus and sino-tubular junction) according to the patient's geometric height (geometric height-oriented strategy). In this paper, we summarized our tips of remodeling of sinus of Valsalva operation.

Objectives: The extensibility of the aortic root after the remodeling procedure was evaluated using 4-dimentional computed tomography( 4D-CT).

Patients and methods: Seventeen patients( 13 males/4 females), mean age 52 years, who had undergone the remodeling procedure in the last 3 years were included. To understand the dynamics of the aortic root after reconstruction, the R-R interval on the electrocardiogram was divided into 10 equal parts, and the percentage change in area of the basal ring/Valsalva sinus/sino-tubular junction (STJ) level was calculated to evaluate the extensibility of the aortic root. For the basal ring, changes in ellipticity and circumference were also compared.

Results: Basal ring, Valsalva sinus, and STJ area changes with cardiac cycle were similar to those in the control group. Basal ring showed a regular circle in systole and an oval in diastole, and its circumference was enlarged in systole.

Conclusions: The use of 4D-CT made it possible to evaluate the extensibility of the aortic root after remodeling procedure. In particular, the mobility of the basal ring is large, suggesting that it guarantees the physiological opening and closing of the valve and contributes to its durability.

Background: Selective sinus replacement seems a reasonable option in cases requiring replacement of one or two sinuses of Valsalva, especially with acute aortic dissection and high bleeding risk.

Methods: Six patients (average age 58±17 years;five males) underwent selective replacement of the right sinus of Valsalva with right coronary artery bypass grafting (n=5) in 2015-2023. Five patients developed acute aortic dissection and one developed aneurysm of the right sinus of Valsalva.

Results: All patients survived the operation, and there were no cases requiring re-exploration for bleeding. Intraoperative transesophageal echocardiography showed trivial or less aortic regurgitation (AR) in all patients. Cardiopulmonary bypass time, aortic cross-clamping time, and lower body circulatory arrest time were 214±28 min, 159±22 min, and 31±6 min (n=5), respectively. During follow-up of 55±44 (4-104) months, all patients were asymptomatic. AR was mild or less in four patients, mild-moderate in one patient, and severe in one patient. All patients had normal cardiac function without left ventricular enlargement, and so no reoperation was required.

Conclusions: Although this method appears to be relatively safe and effective, some patients developed late AR. Long-term follow-up of larger numbers of patients will be necessary to confirm its effectiveness.

The case is an 80-year-old woman with Sjögren's syndrome. During the follow-up of multiple pulmonary nodules, an enlarged nodule was observed in the peripheral of the right S3 interlobar region. Fluorodeoxyglucose- positron emission tomography (FDG-PET) showed FDG accumulation only in the S3 nodule, which led to suspicion of primary lung cancer. Because of its difficult location to reach by bronchoscopy, a right lung S3 segmentectomy was performed. Intraoperative findings revealed a hard yellowish- white nodule just below the pleura. Pathological examination showed that the nodule consisted of an acidophilic structureless material, which was positive for Congo red staining and disappeared after permanganate treatment. Based on the above findings, we diagnosed amyloid A( AA)-type amyloidosis. In this case, the nodule was located just below the pleura and we could observe it by thoracoscopy. There have been few reports of thoracoscopic observation of pulmonary amyloidosis, and we report with intraoperative findings.

Dextrocardia associated with situs inversus totalis is a rare congenital anomaly. We herein report a patient with this condition and ischemic coronay artery disease who underwent emergency surgical myocardial revascularization. A 76-year-old man was admitted to our hospital with a diagnosis of unstable angina pectoris. He had incessant ventricular fibrillation attack on the second day of hospitalization. Emergent coronary angiography revealed total obstruction of the anatomically left anterior descending and right coronary arteries, and severe stenosis in the anatomically left circumflex artery. Emergent off-pump coronary artery bypass using saphenous vein grafts was successfully performed. Intraoperatively, the main surgeon continuouly stood on the patient's right side except during anastosiso of a vein graft to the left circumflex artery. Postoperative course was almost uneventful aside from transient renal replacement and prolonged ventilation.

We report two rare cases of cardiac tamponade after left upper lobectomy. Case 1:A 76-year-old man underwent thoracoscopic left upper lobectomy and lymph node dissection for lung cancer. The patient suddenly developed cardiac tamponade the day after surgery. Emergency surgery was performed to stop bleeding and confirm the source of bleeding, and dark red pericardial fluid and hematoma were observed in the pericardial sac. There was no postoperative recurrence of cardiac tamponade. He died 1 year and 2 months after the operation. Case 2:A 77-year-old woman underwent thoracoscopic left upper lobectomy and lymph node dissection for lung cancer. The patient did well until the 6th postoperative day. On the 7th postoperative day, she complained of sudden severe back pain, immediately after which she lost consciousness and went into cardiopulmonary arrest. The echocardiography revealed cardiac tamponade, and emergency pericardiocentesis was performed. The patient died without circulatory improvement despite drainage of approximately 200 ml of bloody pericardial fluid. The pathological findings of autopsy revealed penetrating atherosclerotic ulcer at the descending aorta. We speculated that severe back pain caused the afterload of left ventricle and the increase in left atrial pressure through mitral regurgitation, which might result in a bleeding from the staple-line of superior pulmonary vein in the pericardium.

The case is a 76-year-old woman. She was admitted to the hospital because of chest and back pain. Coronary angiography revealed a 62-mm giant coronary artery aneurysm originating from the left main trunk( LMT), and urgent surgery was performed. Coronary artery-pulmonary artery fistula along with coronary artery aneurysm was completely removed by surgery. In this case, the reconstruction strategy for the LMT was crucial. The aneurysm wall was completely resected, allowing the coronary artery to return to its original course, and the length of the LMT defect was <2 cm. We determined that anatomical reconstruction of the LMT was optimal and succeeded in replacing a short great saphenous vein corresponding to the length of the defect. The patient was discharged without any complications.